Telecare Intervention Improves Chronic Pain for VA Patients

Larry Hand

July 15, 2014

A telecare intervention using basic telephone technology and collaborative care management resulted in clinically meaningful improvements in chronic musculoskeletal pain compared with usual care, according to an article published online July 15 in JAMA.

Kurt Kroenke, MD, from the Veterans Administration (VA) Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana, and colleagues conducted a randomized trial involving 250 patients from 5 primary care clinics within the center between June 2010 and May 2012.

Of the 250 patients, research assistants randomly assigned 124 to an intervention group and 126 to a usual-care group. All patients had chronic musculoskeletal pain for at least 3 months of at least moderate intensity, meaning a Brief Pain Inventory score of 5 or more on a 10-point scale. Movement of 1 point on the scale is considered clinically meaningful.

The intervention consisted of automated symptom monitoring (ASM) for 12 months coupled with an algorithm-guided stepped care approach to optimize treatment with analgesics. Depending on patient preferences, ASM consisted of interactive voice-recorded telephone calls or was conducted over the Internet.

ASM reports were scheduled every week at first and then graduated down to monthly as the trial progressed. ASM measured 15 items, 7 symptom-related items, and 8 items pertaining to how difficult pain made performing usual patient activities.

The researchers based a stepped care algorithm on systematic literature reviews of pharmacological therapy for chronic pain. The reviews covered 6 major categories of analgesics, from simple analgesics to opioids. From ASM and nurse calls, the algorithm prompted adjustments in type or dose of analgesic.

A nurse care manager initially oriented the patients and responded to prompts from ASM. A physician pain specialist was available if needed.

Significantly Less Pain

Patients in the intervention group had significantly greater improvement in Brief Pain Inventory scores after 12 months, from 5.31 at baseline to 3.57 after the intervention compared with 5.12 and 4.59 for the usual-care group (P < .001). Similar results occurred for pain severity and pain interference.

Intervention patients received more analgesics for more months and at a mean higher dose than usual-care patients; opioid use was unchanged between groups for the 12 months. Of 166 patients not taking opioids at the start, opioids were started for only 6 (3.6%).

Patients in the usual-care group were more likely to experience worsening pain, the researchers write, "demonstrating a greater risk of deterioration in the absence of systematic approaches to optimizing pain therapy."

One limitation of the study is the potential lack of generalization of the VA-only results.

The researchers conclude, however, "Telecare collaborative management substantially increased the proportion of primary care patients with improved chronic musculoskeletal pain. This was accomplished by optimizing nonopioid analgesic medications using a stepped care algorithm and monitoring."

Promising Strategy

In an accompanying editorial, Michael E. Ohl, MD, MSPH, and Gary E. Rosenthal, MD, from the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa, write that the study describes "a promising telecare strategy that may enhance the ability of primary care practices to effectively treat patients with chronic pain."

The editorialists write that the use of common telephone technology and simple monitoring technology, combined with the fact that the intervention relied primarily on a nurse care manager to oversee symptom monitoring and handle stepped care adjustments, means the intervention could be implemented without adding considerable time for primary care physicians.

"The authors estimated that the intervention required 3 to 4 hours of nurse care manager time and 1 hour of physician time per patient during a 12-month period," the editorialists write. "Thus, a single nurse could potentially manage the care of 500 to 600 patients with the support of a 0.25 full-time equivalent physician pain specialist."

On a related note, the Utah Division of Occupational Professional Licensing issued an emergency stop order to a physician who practices telemedicine in Utah from a Western Pacific island. The agency claimed the physician did not have enough contact with patients before prescribing buprenorphine and naloxone (Suboxone, Reckitt Benckiser).

This research was supported by the VA Health Services Research and Development and a VA Career Development award to Dr. Kroenke. Dr. Kroenke has reported receiving honoraria from Eli Lily outside of the submitted work. The other authors and the editorialists have disclosed no relevant financial relationships.

JAMA. Published online July 15, 2014.


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