A Controlled Trial of Methods for Managing Pain in Primary Care Patients With or Without Co-Occurring Psychosocial Problems

Tim A. Ahles; John H. Wasson; Janette L. Seville; Deborah J. Johnson; Bernard F. Cole; Brett Hanscom; Therese A. Stukel; Elizabeth McKinstry

doi:10.1370/afm.527

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Figure 1.
Flow diagram of enrollment and randomization.
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Figure 2.
Impact of INFOFEED+NE on patient-reported functional outcomes (patients with pain and psychosocial problems).
Note: Open circles represent the difference in change scores between INFOFEED+NE and controls, and the lines represent the 95% confidence interval.
INFOFEED+NE = patient information and physician feedback plus nurse-educator, SF-36 = Medical Outcomes Study 36-Item Short-Form; BP = bodily pain; RP = role physical; PF = physical function; VT = vitality; RE = role emotional; SF = social function; FIE = functional interference estimate.

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Table 1.

Baseline Demographic Characteristics by Cohort and Intervention

	Cohort 1			Cohort 2
Characteristics	Usual Care (n = 275) No. (%)	INFOFEED (n = 320) No. (%)	P Value	Usual Care (n = 155) No. (%)	INFOFEED (n = 132) No. (%)	INFOFEED+NE (n = 184) No. (%)	P Value
INFOFEED = information and feedback; INFOFEED+NE = information and feedback plus a nurse-educator.
Mean age, years (SD)	49.3 (10.9)	47.9 (11.1)	.16	46.3 (10.7)	47.0 (11.3)	46.4 (11.3)	.86
Female	178 (65)	208 (66)	.9	92 (60)	89 (68)	128 (70)	.11
Race
White	263 (96)	307 (96)	.38	137 (88)	122 (92)	177 (96)	.065
American Indian, Alaskan	3 (1.1)	6 (1.9)		2 (1.3)	4 (3)	1 (0.54)
Asian, Islander	0 (0)	0 (0)		1 (0.65)	0 (0)	1 (0.54)
Black	0 (0)	1 (0.31)		2 (1.3)	0 (0)	0 (0)
Hispanic	0 (0)	1 (0.31)		3 (1.9)	0 (0)	0 (0)
Other, mixed, unkown	9 (3.3)	5 (1.6)		10 (6.5)	6 (4.5)	5 (2.7)
Education
Less than high school	10 (3.7)	15 (4.7)	.052	18 (12)	6 (4.6)	15 (8.2)	.1
High school graduate	82 (30)	64 (20)		46 (30)	55 (42)	62 (34)
Some college or 2-y degree	91 (33)	107 (34)		61 (40)	39 (30)	58 (32)
College graduate	32 (12)	50 (16)		9 (5.9)	10 (7.6)	20 (11)
Postgraduate or advanced degree	58 (21)	83 (26)		19 (12)	21 (16)	28 (15)
Marital status
Single	26 (9.6)	34 (11)	.91	20 (13)	16 (12)	19 (10)	.94
Married	194 (71)	216 (68)		86 (56)	71 (54)	106 (58)
Separated	1 (0.37)	1 (0.31)		6 (3.9)	7 (5.3)	8 (4.4)
Divorced	37 (14)	51 (16)		34 (22)	34 (26)	45 (25)
Widowed	14 (5.1)	16 (5)		7 (4.6)	4 (3)	4 (2.2)
Employment status
Working full-time	167 (61)	180 (57)	.84	67 (44)	54 (41)	79 (43)	.24
Working part-time	42 (15)	54 (17)		25 (16)	24 (18)	22 (12)
Homemaker	15 (5.5)	22 (7)		13 (8.5)	12 (9.1)	10 (5.5)
Disabled	13 (4.8)	16 (5.1)		36 (24)	25 (19)	43 (23)
Unemployed	5 (1.8)	8 (2.5)		6 (3.9)	6 (4.5)	6 (3.3)
Retired	30 (11)	36 (11)		6 (3.9)	11 (8.3)	20 (11)
Student	1 (0.37)	0 (0)		0 (0)	0 (0)	3 (1.6)
Duration of pain problems
3 yrs or less	130 (49)	150 (49)	.97	63 (42)	34 (27)	58 (32)	.029
4 yrs or more	136 (51)	158 (51)		86 (58)	90 (73)	121 (68)
Substance abuse	0 (0)	0 (0)	–	17 (16)	20 (25)	11 (8.4)	.005
Comorbidities
High blood pressure	64 (23)	63 (20)	.34	42 (27)	40 (30)	49 (27)	.76
Heart trouble or hardening of arteries	16 (5.9)	22 (6.9)	.72	10 (6.5)	14 (11)	17 (9.2)	.45
Diabetes	22 (8.1)	16 (5)	.19	17 (11)	16 (12)	20 (11)	.94
Arthritis	87 (32)	102 (32)	.99	49 (32)	53 (40)	78 (42)	.12
Asthma, bronchitis or emphysema	35 (13)	42 (13)	.97	30 (19)	23 (17)	49 (27)	.11
Serious obesity	46 (17)	33 (10)	.03	31 (20)	33 (25)	41 (22)	.62

