Development and validation of a self-efficacy scale for use in British patients with rheumatoid arthritis (RASE)

Effectiveness of a novel digital patient education programme to support self-management of early rheumatoid arthritis: a randomized controlled trial

OBJECTIVES

To evaluate the effectiveness of a novel digital patient education (PE) programme in improving self-management in patients newly diagnosed with rheumatoid arthritis (RA).

METHODS

This was a parallel, open-label, two-armed, randomized controlled trial with superiority design. Patients from five rheumatology clinics were randomized into digital PE (intervention) or face-to-face PE (control). The primary outcome was self-efficacy, measured by average difference in the Rheumatoid Arthritis Self-Efficacy (RASE) score from baseline to month 12. Secondary outcomes were RA knowledge, health literacy, adherence and quality of life. Healthcare utilization data and digital PE programme usage were recorded. Self-efficacy, knowledge and health literacy data were analysed using mixed-effects repeated measures modelling; adherence using logistic regression, and quality of life and healthcare utilization using descriptive statistics with the Wilcoxon rank-sum test.

RESULTS

Of the 180 patients randomized (digital PE, n = 89; face-to-face PE, n = 91), 175 had data available for analysis. Median age was 59.0 years and 61% were women. The average difference in self-efficacy between groups from baseline to month 12 was significant by a -4.34 difference in RASE score, favouring the intervention group (95% CI: -8.17 to -0.51; P = 0.026). RA knowledge, health literacy and quality of life showed minor improvements over time but no difference between groups, except out-patient clinic contacts, which were fewer in the intervention group.

CONCLUSION

The findings suggest that digital PE is effective in improving self-efficacy and therefore self-management in patients with early RA. This intervention has potential to lower healthcare costs by decreasing out-patient clinic contacts.

TRIAL REGISTRATION NUMBER

clinicaltrials.gov, NCT04669340.

Responsiveness of multiple patient-reported outcome measures for acute postsurgical pain: primary results from the international multi-centre PROMPT NIT-1 study

BACKGROUND

Postsurgical outcome measures are crucial to define the efficacy of perioperative pain management; however, it is unclear which are most appropriate. We conducted a prospective study aiming to assess sensitivity-to-change of patient-reported outcome measures assessing the core outcome set of domains pain intensity (at rest/during activity), physical function, adverse events, and self-efficacy.

METHODS

Patient-reported outcome measures were assessed preoperatively, on day 1 (d1), d3, and d7 after four surgical procedures (total knee replacement, breast surgery, endometriosis-related surgery, and sternotomy). Primary outcomes were sensitivity-to-change of patient-reported outcome measures analysed by correlating their changes (d1-d3) with patients' global impression of change and patients' specific impression of change items as anchor criteria. Secondary outcomes included identification of baseline and patient characteristic variables explaining variance in change for each of the scales and descriptive analysis of various patient-reported outcome measures from different domains and after different surgeries.

RESULTS

Of 3322 patients included (18 hospitals, 10 countries), data from 2661 patients were analysed. All patient-reported outcome measures improved on average over time; the median calculated sensitivity-to-change for all patient-reported outcome measures (overall surgeries) was 0.22 (range: 0.07-0.31, scale: 0-10); all changes were independent of baseline data or patient characteristics and similar between different procedures.

CONCLUSIONS

Pain-related patient-reported outcome measures have low to moderate sensitivity-to-change; those showing higher sensitivity-to-change from the same domain should be considered for inclusion in a core outcome set of patient-reported outcome measures to assess the effectiveness and efficacy of perioperative pain management.

Self-management education for children with epilepsy and their caregivers. A scoping review

Self-management education programs have been highly successful in preparing people to manage medical conditions with recurring events. A detailed curriculum for epilepsy patients, and their caretakers, is lacking. Here we assess what is available for patients who have disorders with recurring events and offer an approach to developing a potential self-care curriculum for patients with seizures and their caregivers. Among the anticipated components are a baseline efficacy assessment and training tailored to increasing self-efficacy, medication compliance, and stress management. Those at risk of status epilepticus will also need guidance in preparing a personalized seizure action plan and training in how to decide when rescue medication is appropriate and how to administer the therapy. Peers, as well as professionals, could teach and provide support. To our knowledge, no such programs are currently available in English. We encourage their creation, dissemination, and widespread use.

Brief intervention to reduce fatigue impact in patients with inflammatory arthritis: design and outcomes of a single-arm feasibility study

OBJECTIVES

Patients with inflammatory arthritis report that fatigue is challenging to manage. We developed a manualised, one-to-one, cognitive-behavioural intervention, delivered by rheumatology health professionals (RHPs). The Fatigue - Reducing its Effects through individualised support Episodes in Inflammatory Arthritis (FREE-IA) study tested the feasibility of RHP training, intervention delivery and outcome collection ahead of a potential trial of clinical and cost-effectiveness.

METHODS

In this single-arm feasibility study, eligible patients were ≥18 years, had a clinician-confirmed diagnosis of an inflammatory arthritis and scored ≥6/10 on the Bristol Rheumatoid Arthritis Fatigue (BRAF) Numerical Rating Scale (NRS) Fatigue Effect. Following training, RHPs delivered two to four sessions to participants. Baseline data were collected before the first session (T0) and outcomes at 6 weeks (T1) and 6 months (T2). The proposed primary outcome was fatigue impact (BRAF NRS Fatigue Effect). Secondary outcomes included fatigue severity and coping, disease impact and disability, and measures of therapeutic mechanism (self-efficacy and confidence to manage health).

RESULTS

Eight RHPs at five hospitals delivered 113 sessions to 46 participants. Of a potential 138 primary and secondary outcome responses at T0, T1 and T2, there were 13 (9.4%) and 27 (19.6%) missing primary and secondary outcome responses, respectively. Results indicated improvements in all measures except disability, at either T1 or T2, or both.

CONCLUSIONS

This study showed it was feasible to deliver the intervention, including training RHPs, and recruit and follow-up participants with high retention. While there was no control group, observed within-group improvements suggest potential promise of the intervention and support for a definitive trial to test effectiveness.

Factors associated with patient activation in inflammatory arthritis: a multisite cross-sectional study

Objectives

Patient activation covers the skills, abilities and behaviour that impact how able and willing someone is to take an active role in self-managing their health. This study explored clinical and psychosocial factors associated with patient activation in rheumatology patients.

Methods

This was a cross-sectional study using postal survey methods. Participants with inflammatory rheumatic conditions were from six rheumatology centres in England. Patient activation was captured using the Patient Activation Measure (PAM). Twenty-nine explanatory factors were tested for potential association with patient activation in univariable and multivariable analyses. In preliminary multivariable analyses, factors found to have an association with patient activation at a P < 0.1 level were entered into the final multivariable model. Those that remained significant at a P < 0.05 level were considered associated with patient activation.

Results

The sample comprised 251 participants (74% female) with a mean age of 59.31 years (s.d. 12.69), disease duration of 14.48 years (s.d. 12.52) and a PAM score of 58.3 (s.d. 11.46). Of the 29 candidate factors, 25 were entered into a preliminary multivariable analysis. In the final multivariable analysis, four factors (self-efficacy, the illness belief that treatment will control participants’ condition and two dimensions of health literacy) were significantly associated with patient activation. This final model accounted for 40.4% of the variance in PAM scores [F(4, 246) = 41.66, P < 0.001].

Conclusions

Patient activation is important in managing rheumatic conditions. Our data confirm that self-efficacy and health literacy are particular targets for patient activation interventions.

Evaluation of a multidisciplinary care model to improve quality of life in rheumatoid arthritis: a randomised controlled trial

BACKGROUND AND PURPOSE

Health-Related Quality of Life (HR-QOL) is an important patient-reported domain in patients with rheumatoid arthritis (RA). The uptake of multidisciplinary team (MDT) care in RA is generally low, due to initial high demand for resources. We hypothesised that whilst pharmacological treatments are effective in controlling disease activity, a multipronged intervention in an MDT may have a positive impact on HR-QOL.

METHODS

This was a single-centre randomized parallel group, single-blind controlled trial of MDT vs. usual care in an established RA clinic. Data were collected through face-to-face questionnaires, medical records review, and joint counts by a blinded assessor at 0, 3 and 6 months. Adult RA patients were randomly assigned in a single visit to a 6-member MDT (rheumatologist, nurse, social worker, physiotherapist, occupational therapist, and podiatrist) or usual care. MDT providers prescribed medications and counselled patients on managing flares, medication adherence, coping, joint protection, exercise, footwear. The primary outcome was minimal clinically important difference (MCID) in HR-QOL (increase in European QOL-5-Dimension-3-Level, EQ-5D-3L by 0.1) at six months.

