Telehealth Outreach for Chronic Back Pain
慢性背痛的远程医疗外展
基本信息
- 批准号:8278477
- 负责人:
- 金额:--
- 依托单位:
- 依托单位国家:美国
- 项目类别:
- 财政年份:2012
- 资助国家:美国
- 起止时间:2012-07-01 至 2015-06-30
- 项目状态:已结题
- 来源:
- 关键词:Absence of pain sensationAddressAdverse effectsAffectAfghanistanAftercareAnti-Inflammatory AgentsAnti-inflammatoryAntidepressive AgentsBackBack PainBeck depression inventoryBehavioralBrief Pain InventoryCare given by nursesCaringCase ManagerChronic low back painClinicClinic VisitsClinicalClinical TrialsClinical Trials Cooperative GroupCognitiveCognitive TherapyConsultationsControlled Clinical TrialsDataDiseaseDisease ProgressionDistressDouble-Blind MethodEquipment and supply inventoriesFaceFunctional disorderGulf WarHealthHealth StatusHealthcareHeart failureHigh PrevalenceHome environmentHourImprove AccessInheritedInternetInterventionIraqLocationMeasuresMedicalMental DepressionMethodsMilitary PersonnelModelingMonitorMoodsNursesOperative Surgical ProceduresOpioidOutcomePainPain ClinicsPain interferenceParticipantPatient Care TeamPatientsPharmaceutical PreparationsPreventionPrimary Health CarePrimary Nursing CarePsychologistPsychotherapyQuality of lifeRandomizedRandomized Clinical TrialsRecruitment ActivityRehabilitation therapyRelianceReportingResearchResearch DesignResistanceSF-36SamplingSelf ManagementServicesSolutionsSpecialistStructureSubstance abuse problemSupportive careSymptomsTelemedicineTelephoneTestingTherapeutic EffectTimeTrainingTraining ProgramsTravelTriageVeteransVideoconferencesVideoconferencingarmbasebehavioral healthcare burdenchronic back painchronic paincohortcombatdisabilityefficacy testingexperiencefallsflexibilityfollow-upimpressionimprovedimproved functioningindexingmedical specialtiesmeetingsmemberneglectnovel strategiesoutreachprogramsrural areaskillsskills trainingtelehealththerapy developmenttrial comparingurban area
项目摘要
DESCRIPTION (provided by applicant):
Chronic low back pain (CLBP) is a major rehabilitation problem in the VA: it already affects up to 15% of all those in VA primary care, and its high prevalence in discharged combat veterans is likely to add to that care burden. Most back pain patients are not surgical candidates, and medications provide limited analgesia. Symptom control and improved function require a comprehensive approach addressing the cognitive and behavioral aspects of chronic pain. Fortunately, structured, specific rehabilitative treatment, generally conceptualized as Cognitive-Behavioral Self-management Skills Training (CBSST), are available and suitable for implementation in primary care. Over the past 25 years several VA attempts to bridge behavioral health care and primary care have fallen short, perhaps because of three separate but related barriers. These barriers are specialty models; distance; and integration into primary care. The specialty barrier is both that most clinics lack CBSST specialists, and that referral may
have low rates of acceptance by primary care patients. A distance barrier is that face-to- face service requires travel-which may be difficult in both urban and rural areas. The VA has now turned to the Medical Home model to overcome specialty barriers and integrate behavioral healthcare into primary care via nurse care managers and patient-aligned care teams. Great progress has been made integrating some aspects of behavioral care (eg, depression, substance abuse) into primary care via nurse care managers, but chronic back pain largely has been neglected. One approach to improving access and integration is "telehealth" outreach. Studies in diverse medical disorders suggest that CBSST can be delivered efficiently and effectively with minimal therapist contact in home-based care models, using telephone consultation to replace clinic visits. In the preceding period of RR&D Merit Review support (2007-2010) this research team adapted a successful VA Pain Clinic cognitive-behavioral therapy program for use in a minimal therapist contact and home- based/telephone-assisted format. In preliminary results from an ongoing randomized clinical trial comparing telephone-administered CBSST to a strong control condition (Supportive Psychotherapy), a significantly higher proportion of CBSST patients reported both overall "improvement" and > 25% "improvement" at 8-week end of treatment (all ps < .05). Such results are impressive and an important proof of concept. Nevertheless the 8-week, 12- session format and use of masters psychologists is too specialty-driven, and not truly integrated into primary care. We propose to test the efficacy of a version of our telehealth intervention in an integrated way using primary care nurse managers to overcome both barriers to access and fragmentation of care. The research design is a double blind, randomized, two-arm, parallel groups clinical trial. Patients with CLBP recruited from VA San Diego primary care clinics will receive either the home-based, telephone supported, minimal therapist contact CBSST 8-week intervention (N=70) delivered by medical nurse care managers, or a Supportive Care Control (N=70) condition matched for nurse contact time (8 hours). The primary data analytic strategy will be an intent-to-treat analysis of al participants as randomized, utilizing a linear mixed-model approach. The primary end point will be back-related disability (Oswestry Disability Index). Secondary end points will be pain interference (Brief Pain Inventory), mood (Beck Depression Inventory), general function (Short Form-36), activity (Actigraph(R)), and overall health status (Patient Global Impression of Change). Analyses will test for 8-week end-of-treatment and durability of therapeutic effect at 1, 3, and 6 months post-teatment. Rigorously controlled clinical trials of the type proposed could contribute to more effective, accessible, integrated back pain treatment.