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Table 2.

Baseline Scores and 6-Month and 1-Year Outcomes for Cohort 1

Measures	Usual Care Mean (SD)	INFOFEED Mean (SD)	Significance
INFOFEED = patient information and physician feedback.
* Adjusted for education, obesity, and baseline Medical Outcomes Study 36-Item Short-Form role physical score.
Baseline measures	(n = 275)	(n = 320)	P Value
Bodily pain	58.0 (18)	59.7 (18.4)	.24
Role physical	54.8 (38.5)	60.3 (39.1)	.084
Physical function	71.6 (22.1)	72.2 (23.1)	.73
Vitality	52.2 (15)	51.2 (14.6)	.42
Role emotional	81.3 (31.2)	79.4 (33.5)	.49
Social function	82.1 (19.6)	81.6 (19.5)	.77
Functional interference estimate	18.3 (4.6)	18.5 (5.1)	.69
Health care utilization
Total doctor visits	3.7 (4.9)	3.4 (5.6)	.54
Days in hospital	0.26 (1.3)	0.39 (1.7)	.34
Days at home, in bed	2.6 (8.5)	3.1 (11.1)	.52
6-Month change from baseline	(n = 245)	(n = 284)	P Value*
Bodily pain	4.6 (17.8)	4.1 (18.8)	.91
Role physical	7.0 (39.8)	6.2 (39.1)	.89
Physical function	0.9 (14.7)	2.0 (16.6)	.67
Vitality	1.2 (12.5)	2.4 (13.4)	.085
Role emotional	−2.3 (37.8)	0.5 (39.2)	.4
Social function	−2.4 (20.5)	0.7 (20.9)	.03
Functional interference estimate	0.3 (4.3)	0.7 (4.6)	.27
Health care utilization
Total doctor visits	0.5 (5.9)	0.0 (6.9)	.53
Days in hospital	0.0 (1.2)	−0.2 (1.6)	.019
Days at home, in bed	0.6 (8)	−1.0 (12.4)	.31
1-Year change from baseline	(n = 252)	(n = 277)	P Value*
Bodily pain	4.8 (20.2)	3.4 (20.3)	.54
Role physical	7.6 (44.5)	3.7 (40.6)	.34
Physical function	1.5 (15.4)	1.7 (17.3)	.8
Vitality	0.2 (13.6)	1.4 (13.5)	.23
Role emotional	−3.3 (36.4)	−1.7 (39.2)	.71
Social function	−1.5 (19.6)	−0.8 (21.5)	.65
Functional interference estimate	0.2 (4.6)	0.4 (4.8)	.83
Health care utilization
Total doctor visits	−0.2 (5.6)	−0.5 (5.8)	.76
Days in hospital	0.0 (1.2)	−0.2 (1.4)	.05
Days at home, in bed	−0.2 (11.6)	−0.8 (14)	.69

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Table 3.