RESULTS

140 patients (86.3% female, 53.4% Chinese, median (IQR) age 56.6 (46.7, 62.4) years); 70 were randomized to each arm. Median (IQR) disease duration was 5.5 (2.4, 11.0) years and disease activity in 28 joints (DAS28) was 2.87 (2.08, 3.66). 123 patients completed the study. Twenty-six (40.6%) MDT vs. 23 (34.3%) usual care patients achieved an MCID in EQ-5D-3L, OR 1.3 (0.6, 2.7). In multivariable logistic regression, baseline EQ-5D-3L was the only predictor of achieving MCID. There was more disease modifying anti-rheumatic drug escalation in MDT (34.4% vs. 19.4%). Patients with high disease activity were more likely to achieve MCID in the MDT arm.

CONCLUSIONS

A single visit by stable patients with low disease activity to an MDT failed to achieve MCID in the EQ-5D-3L; however, did achieve small but significant improvements in the EQ-5D-3L, DAS28, pain, coping and self-efficacy. To be sustainable, MDT care should be targeted at patients with high disease activity or those with a new diagnosis of RA.

TRIAL REGISTRATION

The study is registered on ClinicalTrials.gov, identifier: NCT03099668.

Group cognitive-behavioural programme to reduce the impact of rheumatoid arthritis fatigue: the RAFT RCT with economic and qualitative evaluations

BACKGROUND

Fatigue is a major problem in rheumatoid arthritis (RA). There is evidence for the clinical effectiveness of cognitive-behavioural therapy (CBT) delivered by clinical psychologists, but few rheumatology units have psychologists.

OBJECTIVES

To compare the clinical effectiveness and cost-effectiveness of a group CBT programme for RA fatigue [named RAFT, i.e. Reducing Arthritis Fatigue by clinical Teams using cognitive-behavioural (CB) approaches], delivered by the rheumatology team in addition to usual care (intervention), with usual care alone (control); and to evaluate tutors' experiences of the RAFT programme.

DESIGN

A randomised controlled trial. Central trials unit computerised randomisation in four consecutive cohorts within each of the seven centres. A nested qualitative evaluation was undertaken.

SETTING

Seven hospital rheumatology units in England and Wales.

PARTICIPANTS

Adults with RA and fatigue severity of ≥ 6 [out of 10, as measured by the Bristol Rheumatoid Arthritis Fatigue Numerical Rating Scale (BRAF-NRS)] who had no recent changes in major RA medication/glucocorticoids.

INTERVENTIONS

RAFT - group CBT programme delivered by rheumatology tutor pairs (nurses/occupational therapists). Usual care - brief discussion of a RA fatigue self-management booklet with the research nurse.

MAIN OUTCOME MEASURES

Primary - fatigue impact (as measured by the BRAF-NRS) at 26 weeks. Secondary - fatigue severity/coping (as measured by the BRAF-NRS); broader fatigue impact [as measured by the Bristol Rheumatoid Arthritis Fatigue Multidimensional Questionnaire (BRAF-MDQ)]; self-reported clinical status; quality of life; mood; self-efficacy; and satisfaction. All data were collected at weeks 0, 6, 26, 52, 78 and 104. In addition, fatigue data were collected at weeks 10 and 18. The intention-to-treat analysis conducted was blind to treatment allocation, and adjusted for baseline scores and centre. Cost-effectiveness was explored through the intervention and RA-related health and social care costs, allowing the calculation of quality-adjusted life-years (QALYs) with the EuroQol-5 Dimensions, five-level version (EQ-5D-5L). Tutor and focus group interviews were analysed using inductive thematic analysis.

RESULTS

A total of 308 out of 333 patients completed 26 weeks (RAFT, n/N = 156/175; control, n/N = 152/158). At 26 weeks, the mean BRAF-NRS impact was reduced for the RAFT programme (-1.36 units; p < 0.001) and the control interventions (-0.88 units; p < 0.004). Regression analysis showed a difference between treatment arms in favour of the RAFT programme [adjusted mean difference -0.59 units, 95% confidence interval (CI) -1.11 to -0.06 units; p = 0.03, effect size 0.36], and this was sustained over 2 years (-0.49 units, 95% CI -0.83 to -0.14 units; p = 0.01). At 26 weeks, further fatigue differences favoured the RAFT programme (BRAF-MDQ fatigue impact: adjusted mean difference -3.42 units, 95% CI -6.44 to - 0.39 units, p = 0.03; living with fatigue: adjusted mean difference -1.19 units, 95% CI -2.17 to -0.21 units, p = 0.02; and emotional fatigue: adjusted mean difference -0.91 units, 95% CI -1.58 to -0.23 units, p = 0.01), and these fatigue differences were sustained over 2 years. Self-efficacy favoured the RAFT programme at 26 weeks (Rheumatoid Arthritis Self-Efficacy Scale: adjusted mean difference 3.05 units, 95% CI 0.43 to 5.6 units; p = 0.02), as did BRAF-NRS coping over 2 years (adjusted mean difference 0.42 units, 95% CI 0.08 to 0.77 units; p = 0.02). Fatigue severity and other clinical outcomes were not different between trial arms and no harms were reported. Satisfaction with the RAFT programme was high, with 89% of patients scoring ≥ 8 out of 10, compared with 54% of patients in the control arm rating the booklet (p < 0.0001); and 96% of patients and 68% of patients recommending the RAFT programme and the booklet, respectively, to others (p < 0.001). There was no significant difference between arms for total societal costs including the RAFT programme training and delivery (mean difference £434, 95% CI -£389 to £1258), nor QALYs gained (mean difference 0.008, 95% CI -0.008 to 0.023). The probability of the RAFT programme being cost-effective was 28-35% at the National Institute for Health and Care Excellence's thresholds of £20,000-30,000 per QALY. Tutors felt that the RAFT programme's CB approaches challenged their usual problem-solving style, helped patients make life changes and improved tutors' wider clinical practice.

LIMITATIONS

Primary outcome data were missing for 25 patients; the EQ-5D-5L might not capture fatigue change; and 30% of the 2-year economic data were missing.

CONCLUSIONS

The RAFT programme improves RA fatigue impact beyond usual care alone; this was sustained for 2 years with high patient satisfaction, enhanced team skills and no harms. The RAFT programme is < 50% likely to be cost-effective; however, NHS costs were similar between treatment arms.

FUTURE WORK

Given the paucity of RA fatigue interventions, rheumatology teams might investigate the pragmatic implementation of the RAFT programme, which is low cost.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN52709998.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 57. See the NIHR Journals Library website for further project information.

Effectiveness of health education by telephone follow-up on self-efficacy among discharged patients with rheumatoid arthritis: A randomised control trial

AIMS AND OBJECTIVES

To explore the effectiveness of a health education programme by telephone follow-up on the self-efficacy of patients with rheumatoid arthritis (RA).

BACKGROUND

Self-efficacy is increasingly perceived to be a cornerstone in improving the capacity of self-management. However, a paucity of research has demonstrated the effectiveness of health education by the use of a telephone follow-up for RA patients in China.

DESIGN

This study was a randomised control trial.

METHODS

Recruited patients were randomly divided into control and intervention groups. The intervention group accepted health education by telephone follow-up four times after the patients were discharged. The patients in the control group only accepted telephone follow-up once after they were discharged. Self-efficacy was measured by the use of the Rheumatoid Arthritis Self-Efficacy Questionnaire (RASE), and data were collected at the day before the discharge, the 12th week and the 24th week after patients were discharged. The CONSORT checklist was used to check the procedure.

RESULTS

A total of 92 discharged patients with rheumatoid arthritis were enrolled. The sociodemographic indexes of the control and intervention groups had no significant differences at baseline (p > .05). The RASE score of the intervention group was higher than that of the control group (p < .05) at the 12th week and the 24th week.

CONCLUSION

The HET improved the self-efficacy of the discharged patients with RA in the 12th week and the 24th week after discharge. This study demonstrated that our HET can improve the short-term and long-term effects of self-efficacy, which implies that the clinical nursing staff should increase the frequency of HET to improve the patients' knowledge and abilities of self-management.

RELEVANCE TO CLINICAL PRACTICE

Patients with RA will benefit from a health education programme by telephone follow-up; thus, it is necessary for nursing managers to implement this programme.

