Evaluation and cultural adaptation of a German version of the AIMS2-SF questionnaire (German AIMS2-SF)

The validity and reliability of the Turkish version of the Arthritis Impact Measurement Scale 2-Short Form (AIMS2-SF) for rheumatoid arthritis

The objective of this study is to investigate the validity and reliability of the Turkish version of the Arthritis Impact Measurement Scale 2-Short Form (AIMS2-SF). Subjects fulfilling the ACR 2010 classification criteria for RA were enrolled into the study. Scale reliability was investigated using test-retest reliability (intra-class correlation coefficient-ICC) and internal consistency approaches (Cronbach's α). Spearman's rank correlation coefficients evaluated relationships between quantitative parameters and validity. Construct validity was assessed by correlating AIMS2-SF with clinical parameters and functional parameters including, Nottingham Health Profile (NHP), Health Assessment Questionnaire (HAQ), Beck Depression Inventory (BDI) and Duruöz Hand Index (DHI). One hundred and sixteen patients (105 females and 11 males) were recruited. The mean age ± standard deviation (SD) was 52.45 ± 11.48 years. Cronbach's α was 0.88 and the ICC was 0.91. There were significant correlations (rho and p values) with parameters directly related to health-related quality of life (HRQoL); NHP subscales (energy levels: 0.54, pain: 0.62, emotional reaction: 0.50, sleep 0.44, social interaction: 0.51, physical activity: 0.61; p < 0.0005), HAQ (0.60, p < 0.0005), BDI (0.63, p < 0.001) and DHI (0.63, p < 0.0005). Poor or non-significant correlations were found for parameters not directly related to QoL, such as age (0.07, p = 0.45) and disease duration (0.12, p = 0.21); however, disease activity (0.43, p < 0.0005) and NRS pain (0.46, p < 0.0005) were correlated with AIMS2-SF as moderate. The Turkish AIMS2-SF version is a reliable and valid tool that may be used to evaluate QoL for RA. The scale can be easily used in daily practice.

Patients' Assessment of Chronic Illness Care (PACIC): Validation and Evaluation of PACIC Scale among Patients with Type 2 Diabetes in Hungary

Introduction:

The aims of this study were to evaluate the psychometric properties of the Hungarian translation of the PACIC in a sample of patients with type 2 diabetes and to reveal the associations between the mean PACIC scores and the number of chronic diseases, or visits to GPs, and specialist. An exploratory factor analysis (EFA) has also been performed to test the structural validity of the PACIC scale.

Methods:

The Hungarian version of PACIC was validated using randomly selected patients with type 2 diabetes (N = 684) from licensed GP practices.

Results:

Floor (1.6%–30.2%) and ceiling effects (11.3–33.6%) were similar of the PACIC scale. The internal consistency of the total scale (Cronbach’s alpha 0.93) was excellent and subscales were good (between 0.73–0.9). The mean scores of each PACIC subscale group were between 2.99–3.53. There was a weak significant correlation between the mean PACIC scores of subscales and the number of GP visits (p < 0.001), and specialist visits (p < 0.001). The EFA identified four factors on the sample (KMO = 0.931). Gender and education showed correlation with some new factors.

Conclusion:

The psychometric properties of the Hungarian version of PACIC questionnaire showed a reasonable level of validity among patients with type 2 diabetes. Now, this instrument is ready to assess the chronic care of diabetic patients in Hungary.

The Western Ontario and McMaster Universities Osteoarthritis, Lequesne Algofunctional index, Arthritis Impact Measurement Scale-short form, and Visual Analogue Scale in patients with knee osteoarthritis: responsiveness and minimal clinically important differences

PURPOSE

The goal of this study was to see whether the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC), Lequesne Algofunctional index and the Arthritis Impact Measurement Scale-short form (AIMS2-SF) could changes after physiotherapy interventions (i.e., responsiveness) and to determine Minimal Clinically Important Difference (MCID) in the performance of the people with knee osteoarthritis.

MATERIALS AND METHODS

A convenient sample of 116 people with knee osteoarthritis completed the tools at baseline and then again after 10 sessions physiotherapy intervention. Two techniques were used to determine responsiveness: The receiver operating characteristics (ROC) method and the correlation analysis.