Baseline Scores and 6-Month and 1-Year Outcomes for Cohort 2

Measures	Usual Care Mean (SD)	INFOFEED Mean (SD)	INFOFEED+NE Mean (SD)	INFOFEED vs Control	INFOFEED+NE vs Control
INFOFEED = patient information and physician feedback; INFOFEED+NE = patient information and physician feedback plus nurse-educator.
* Adjusted for race, pain duration, history of substance abuse, baseline function interference estimate score, the number of days spent in a hospital before baseline, and the total number of visits to doctors before baseline.
Baseline	(n = 155)	(n = 132)	(n = 184)	P Value	P Value
Bodily pain	40.4 (24.1)	45.0 (20.8)	42.3 (20.9)	.09	.45
Role physical	31.4 (39.1)	33.9 (38.5)	29.1 (35.5)	.58	.57
Physical function	49.9 (28.9)	51.6 (27.6)	49.4 (29.4)	.62	.89
Vitality	36.8 (16.5)	36.3 (15.7)	36.3 (15.3)	.81	.79
Role emotional	47.9 (44.8)	47.5 (45.1)	45.4 (41.4)	.93	.59
Social function	52.5 (27.7)	56.2 (26.8)	54.2 (27.7)	.25	.58
Functional interference estimate	13.4 (6.6)	15 (5.1)	13.7 (5.7)	.029	.77
Health care utilization
Total doctor visits	5.8 (6.3)	4.7 (5)	7.5 (9.4)	.12	.047
Days in hospital	0.33 (1.4)	0.98 (2.9)	0.58 (1.9)	.02	.2
Days at home, in bed	8.4 (17.5)	8.3 (21.5)	5.9 (14)	.97	.19
6-Month change from baseline	(n = 134)	(n = 115)	(n = 144)	P Value*	P Value*
Bodily pain	2.2 (19.3)	3.9 (18.8)	7.6 (21.3)	.16	.011
Role physical	1.7 (36.6)	3.1 (35.1)	12.5 (37.7)	.096	.025
Physical function	0.77 (17.9)	1.8 (18.3)	6.0 (18.7)	.11	.062
Vitality	−0.43 (13.6)	2.1 (14)	7.3 (12.6)	.059	<.001
Role emotional	−0.26 (41.2)	6.9 (41.3)	8.5 (42.1)	.083	.048
Social function	3.1 (24.3)	6.0 (23.3)	10.0 (24)	.31	.058
Functional interference estimate	−0.98 (5.5)	−0.078 (5.6)	0.96 (5.2)	.042	.027
Health care utilization
Total doctor visits	1.2 (8.5)	0.61 (7)	0.13 (9.5)	.7	.28
Days in hospital	−0.16 (1.6)	−0.31 (2.5)	−0.12 (2.6)	.84	.21
Days at home, in bed	−0.14 (16.7)	−3.1 (16.9)	0.027 (9.6)	.083	.82
1-Year change from baseline	(n = 126)	(n = 114)	(n = 158)	P Value*	P Value*
Bodily pain	3.6 (22.9)	2.1 (19.7)	7.8 (22.3)	.95	.06
Role physical	4.8 (37.3)	5.5 (38.5)	10.1 (39.4)	.32	.11
Physical function	3.2 (17.7)	1.7 (15.9)	5.0 (17.8)	.97	.22
Vitality	3.7 (14.7)	0.92 (15.4)	7.4 (15.7)	.84	.048
Role emotional	3.8 (45.4)	5.9 (46.6)	13.9 (43.7)	.25	.046
Social function	1.3 (25.5)	3.4 (24)	7.3 (26.9)	.58	.084
Functional interference estimate	0.65 (4.9)	0.43 (5.3)	1.5 (5.9)	.12	.02
Health care utilization
Total doctor visits	1.7 (9.1)	0.49 (6.4)	−0.16 (8.8)	.8	.64
Days in hospital	0.022 (2.1)	−0.52 (2.8)	0.087 (2.8)	.42	.82
Days at home, in bed	0.96 (18.4)	−4.4 (20.3)	−1.0 (16.1)	.13	.56

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The Article in Brief

A Controlled Trial of Methods for Managing Pain in Primary Care Patients With or Without Co-Occurring Psychosocial Problems

Tim A. Ahles, PhD, and colleagues

Background Pain is common among primary care patients and is difficult to manage. This study tested a program in which patients received information tailored to their pain problems. Patients with pain and psychosocial problems (such as emotional problems or substance abuse) received telephone coaching from a nurse who taught them skills in problem-solving and pain management. Doctors received feedback about their patients' problems and concerns.

What This Study Found For patients with pain and psychosocial problems, telephone-based assistance can reduce pain, improve psychosocial problems, and improve physical functioning.

Implications

Tailored information for patients with pain, combined with feedback to physicians and telephone nurse support of pain self-management, appears to be effective. Further study is needed to determine the most cost-effective method for sharing information and providing support in such a program.