Efficacy of a Web-Based Self-Management Enhancing Program for Patients with Rheumatoid Arthritis: Explorative Randomized Controlled Trial

Background

Web-based self-management enhancing programs have the potential to support patients with rheumatoid arthritis (RA) in their self-management; for example, improve their health status by increasing their self-efficacy or taking their prescribed medication. We developed a Web-based self-management enhancing program in collaboration with RA patients and professionals as co-designers on the basis of the intervention mapping framework. Although self-management programs are complex interventions, it is informative to perform an explorative randomized controlled trial (RCT) before embarking on a larger trial.

Objective

This study aimed to evaluate the efficacy of a Web-based self-management enhancing program for patients with RA and identify outcome measures most likely to capture potential benefits.

Methods

A multicenter exploratory RCT was performed with an intervention group and a control group. Both groups received care as usual. In addition, the intervention group received 12 months of access to a Web-based self-management program. Assessment occurred at baseline, 6 months, and 12 months. Outcome measures included self-management behavior (Patient Activation Measurement, Self-Management Ability Scale), self-efficacy (Rheumatoid Arthritis task-specific Self-Efficacy, Perceived Efficacy in Patient-Physician Interaction), general health status (RAND-36), focus on fatigue (Modified Pain Coping Inventory for Fatigue), and perceived pain and fatigue (Numeric Rating Scales). A linear mixed model for repeated measures, using the intention-to-treat principle, was applied to study differences between the patients in the intervention (n=78) and control (n=79) groups. A sensitivity analysis was performed in the intervention group to study the influence of patients with high (N=30) and low (N=40) use of the intervention.

Results

No positive effects were found regarding the outcome measurements. Effect sizes were low.

Conclusions

Based on these results, it is not possible to conclude on the positive effects of the intervention or to select outcome measures to be regarded as the primary/main or secondary outcomes for a future trial. A process evaluation should be performed to provide more insight into the low compliance with and effectiveness of the intervention. This can determine for whom this sort of program will work and help to fine-tune the inclusion criteria.

Trial Registration

Netherlands Trial Register NTR4871; https://www.trialregister.nl/trial/4726

Reducing arthritis fatigue impact: two-year randomised controlled trial of cognitive behavioural approaches by rheumatology teams (RAFT)

OBJECTIVES

To see if a group course delivered by rheumatology teams using cognitive-behavioural approaches, plus usual care, reduced RA fatigue impact more than usual care alone.

METHODS

Multicentre, 2-year randomised controlled trial in RA adults (fatigue severity>6/10, no recent major medication changes). RAFT (Reducing Arthritis Fatigue: clinical Teams using CB approaches) comprises seven sessions, codelivered by pairs of trained rheumatology occupational therapists/nurses. Usual care was Arthritis Research UK fatigue booklet. Primary 26-week outcome fatigue impact (Bristol RA Fatigue Effect Numerical Rating Scale, BRAF-NRS 0-10). Intention-to-treat regression analysis adjusted for baseline scores and centre.

RESULTS

308/333 randomised patients completed 26 week data (156/175 RAFT, 152/158 Control). Mean baseline variables were similar. At 26 weeks, the adjusted difference between arms for fatigue impact change favoured RAFT (BRAF-NRS Effect -0.59, 95% CI -1.11 to -0.06), BRAF Multidimensional Questionnaire (MDQ) Total -3.42 (95% CI -6.44 to -0.39), Living with Fatigue -1.19 (95% CI -2.17 to -0.21), Emotional Fatigue -0.91 (95% CI -1.58 to -0.23); RA Self-Efficacy (RASE, +3.05, 95% CI 0.43 to 5.66) (14 secondary outcomes unchanged). Effects persisted at 2 years: BRAF-NRS Effect -0.49 (95% CI -0.83 to -0.14), BRAF MDQ Total -2.98 (95% CI -5.39 to -0.57), Living with Fatigue -0.93 (95% CI -1.75 to -0.10), Emotional Fatigue -0.90 (95% CI -1.44, to -0.37); BRAF-NRS Coping +0.42 (95% CI 0.08 to 0.77) (relevance of fatigue impact improvement uncertain). RAFT satisfaction: 89% scored > 8/10 vs 54% controls rating usual care booklet (p<0.0001).

CONCLUSION

Multiple RA fatigue impacts can be improved for 2 years by rheumatology teams delivering a group programme using cognitive behavioural approaches.

TRIAL REGISTRATION NUMBER

ISRCTN52709998.

Cognitive-behavioural theories and adherence: Application and relevance in antiretroviral therapy

Background

Adherence in chronic disease conditions is described as the extent to which a person‘s behaviour corresponds to the prescribed medical advice of the healthcare provider. This is not limited to medication intake only but also includes acts such as following instructions regarding dietary or fluid restrictions and taking medicines at the prescribed times and intervals. Although adherence to antiretroviral therapy (ART) is a predictor of good clinical outcome among HIV-infected persons on ART, it is a major challenge and strict adherence is not very common. This article aims to examine the application and relevance of some cognitive-behavioural theories in antiretroviral therapy adherence

Methods

After doing a thorough literature review, contemporary theories of health behaviour at the individual and interpersonal levels referred to as cognitive-behavioural theories were explored. This review highlights some aspects of the cognitive perspective of health behaviour theories as a good theoretical framework that could be used for organising thoughts about adherence and other health behaviours among patients on lifelong treatment such as ART.

Results

Key concepts of these theories stipulate that behaviour is mediated by cognition i.e. knowledge and attitude affect the person’s action. In addition, cognitive-behavioural theories recognise knowledge alone as being insufficient to produce behavioural change; a person’s perception, motivation, skills and social environment are all influential in the process of behavioural change.

Conclusion

Prediction of medication adherence is complex, and health-related knowledge and beliefs alone are insufficient to achieve behaviour change, especially in chronic conditions such as HIV/AIDS. However, people can control or influence the events affecting their lives by integrating cognitive, social, and behavioural sub-skills related to beliefs of personal efficacy in performing these skills.

What we know about the purpose, theoretical foundation, scope and dimensionality of existing self-management measurement tools: A scoping review

OBJECTIVES

To identify self-report, self-management measures for adults with chronic conditions, and describe their purpose, theoretical foundation, dimensionality (multi versus uni), and scope (generic versus condition specific).

METHODS

A search of four databases (8479 articles) resulted in a scoping review of 28 self-management measures.

RESULTS

Although authors identified tools as measures of self-management, wide variation in constructs measured, purpose, and theoretical foundations existed. Subscales on 13 multidimensional tools collectively measure domains of self-management relevant to clients, however no one tool's subscales cover all domains.

CONCLUSIONS

Viewing self-management as a complex, multidimensional whole, demonstrated that existing measures assess different, related aspects of self-management. Activities and social roles, though important to patients, are rarely measured. Measures with capacity to quantify and distinguish aspects of self-management may promote tailored patient care.

PRACTICE IMPLICATIONS

In selecting tools for research or assessment, the reason for development, definitions, and theories underpinning the measure should be scrutinized. Our ability to measure self-management must be rigorously mapped to provide comprehensive and system-wide care for clients with chronic conditions. Viewing self-management as a complex whole will help practitioners to understand the patient perspective and their contribution in supporting each individual patient.

Increasing podiatry referrals for patients with inflammatory arthritis at a tertiary hospital in Singapore: A quality improvement project

BACKGROUND

Foot disease is highly prevalent in people with inflammatory arthritis and is often under-recognized. Podiatry intervention can significantly reduce foot pain and disability, with timely access being the key factor. The aim of this study was to plan and implement a quality improvement project to identify the barriers to, and improve, uptake of podiatry services among patients with inflammatory arthritis-related foot problems seen at a tertiary hospital in Singapore.

METHOD

A 6-month quality improvement program was conducted by a team of key stakeholders using quality improvement tools to identify, implement and test several interventions designed to improve uptake of podiatry services. The number of patients referred for podiatry assessment was recorded on a weekly basis by an experienced podiatrist. The criterion for appropriate referral to podiatry was those patients with current or previous foot problems such as foot pain, swelling and deformity.

RESULTS

Interventions included education initiatives, revised workflow, development of national guidelines for inflammatory arthritis, local podiatry guidelines for the management of foot and ankle problems, routine use of outcome measures, and introduction of a fully integrated rheumatology-podiatry service with reduced cost package. Referral rates increased from 8% to 11%, and were sustained beyond the study period. Complete incorporation of podiatry into the rheumatology consultation as part of the multidisciplinary team package further increased referrals to achieve the target of full uptake of the podiatry service.