RESULT

All of the tools showed the AUC of greater than 0.70 (AUC ranges = 0.72 - 0.83). For the WOMAC, Lequesne Algofunctional index, AIMS2-SF and VAS-pain, optimal cutoff points were 12.5, 2.75, 4.5 and 2.5 points, respectively. The gamma correlation between WOMAC, Lequesne Algofunctional index, AIMS2-SF, VAS-pain, and Global Rating Change (GRC) scores was 0.55, 0.52, 0.40, and 0.46, respectively.

CONCLUSION

In people with knee osteoarthritis, the WOMAC has the maximum responsiveness to clinical changes. The MCID values identify in this study will aid in determining whether or not an individual with knee osteoarthritis has undergone a true improvement since receiving physiotherapy. IMPLICATIONS FOR REHABILITATIONThe results of this study provide valuable information regarding to the ability of outcome measures to detect treatment effects in patients with knee osteoarthritis.The WOMAC questionnaire is a responsive tool to measure the changes in functional activity due to physiotherapy intervention in patients with knee osteoarthritis.A patient with knee osteoarthritis had to change at least 12.5 scores on the WOMAC to be judged as having clinically changed.

eHealth-supported case management for patients with panic disorder or depression in primary care: Study protocol for a cRCT (PREMA)

Background

Panic disorder (PD), frequently occurring with agoraphobia (AG), and depression are common mental disorders in primary care and associated with considerable individual and societal costs. Early detection and effective treatment of depression and PD/AG are of major importance. Cognitive behavioural exposure exercises have been shown to be effective in reducing anxiety and depressive symptoms. Practice team-based case management can improve clinical outcomes for patients with chronic diseases in primary care. The present study aims at evaluating the effects and cost-effectiveness of a primary care team-based intervention using behavioural therapy elements and case management supported by eHealth components in patients with PD/AG or depression compared to treatment as usual.

Methods/design

This is a two-arm cluster-randomized, controlled trial (cRCT). General practices represent the units of randomisation. General practitioners recruit adult patients with depression and PD ± AG according to the International Classification of Diseases, version 10 (ICD-10). In the intervention group, patients receive cognitive behaviour therapy-oriented psychoeducation and instructions to self-managed exposure exercises in four manual-based appointments with the general practitioner. A trained health care assistant from the practice team delivers case management and is continuously monitoring symptoms and treatment progress in ten protocol-based telephone contacts with patients. Practice teams and patients are supported by eHealth components. In the control group, patients receive usual care from general practitioners. Outcomes are measured at baseline (T0), at follow-up after 6 months (T1), and at follow-up after 12 months (T2). The primary outcome is the mental health status of patients as measured by the Mental Health Index (MHI-5). Effect sizes of 0.2 standard deviation (SD) are regarded as relevant. Assuming a drop-out rate of 20% of practices and patients each, we aim at recruiting 1844 patients in 148 primary care practices. This corresponds to 12.5 patients on average per primary care practice. Secondary outcomes include depression and anxiety-related clinical parameters and health-economic costs.

Discussion

If the intervention is more effective than treatment as usual, the three-component (cognitive behaviour therapy, case-management, eHealth) primary care-based intervention for patients suffering from PD/AG or depression could be a valuable low-threshold option that benefits patients and primary care practice teams.

Trial registration

German clinical trials register, DRKS00016622. Registered on February 22nd, 2019.

How Much Information and Participation Do Patients with Inflammatory Rheumatic Diseases Prefer in Interaction with Physicians? Results of a Participatory Research Project

OBJECTIVE

Patient preferences for information and participation in medical decision-making are important prerequisites to realize a shared decision between patients and physicians. This paper aims at exploring these preferences in German patients with inflammatory rheumatic diseases and at identifying relevant determinants of these preferences.

METHODS

In a cross-sectional survey, adult patients with rheumatoid arthritis (RA), spondyloarthritis (SA) or different connective tissue diseases (CTS) filled out a questionnaire. Data were collected via a written questionnaire (1) sent to members of a regional self-help group or (2) handed out to patients at their rheumatologist's appointment, and (3) via an online questionnaire available nationwide. Measurements included information and participation preferences (Autonomy Preference Index; API: 0-100), as well as health-related and sociodemographic variables. Analyses included ANOVAs (group differences) and multiple regression analyses (determinants of preferences). To ensure the analysis was patient-centered we involved a trained representative of the German League Against Rheumatism as a research partner.

