Collaborative Care for Chronic Pain in Primary Care A Cluster Randomized Trial
Collaborative Care for Chronic Pain in Primary Care A Cluster Randomized Trial
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DOI：
10.1001/jama.2009.377
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发表时间：
2009-03-25
影响因子：
120.7
通讯作者：
Gerrity, Martha S.
中科院分区：
文献类型：
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作者：
Dobscha, Steven K.;Corson, Kathryn;Gerrity, Martha S.
背景慢性疼痛在初级保健患者中很常见，并且与痛苦、残疾和增加的卫生保健使用有关。目的评估在退伍军人事务部初级保健环境中，协作干预是否可以改善慢性疼痛相关的结果，包括共病抑郁的严重程度。和参与者在1个部门的5个初级保健诊所进行的疼痛治疗干预与常规治疗的协作护理援助的群集随机对照试验退伍军人事务医疗中心42名初级保健临床医生被随机分配到疼痛治疗干预组或常规治疗组。401名患者诊断为肌肉骨骼疼痛，中度或更高的疼痛强度，残疾持续12周或更长时间，并被分配到与临床医生相同的治疗组。招募于2006年1月至2007年1月进行，随访于2008年1月结束。疼痛治疗的干预援助包括2次临床医生教育计划，患者评估，教育和激活，症状监测，向临床医生提供反馈和建议，主要结果测量12个月内疼痛相关残疾的变化（Roland-Morris功能障碍问卷，范围0-24），疼痛强度（慢性疼痛分级[CPG]疼痛强度子量表，范围为0-100）和抑郁（患者健康问卷9 [PHQ-9]，范围0-27），以β系数衡量结果干预患者与疼痛治疗小组的平均接触次数（SD）为10.6（4.5）。与接受常规治疗的患者相比，干预患者在疼痛相关残疾方面表现出更大的改善（Roland-Morris功能障碍问卷β，-0.101 [95%置信区间{CI}，-0.163至-0.040]; P=.004和CPG疼痛强度子量表β，-0.270 [95% CI，-0.480至-0.061]; P=.01）。在基线抑郁的患者中（PHQ-9评分>= 10），与接受常规治疗的患者相比，接受干预的患者抑郁严重程度的改善更大（PHQ-9 β，-0.177 [95% CI，-0.295至-0.060]; P= 0.003）。疼痛辅助治疗干预组和常规治疗组基线和12个月之间的评分差异分别为Roland-Morris功能障碍问卷-1.4 vs-0.2，CPG疼痛强度子量表-4.7 vs-0.6，PHQ-9评分为-3.7vs-1.2。结论疼痛治疗协作干预的辅助治疗在多种结局指标方面有一定的改善，但具有统计学意义。clinicaltrials.gov
Context Chronic pain is common in primary care patients and is associated with distress, disability, and increased health care use.Objective To assess whether a collaborative intervention can improve chronic pain related outcomes, including comorbid depression severity, in a Department of Veterans Affairs primary care setting.Design, Setting, and Participants Cluster randomized controlled trial of a collaborative care assistance with pain treatment intervention vs treatment as usual at 5 primary care clinics of 1 Department of Veterans Affairs Medical Center. Forty-two primary care clinicians were randomized to the assistance with pain treatment intervention group or the treatment as usual group. The 401 patients had musculoskeletal pain diagnoses, moderate or greater pain intensity, and disability lasting 12 weeks or longer and were assigned to the same treatment groups as their clinicians. Recruitment occurred from January 2006 to January 2007 and follow-up concluded in January 2008.Intervention Assistance with pain treatment included a 2-session clinician education program, patient assessment, education and activation, symptom monitoring, feedback and recommendations to clinicians, and facilitation of specialty care.Main Outcome Measures Changes over 12 months in pain-related disability (Roland-Morris Disability Questionnaire, range of 0-24), pain intensity (Chronic Pain Grade [CPG] Pain Intensity subscale, range of 0-100), and depression (Patient Health Questionnaire 9 [PHQ-9], range of 0-27), measured as beta coefficients (difference in slopes in points per month).Results Intervention patients had a mean (SD) of 10.6 (4.5) contacts with the assistance with pain treatment team. Compared with the patients receiving treatment as usual, intervention patients showed greater improvements in pain-related disability (Roland-Morris Disability Questionnaire beta, -0.101 [95% confidence interval {CI}, -0.163 to -0.040]; P=.004 and CPG Pain Intensity subscale beta, -0.270 [95% CI, -0.480 to -0.061]; P=.01). Among patients with baseline depression (PHQ-9 score >= 10), there was greater improvement in depression severity in patients receiving the intervention compared with patients receiving treatment as usual (PHQ-9 beta, -0.177 [95% CI, -0.295 to -0.060]; P=.003). The differences in scores between baseline and 12 months for the assistance with pain treatment intervention group and the treatment as usual group, respectively, were -1.4 vs -0.2 for the Roland-Morris Disability Questionnaire, -4.7 vs -0.6 for the CPG Pain Intensity subscale, and -3.7 vs -1.2 for PHQ-9.Conclusion The assistance with pain treatment collaborative intervention resulted in modest but statistically significant improvement in a variety of outcome measures.Trial Registration clinicaltrials.gov Identifier: NCT00129480