CONCLUSION

Through a structured quality improvement program, referrals to podiatry increased and improved the uptake and acceptance of rheumatology-podiatry services.

Rasch analysis of the Norwegian version of the Arthritis Self-Efficacy Scale (ASES)

OBJECTIVES

To apply the Rasch model to the Norwegian version of the Arthritis Self-Efficacy Scale (ASES).

METHOD

The ASES was included in a self-administered questionnaire sent to 224 patients attending one of three rehabilitation centres for rheumatic diseases in Norway in 2009. The fit of the ASES to the Rasch model was assessed together with hypothesized associations with the Modified Health Assessment Questionnaire (MHAQ), the 36-item Short Form Health Survey (SF-36), the numerical rating scale (NRS) for pain, and NRS fatigue.

RESULTS

A total of 145 (64.7%) patients responded to the questionnaire. The two scales of other symptoms and pain showed good fit to the Rasch model with no evidence for differential item functioning (DIF) according to eight sociodemographic and disease-related variables. The Person Separation Index (PSI), which is equivalent to Cronbach's alpha, ranged from 0.74 to 0.78. Correlations with scores for other instruments were as hypothesized: ASES pain had the highest correlations with SF-36 pain and NRS pain and ASES other symptoms had the highest correlations with other aspects of the SF-36 and NRS fatigue.

CONCLUSIONS

The ASES had good fit to the Rasch model and correlations with other instrument scores that followed hypotheses, lending further support to the application of the instrument in patients with rheumatic diseases.

Relationship between self-efficacy, beliefs, and physical activity in inflammatory arthritis

Background:

The benefits of physical activity (PA) in inflammatory arthritis (IA) patients are well-established. However, levels of PA in the IA population are suboptimal and the psychological determinants of PA are poorly understood.

Objective:

The study aimed to examine the self-reported PA levels and psychological determinants of PA for the IA population.

Methods:

A cross-sectional study of people with rheumatoid arthritis (RA) and psoriatic arthritis (PsA) was conducted to explore the association between demographic and psychological variables such as self-efficacy and belief about PA, and levels of PA and energy expenditure (EE). PA was recorded using the Yale Physical Activity Survey (YPAS).

Results:

A total of 102 participants were included in the study. Participants reported low levels of PA [mean ± standard deviation (SD), 24.3 ± 18.2]. Beliefs about PA, but not self-efficacy, correlated with levels of self-report PA over the past week (r = 0.25, p = 0.01), over the past month (r = 0.21, p = 0.04), and EE (r = 0.31, p = 0.01).

Conclusion:

People with IA have decreased levels of PA. Beliefs about PA are associated with levels of self-report PA and EE in this population. These data provide a useful signpost for guiding and designing interventions to improve PA levels in IA populations by altering beliefs about PA.

An Online Tailored Self-Management Program for Patients With Rheumatoid Arthritis: A Developmental Study

Background

Every day rheumatoid arthritis (RA) patients make many decisions about managing their disease. An online, computer-tailored, self-management program can support this decision making, but development of such a program requires the active participation of patients.

Objective

To develop an online, computer-tailored, self-management program integrated with the nursing care, as nurses have an important role in supporting self-management behavior.

Methods

The intervention mapping framework was used to develop the program. Development was a multistep process: (1) needs assessment; (2) developing program and change objectives in a matrix; (3) selecting theory-based intervention methods and practical application strategies; (4) producing program components; (5) planning and adoption, implementation, and sustainability; and (6) planning for evaluation.

Results

After conducting the needs assessment (step 1), nine health-related problems were identified: (1) balancing rest and activity, (2) setting boundaries, (3) asking for help and support, (4) use of medicines, (5) communicating with health professionals, (6) use of assistive devices, (7) performing physical exercises, (8) coping with worries, and (9) coping with RA. After defining performance and change objectives (step 2), we identified a number of methods which could be used to achieve them (step 3), such as provision of general information about health-related behavior, self-monitoring of behavior, persuasive communication, modeling, and self-persuasion and tailoring. We described and operationalized these methods in texts, videos, exercises, and a medication intake schedule. The resulting program (step 4) consisted of an introduction module and nine modules dealing with health-related problems. The content of these modules is tailored to the user’s self-efficacy, and patients can use the online program as often as they want, working through a module or modules at their own speed. After implementation (step 5), the program will be evaluated in a two-center pilot trial involving 200 RA patients. Log-in data and qualitative interviews will used for a process evaluation.

Conclusions

The intervention mapping framework was used to guide development of an online computer-tailored self-management program via a process which could serve as a model for the development of other interventions. A pilot randomized controlled trial (RCT) will provide insight into the important outcome measures in preparation for a larger RCT. The process evaluation will provide insight into how RA patients use the program and the attrition rate.

Trial Registration

Netherlands Trial Register (NTR): NTR4871; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4871 [accessed 13-NOV-15] http://www.webcitation.org/6d1ZyIoEy

Expectations of new treatment in rheumatoid arthritis: developing a patient-generated questionnaire

BACKGROUND

Service-user partnerships in research exist in mental health, but there have been few advances in other disciplines, apart from cancer.

OBJECTIVES

To develop a patient-generated expectancy measure for new treatments in rheumatoid arthritis (RA), using a participatory method.

METHOD

Stage 1: three repeated focus groups and two expert panels with patients with RA conducted by a patient researcher to generate items for the draft questionnaire. Stage 2: feasibility study of draft scale with consecutive outpatient attendees.

RESULTS

Patients identified 21 dimensions of new treatment expectations, grouped into (i) physical, (ii) psycho-social and (iii) expectations relating to the impact of treatment. This resulted in a draft instrument assessed in a feasibility study.

DISCUSSION AND CONCLUSION

The participatory research method was useful in involving patients actively in research and to produce collaboratively a feasible, valid and acceptable measure in RA. The scale will be included in a longitudinal observational study, with newly diagnosed patients, to assess (i) whether the new scale demonstrates sensitivity to change for expectations when receiving new treatment and (ii) participants' completion rate of the new scale compared with five instruments included in the future study.

Protocol for a randomised controlled trial for Reducing Arthritis Fatigue by clinical Teams (RAFT) using cognitive-behavioural approaches

INTRODUCTION

Rheumatoid arthritis (RA) fatigue is distressing, leading to unmanageable physical and cognitive exhaustion impacting on health, leisure and work. Group cognitive-behavioural (CB) therapy delivered by a clinical psychologist demonstrated large improvements in fatigue impact. However, few rheumatology teams include a clinical psychologist, therefore, this study aims to examine whether conventional rheumatology teams can reproduce similar results, potentially widening intervention availability.

METHODS AND ANALYSIS

This is a multicentre, randomised, controlled trial of a group CB intervention for RA fatigue self-management, delivered by local rheumatology clinical teams. 7 centres will each recruit 4 consecutive cohorts of 10-16 patients with RA (fatigue severity ≥ 6/10). After consenting, patients will have baseline assessments, then usual care (fatigue self-management booklet, discussed for 5-6 min), then be randomised into control (no action) or intervention arms. The intervention, Reducing Arthritis Fatigue by clinical Teams (RAFT) will be cofacilitated by two local rheumatology clinicians (eg, nurse/occupational therapist), who will have had brief training in CB approaches, a RAFT manual and materials, and delivered an observed practice course. Groups of 5-8 patients will attend 6 × 2 h sessions (weeks 1-6) and a 1 hr consolidation session (week 14) addressing different self-management topics and behaviours. The primary outcome is fatigue impact (26 weeks); secondary outcomes are fatigue severity, coping and multidimensional impact, quality of life, clinical and mood status (to week 104). Statistical and health economic analyses will follow a predetermined plan to establish whether the intervention is clinically and cost-effective. Effects of teaching CB skills to clinicians will be evaluated qualitatively.

ETHICS AND DISSEMINATION

Approval was given by an NHS Research Ethics Committee, and participants will provide written informed consent. The copyrighted RAFT package will be freely available. Findings will be submitted to the National Institute for Health and Care Excellence, Clinical Commissioning Groups and all UK rheumatology departments.

TRIAL REGISTRATION NUMBER

ISRCTN

52709998; Protocol v3 09.02.2015.

Do patient-reported outcome measures cover personal factors important to people with rheumatoid arthritis? A mixed methods design using the International Classification of Functioning, Disability and Health as frame of reference

Background

Personal factors (PFs) are internal factors that determine functioning and the individuals’ experience of disability. Their coverage by patient-reported outcome measures (PROMs) has not been examined in rheumatoid arthritis (RA) so far. The aims of this study were to identify PFs important in the life stories of people with RA and to determine their coverage by PROMs used in RA.

