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A telecare intervention within the primary care practice setting elicited clinically meaningful and statistically significant improvements in long-standing chronic joint and other musculoskeletal pain, according to a report published online July 15 in JAMA.
A total of 250 adults with refractory, moderately severe regional (joints, limbs, back, or neck) or generalized (fibromyalgia or widespread) musculoskeletal pain of long duration participated in a randomized, blinded, 1-year clinical trial comparing the telecare intervention (124 patients) against usual chronic pain treatment (126 patients) in the primary care setting, reported Dr. Kurt Kroenke of the Veterans Affairs Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, and his associates.
The intervention had three key components: frequent automated monitoring of patient symptoms using telephone or Internet voice recordings; nurse calls to patients who reported inadequate treatment response, adverse effects, or nonadherence; and analgesic management using a stepped-care algorithm, which was implemented by a nurse-manager who worked with a physician pain specialist, in collaboration with the primary care physician. The estimated total time spent per patient during the study year was 3-4 hours for the study nurse and 1 hour for the study physician.
Patients frequently checked in to the automated system to report their pain, anxiety, and depression symptoms; how difficult their pain made it for them to carry out usual activities; their adherence to medications; the degree of relief they obtained from pain medications; any change in pain, including the degree of improvement; adverse effects from their analgesics; and whether they wanted to change their medication regimen or speak to a nurse.
The medication algorithm called for the stepwise use of simple analgesics (acetaminophen and nonsteroidal anti-inflammatory drugs); tricyclic antidepressants (amitriptyline and nortriptyline) and cyclobenzaprine; tramadol; gabapentoids (gabapentin and pregabalin); topical analgesics; and opioids.
After 1 year, patients in the intervention group showed significantly greater improvement than the control group in measures of total pain, pain severity, and pain interference with daily activities, along with significantly greater satisfaction with their medical care. They were nearly twice as likely to report a 30% improvement from baseline (51.7%) than were patients in the usual-care group (27.1%).
They also were much less likely to report worsening pain (19.2% vs. 36.0%), which indicates a reduced risk of deterioration of their condition because their pain therapy was optimized, and much more likely to rate their medication as "good to excellent" (73.9% vs. 50.9%). And they reported greater improvements in secondary outcomes such as depression, anxiety, somatization, sleep, and social functioning, the investigators reported (JAMA 2014;312:240-248).
Patients in the intervention group received a greater number of analgesics for a greater length of time and at a higher mean dose than did those in the control group. However, only six patients in the entire study population initiated opioid use, and the median daily dose for all patients taking opioids was identical at the end of the study to what it was at the beginning. The two study groups showed no differences in their use of health care services such as outpatient visits, emergency department visits, and hospitalizations.
This study was supported by the U.S. Department of Veterans Affairs’ Health Services Research and Development Service. Dr. Kroenke reported receiving honoraria from Eli Lilly for work unrelated to this study.
This promising intervention doesn’t require significant additional time or effort from primary care physicians and is simple enough that it could be implemented in most primary care settings, said Dr. Michael E. Ohl and Dr. Gary E. Rosenthal.
"The authors estimated that the intervention required 3-4 hours of nurse-manager time and 1 hour of physician time per patient during a 12-month period. Thus, a single nurse could potentially manage the care of 500-600 patients with the support of a 0.25 full-time equivalent physician pain specialist," they noted.
Dr. Ohl and Dr. Rosenthal are at the Iowa City VA Medical Center and in the department of internal medicine at the University of Iowa. Dr. Rosenthal is also at the Institute for Clinical and Translational Sciences at the university. They reported no financial conflicts of interest. These remarks were taken from their editorial accompanying Dr. Kroenke’s report (JAMA 2014;312:235-6).
This promising intervention doesn’t require significant additional time or effort from primary care physicians and is simple enough that it could be implemented in most primary care settings, said Dr. Michael E. Ohl and Dr. Gary E. Rosenthal.
