Kim, H.S., Shin, S.J., Kim, S.C., An, S., Rha, S.Y., Ahn, J.B., . . . Lee, S. (2013). Randomized controlled trial of standardized education and telemonitoring for pain in outpatients with advanced solid tumors. Supportive Care in Cancer, 21, 1751–1759.

To evaluate whether standardized educational tools, with or without telemonitoring, can improve the pain levels, pain interference, anxiety, depression, distress, performance, and quality of life of outpatients with cancer who have advanced tumors

Patients were randomized to receive either standard pain education plus telemonitoring or standard education alone. A nurse practitioner (NP) performed telemonitoring of pain every day for one week. The NP telephoned the patients and asked for average visual analog scale (VAS) pain score and worst VAS pain score in the last 24 hours. This provided patients with the opportunity to assess the severity of pain themselves. Using the National Comprehensive Cancer Care Network (NCCN) guidelines for pain management, the NP advised patients whether to increase or decrease medication. The NP was trained in pain management but had no specific training for other psychosocial interventions. Standard education included a video and booklet with individual coaching, to correct misconceptions, and an outline of decision making for pain control. Outcomes were measured at one week, and average pain was measured at two months.

• The study reported on a sample of 108 patients.
• Mean patient age was 59.8 years.
• The sample was 67.6% male and 32.4% female.
• The sample included patients with stage IV solid tumors (breast, gastrointestinal, genitourinary, lung, head and neck, and other).
• Most patients had been prescribed opioid analgesics.

• Single site
• Outpatient
• Seoul, Republic of Korea

• Patients were undergoing the end-of-life phase of care.
• The study has clinical applicability for elder care and palliative care.

A randomized controlled trial design was used.

• Brief Pain Inventory (BPI)
• Hospital Anxiety and Depression Scale (HADS)
• Distress Thermometer
• European Organization for Research and Treatment of Cancer quality of life questionnaire
• Karnofsky Performance Status score

Pain intensity, for all patients, had significantly improved at one week, including worst pain (7.3–5.7, p < 0.01) and average pain (4.6–3.8, p < 0.01). Additionally, anxiety (HADS score ≥ 11, 75%–56%, p < 0.01), depression (HADS score ≥ 11, 73%–51%, p < 0.01), quality of life (fatigue and insomnia), and Karnofsky score (32–66, p < 0.01) were significantly improved at one week. However, the level of distress did not improve. The study revealed no significant differences between groups in these areas.

Standardized pain education delivered by a nursing specialist is an efficient means of improving not only pain but also anxiety, depression, performance, and quality of life. This study did not show that the addition of telemonitoring substantially improved pain management in the outpatient setting.

• The study had risk of bias due to the lack of an appropriate attentional control condition.
• A one-week study may be too short to show significant improvement in pain outcomes.
• To extend this study, researchers should conduct a baseline screening with multiple variable assessments in addition to the Karnofsky score.

Findings show that comprehensive pain education was associated with short-term reduction in pain, anxiety, and depression scores. The addition of telemonitoring follow-up for pain management did not result in a significant difference in these scores; however, the follow-up period  was only one week. Longer-term studies of the effects of monitoring via telephone and other technologies, for the purpose of improved symptom management, may be helpful in identifying effective methods of improving symptom control in outpatient settings.