Dobscha Steven K, Corson Kathryn, Perrin Nancy A, Hanson Ginger C, Leibowitz Ruth Q, Doak Melanie N, Dickinson Kathryn C, Sullivan Mark D, Gerrity Martha S
Portland Center for the Study of Chronic, Comorbid Mental and Physical Disorders, Portland, OR, USA.
JAMA. 2009 Mar 25;301(12):1242-52. doi: 10.1001/jama.2009.377.
Chronic pain is common in primary care patients and is associated with distress, disability, and increased health care use.
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.
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.
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).
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 > or = 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.
The assistance with pain treatment collaborative intervention resulted in modest but statistically significant improvement in a variety of outcome measures.
clinicaltrials.gov Identifier: NCT00129480.
慢性疼痛在初级保健患者中很常见，并且与痛苦、残疾以及医疗保健使用增加有关。
评估在退伍军人事务部初级保健机构中，一种协作干预措施是否能够改善与慢性疼痛相关的结果，包括共病抑郁的严重程度。
设计、设置和参与者：在一家退伍军人事务医疗中心的5家初级保健诊所进行的一项整群随机对照试验，比较疼痛治疗协作护理干预与常规治疗。42名初级保健临床医生被随机分配到疼痛治疗协助干预组或常规治疗组。401名患者被诊断为肌肉骨骼疼痛，疼痛强度为中度或更高，且残疾持续12周或更长时间，并被分配到与其临床医生相同的治疗组。招募时间为2006年1月至2007年1月，随访于2008年1月结束。
疼痛治疗协助包括一个为期两期的临床医生教育项目、患者评估、教育与激励、症状监测、向临床医生提供反馈和建议以及促进专科护理。
在12个月内，疼痛相关残疾（罗兰-莫里斯残疾问卷，范围为0至24）、疼痛强度（慢性疼痛分级[CPG]疼痛强度子量表，范围为0至100）和抑郁（患者健康问卷9[PHQ-9]，范围为0至27）的变化，以β系数（每月点数斜率的差异）衡量。
干预组患者与疼痛治疗协助团队平均（标准差）接触10.6（4.5）次。与接受常规治疗的患者相比，干预组患者在疼痛相关残疾方面有更大改善（罗兰-莫里斯残疾问卷β系数，-0.101[95%置信区间{CI}，-0.163至-0.040]；P = 0.004），在CPG疼痛强度子量表方面也有更大改善（β系数，-0.270[95%CI，-0.480至-0.061]；P = 0.01）。在基线时有抑郁（PHQ-9评分≥10）的患者中，接受干预的患者在抑郁严重程度方面比接受常规治疗的患者有更大改善（PHQ-9β系数，-0.177[95%CI，-0.295至-0.060]；P = 0.003）。疼痛治疗协助干预组和常规治疗组在基线和12个月时的评分差异分别为：罗兰-莫里斯残疾问卷为-1.4对-0.2，CPG疼痛强度子量表为-4.7对-0.6，PHQ-9为-3.7对-1.2。
疼痛治疗协作干预在多种结局指标上带来了适度但具有统计学意义的改善。
clinicaltrials.gov标识符：NCT00129480。