"The authors estimated that the intervention required 3-4 hours of nurse-manager time and 1 hour of physician time per patient during a 12-month period. Thus, a single nurse could potentially manage the care of 500-600 patients with the support of a 0.25 full-time equivalent physician pain specialist," they noted.
Dr. Ohl and Dr. Rosenthal are at the Iowa City VA Medical Center and in the department of internal medicine at the University of Iowa. Dr. Rosenthal is also at the Institute for Clinical and Translational Sciences at the university. They reported no financial conflicts of interest. These remarks were taken from their editorial accompanying Dr. Kroenke’s report (JAMA 2014;312:235-6).
This promising intervention doesn’t require significant additional time or effort from primary care physicians and is simple enough that it could be implemented in most primary care settings, said Dr. Michael E. Ohl and Dr. Gary E. Rosenthal.
"The authors estimated that the intervention required 3-4 hours of nurse-manager time and 1 hour of physician time per patient during a 12-month period. Thus, a single nurse could potentially manage the care of 500-600 patients with the support of a 0.25 full-time equivalent physician pain specialist," they noted.
Dr. Ohl and Dr. Rosenthal are at the Iowa City VA Medical Center and in the department of internal medicine at the University of Iowa. Dr. Rosenthal is also at the Institute for Clinical and Translational Sciences at the university. They reported no financial conflicts of interest. These remarks were taken from their editorial accompanying Dr. Kroenke’s report (JAMA 2014;312:235-6).
A telecare intervention within the primary care practice setting elicited clinically meaningful and statistically significant improvements in long-standing chronic joint and other musculoskeletal pain, according to a report published online July 15 in JAMA.
A total of 250 adults with refractory, moderately severe regional (joints, limbs, back, or neck) or generalized (fibromyalgia or widespread) musculoskeletal pain of long duration participated in a randomized, blinded, 1-year clinical trial comparing the telecare intervention (124 patients) against usual chronic pain treatment (126 patients) in the primary care setting, reported Dr. Kurt Kroenke of the Veterans Affairs Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, and his associates.
The intervention had three key components: frequent automated monitoring of patient symptoms using telephone or Internet voice recordings; nurse calls to patients who reported inadequate treatment response, adverse effects, or nonadherence; and analgesic management using a stepped-care algorithm, which was implemented by a nurse-manager who worked with a physician pain specialist, in collaboration with the primary care physician. The estimated total time spent per patient during the study year was 3-4 hours for the study nurse and 1 hour for the study physician.
Patients frequently checked in to the automated system to report their pain, anxiety, and depression symptoms; how difficult their pain made it for them to carry out usual activities; their adherence to medications; the degree of relief they obtained from pain medications; any change in pain, including the degree of improvement; adverse effects from their analgesics; and whether they wanted to change their medication regimen or speak to a nurse.
The medication algorithm called for the stepwise use of simple analgesics (acetaminophen and nonsteroidal anti-inflammatory drugs); tricyclic antidepressants (amitriptyline and nortriptyline) and cyclobenzaprine; tramadol; gabapentoids (gabapentin and pregabalin); topical analgesics; and opioids.
After 1 year, patients in the intervention group showed significantly greater improvement than the control group in measures of total pain, pain severity, and pain interference with daily activities, along with significantly greater satisfaction with their medical care. They were nearly twice as likely to report a 30% improvement from baseline (51.7%) than were patients in the usual-care group (27.1%).
They also were much less likely to report worsening pain (19.2% vs. 36.0%), which indicates a reduced risk of deterioration of their condition because their pain therapy was optimized, and much more likely to rate their medication as "good to excellent" (73.9% vs. 50.9%). And they reported greater improvements in secondary outcomes such as depression, anxiety, somatization, sleep, and social functioning, the investigators reported (JAMA 2014;312:240-248).
Patients in the intervention group received a greater number of analgesics for a greater length of time and at a higher mean dose than did those in the control group. However, only six patients in the entire study population initiated opioid use, and the median daily dose for all patients taking opioids was identical at the end of the study to what it was at the beginning. The two study groups showed no differences in their use of health care services such as outpatient visits, emergency department visits, and hospitalizations.
