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Evidence Library

The research behind Continuous Care.

The homepage makes the commercial case. This page makes the clinical one. Peer-reviewed evidence on this page was selected specifically for outpatient pain, orthopedic, physiatry, and musculoskeletal specialty settings, with emerging evidence labeled separately where applicable.

Clinical statistics on this page are drawn from peer-reviewed published research. Regulatory and billing references are sourced from CMS policy guidance documents and are not peer-reviewed research. Goyal et al. (2025) is a preprint awaiting peer review and is labeled accordingly in the Emerging Evidence section.

Section 01 - Surgical outcomes

Unaddressed mental health is associated with significantly worse surgical outcomes — and the literature shows these risks are identifiable and screenable before surgery.

Three large Journal of Arthroplasty studies show that preoperative depression and anxiety are not incidental findings. They are measurable predictors of outcomes your practice is already judged on: readmissions, dissatisfaction, and post-surgical opioid escalation.

The surgical plan is usually documented in detail. The psychological risk profile usually is not. Yet the evidence shows that untreated depressive symptoms before surgery are among the strongest independent predictors of what happens after.

These are not small or isolated findings. The readmission meta-analysis covers 395,815 TJA cases. The opioid refill study covers 23,726 TKA patients. The dissatisfaction finding comes from a prospective cohort with 4-year follow-up. Together, they describe a consistent risk pattern in exactly your patient population.

Depression is associated with higher pain perception, weaker adherence to rehab protocols, and greater likelihood of prolonged opioid use. These signals are easy to miss in a brief pre-op visit. They are far easier to detect with structured between-visit screening.

source: Ali A, Lindstrand A, Sundberg M, Flivik G. J Arthroplasty, 2017. PMID: 27692782. DOI: 10.1016/j.arth.2016.09.012.

The pattern across studies: preoperative depression predicts 1.86x higher readmission, 6x higher dissatisfaction, and prolonged opioid use after joint surgery was independently associated with preoperative depression through 1 year postoperatively (OR 1.14, 95% CI 1.09-1.18).

Meta-analysis - 395,815 TJA cases

Higher 30-day readmission risk after TJA with preoperative depression

A meta-analysis of nearly 400,000 TJA cases found that preoperative depression independently predicted 30-day readmission. In pooled analysis, depression was associated with 1.86x higher readmission risk across study designs, settings, and patient populations.

source: Harin Kim, et al. Association Between Preoperative Depression and Readmission Rate Following Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty, 2021. PMID: 34244031. DOI: 10.1016/j.arth.2021.06.018.

Prospective cohort - 186 patients, 4-year follow-up

Preoperative anxiety/depression was the strongest independent predictor of TKA patient dissatisfaction among all variables studied in this prospective cohort (Ali et al., 2017, n=186, 4-year follow-up, PMID: 27692782).

This prospective study found that preoperative psychological distress made patients 6x more likely to be dissatisfied after TKA.

source: Ali A, Lindstrand A, Sundberg M, Flivik G. J Arthroplasty, 2017. PMID: 27692782. DOI: 10.1016/j.arth.2016.09.012.

Retrospective cohort - 23,726 primary TKA cases

Preoperative depression and prolonged opioid use after TKA

Preoperative depression was a significant independent predictor of prolonged opioid use after TKA at up to 1 year post-surgery (OR 1.14, 95% CI 1.09–1.18), n=23,726.

source: Namba RS, Singh A, Paxton EW, Inacio MCS. J Arthroplasty, 2018;33(8):2449-2454. PMID: 29753617. DOI: 10.1016/j.arth.2018.03.068.

Section 02 - Psychosocial risk

The #1 predictor of musculoskeletal outcomes isn't anatomy. It's how the patient thinks about pain.

Pain catastrophizing is the #1 modifiable psychological predictor of poor MSK outcomes — identifiable before surgery, across 85 studies and 13,628 patients.

source: Martinez-Calderon et al. Clinical Journal of Pain, 2019. PMID: 30664551. DOI: 10.1097/AJP.0000000000000676. Evidence quality: very low per GRADE criteria.

#1

Modifiable psychological predictor of poor MSK outcomes

Pain catastrophizing — across 85 studies and 13,628 patients.

85

independent studies included

13,628

patients across all studies

Clin J Pain

Systematic review, 2019

GRADE

Very low evidence quality

source: Martinez-Calderon et al. Clinical Journal of Pain, 2019. PMID: 30664551. DOI: 10.1097/AJP.0000000000000676. Evidence quality: very low per GRADE criteria.

