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Original Investigation |

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

Kurt Kroenke, MD1,2,3; Erin E. Krebs, MD4,5; Jingwei Wu, MS6; Zhangsheng Yu, PhD6; Neale R. Chumbler, PhD7; Matthew J. Bair, MD1,2,3
[+] Author Affiliations
1VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
2Department of Medicine, Indiana University School of Medicine, Indianapolis
3Regenstrief Institute, Indianapolis, Indiana
4VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
5University of Minnesota Medical School, Minneapolis
6Department of Biostatistics, Indiana University School of Medicine, Indianapolis
7Department of Health Policy and Management, College of Public Health, University of Georgia, Athens
JAMA. 2014;312(3):240-248. doi:10.1001/jama.2014.7689.
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Importance  Chronic musculoskeletal pain is among the most prevalent, costly, and disabling medical disorders. However, few clinical trials have examined interventions to improve chronic pain in primary care.

Objective  To determine the effectiveness of a telecare intervention for chronic pain.

Design, Setting, and Participants  The Stepped Care to Optimize Pain Care Effectiveness (SCOPE) study was a randomized trial comparing a telephone-delivered collaborative care management intervention vs usual care in 250 patients with chronic (≥3 months) musculoskeletal pain of at least moderate intensity (Brief Pain Inventory [BPI] score ≥5). Patients were enrolled from 5 primary care clinics in a single Veterans Affairs medical center from June 2010 through May 2012, with 12-month follow-up completed by June 2013.

Interventions  Patients were randomized either 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 coupled automated symptom monitoring with an algorithm-guided stepped care approach to optimizing analgesics.

Main Outcomes and Measures  Primary outcome was the BPI total score, which ranges from 0 (“no pain”) to 10 (“pain as bad as you can imagine”) and for which a 1-point change is considered clinically important. Secondary pain outcomes included BPI interference and severity, global pain improvement, treatment satisfaction, and use of opioids and other analgesics.

Results  Overall, mean (SD) baseline BPI scores in the intervention and control groups were 5.31 (1.81) and 5.12 (1.80), respectively. Compared with usual care, the intervention group had a 1.02-point lower (95% CI, −1.58 to −0.47) BPI score at 12 months (3.57 vs 4.59). Patients in the intervention group were nearly twice as likely to report at least a 30% improvement in their pain score by 12 months (51.7% vs 27.1%; relative risk, 1.9 [95% CI, 1.4 to 2.7]), with a number needed to treat of 4.1 (95% CI, 3.0 to 6.4) for a 30% improvement. Secondary pain outcomes also improved. Few patients in either group required opioid initiation or dose escalation.

Conclusions and Relevance  Telecare collaborative management 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.

Trial Registration  clinicaltrials.gov Identifier: NCT00926588

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Figure.
Flow of SCOPE Study

SCOPE indicates Stepped Care to Optimize Pain Care Effectiveness.

aHad no follow-up assessments after baseline and therefore not included in the primary analysis, since at least 1 follow-up data point is required for mixed-effects model repeated-measures analysis.

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