Methods

The qualitative data of people with RA was explored to identify PFs. Additionally a systematic literature search was conducted to find PROMs used in RA. PROMs items were linked to the components, domains and categories of the International Classification of Functioning, Disability and Health (ICF) to determine the coverage of important PFs by PROMs.

Results

Twelve PFs were found to be important in the life stories of people with RA. The PFs coping and reflecting about one’s life in an optimistic way were covered most frequently, each by 14 of the 42 explored PROMs, while job satisfaction was not covered at all. The London Coping with Rheumatoid Arthritis Questionnaire, General Self-Efficacy Scale, Arthritis Self-Efficacy Scale, Rheumatoid Arthritis Self-Efficacy Questionnaire and Revised Ways of Coping Inventory covered most PFs. Nineteen PROMs did not cover any of the PFs.

Conclusion

Several PFs were identified as important in the life stories of people with RA, but only 55% of the PROMS covered some of these PFs. When evaluating PFs important to people with RA, health professionals should be alert on which PROMs can be used to assess which PFs.

Psychometric Properties of the Coping Self-Efficacy Scale Among HIV-Infected Iranian Patients

BACKGROUND

Self-efficacy is an important predicator of coping with stress.

OBJECTIVES

This study aimed to determine the psychometric characteristics of the coping self-efficacy (CSE) scale among HIV-infected Iranian patients.

PATIENTS AND METHODS

Psychometric properties of the CSE scale were examined by using a cross-sectional study design. One hundred and twenty HIV-infected Iranian patients that had been referred to the Counseling of Behavioral Diseases Center at Imam Khomeini Hospital in Tehran, Iran in 2014 were selected through simple random sampling method. To determine the Content Validity Index (CVI) and the content validity ratio (CVR), a panel of experts (n = 20) reviewed items of CSE scale. Reliability was estimated through the internal consistency (n = 30) and the conformity factor analysis was performed.

RESULTS

Iranian version of the CSE scale contained 16 items, including 7 items on the "use of problem-focused coping" method, 5 items on "stopping unpleasant emotions and thoughts", and 4 items on "getting support from friends and family". CVI and CVR scores were 0.79, 0.42 and more, respectively. Internal consistencies (range, 0.64 to 0.84) of 3 subscales were acceptable. Confirmatory factor analysis showed that comparative indices of the model, including CFI, IFI, GFI, RMSEA, and Chi-square (χ2/df) were 0.96, 0.95, 0.84, 0.83, and 1.82, respectively, which indicated a good fit for the data.

CONCLUSIONS

The Iranian version of the CSE scale is a valid instrument to measure the coping self-efficacy among people living with HIV in research and community settings in Iran.

Self-efficacy as an appraisal that moderates the coping-emotion relationship: associations among people with rheumatoid arthritis

The way a coping strategy is expressed might depend on the nature of underlying efficacy expectations. For example, a cognitive coping strategy may have different content depending on efficacy beliefs underpinning the strategy's formulation and application. As such, self-efficacy (SE), as an appraisal, may moderate relationships between coping and outcomes: coping effects may differ depending on SE. This process was examined in 127 rheumatoid arthritis patients attending routine patient education/self-management programmes. Participants completed questionnaire measures of SE, coping, anxiety and depression at baseline and at 8 weeks follow-up. Regression analyses focused on coping and SE change variables, and their concurrent association with measures of change in anxiety and depression. Results highlighted contributions to these emotional variables from interactions between coping and SE. The nature of associations between coping and emotional outcomes was found to differ according to efficacy appraisals. This may have implications for clinical practice in that the adaptive significance of adjustment efforts may differ according to underlying SE.

Does self-efficacy influence recovery and well-being in osteoarthritis patients undergoing joint replacement? A systematic review

Objective:

To investigate the role of self-efficacy in functional recovery and well-being outcomes in osteoarthritis patients, undergoing hip or knee replacement surgery.

Data sources:

Studies were identified using MEDLINE via PUB med, PsycINFO and CINAHL from inception to July 2013.

Methods:

Three search strategies that combined key terms of ‘self-efficacy’, ‘functional recovery’, ‘well-being’ and ‘joint replacement’ were applied. Titles and abstracts were screened for eligibility and, accordingly, potentially eligible studies were retrieved for review. Included studies were assessed in terms of their quality, and data were extracted by two independent reviewers. A narrative synthesis of results was conducted.

Results:

In total, 836 articles were identified and after electronic de-duplication, 708 articles remained. After screening 15 articles were retrieved as potentially eligible and eight articles were included in the review. Of the eight studies ( n = 967 patients), seven had a prospective design and all studies were considered of good quality. No fully conclusive evidence for the influence of self-efficacy upon functional recovery outcomes was found. When the timing of self-efficacy measurement was examined, post-operative self-efficacy was found to be related to functional recovery outcomes.

Conclusion:

Presurgical self-efficacy was the least consistent predictor of functional outcomes while postoperative self-efficacy was more consistently associated with recovery outcomes such as longer distance ambulation, exercise repetition and frequency, walking speed and disability.

Measurement properties of instruments assessing self-efficacy in patients with rheumatic diseases

The measurement properties of instruments assessing self-efficacy (SE) in patients with rheumatic diseases were reviewed. The consensus-based standards for the selection of health measurement instruments (COSMIN) checklist was applied following systematic searches of seven electronic databases from 1989 to December 2011. Fifteen articles met the inclusion criteria that included the arthritis SE scales (ASES), generalized SE scale (GSES), joint protection SE scale (JP-SES), Marcus & Resnick SE exercise behaviour (SEEB) instruments, and RA SE scale (RASE). The ASES and RASE have undergone more than one evaluation. There was little formal evaluation of content validity for the instruments. Evidence for the RASE suggests that it is not unidimensional. The JP-SES and SEEB were evaluated using modern psychometric methods. The instruments require further evaluation before application. The quality of the evidence for the ASES and RASE is generally poor. The generic focus of the GSES limits its relevance. The JP-SES and SEEB have only undergone one evaluation and that relating to the latter was narrow in scope. Future studies should address these methodological weaknesses.

Association of self-efficacy and outcome expectations with physical activity in adults with arthritis

Background and Purpose. The purpose of this study is to determine whether higher baseline levels of (a) self-efficacy for physical activity, (b) self-efficacy for arthritis self-management, and (c) outcome expectations for exercise are associated with higher physical activity levels following an exercise intervention for adults with arthritis. Methods. A secondary analysis of the intervention cohort (n = 130) within a randomized controlled trial of the People with Arthritis Can Exercise program was performed. Multiple linear regression evaluated the relationship between physical activity at a time point three months after the completion of an exercise intervention and three main explanatory variables. Results. After controlling for baseline physical activity, neither self-efficacy for arthritis self-management nor outcome expectations for exercise related to three-month physical activity levels. There was a relationship between three-month physical activity and self-efficacy for physical activity. Conclusions. Future research is needed to evaluate the ability of self-efficacy-enhancing programs to increase physical activity in adults with arthritis.

The impact on self-efficacy of different types of follow-up care and disease status in patients with rheumatoid arthritis--a randomized trial

OBJECTIVE

To explore the impact from different types of outpatient care, demographic and disease related variables on self-efficacy beliefs (SE) in patients with established rheumatoid arthritis (RA) after completing an educational program.

METHODS

287 adult RA outpatients with low disease activity and moderate physical disability from two Danish rheumatology clinics were randomized for follow-up care. (1) planned rheumatologist's consultations, (2) a shared care model without planned consultations, (3) planned nursing consultations. The participants' SE were assessed by the Danish versions of the rheumatoid arthritis self-efficacy questionnaire (RASE) and the arthritis self-efficacy scale (ASES). Data were collected at baseline, 3 months and one-year follow up and were explored in random intercept models.

RESULTS

Following an educational programme the nursing group increased or stabilized their SE during the first year compared to the medical and the shared care group. SE in the shared care group did not differ significantly from the medical group. No difference between the groups was seen in disease activity at any time.

CONCLUSION

Nursing consultations provide opportunities for maintenance of the patients' SE after patient education.

PRACTICE IMPLICATIONS

Implementation of nursing consultations as part of follow-up care in patients with stable RA is recommended.