RESULTS

1616 patients returned questionnaires [44% response, 79% female, mean age 54 years, diagnoses 63% RA, 28% SA, 19% CTS]. Participants reported a concurring major preference for information but vastly different preferences for participation. A greater preference for participation was associated with female sex, younger age, higher household income, and self-help group membership. Conversely, a lower preference for participation was linked to blue-collar workers, retirement, higher confidence in the rheumatologist, and poorer health literacy.

CONCLUSION

Whereas patients consistently welcome comprehensive information about their disease and its different treatment options, not all patients wish to be involved in therapeutic decisions. Especially older patients with lower education status and lower health literacy, but higher confidence in their rheumatologist tend to leave the decisions rather to the physician. Different preferences should be considered in the doctor-patient communication.

Evaluating the consequences of rheumatoid arthritis

Patients and non-patients tend to attach different utility values to the state of suffering from specific illnesses. This observation naturally leads to the question whose utility values should be used as the basis in cost-effectiveness analysis (CEA). Intuitively, one would presume that patients are better informed about the consequences of their illness, and public authorities should, therefore, use the patients' utility values in CEA. Contrary to this presumption, it has been argued that society at large should determine which values are to be used and not the patients because, in the end, it is societal resources that are to be allocated. Against this background, we use data from a discrete choice experiment (DCE) that was completed by patients of rheumatoid arthritis (RA) and non-patients to explore the discrepancies between the two groups' utility estimates for typical consequences of RA. Our results indicate that both groups attach remarkably similar part-worth utilities to the symptoms pain, fatigue, and functional limitations. However, non-patients significantly undervalue the ability to work when compared to patients.

The Patient Assessment of Chronic Illness Care questionnaire: evaluation in patients with mental disorders in primary care

The Chronic Care Model provides evidence-based recommendations to improve the care for patients with chronic conditions. The Patient Assessment of Chronic Illness Care questionnaire (PACIC) is an instrument to evaluate the patient's perspective on receipt of care delivered in the five domains patient activation, delivery system, goal setting, problem solving, and follow-up. The aim of this study was to assess the psychometric characteristics of the PACIC in 442 primary care patients with major depression. The psychometric properties were good. We found possible ceiling effects in the two subscales 'patient activation' (12.9%) and 'problem solving/contextual' (8.9%), as well as floor effects in 'goal setting/tailoring' (4.6%). The Cronbach's α coefficient for the total scale was excellent (0.91). We found two major factors, which we labeled according to the PACIC domains as composite factors 'patient activation and problem solving' as well as 'goal setting and coordination'. The perspective of patients with mental disorders, such as depression, on primary chronic illness care can be assessed adequately by the PACIC.

Cultural adaptation and validation of the Persian version of the Arthritis Impact Measurement Scales 2-Short Form in patients with osteoarthritis of the knee

PURPOSE

To translate and validate the Persian version of the Arthritis Measurement Scales 2-Short Form (AIMS2-SF) in patients with osteoarthritis (OA) of the knee.

METHOD

The translation and cultural adaptation of the original questionnaire was carried out in accordance with published guidelines. One hundred and fourteen consecutive Persian-speaking patients with OA of the knee were participated in this study. The Short Form Health Survey (SF-36) and visual analogue scales (VAS) for pain and joint stiffness were used to test convergent validity of the Persian AIMS2-SF. In addition, 35 randomly selected patients were asked to complete the questionnaire 3 days later for the second time.

RESULTS

The Persian AIMS2-SF showed statistically significant good convergent validity, as assessed with the relevant subscales of the Persian SF-36 and VAS for pain and joint stiffness. Cronbach's alpha coefficient for the Persian AIMS2-SF components ranged from 0.68 to 0.80. The Persian AIMS2-SF components showed good to excellent test-retest reliability with intraclass correlation coefficient ranged from 0.72 to 0.83 (p < 0.01).

