Providing care by telephone: Using communication tools to expand patients' access to care

Providing care by telephone: Using communication tools to expand patients' access to care
Providing care by telephone: Using communication tools to expand patients' access to care

Robotic phone calls made en masse to deliver political messages or advertise products and services are often an unwelcome intrusion; however, the telephone can actually be a useful medical device. Whether it is used for questionnaires, assessments, consultations, coaching, or other interventions, the telephone provides an affordable way to reach a large number of patients and is an efficient use of grants and other limited resources.

TELEPHONE-ADMINISTERED CBT

The telephone has been used successfully in medicine for a while. A recently published paper describes the use of telephone-administered cognitive behavior therapy (CBT) to reduce post-traumatic stress disorder (PTSD) and distress symptoms after hematopoietic stem-cell transplantation. The authors conclude that CBT by phone is effective for reducing illness-related PTSD symptoms and general distress.1

A recent study published in the Journal of Pain described how the telephone can be used in pain management. Researchers used a system called Therapeutic Interactive Voice Response (TIVR), a telephone-based, automated maintenance enhancement program, for patients with chronic pain who had just completed 11 weeks of CBT. TIVR was developed for the enhancement and maintenance of CBT skills. The study's goal was to reduce subjects' opioid analgesic use. Follow-ups were at 4 and 8 months. By the 8-month follow-up, 10% of the TIVR subjects were able to discontinue their antidepressant medications, 21% had stopped using opioid analgesics, and 23% had discontinued their NSAIDs. By contrast, the control group increased their use of opioids and NSAIDs. The researchers wrote that the telephone maintenance enhancement program can help to reduce opioid analgesic use in patients with chronic pain.2

MANAGING CANCER BY PHONE

What about cancer-related pain? Telephone-based care management can reduce the pain and depression of cancer more effectively than can traditional disease management. Symptoms may be untreated or undertreated in geographically dispersed or rural areas where getting to an oncologist, or even to a general physician, is difficult for cancer patients. The problem was addressed in the Indiana Cancer Pain and Depression (INCPAD) trial that was initiated in 2006 by Kurt Kroenke, MD, and colleagues at the Richard Roudebush VA Medical Center, Indiana University, and Regenstrief Institute in Indianapolis. The study was designed to treat cancer patients who had depression, pain, or both.3

Dr. Kroenke explained, "Because oncologists are busy with testing, chemotherapy, and other treatments, they often have too little time left for quality of life issues, such as pain and depression. We felt one solution might be a partnership between a telephone-based symptom management team and community-based oncology practices."

Once enrolled in the study, participants received automated symptom monitoring calls that instructed them to rate their depression and pain on a scale of 1 to 10. Some patients elected to communicate via the Internet. A nurse-physician specialist team reviewed the data collected. Then a nurse care manager trained in evaluating symptom response and medication adherence, and in providing education about pain and depression, called the patients to discuss their symptoms, concerns, and treatment. When treatment adjustments were necessary, the nurse used evidence-based guidelines. The study participants said that they appreciated having someone to talk to who understood their disease and who could help them. They no longer felt isolated.

GREATER IMPROVEMENT IN THE INTERVENTION GROUP

The study included 405 patients (averageage, 59 years). The patients were randomly divided between the intervention and usual care groups in the study; 131 had only depression, 96 had only pain, and 178 experienced both depression and pain. The researchers found that of the 274 patients with pain, 137 in the intervention group experienced more improvement in pain severity than the 137 patients in the usual-care group.

Of the 309 patients with depression, 154 in the intervention group experienced significantly greater improvement in the severity of their depression than the 155 patients in the usual-care group. The study also found that the intervention group had better results in terms of mental health, vitality, and physical symptoms.

TECHNOLOGY-ENHANCED NURSING EXPERTISE

According to Dr. Kroenke, "Technology, in the form of automated calls repeated until an adequate treatment response occurred, allowed us to gather data on symptom severity at a time convenient for the patient, making the process very patient-centered. It also allowed the nurse manager to work at a higher level to improve the quality of life of these cancer patients. And it gave these patients, many of whom lived in underserved rural areas, one-stop assistance they probably would not have had access to unless they went to a major cancer center."

The INCPAD trial is still active. Information and trial registration is available at www.clinicaltrials.gov,identifier: NCT00313573. ONA

Bette Kaplan is a medical writer in Tenafly, New Jersey.

REFERENCES

1. DuHamel KN, Mosher CE, Winkel G, et al. Randomized clinical trial of telephone-administered cognitive-behavioral therapy to reduce post-traumatic stress disorder and distress symptoms after hematopoietic stem-cell transplantation [published online ahead of print July 12, 2010]. J Clin Oncol. doi:10.1200/JCO.2009.26.8722.

2. Naylor MR, Naud S, Keefe FJ, Helzer JE. Thera-peutic interactive voice response (TIVR) to reduce analgesic medication use for chronic pain management [published online ahead of print July 8, 2010]. J Pain. doi:10.1016/j.jpain.2010.03.019.

3. Kroenke K, Theobald D, Wu J, et al. Effect of telecare management on pain and depression in patients with cancer: a randomized trial. JAMA. 2010;304(2):163-171.

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