Self-efficacy as an outcome measure and its association with physical disease-related variables in persons with rheumatoid arthritis: a literature review

BACKGROUND

Studies have demonstrated a positive impact of patient education on self-efficacy in persons with rheumatoid arthritis (RA). However, the relationship between self-efficacy, physical disease-related variables and educational interventions has not yet been reviewed.

AIM

The aims of this study, in relation to persons with RA, were: 1) to provide an overview of the existing research into the association between self-efficacy and physical disease-related variables and, with this knowledge, 2) to provide an overview of the existing research on the effect of different types of educational interventions on self-efficacy.

METHOD

A systematic literature search was performed using eight databases, based on the terms 'rheumatoid arthritis' AND 'self-efficacy'. In total, 74 studies reporting associations between self-efficacy and physical disease-related variables and using self-efficacy as an outcome measure in educational interventions were included.

RESULTS

The scores obtained by the most commonly used questionnaire, the Arthritis Self-Efficacy Scale (ASES), was highly associated with physical disability, pain, fatigue and disease duration. If educational activities had a positive impact on self-efficacy, disease-related variables usually improved as well. Evidence is scarce as to whether disease-related variables affect patients' self-efficacy or vice versa and whether individual consultations can affect patients' self-efficacy.

CONCLUSION

The scores attained by the ASES is highly associated with physical disease-related variables. This relationship requires further research using a specific study design to restrict bias when evaluating the impact of interventions on self-efficacy in persons with RA. Research is needed on whether individual consultations can affect patients' self-efficacy. Disease-related variables do not affect the Rheumatoid Arthritis Self-Efficacy (RASE) questionnaire but this needs further exploration.

Self-management of fatigue in rheumatoid arthritis: a randomised controlled trial of group cognitive-behavioural therapy

OBJECTIVES

To investigate the effect of group cognitive behavioural therapy (CBT) for fatigue self-management, compared with groups receiving fatigue information alone, on fatigue impact among people with rheumatoid arthritis (RA).

METHODS

Two-arm, parallel randomised controlled trial in adults with RA, fatigue ≥ 6/10 (Visual Analogue Scale (VAS) 0-10, high bad) and no recent change in RA medication. Group CBT for fatigue self-management comprised six (weekly) 2 h sessions, and consolidation session (week 14). Control participants received fatigue self-management information in a 1 h didactic group session. Primary outcome at 18 weeks was the impact of fatigue measured using two methods (Multi-dimensional Assessment of Fatigue (MAF) 0-50; VAS 0-10), analysed using intention-to-treat analysis of covariance with multivariable regression models.

RESULTS

Of 168 participants randomised, 41 withdrew before entry and 127 participated. There were no major baseline differences between the 65 CBT and 62 control participants. At 18 weeks CBT participants reported better scores than control participants for fatigue impact: MAF 28.99 versus 23.99 (adjusted difference -5.48, 95% CI -9.50 to -1.46, p=0.008); VAS 5.99 versus 4.26 (adjusted difference -1.95, 95% CI -2.99 to -0.90, p<0.001). Standardised effect sizes for fatigue impact were MAF 0.59 (95% CI 0.15 to 1.03) and VAS 0.77 (95% CI 0.33 to 1.21), both in favour of CBT. Secondary outcomes of perceived fatigue severity, coping, disability, depression, helplessness, self-efficacy and sleep were also better in CBT participants.

CONCLUSIONS

Group CBT for fatigue self-management in RA improves fatigue impact, coping and perceived severity, and well-being.

TRIAL REGISTRATION

ISRCTN 32195100.

Self-efficacy in rheumatoid arthritis: translation and test of validity, reliability and sensitivity of the Danish version of the Rheumatoid Arthritis Self-Efficacy Questionnaire (RASE)

OBJECTIVES

To describe the translation and test of the Danish version of the original British 'Rheumatoid Arthritis Self-Efficacy Questionnaire' (RASE).

METHODS

The questionnaire was forward and back translated by individuals with Danish and English as their respective primary languages. The questionnaire was tested by five lay-people and in the field by 10 + five persons with rheumatoid arthritis (RA). A test-retest was performed on 62 outpatients with RA. The sensitivity of the adapted Danish version of RASE (RASE-DK) was finally tested on 106 outpatients with RA - before, immediately after and three months after they had participated in a short self-management course performed by a multidisciplinary team.

RESULTS

RASE-DK showed good face validity, but 'relaxation' was interpreted in various ways. Internal consistency evaluated by Cronbach's alpha was 0.91. Reliability evaluated by the intra-class correlation coefficient (ICC) was 0.88. A Bland-Altman plot showed good agreement. RASE-DK, like the original English version of RASE, was not associated with disease activity (Disease Activity Score, DAS-28) or disability (Health Assessment Questionnaire, HAQ), and correlated significantly with the Arthritis Self-Efficacy Scale (ASES) subscales 'other' and 'pain', and total ASES. RASE-DK showed a highly significant change, from baseline to immediately after participation in the short course (p < 0.001). The effect faded during the following three months.

CONCLUSION

RASE-DK met the appropriate standards for validity, reliability and sensitivity, and is appropriate for use in Denmark. However, the concept of self-efficacy may be too abstract for a few individuals, and relaxation is interpreted in various ways by the Danish patients.

Treatment-related and patient-related expectations of patients with musculoskeletal disorders: a systematic review of published measurement tools

OBJECTIVES

Many of the various types of treatments that are used in the rehabilitation of patients with musculoskeletal disorders (MSD) require active involvement of the patient. Patient expectations, for instance with regard to treatment, such as physical therapy, could be important prognostic factors. Behavioral interventions to modify those expectations might improve treatment outcome and prevent chronicity. To facilitate this field of research, valid and reliable measurement instruments to assess patient expectations are needed. The aim of this systematic overview was to identify all the relevant published measurement instruments and to describe their clinimetric properties.

METHODS

A systematic search of the relevant databases was performed, and all relevant articles were included. Two independent reviewers included the relevant articles and assessed the clinimetric properties.

RESULTS

A total of 24 measurement instruments were eligible for inclusion in the review. For most types of MSD, there was only one instrument available. Construct validity, assessed with factor analysis, was tested in two-thirds of the instruments. Other forms of construct validity (eg, convergent validity and divergent validity) were only tested in 10 of the 24 instruments. Reproducibility was only tested in 5 instruments, but the test methods were seldom satisfactory, hampering the interpretation of these results.

DISCUSSION

In summary, many instruments have been developed for the treatment of many types of MSD, but the data regarding the validity or reliability of many of the instruments included in this review are scarce. Therefore, in the first place, we strongly recommend that further research is to be carried out to assess the validity and reliability of these instruments. Secondly, it is necessary to assess the instrument's ability to detect change to be able to evaluate the effectiveness of interventions that focus on self-efficacy and outcome expectations.

Can the application of control theory assist patient management in rheumatoid arthritis?

Supporting patient self-management is an important part of the care of patients with rheumatoid arthritis (RA) but patients vary in their capacity and willingness to manage their illness and may feel overwhelmed by the challenge of controlling the impact on their life. This paper discusses the value and importance of control theory and how it might be applied to enhance patients' self-management. Not only does it offer a means of identifying those who might have greatest difficulty in managing their illness, but it also points the way to effective interventions.

Item Response Theory Analysis of Two Questionnaire Measures of Arthritis-Related Self-Efficacy Beliefs from Community-Based US Samples

Using item response theory (IRT), we examined the Rheumatoid Arthritis Self-efficacy scale (RASE) collected from a People with Arthritis Can Exercise RCT (346 participants) and 2 subscales of the Arthritis Self-efficacy scale (ASE) collected from an Active Living Every Day (ALED) RCT (354 participants) to determine which one better identifies low arthritis self-efficacy in community-based adults with arthritis. The item parameters were estimated in Multilog using the graded response model. The 2 ASE subscales are adequately explained by one factor. There was evidence for 2 locally dependent item pairs; two items from these pairs were removed when we reran the model. The exploratory factor analysis results for RASE showed a multifactor solution which led to a 9-factor solution. In order to perform IRT analysis, one item from each of the 9 subfactors was selected. Both scales were effective at measuring a range of arthritis SE.

Patient perspective of measuring treatment efficacy: the rheumatoid arthritis patient priorities for pharmacologic interventions outcomes

OBJECTIVE

Collaboration with patients with rheumatoid arthritis (RA) highlights that outcomes important to them include fatigue, coping, and life enjoyment. However, these are not commonly measured in clinical trials. There is little evidence about which outcomes patients would prioritize, or what factors influence patients' prioritization. Our objective was to develop a complementary core set with patients to promote inclusion of their priority outcomes in pharmacologic interventions.

