Kroenke, K., Theobald, D., Wu, J., Norton, K., Morrison, G., Carpenter, J., & Tu, W. (2010). Effect of telecare management on pain and depression in patients with cancer: A randomized trial. JAMA: The Journal of the American Medical Association, 304(2), 163–171. 

To determine whether centralized telephone-based care management cued by automated symptom monitoring can improve depression and pain in patients with cancer

In this study, called the Indiana Cancer Pain and Depression Trial, centralized telecare management was conducted by a nurse-physician specialist team that worked in concert with automated home-based symptom monitoring. The means of monitoring was interactive voice recording or Internet. A nurse care manager assessed symptom response and medication adherence, provided pain- and depression-specific education, and made treatment adjustments according to evidence-based guidelines. Intervention patients received scheduled calls (at baseline, at 1 week, and at 4 and 12 weeks) and received calls when automated monitoring indicated problems in symptom management. Control group received usual care. Data were collected at baseline and at months 1, 3, 6, and 12.

• The sample was composed of 405 patients, 202 in the intervention group and 203 in the control group.
• Mean patient age in the intervention group was 58.7 years (SD = 11 years); in the control group, 59 years (SD = 10.6 years).
• In the intervention group, 63% of patients were female and 37% were male. In the control group, 72% were female and 28% were male.
• The sample included diverse cancer types (more than 20% of patients had breast cancer) and various disease stages. Patients had to have depression, pain, or both to be eligible. Depression was defined by a score equal or greater than 10 on the Patient Health Questionnaire-9; cancer pain, by a worst-pain score equal or greater than 6 on the Brief Pain Inventory (BPI). Baseline demographic and clinical characteristics between groups were balanced.

• Multisite
• Outpatient
• Sixteen community-based urban and rural oncology practices in Indiana

Randomized controlled trial

• Twenty-item Hopkins Symptom Checklist (HSCL-20), to measure depression severity
• BPI, to measure pain severity 
• Single-item scale, 0–10, to measure overall quality of life
• SF-12 Health Survey, to measure physical and mental components
• Generalized Anxiety Disorder questionnaire, to measure anxiety
• Somatic Symptom Scale, to measure physical-symptom burden

• Over the 12 months of the trial, of the 274 patients with pain, the 137 patients in the intervention group had greater decreases in pain severity (≥ 30% decrease), as measured by the BPI (as a continuous severity score or as a categorical pain responder), than did the 137 patients in the usual care group (p < 0.001 for both groups).
• Over the 12 months of the trial, of the 309 patients with depression, the 154 patients in the intervention group had greater decreases in depression (≥ 50% decrease), as measured by the HSCL-20 (as a continuous severity score or as a categorical depression responder), than did the 155 patients in the usual care group (p < 0.001).
• The standardized effect size for between-group differences at 3 and 12 months was 0.67 (95% CI 0.33–1.02) and 0.39 (95% CI 0.01–0.77) for pain and 0.42 (95% CI 0.16–0.69) and 0.41 (95% CI 0.08–0.72) for depression.
• The intervention group had better outcomes in several health-related quality-of-life domains: mental health, vitality, anxiety, and physical-symptom burden.

This study showed that centralized telecare management with automated symptom monitoring may be a feasible approach for geographically dispersed urban and rural oncology practices. This approach may be effective in improving the pain and depression of cancer patients.

Lack of control of the type of cancer treatment and of the time lapse since treatment might have affected study findings.

Cost will be involved in training the care manager and in the hiring of trained personnel. The cost-effectiveness of the collaborative care model needs to be further examined. Findings suggest that telecare management used with automatic systems cued by patient problems can be an effective approach.