This study was supported by the U.S. Department of Veterans Affairs’ Health Services Research and Development Service. Dr. Kroenke reported receiving honoraria from Eli Lilly for work unrelated to this study.
A telecare intervention within the primary care practice setting elicited clinically meaningful and statistically significant improvements in long-standing chronic joint and other musculoskeletal pain, according to a report published online July 15 in JAMA.
A total of 250 adults with refractory, moderately severe regional (joints, limbs, back, or neck) or generalized (fibromyalgia or widespread) musculoskeletal pain of long duration participated in a randomized, blinded, 1-year clinical trial comparing the telecare intervention (124 patients) against usual chronic pain treatment (126 patients) in the primary care setting, reported Dr. Kurt Kroenke of the Veterans Affairs Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, and his associates.
The intervention had three key components: frequent automated monitoring of patient symptoms using telephone or Internet voice recordings; nurse calls to patients who reported inadequate treatment response, adverse effects, or nonadherence; and analgesic management using a stepped-care algorithm, which was implemented by a nurse-manager who worked with a physician pain specialist, in collaboration with the primary care physician. The estimated total time spent per patient during the study year was 3-4 hours for the study nurse and 1 hour for the study physician.
Patients frequently checked in to the automated system to report their pain, anxiety, and depression symptoms; how difficult their pain made it for them to carry out usual activities; their adherence to medications; the degree of relief they obtained from pain medications; any change in pain, including the degree of improvement; adverse effects from their analgesics; and whether they wanted to change their medication regimen or speak to a nurse.
The medication algorithm called for the stepwise use of simple analgesics (acetaminophen and nonsteroidal anti-inflammatory drugs); tricyclic antidepressants (amitriptyline and nortriptyline) and cyclobenzaprine; tramadol; gabapentoids (gabapentin and pregabalin); topical analgesics; and opioids.
After 1 year, patients in the intervention group showed significantly greater improvement than the control group in measures of total pain, pain severity, and pain interference with daily activities, along with significantly greater satisfaction with their medical care. They were nearly twice as likely to report a 30% improvement from baseline (51.7%) than were patients in the usual-care group (27.1%).
They also were much less likely to report worsening pain (19.2% vs. 36.0%), which indicates a reduced risk of deterioration of their condition because their pain therapy was optimized, and much more likely to rate their medication as "good to excellent" (73.9% vs. 50.9%). And they reported greater improvements in secondary outcomes such as depression, anxiety, somatization, sleep, and social functioning, the investigators reported (JAMA 2014;312:240-248).
Patients in the intervention group received a greater number of analgesics for a greater length of time and at a higher mean dose than did those in the control group. However, only six patients in the entire study population initiated opioid use, and the median daily dose for all patients taking opioids was identical at the end of the study to what it was at the beginning. The two study groups showed no differences in their use of health care services such as outpatient visits, emergency department visits, and hospitalizations.
This study was supported by the U.S. Department of Veterans Affairs’ Health Services Research and Development Service. Dr. Kroenke reported receiving honoraria from Eli Lilly for work unrelated to this study.
FROM JAMA
Key clinical finding: A hands-off telecare approach helps patients with chronic joint and other musculoskeletal pain manage it.
Major finding: Patients in the intervention group showed significantly greater improvement than the control group in measures of total pain, pain severity, and pain interference with daily activities; they were nearly twice as likely to report a 30% improvement from baseline (51.7%) than were patients in the usual-care group (27.1%), much less likely to report worsening pain (19.2% vs. 36.0%), and much more likely to rate their medication as "good to excellent" (73.9% vs. 50.9%).
Data source: A 1-year randomized, controlled trial involving 250 adults with refractory, moderately severe, chronic musculoskeletal pain.
Disclosures: This study was supported by the U.S. Department of Veterans Affairs’ Health Services Research and Development Service.