METHODS

Nominal groups were conducted with RA patients to rank 63 outcomes generated from previous in-depth interviews. A multicenter postal survey provided the final selection of core outcomes for the Rheumatoid Arthritis Patient Priorities for Pharmacologic Interventions (RAPP-PI), in which RA patients rated the importance of the priority outcomes from the nominal groups and ranked the top 6.

RESULTS

Twenty-six patients participated in 5 nominal group discussions and reduced the 63 initial outcomes to the 32 most important. A total of 254 participants in the survey ranked priority treatment outcomes to form the RAPP-PI: pain, activities of daily living, joint damage, mobility, life enjoyment, independence, fatigue, and valued activities. The 8 priorities represent 3 domains of treatment outcomes: direct impact of RA, psychosocial well-being, and function/participation. Chi-square tests showed that disease severity, disease duration, sex, and patients' perceptions of managing, self-efficacy, and normality influenced the selection of priority treatment outcomes.

CONCLUSION

Collaboration with patients has captured their perspectives of priority outcomes from pharmacologic interventions. Although there is some overlap with professional core outcomes, the additional use of this complementary set will give a broader evaluation of effectiveness of interventions from the key stakeholders: patients.

Development and psychometric properties of a joint protection self-efficacy scale

INTRODUCTION

Self-efficacy is one of the most powerful determinants of behaviour change. To increase effectiveness of joint protection (JP) education, it may be important to address perceptions of JP self-efficacy directly. The aim of this study was to develop a scale to measure JP self-efficacy (JP-SES) in people with rheumatoid arthritis (RA).

METHODS

Instrument development included item generation, construct validity, and reliability testing. Rasch analysis was applied to determine construct validity and the revised JP-SES was tested again to confirm validity and establish test-retest reliability and internal consistency.

RESULTS

A total of 46 items were generated by literature review, occupational therapists, and people with RA. After semi-structured interviews and field-testing with RA participants, a 26-item questionnaire draft was constructed and tested. Rasch analysis to determine construct validity reduced the JP-SES to 13 items with good overall fit values. Rasch analysis of confirmatory validity resulted in a final 10-item version of the JP-SES. Test-retest results supported the validity of the scale, with high internal consistency (α = 0.92) and good test-retest reliability (r(s) = 0.79; p < 0.001).

CONCLUSIONS

The JP-SES is a valid and reliable scale to assess perceived ability of people with RA to apply JP methods. The JP-SES could help stimulate the use of efficacy-enhancing methods in JP education.

Self-efficacy instruments for patients with chronic diseases suffer from methodological limitations--a systematic review

Background

Measurement of self-efficacy requires carefully developed and validated instruments. It is currently unclear whether available self-efficacy instruments for chronic diseases fulfill these requirements. Our aim was to systematically identify all existing self-efficacy scales for five major chronic diseases and to assess their development and validation process.

Methods

We conducted a systematic literature search in electronic databases (MEDLINE, PSYCHINFO, and EMBASE) to identify studies describing the development and/or validation process of self-efficacy instruments for the five chronic diseases diabetes, chronic obstructive pulmonary disease (COPD), asthma, arthritis, and heart failure. Two members of the review team independently selected articles meeting inclusion criteria. The self-efficacy instruments were evaluated in terms of their development (aim of instrument, a priori considerations, identification of items, selection of items, development of domains, answer options) and validation (test-retest reliability, internal consistency reliability, validity, responsiveness) process.

Results

Of 584 potentially eligible papers we included 25 (13 for diabetes, 5 for asthma, 4 for arthritis, 3 for COPD, 0 for heart failure) which covered 26 different self-efficacy instrument versions. For 8 instruments (30.8%), the authors described the aim before the scales were developed whereas for the other instruments the aim was unclear. In one study (3.8%) a priori considerations were specified. In none of the studies a systematic literature search was carried out to identify items. The item selection process was often not clearly described (38.5%). Test-retest reliability was assessed for 9 instruments (34.6%), validity using a correlational approach for 18 (69.2%), and responsiveness to change for 3 (11.5%) instruments.

Conclusion

The development and validation process of the majority of the self-efficacy instruments had major limitations. The aim of the instruments was often not specified and for most instruments, not all measurement properties that are important to support the specific aim of the instrument (for example responsiveness for evaluative instruments) were assessed. Researchers who develop and validate self-efficacy instruments should adhere more closely to important methodological concepts for development and validation of patient-reported outcomes and report their methods more transparently. We propose a systematic five step approach for the development and validation of self-efficacy instruments.

A randomized controlled trial of the people with arthritis can exercise program: symptoms, function, physical activity, and psychosocial outcomes

OBJECTIVE

To evaluate the basic 8-week People with Arthritis Can Exercise (PACE) program for improvements in primary (symptoms, functioning, level of physical activity) and secondary (psychosocial) outcomes.

METHODS

A total of 346 individuals with self-reported arthritis from 18 sites participated in a randomized controlled trial of PACE. Outcomes were measured at baseline and 8 weeks. The intervention group completed self-reported assessments at 3 and 6 months. Two-level multiple linear regression models were estimated to calculate adjusted outcome means in the intervention and control groups. A mixed-effects repeated-measures model was used to calculate adjusted means in the intervention group at 3 and 6 months. Both intent-to-treat (ITT) and as-treated (AT) analyses were conducted.

RESULTS

At 8 weeks, the intervention group had improvements in the following outcomes: 2 symptom outcomes (pain, fatigue) and 1 psychosocial outcome (self-efficacy for managing arthritis) in the ITT analyses; 1 symptom outcome (pain), 1 function outcome (chair stands), and 1 psychosocial outcome (self-efficacy for arthritis management) in the AT analyses. In addition, completers who attended>or=9 classes had improvements in 3 symptom outcomes (pain, fatigue, stiffness), 2 function outcomes (10-pound lifts, chair stands), and 1 psychosocial outcome (self-efficacy for arthritis management) at 8 weeks. Relative to baseline, PACE participants maintained significant improvements in symptoms at 6 months, but declined in function and self-efficacy for exercise.

CONCLUSION

If adults with arthritis attend a majority of PACE classes, they may expect improvements in symptoms, self-efficacy for arthritis management, and upper and lower extremity function. Achieving sustained improvement in outcomes may require continued participation in PACE.

Sensitivity to change of the Rheumatoid Arthritis Self-Efficacy scale (RASE) and predictors of change in self-efficacy

OBJECTIVES

Patient education in rheumatoid arthritis (RA) aims to improve health outcomes by prompting people to adopt self-management behaviours. One precursor for initiating behaviour change is self-efficacy (SE), a belief that you can do a task. This study tested the sensitivity to change of a new scale to measure SE for self-management in people with RA, the Rheumatoid Arthritis Self-Efficacy scale (RASE). Exploratory analysis examined potential predictors of change in SE.

METHODS

People with RA at 11 rheumatology centres, who had accepted an education programme as part of clinical care, completed questionnaires at baseline, and two and eight weeks after their programme end. Programmes were not standardized, as this was a pragmatic study in clinical practice.

RESULTS

A total of 128 patients participated. After controlling for baseline scores, the RASE showed small but significant improvements in SE from baseline (RASE 107.57, CI 105.42-109.72) to two weeks after programme end (RASE 110.80, CI 108.60-112.99), and eight weeks (RASE 110.62, CI 108.40-112.85, p<0.001). Standardized response means, calculated both by absolute and percentage change, were 0.339 and 0.371 at two weeks after programme end, and 0.321 and 0.352 at eight weeks. Changes in the RASE were associated with behaviour initiation at two and eight weeks (r=0.419, r=0.342, p<0.001). No substantial predictors of change in SE could be identified.

CONCLUSIONS

The RASE is sensitive to change in a cohort of people with RA in the UK receiving education programmes as routine clinical care. Exploratory analysis did not identify clinical or psychological factors that predict change in SE, suggesting that programmes should not be restricted to particular patients.

Perceptions of self-efficacy and rehabilitation among neurologically disabled adults

OBJECTIVE

To explore constructs relevant to self-efficacy in neurological rehabilitation.

DESIGN

Qualitative methods using semi-structured interviews.

SETTING

Specialist neurological rehabilitation unit, Liverpool, UK.

SUBJECTS

Twenty-four patients (12 male) with experience of inpatient rehabilitation, aged 17-59 (mean 38.1) years at onset, with diagnoses of stroke (n = 8), traumatic brain injury (n = 6) or other monophasic neurological impairment (n = 10).

