Telecare Monitoring of Chronic Pain May Result in Improved Pain Control

Kurt Kroenke, M.D. Professor of Medicine, Indiana University School of Medicine Research Scientist, Indiana University Center for Health Services and Outcomes Research Research Scientist, Center for Health Services Research, Regenstrief Institute, Inc. Director of Education and Training Programs, Regenstrief Institute, Inc. Core Investigator, VA HSR&D Center for Health Information and CommunicationMedicalResearch.com Interview with:
Kurt Kroenke, M.D.
Professor of Medicine, Indiana University School of Medicine
Research Scientist, Indiana University Center for Health Services and Outcomes Research
Research Scientist, Center for Health Services Research, Regenstrief Institute, Inc.
Director of Education and Training Programs, Regenstrief Institute, Inc.
Core Investigator, VA HSR&D Center for Health Information and Communication

Medical Research: What are the main findings of the study?

Dr. Kroenke: The telecare intervention including monitoring of pain using automated phone calls or the Internet with contacts by a nurse care manager who met weekly with a physician pain specialist to discuss treatment of new patients or patients already being followed who were not improving.

  • Almost twice as many patients in the telecare group had improvement in their pain compared to the usual care control group (52% vs. 27%).
  • Moreover, nearly twice as many patients in the usual care group got worse over 12 months (36% vs. 19%).  Thus, patients with chronic pain may not only fail to improve with current treatment, they in fact can get worse over time.
  • Although one-third of these chronic pain patients were on opioids at start of study, there were very few patients in which opioids needed to be started or dose increased.
  • The intervention group was about equally divided between those who chose to do automated symptom monitoring (ASM) by IVR (51%) or internet (49%).  The majority of patients rated the monitoring as easy to do, and the telecare intervention helpful.


Medical Research: Were any of the findings unexpected?

Dr. Kroenke: Most patients had pain for many years, in more than one area of the body, and had tried multiple treatments.  Even with this, the intervention helped. It is possible the benefits would even be greater in patients with pain of shorter duration with fewer previous treatment failures.

Second, improvement was gradual occurring slowly over the 12 months of the trial.  In contrast to depression, for which telephone-based collaborative care has been extensively studied and proven effective, and where the quickest improvement is in the first 1-3 months, pain has small improvements in the first few months with benefits accruing slowly over time.  Also, clinically important improvements are more modest. Whereas for depression, a 50% improvement is considered a response, the threshold for pain is a 30% improvement. Thus, expect smaller, slower improvements over time with pain, but the end result is still considered important by patients.

Medical Research: What should clinicians and patients take away from your report?

Dr. Kroenke:

  • Chronic pain can be improved by changing or adjusting medications without increasing the use of opioids.
  • This can be done through a largely telecare approach combining home-based pain monitoring using automated phone calls or an Internet (web-based) approach with a nurse care manager-physician team.

Medical Research: What recommendations do you have for future research as a result of this study?

  • We focused primarily on adjusting pain medicines. There are also nonpharmacological treatments (pain self-management programs, cognitive-behavioral therapy, exercise, some complementary medicine treatments in selected patients).
  • Also a third to half of patients with perseistent pain develop depression or anxiety, and it has been shown that treatment of these mood symptoms can provide further benefits.
  • Telecare approaches may be easier on the patients but need to reimbursed to expand their availability.

Citation:

Telecare Collaborative Management of Chronic Pain in Primary Care: A Randomized Clinical Trial

Kurt Kroenke MD, Erin E. Krebs MD, Jingwei Wu MS, Zhangsheng Yu PhD, Neale R. Chumbler PhD, Matthew J. Bair MD

JAMA. 2014;312(3):240-248. doi:10.1001/jama.2014.7689

 

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