PUBLIC HEALTH RELEVANCE:
Chronic back pain (pain for > 6 months), is a major, treatment-resistant, disabling medical problem for about 15% of veterans in primary care. Gulf War, Iraq, and Afghanistan veterans report back pain rates exceeding 30%, suggesting the VA will continue to face this problem. Cognitive Behavioral Self Management Skills Training (CBSST) improves function in back pain, but is underutilized due to reliance on a referral-based, specialty-clinic model. Using the Medical
Home model and its principles of telemedicine, flexible triage, and nurse care managers, we propose to test the efficacy of a telephone- administered, nurse-led, stepped care CBSST for improving back pain outcomes. Rigorously controlled clinical trials of the type proposed could contribute to more accessible, integrated pain treatment.
描述(由申请人提供):
慢性下腰痛(CLBP)是退伍军人管理局的一个主要康复问题:它已经影响了15%的退伍军人管理局初级保健人员,其在退伍军人中的高患病率可能会增加护理负担。大多数背痛患者不是手术候选人,药物提供有限的镇痛。症状控制和改善功能需要一个全面的方法来解决慢性疼痛的认知和行为方面。幸运的是,结构化的,具体的康复治疗,一般概念为认知行为自我管理技能培训(CBSST),是可用的,适合在初级保健实施。在过去的25年里,退伍军人事务部几次试图弥合行为卫生保健和初级保健的努力都失败了,也许是因为三个独立但相关的障碍。这些障碍是专科模式;距离;和融入初级保健。专业障碍是大多数诊所缺乏CBSST专家,而且转诊可能
初级保健患者的接受率很低。距离障碍是面对面的服务需要旅行,这在城市和农村地区都很困难。VA现在已经转向医疗之家模式,以克服专业障碍,并通过护士护理经理和患者对齐的护理团队将行为医疗保健整合到初级保健中。通过护理经理将行为护理的某些方面(例如抑郁症,药物滥用)整合到初级保健中取得了很大进展,但慢性背痛在很大程度上被忽视了。 改善获得服务和融入社会的一个办法是“远程保健”推广。在不同的医学疾病的研究表明,CBSST可以提供高效和有效的最小的治疗师接触,以家庭为基础的护理模式,使用电话咨询,以取代诊所的访问。在RR&D Merit Review支持的前期(2007-2010年),该研究团队采用了成功的VA疼痛诊所认知行为治疗计划,以最小化治疗师接触和基于家庭/电话辅助的形式使用。在一项正在进行的随机临床试验的初步结果中,将电话给药CBSST与强对照条件(支持性心理治疗)进行比较,在治疗8周结束时,CBSST患者报告总体“改善”和> 25%“改善”的比例显著较高(所有ps < .05)。 这些结果令人印象深刻,是概念的重要证明。然而,8周,12届格式和使用硕士心理学家太专业驱动,并没有真正融入初级保健。我们建议测试的一个版本的远程医疗干预的有效性,在一个综合的方式使用初级保健护士管理者,以克服障碍,获得和破碎的护理。 研究设计为双盲、随机、双臂、平行组临床试验。从VA San Diego初级保健诊所招募的CLBP患者将接受由医疗护士护理经理提供的基于家庭、电话支持、最小治疗师接触CBSST 8周干预(N=70),或与护士接触时间(8小时)匹配的支持性护理对照(N=70)条件。主要数据分析策略将是使用线性混合模型方法对所有随机化受试者进行意向治疗分析。主要终点为背部相关残疾(奥斯韦斯特里残疾指数)。次要终点将是疼痛干扰(简明疼痛量表)、情绪(贝克抑郁量表)、一般功能(简表-36)、活动(Actigraph(R))和总体健康状况(患者总体印象变化)。分析将测试8周治疗结束和治疗后1、3和6个月的疗效持久性。严格控制的临床试验的类型提出可以有助于更有效的,可访问的,集成的背部疼痛治疗。
公共卫生相关性:
慢性背痛(疼痛> 6个月),是一个主要的,难治性,致残的医疗问题,约15%的退伍军人在初级保健。海湾战争,伊拉克和阿富汗退伍军人报告背痛率超过30%,这表明退伍军人事务部将继续面临这个问题。认知行为自我管理技能训练(CBSST)可以改善背痛的功能,但由于依赖于基于诊所的专业诊所模式,因此未得到充分利用。使用国际医学
家庭模式及其远程医疗、灵活分诊和护理管理者的原则,我们建议测试电话管理、护士主导、阶梯式护理CBSST改善背痛结局的疗效。严格控制的临床试验的类型提出可以有助于更容易,综合疼痛治疗。
项目成果
期刊论文数量(0)
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JOSEPH H ATKINSON其他文献
JOSEPH H ATKINSON的其他文献
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{{ truncateString('JOSEPH H ATKINSON', 18)}}的其他基金
CLINICAL TRIAL: TELEHEALTH OUTREACH FOR CHRONIC BACK PAIN
临床试验:针对慢性背痛的远程医疗服务
- 批准号:
8166842 - 财政年份:2009
- 资助金额:
-- - 项目类别:
CLINICAL TRIAL: EFFICACY OF ANTIDEPRESSANTS IN CHRONIC BACK PAIN
临床试验:抗抑郁药治疗慢性背痛的疗效
- 批准号:
8166788 - 财政年份:2009
- 资助金额:
-- - 项目类别:
CLINICAL TRIAL: EFFICACY OF ANTIDEPRESSANTS IN CHRONIC BACK PAIN
临床试验:抗抑郁药治疗慢性背痛的疗效
- 批准号:
7950919 - 财政年份:2008
- 资助金额:
-- - 项目类别:
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