Pain catastrophizing is not a personality trait - it is a cognitive pattern that can be identified with validated screening instruments and addressed through structured support.

A 2019 systematic review in the Clinical Journal of Pain synthesized 85 studies covering 13,628 patients across chronic pain, spine, and musculoskeletal populations. The evidence was not mixed - catastrophizing emerged as the most consistent predictor across study designs, specialties, and patient demographics.

The clinical implication is direct: a practice that screens for catastrophizing between visits is identifying a modifiable risk factor before poorer outcomes emerge. Continuous Care's monthly psych screening is designed to surface exactly this pattern - systematically, at scale, without adding clinical burden.

  • 1Associated with pain severity, disability, and recovery duration in MSK populations
  • 2Validated across chronic pain, spine surgery, total joint replacement, and physiatry settings
  • 3Can be identified with brief validated instruments - making between-visit screening operationally feasible
  • 4When identified early, psychosocial intervention has demonstrated improvement in functional outcomes before and after surgery

Section 03 - Structured between-visit care

The delivery model isn't theoretical. It was tested at scale in a JAMA-published RCT and is paired here with clearly labeled emerging evidence.

Monthly structured contact between visits - the core mechanism of Continuous Care - has been independently evaluated in the literature across multiple outcome domains. One peer-reviewed randomized trial stands out for its rigor and direct relevance to pain practice.

This is not a speculative outreach model. The peer-reviewed evidence base includes randomized controlled evidence for improved opioid-guideline adherence, and the cost-savings finding is presented separately below as emerging evidence because it is a preprint.

JAMA Internal Medicine, 2017

Nurse care manager-led monthly calls significantly improved opioid guideline adherence across 53 clinicians across 4 safety-net practices

The TOPCARE cluster-randomized controlled trial is the most directly relevant Chronic Care Management (CCM) study in the pain literature. Monthly telephone contacts by nurse care managers - with structured data collection, physician escalation, and auto-documentation - significantly improved adherence to urine drug testing, opioid treatment agreements, and monitoring workflows. 65.9% vs 37.8%, AOR 6.0, p<0.001. The trial did not significantly reduce aberrant drug behaviors or early opioid refill rates. The TOPCARE trial shares key structural elements with Continuous Care — monthly structured patient contact, escalation pathways, and auto-documentation.

Note: TOPCARE used human nurse care managers at primary care practices, not an AI voice agent in a specialty setting.

source: Liebschutz JM, Xuan Z, Shanahan CW, et al. JAMA Internal Medicine, 2017. PMID: 28715535. DOI: 10.1001/jamainternmed.2017.2468.

Emerging Evidence (Preprint — Awaiting Peer Review)

Lower adjusted total healthcare costs for CCM-enrolled patients

A 2025 real-world study of 36,525 patients at a multi-specialty outpatient clinic found that CCM enrollment via monthly LPN telephone contacts produced 17.1% lower adjusted total healthcare costs.

This finding is presented as emerging evidence because the study is currently a medRxiv preprint. It is not yet peer-reviewed, and findings may change prior to publication.

source: Goyal MK, et al. medRxiv preprint, 2025. Not yet peer-reviewed. Findings subject to change prior to publication.

A 2023 JGIM systematic review of 18 CCM RCTs in pain populations found that 10 of 18 trials targeted mental health as the primary intervention pathway - confirming that effective CCM in pain care is often behavioral-health integrated.

The same review found significant improvement in pain severity outcomes in 11 of 18 RCTs, with the strongest effect sizes in programs that combined monthly contact with structured psychological support.

Section 04 - Reimbursement

Chronic pain qualifies. The CPT codes are established. The documentation is automated.

Chronic Care Management reimbursement has existed since 2015. CMS explicitly confirmed chronic pain as a qualifying condition in June 2025. What has prevented most pain practices from capturing it is operational, not regulatory - the documentation burden is too high to sustain without automation.

CMS Policy Confirmation

CMS explicitly includes chronic pain among qualifying conditions for Chronic Care Management reimbursement under Medicare and Medicare Advantage.

Centers for Medicare & Medicaid Services. Chronic Care Management Services. MLN909188. June 2025.

Only 3.4% of Medicare-eligible patients are currently enrolled in CCM - more than a decade after the reimbursement launched. The barrier is not eligibility. The barrier is operational: practices cannot sustain the documentation requirements without a system built to handle them. Continuous Care is that system.