RESULTS

Eleven themes emerged from the data that reflect self-efficacy beliefs: self-reliance and independence were deemed important and many patients recognized the importance of determination, making time to take an active role and working in partnership with the multidisciplinary team. Patients had complex information needs but were able to use goal setting and the vicarious experiences of other inpatients to map out the stages of their own recovery. It was important for patients to be able to recognize for themselves that they were making progress and they valued external reassurance on this from other patients, staff and visitors. A number of difficulties were identified that interfered with their developing self-efficacy in rehabilitation, such as structuring their time. Two different models for rehabilitation emerged from the data, 'recovery' and 'adaptation'.

CONCLUSIONS

Patients consistently identified 11 factors falling in the supraordinate themes of self, others and process, and these influenced their self-efficacy to participate in neurological rehabilitation. Patients consider rehabilitation in terms of either an 'adaptation' or 'recovery' model.

A new instrument for measuring self-efficacy in patients with an anterior cruciate ligament injury

It has been suggested that self-efficacy belief is of major importance for rehabilitation outcome after sports-related injuries. No instruments are, however, available to evaluate perceived self-efficacy for prognostic and outcome expectations in patients with an anterior cruciate ligament (ACL) injury. Perceived self-efficacy is defined as a judgment of one's potential ability to carry out a task, rather than a measure of whether or not one actually can or does perform the task. The purpose of this study was to develop a reliable and valid instrument for measuring perceived self-efficacy in patients with an ACL injury. A total of 210 male and female patients with an ACL injury were included in this study. The items were generated by health professionals with long clinical experience of patients with an ACL injury and by discussions with patients. After item analysis and item reduction, based on the results from 88 patients, the final 22-item version of the Knee Self-Efficacy Scale (K-SES) was evaluated in 18 patients for test-retest reliability and in 104 patients for internal consistency and validity. The K-SES was compared with the Multidimensional Health Locus of Control (MHLC), Coping Strategies Questionnaire (CSQ), SF-36 and Knee Injury and Osteoarthritis Outcome Score (KOOS) instruments. A factor analysis was also performed on the K-SES. The test-retest revealed a correlation of r(s)=0.73 between test-days and an intraclass correlation coefficient of 0.75. No significant difference between test-days was found. The internal consistency was 0.94, as calculated with Cronbach's alpha. There were low correlations between the K-SES and MHLC and the K-SES and CSQ, respectively. A strong correlation was found between the K-SES and physical functioning, as measured by the SF-36 (r(s)=0.8). All the sub-scales in the KOOS correlated moderately to strongly (r(s)=0.4-0.7) to the K-SES. The factor analysis produced two factors of importance. Factor one was related to how patients perceived their present physical performance/function, while factor two was related to how patients perceived the future physical performance/prognosis of their knee. Good reliability and good face, content, construct and convergent validity were demonstrated for this new instrument (K-SES) for measuring perceived self-efficacy in patients with an ACL injury. The K-SES is recommended for studies designed to evaluate prognostic and outcome expectations of perceived self-efficacy in patients with an ACL-insufficient knee.

An integrative model of shared decision making in medical encounters

OBJECTIVE

Given the fluidity with which the term shared decision making (SDM) is used in teaching, assessment and research, we conducted a focused and systematic review of articles that specifically address SDM to determine the range of conceptual definitions.

METHODS

In April 2005, we ran a Pubmed (Medline) search to identify articles published through 31 December 2003 with the words shared decision making in the title or abstract. The search yielded 681 citations, 342 of which were about SDM in the context of physician-patient encounters and published in English. We read and reviewed the full text of all 342 articles, and got any non-redundant references to SDM, which yielded an additional 76 articles.

RESULTS

Of the 418 articles examined, 161 (38.5%) had a conceptual definition of SDM. We identified 31 separate concepts used to explicate SDM, but only "patient values/preferences" (67.1%) and "options" (50.9%) appeared in more than half the 161 definitions. Relatively few articles explicitly recognized and integrated previous work.

CONCLUSION

Our review reveals that there is no shared definition of SDM. We propose a definition that integrates the extant literature base and outlines essential elements that must be present for patients and providers to engage in the process of SDM.

PRACTICE IMPLICATIONS

The integrative definition of SDM is intended to provide a useful foundation for describing and operationalizing SDM in further research.

Development and validation of the Communication and Attitudinal Self-Efficacy scale for cancer (CASE-cancer)

We sought to develop a reliable and valid measure of patient self-efficacy within the context of productive communication and positive attitude for cancer patients. A set of 19 potential items for the Communication and Attitudinal Self-Efficacy scale for cancer (CASE-cancer) was pilot tested with 50 cancer patients. Based on the pilot test, item valence was made consistent (i.e., all items worded positively) and the response scale was simplified. The CASE-cancer was then administered to 127 persons receiving cancer treatment at general oncology clinics in Shreveport, Louisiana and Chicago, Illinois. Psychometric analyses revealed three 4-item factors: understanding and participating in care, maintaining a positive attitude, and seeking and obtaining information. The CASE-cancer proved to have high internal consistency and construct validity. Moreover, scale items performed similarly across literacy levels. The CASE-cancer is a psychometrically-sound tool that may provide new information on important mediating factors of cancer care. Our two-step approach to presenting response options may also provide a model for helping lower literate patients more accurately respond to survey items.

Beliefs about medications: a questionnaire survey of people with rheumatoid arthritis

OBJECTIVES

To investigate beliefs about medications held by people with rheumatoid arthritis (RA), what factors are related to these specific medication beliefs, and whether these beliefs influence adherence.

METHODS

The design was a cross-sectional postal questionnaire survey of people with RA. The Beliefs about Medicines Questionnaire was used to assess beliefs about the necessity of medication and concerns about it. Questionnaires were mailed to 600 out-patients with RA.

RESULTS

The response rate was 57.3%. Most (74.3%) respondents agreed or strongly agreed that their arthritis medications are necessary for their health. However, 47.4% were concerned about potential adverse consequences. The overall necessity score (mean 19.2, s.d. 3.13) was higher than the concerns score (mean 15.84, s.d. 3.53; P<0.001). Greater disability was associated with higher necessity scores (r = 0.36; P<0.001). Greater helplessness correlated with higher concerns scores (r = 0.49; P<0.001). There was no association between RA knowledge and beliefs about medications (necessity scale, r = 0.02, P = 0.66; concerns scale, r=-0.08, P = 0.14). Concerns scores for non-adherent participants (mean 17.88, s.d. 3.29) were higher than for the adherent group (mean 15.64, s.d. 3.51; P = 0.002).

CONCLUSIONS

Most people with RA have positive beliefs about the necessity of their medication. However, levels of concern are high and associate with helplessness and non-adherence. The Beliefs about Medicines Questionnaire may identify people at risk of poor adherence and provide a focus for patients to discuss their beliefs, providing opportunities to improve adherence.

Clinical and psychological outcomes of patient education in rheumatoid arthritis

OBJECTIVE

Evidence that patient education improves outcome in self-selected patients is often based on studies using patients with a mixture of diagnoses (primarily osteoarthritis) and where the education is delivered in a community setting. This study explored whether hospital outpatients with rheumatoid arthritis (RA) who were offered a self-management programme showed a similar response.

METHODS

A randomized controlled trial was undertaken of either observation or observation plus an educational intervention of five sessions (12.5 hours) designed to enhance self-management. Pain and self-efficacy for pain were the primary outcome measures. These and other standardized assessments were made at 0, 4, 8 and 36 weeks for a variety of psychological and disease states. Knowledge of RA and its treatment was measured at 0 and 4 weeks using a multiple-choice questionnaire.

RESULTS

Sixty-eight of 79 randomized patients provided adequate data. In those randomized to be offered education, knowledge of RA and its treatment increased by 18% compared to 9% in controls (p = 0.058). Self-efficacy for pain improved between weeks 0 and 4 by 10.3% (p = 0.015) in those offered education, and by 14.1% in those who were offered and accepted education (p = 0.001) but the difference from controls was not maintained after four weeks. There were no significant differences between groups in pain or in any of the remaining variables. Most patients reported that the education had been helpful.

CONCLUSIONS

Patients offered education gained knowledge and reported personal benefit, but only improved in self-efficacy for pain and only for a short time. RA patients drawn from hospital outpatient clinics and allocated to an educational intervention may not gain changes in health status as measured by the instruments employed in this study.