A telephone-delivered intervention, which included automated symptom monitoring, produced clinically meaningful improvements in chronic musculoskeletal pain compared to usual care, according to a study in JAMA.
Pain is the most common symptom reported both in the general population and patients seen in primary care, the leading cause of work disability, and a condition that costs the United States more than $600 billion each year in health care and lost productivity. Musculoskeletal pain accounts for nearly 70 million outpatient visits annually in the United States each year. Telemedicine strategies for pain care have been proposed but not rigorously tested to date, according to background information in the article.
Kurt Kroenke, M.D., of Roudebush VA Medical Center, Indiana University School of Medicine, and the Regenstrief Institute, Indianapolis, and colleagues randomly assigned 250 patients with chronic musculoskeletal pain to an intervention group (n = 124) or to a usual care group whose members received all pain care as usual from their primary care physicians (n = 126). The intervention group received 12 months of telecare management that included automated symptom monitoring with an algorithm-guided approach to optimizing pain medications.
Among the key results of the trial:
- Patients in the intervention group were nearly twice as likely to report at least a 30 percent improvement in their pain score by 12 months (51.7 percent vs 27.1 percent);
- The intervention was associated with clinically meaningful improvements in pain and a greater rate of improvement (56 percent vs 31 percent);
- Patients in the usual care group were almost twice as likely to experience worsening of pain by 6 months compared with those in the intervention group (36 percent vs 19 percent);
- Few patients in either group were started on opioids or had escalations in their opioid dose during the study period;
- Patients in the intervention group were also more likely to rate as good to excellent the medication prescribed for their pain (73.9 percent vs 50.9 percent) as well as the overall treatment of their pain (76.7 percent vs 51.6 percent).
"The intervention was effective, even though most trial participants reported pain that had been present for many years, that involved multiple sites, and that had been unsuccessfully treated with numerous analgesics," the authors write. "The improvement in pain with minimal opioid initiation or dose escalation is noteworthy, given increasing concerns about the consequences of long-term opioid use."
The researchers add that the results of this trial, along with findings from a previous trial conducted among patients with cancer, show that algorithm-guided optimization of pain medication can be efficiently delivered through a predominantly telephone and Internet-based approach.
Editorial - Advancing Telecare for Pain Treatment in Primary Care
Michael E. Ohl, M.D., M.S.P.H., and Gary E. Rosenthal, M.D., of the University of Iowa Carver College of Medicine, Iowa City, comment on this study in an accompanying editorial.
"Historically, implementation of collaborative care innovations - such as collaborative care for depression - has been slow. However, there is reason to believe that telecare for chronic pain can be more rapidly implemented into routine practice. Adoption of collaborative care for depression was hindered by the fee-for-service payment system, which favors procedures and in-person physician visits over team-based and between-visit care. Recent movement toward reimbursement for telehealth and between-visit care may make telecare for pain management more attractive to primary care practices."
"In summary, Kroenke et al describe a promising telecare strategy that may enhance the ability of primary care practices to effectively treat patients with chronic pain. Additional studies are required to determine the generalizability, sustainability, and cost-effectiveness of this strategy and to assess how it may best be incorporated within primary care practices."