Also Qualifies for Chronic Care Management (CCM)

Diabetes - Hypertension - Heart disease - COPD - Chronic pain - Osteoarthritis - Depression - Anxiety - Any two or more qualifying chronic conditions expected to last 12+ months

CPT CodeService Description~Rate/Month
99490

CCM - Standard

20+ min non-face-to-face, 2+ chronic conditions, consent on file

~$62
99487

Complex CCM

60+ min, moderate-to-high complexity, care plan revision

~$93
99489

Complex CCM Add-On

Each additional 30 min of complex CCM

~$47
99491

CCM - Physician/QHP

30+ min personally performed by physician or QHP

~$84

Rates are approximate 2026 Medicare national averages. Actual reimbursement varies by payer, locality, and documentation. Psych screening codes (96127, 96160) billed separately. Continuous Care generates documentation supporting all applicable codes automatically.

Section 05 - How we characterize the evidence

We hold ourselves to the same standard we hold our sources.

Clinical credibility requires intellectual honesty. Here is how we classify the evidence behind Continuous Care - what is strong enough to state directly, what requires careful framing, and what we do not claim.

Strongest - State directly

  • 1
    Preoperative depression is an independent predictor of 30-day readmission after TJA (1.86x, meta-analysis, 395,815 cases)

    source: Harin Kim, et al. Association Between Preoperative Depression and Readmission Rate Following Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty, 2021. PMID: 34244031. DOI: 10.1016/j.arth.2021.06.018.

  • 2
    Preoperative anxiety/depression was the strongest independent predictor of TKA patient dissatisfaction among all variables studied in this prospective cohort (Ali et al., 2017, n=186, 4-year follow-up, PMID: 27692782).

    source: Ali A, Lindstrand A, Sundberg M, Flivik G. J Arthroplasty, 2017. PMID: 27692782. DOI: 10.1016/j.arth.2016.09.012.

  • 3Monthly structured Chronic Care Management (CCM) contact significantly improved opioid guideline adherence (JAMA-published RCT)
  • 4CMS confirms chronic pain as a qualifying CCM condition

Supported - Phrase carefully

  • -17.1% lower total healthcare costs in CCM-enrolled patients
  • -Preoperative depression was a significant independent predictor of prolonged opioid use after TKA at up to 1 year post-surgery (OR 1.14, 95% CI 1.09–1.18), n=23,726.
  • -10 of 18 CCM pain RCTs targeted mental health as the primary pathway
  • -
    Pain catastrophizing is the #1 modifiable psychological predictor of poor MSK outcomes — identifiable before surgery, across 85 studies and 13,628 patients.

    source: Martinez-Calderon et al. Clinical Journal of Pain, 2019. PMID: 30664551. DOI: 10.1097/AJP.0000000000000676. Evidence quality: very low per GRADE criteria.

Do not claim - Evidence too broad or weak

  • -CCM cures or prevents chronic pain
  • -Psych screening eliminates post-surgical dissatisfaction
  • -All MSK patients have catastrophizing
  • -Revenue estimates are guaranteed

The evidence is clear.The operational question is: who delivers it?

Continuous Care is built to bring structured between-visit support - and the clinical outcomes it is associated with - to outpatient specialty practices without adding staff, manual documentation, or compliance burden.

Book a demoOr email [email protected]

Source references

All sources cited on this page are grouped below by evidence type.

Peer-Reviewed Sources

Harin Kim, et al. Association Between Preoperative Depression and Readmission Rate Following Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty, 2021. PMID: 34244031. DOI: 10.1016/j.arth.2021.06.018.

Ali A, Lindstrand A, Sundberg M, Flivik G. J Arthroplasty, 2017. PMID: 27692782. DOI: 10.1016/j.arth.2016.09.012.

Namba RS, Singh A, Paxton EW, Inacio MCS. J Arthroplasty, 2018;33(8):2449-2454. PMID: 29753617. DOI: 10.1016/j.arth.2018.03.068.

Martinez-Calderon J, et al. Clinical Journal of Pain, 2019. PMID: 30664551. DOI: 10.1097/AJP.0000000000000676. Evidence quality: very low per GRADE criteria.

Liebschutz JM, Xuan Z, Shanahan CW, et al. JAMA Internal Medicine, 2017. PMID: 28715535. DOI: 10.1001/jamainternmed.2017.2468.

Kleinsinger F. The Unmet Challenge of Medication Nonadherence. The Permanente Journal, 2018. PMID: 30005722. DOI: 10.7812/TPP/18-033.

Regulatory References

Centers for Medicare & Medicaid Services. Chronic Care Management Services. MLN909188. June 2025. View source

Emerging Evidence (Preprint — Awaiting Peer Review)

Goyal MK, et al. medRxiv preprint, 2025. Not yet peer-reviewed. Findings subject to change prior to publication.