Pain and analgesics in patients with hard-to-heal ulcers: using telemedicine or standard consultations
Abstract
Objective:
To compare consultations carried out via video with those performed in person for patients with painful, hard-to-heal ulcers, with a focus on ulcer pain and pain treatment. A further aim was to investigate predictors for pain and pain treatment.
Method:
This was a register-based, quasi-experimental study based on data from the Swedish Registry of Ulcer Treatment (RUT). A total of 100 patients with hard-to-heal ulcers diagnosed via video consultation were compared with 1888 patients diagnosed in person with regard to pain assessment, intensity and treatment. Ulcer pain intensity was assessed by the visual analogue scale (VAS). Normally distributed variables (age, VAS) were compared between consultation groups using Student's t-test. Non-normally distributed variables (ulcer size, ulcer duration) were compared using the Mann–Whitney U-test, except for healing time, which was analysed with a log-rank test. Categorical variables (gender, ulcer aetiology and prescribed analgesics) were compared using Pearson's Chi-square test (χ2). A p value of less than 0.05 was considered to indicate statistical significance. Predictors for pain and pain treatment were analysed in multiple regression analyses.
Results:
The results showed a high presence of pain; 71% of patients with pain reported severe ulcer pain. There was no significant difference in ability to assess pain by VAS in the group diagnosed via video consultation (90%) compared with the group diagnosed in person (86%) (χ2, p=0.233). A significantly higher amount of prescribed analgesics was found for patients diagnosed via video (84%) compared with patients diagnosed by in-person assessment (68%) (χ2, p=0.044). Predictors for high-intensity pain were female gender or ulcers due to inflammatory vessel disease, while the predictors for receiving analgesics were older age, longer healing time and being diagnosed via video consultation.
Conclusion:
To identify, assess and treat ulcer pain is equally possible via video as by in-person consultation. The results of this study confirm that patients with hard-to-heal ulcers suffer from high-intensity ulcer pain, with a discrepancy between pain and pain relief. Further well-designed randomised controlled studies are necessary to understand how best to deploy telemedicine in ulcer pain treatment.
Telemedicine has been introduced to healthcare in recent years in order to increase accessibility and facilitate diagnosis and treatment. Telemedicine is the use of electronic communication to allow health professionals to evaluate, diagnose and treat patients remotely. This technology includes video consultation or digital transmission of medical imaging and other clinical data. Although telemedicine is used in ulcer care, knowledge about its importance in pain management remains insufficient. Hard-to-heal ulcers are defined as ulcers that take more than 4–6 weeks to heal.1,2,3 The most common ulcer aetiology consists of venous ulcers, but hard-to-heal ulcers also include arterial ulcers, venous-arterial ulcers, diabetic foot ulcers, pressure ulcers and ulcers due to trauma, rheumatoid arthritis and malignancy.1,3 Ulcer pain is a complex phenomenon involving nociceptive and neuropathic pain4,5 related to the underlying chronic disease6 or directly to the wound.7 Pain management relies primarily on treating the specific underlying disease that is related to ulcer aetiology. Unfortunately, many patients with hard-to-heal ulcers are treated without an aetiological diagnosis and receive suboptimal pain relief as a consequence.8 Pain can be intensified by anxiety, grief about ulcer cause, psychosocial factors, and anger and fear in knowing its long-term treatment outcomes.7,9 Consistent approaches, such as the use of the visual analogue scale (VAS)9,10 to identify ulcer pain and intensity, are recommended for monitoring and follow-up. However, pain is a common problem for patients with hard-to-heal ulcers7,10,11,12,13 and ulcer pain is still inadequately controlled.7,12,14
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