Telehealth Outreach for Chronic Back Pain

慢性背痛的远程医疗外展

• 批准号: 8495803
• 负责人: JOSEPH H ATKINSON
• 金额: --
• 依托单位: VA SAN DIEGO HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 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: https://reporter.nih.gov/project-details/8495803
• 关键词: Absence of pain sensation; Address; Adverse effects; Affect; Afghanistan; Aftercare; Anti-Inflammatory Agents; Anti-inflammatory; Antidepressive Agents; Back; Back Pain; Beck depression inventory; Behavioral; Brief Pain Inventory; Care given by nurses; Caring; Case Manager; Chronic low back pain; Clinic; Clinic Visits; Clinical; Clinical Trials; Clinical Trials Cooperative Group; Cognitive; Cognitive Therapy; Consultations; Controlled Clinical Trials; Data; Disease; Disease Progression; Distress; Double-Blind Method; Equipment and supply inventories; Face; Functional disorder; Gulf War; Health; Health Status; Healthcare; Heart failure; High Prevalence; Home environment; Hour; Improve Access; Inherited; Internet; Intervention; Iraq; Location; Measures; Medical; Mental Depression; Methods; Military Personnel; Modeling; Monitor; Moods; Nurses; Operative Surgical Procedures; Opioid; Outcome; Pain; Pain Clinics; Pain interference; Participant; Patient Care Team; Patients; Pharmaceutical Preparations; Prevention; Primary Health Care; Primary Nursing Care; Psychologist; Psychotherapy; Quality of life; Randomized; Randomized Clinical Trials; Recruitment Activity; Rehabilitation therapy; Reliance; Reporting; Research; Research Design; Resistance; SF-36; Sampling; Self Management; Services; Solutions; Specialist; Structure; Substance abuse problem; Supportive care; Symptoms; Telemedicine; Telephone; Testing; Therapeutic Effect; Time; Training; Training Programs; Travel; Triage; Veterans; Videoconferences; Videoconferencing; arm; base; behavioral health; care burden; chronic back pain; chronic pain; cohort; combat; disability; efficacy testing; experience; falls; flexibility; follow-up; impression; improved; improved functioning; indexing; medical specialties; meetings; member; neglect; novel strategies; outreach; programs; rural area; skills; skills training; telehealth; therapy development; trial comparing; urban area

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.

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：它已经影响到退伍军人管理局所有初级护理人员中高达15%的人，而且它在退役作战老兵中的高患病率可能会增加这种护理负担。大多数背痛患者不适合做手术，药物只能起到有限的止痛作用。症状控制和功能改善需要一种全面的方法来解决慢性疼痛的认知和行为方面。幸运的是，系统的、具体的康复治疗，通常被概念化为认知-行为自我管理技能培训(CBSST)，是可用的，适合在初级保健中实施。在过去的25年里，退伍军人管理局试图在行为保健和初级保健之间架起桥梁的几次尝试都失败了，可能是因为三个独立但相互关联的障碍。这些障碍是专科模式；距离；以及融入初级保健。专业障碍是大多数诊所缺乏CBSST专家，转介可能 初级保健患者接受率较低。一个距离障碍是，面对面的服务需要出差--这在城市和农村地区都可能很困难。退伍军人管理局现在转向医疗之家模式，通过护士护理经理和以患者为中心的护理团队，克服专科障碍，将行为卫生保健整合到初级卫生保健中。通过护士护理经理将行为护理的某些方面(如抑郁、药物滥用)整合到初级护理中已取得了很大进展，但慢性背痛在很大程度上被忽视了。改善获取和融合的一种方法是“远程保健”外展。对各种疾病的研究表明，CBSST可以在以家庭为基础的护理模式中以最少的治疗师接触来高效和有效地提供，使用电话咨询来取代诊所就诊。在RR&D功绩回顾支持的前一阶段(2007-2010)，该研究团队调整了VA疼痛诊所成功的认知行为治疗计划，用于最低限度的治疗师接触和家庭/电话辅助形式。在一项正在进行的随机临床试验的初步结果中，将电话治疗的CBSST与强控制条件(支持性心理疗法)进行了比较，在治疗8周结束时，CBSST患者报告总体“改善”和25%“改善”的比例要高得多(均为PS&lt；。05)。这样的结果令人印象深刻，也是对概念的重要证明。然而，为期8周、12个疗程的硕士心理学家的形式和使用过于专业驱动，没有真正融入初级保健。我们建议以一种综合的方式测试我们的远程健康干预的一个版本的有效性，使用初级保健护士经理来克服获取障碍和护理的碎片化。研究设计为双盲、随机、双臂、平行分组临床试验。从VA圣地亚哥初级保健诊所招募的CLBP患者将接受由医务护士护理经理提供的为期8周的居家、电话支持、最低限度治疗师接触CBSST 8周干预(N=70)，或与护士接触时间(8小时)匹配的支持性护理控制(N=70)条件。主要的数据分析策略将是利用线性混合模型方法，对随机的ALL参与者进行意向治疗分析。主要终点将是与背部相关的残疾(奥斯维斯特里残疾指数)。次要终点将是疼痛干扰(简要疼痛清单)、情绪(贝克抑郁清单)、一般功能(简表-36)、活动(Actigraph(R))和整体健康状况(患者对变化的总体印象)。分析将在治疗后1、3和6个月测试8周的治疗结束和治疗效果的持久性。建议的这种严格控制的临床试验可能有助于更有效、更容易获得、更综合的背痛治疗。