Principal Results
comorbid chronic pain, pain, PTSD, chronic pain, NRS
CHRONIC PAIN, RECRUITMENT, ATTRITION
This study describes the recruitment, onboarding, and attrition in a remotely delivered RCT examining MR. Although recruitment occurred at 3 sites in separate states (Florida, Michigan, and Washington), veteran and partner dyads who responded to recruitment efforts represented 37 US states and 1 territory (Puerto Rico), resulting in a more geographically diverse sample than anticipated. In addition, ICD-10 codes for chronic pain and PTSD were used as sampling criteria for targeted recruitment efforts, which resulted in a sample that reported moderate to severe pain (n=244, >92%) and probable PTSD (n=200, >75%) on the NRS and PCL-5, respectively. Key findings regarding study attrition were that our roughly 27% (97/364) attrition rate exceeded the 20% (46/228) anticipated rate but was still within an acceptable range for chronic pain and PTSD trials [As researchers support efforts to examine nonpharmacological interventions to help individuals manage pain and PTSD, effective delivery of remote CIH interventions is shaped by symptom burden, accessibility of web-based programs, and population characteristics. A rigorous assessment of these factors is imperative to tailor research and programs made accessible for this population. This paper describes attrition during the recruitment, onboarding, and baseline data collection stages of an RCT assessing the efficacy of the MR intervention for veterans with comorbid chronic pain and PTSD and their partners. Examining baseline attrition and influencing factors provides useful enrollment recommendations and lessons learned to inform successful recruitment and retainment in future research and programmatic recruitment efforts specific to remotely delivered interventions designed for this clinically diverse patient population.First, and notably, CDW sampling for contact and eligibility criteria, based on inclusion criteria, to identify eligible participants, resulted in a 5.4% (n=1733) response rate, with a recruitment rate of 1.1% (n=364). These values provide a reasonable expectation of sampling for protocols and interventions of a similar nature [The geographic diversity of remote recruitment of veteran-partner dyads resulted in a national sample 34 US states and 1 territory, which highlights the opportunity for increasing access when conducting remote interventions. Mailings were clearly optimal for geographically diverse recruitment and using RUCA codes created an opportunity to target rural audiences. Overall, baseline demographic characteristics for dyads were reflective of the larger veteran and caregiver population. One notable factor to consider when recruiting for mobile interventions is that most of this population had higher educational levels and daily computer and internet use. This accounts for a self-selection bias based on educational, and computer and internet literacy.Overall, the study attrition rate was about 27% (n=97); we retained over 73% (n=267) of dyads through activation which is standard, based on rates reported in the literature for chronic pain, PTSD, and web-based dyadic interventions [The second most common reason for attrition was active withdrawal—which was cited as time constraints to perform study activities—often related to other competing personal priorities, such as health and family priorities. Identified recruitment and attrition issues were identified early in the project; when possible, iterative approaches were used to adapt the protocol and processes to meet participant needs.Attrition interviews provided some insight into attrition as well; for example, attrition interview participants reported a lack of understanding of the purpose of the MR program. It is important to note that though this project was innovative in its use of remote technology and strategies and was only able to continue during COVID-19 due to its use of remote technology, the most reported recommendation was to increase human interaction. As systems turn to remote access in a post COVID-19 climate, this trial was an opportunity to learn the need to balance remote accessibility with human contact, as technology and remote access to care, though valuable and sometimes necessary, leave the risk of leaving patients feeling disconnected. Lack of program usefulness and awareness of potential benefits, lack of the technical or necessary equipment to participate, or not having a partner to participate in the intervention are programmatic issues that require further in-depth analysis for improving programmatic implementation.While higher than our initial expectations, our final attrition rate is consistent with studies that recruit veterans with chronic pain and PTSD. While previous studies have identified specific barriers for veterans with pain and PTSD seeking treatment for symptom management, these barriers often were associated with in-person treatment. The similar attrition rates reveal either parallel or overlapping factors that make it difficult for veterans to participate in remote interventions for symptom management. Although participant attrition for the MR trial was commiserated with published rates [