CONCLUSIONS

The Persian version of the AIMS2-SF is a reliable and valid instrument to measure functional disability and health-related quality of life in patients with OA of the knee in Iran. It is simple and easy to use and now can be applied in clinical settings and future outcome studies in Iran.

Satisfaction of osteoarthritis patients with provided care is not related to the disease-specific quality of life

BACKGROUND

Osteoarthritis (OA) has a high prevalence in primary care. Patient satisfaction is an important indicator for the quality of care provided to OA patients. Little is known about satisfaction of patients with this condition in a primary care setting in Germany. The aim of the study was to assess current satisfaction of patients and reveal possible disease and quality of life related predictors.

METHODS/DESIGN

Seventy-five German GPs approached 1250 patients with OA consecutively. Sociodemographics, OA-specific quality of life (GERMAN-AIMS2-SF), co-morbidities and depression (using PHQ-9) were assessed. Patient satisfaction was measured by means of the European Task Force on Patient Evaluations of General Practice (EUROPEP) instrument. A stepwise linear regression analysis with the EUROPEP score as dependent variable controlled for the amount of GP visits was performed to assess predictors of satisfaction.

RESULTS

A total of 1021 OA patients returned the questionnaire. The adjusted R(2) of the final model was 0.270 (P < 0.001). The main predictors were the PHQ-9 score (beta = -0.372; P < 0.001), age (beta = -0.185; P < 0.001), living alone (beta = -0.209; P < 0.001) and number of co-morbidities (beta = -0.152; P < 0.001). The only disease-related factor which remained as predictor of patient satisfaction was duration of OA (beta = -0.105; P = 0.008).

DISCUSSION

The finding that depression and social factors are more important for patient satisfaction with provided care than disease-related aspects suggests that these factors need to be considered carefully in treatment. This represents a big challenge within an increasingly specialized health care system. The General Practitioner as the regular and first-choice provider of health care seems to be the most appropriate instance who can accomplish this.

Translation and validation of the Persian version of the Arthritis Impact Measurement Scales 2-Short Form (AIMS2-SF) in patients with rheumatoid arthritis

Cultural adaptation and validation of the Persian version of the Arthritis Measurement Scales 2-Short Form (AIMS2-SF). The translation and cultural adaptation of the original questionnaire was carried out in accordance with published guidelines. Three hundred and fifty consecutive Persian-speaking patients with rheumatoid arthritis (RA) were asked to complete the AIMS2-SF, the Short Form Health Survey (SF-36), and four visual analog scales (VAS) for pain, joint stiffness, and patient's and physician's global assessment to test convergent validity. In addition, 90 randomly selected patients were asked to complete the questionnaire 48 h later for the second time. Moderate to high correlation were found between the AIMS2-SF and subscales of the SF-36 and VAS for pain, morning stiffness, and patient's and physician's global assessment. Cronbach's alpha coefficient for the Persian AIMS2-SF scales ranged from 0.74 to 0.89. The Persian AIMS2-SF scales showed excellent test-retest reliability with Intraclass Correlation Coefficient ranging from 0.83-0.93 (p < 0.01). The results of the present study showed that the Persian AIMS2-SF has reasonably good convergent validity, internal consistency, and test-retest reliability in patients with RA. It can now be applied in clinical settings and future outcome studies in Iran.

Confirmatory factor analysis of the Arthritis Impact Measurement Scales 2 short form in patients with rheumatoid arthritis

OBJECTIVE

To examine the factorial validity of the short form Arthritis Impact Measurement Scales 2 (AIMS2-SF) in patients with rheumatoid arthritis (RA).

METHODS

Data were from a sample of 279 patients with active RA who completed the long form AIMS2 before starting treatment with tumor necrosis factor alpha-blocking agents. Confirmatory factor analyses were conducted to test and compare the fit of the currently used theoretical measurement model of the AIMS2-SF, originally suggested for the long form AIMS2, and 2 alternative models based on previous exploratory research.

RESULTS

A model with the physical dimension divided into upper and lower body limitations was superior to the current model, and both models provided a clearly better fit than a model without a separate symptom dimension. Under the restrictive assumption of uncorrelated error terms, none of the models achieved a consistent and acceptable fit as judged by several goodness-of-fit indices. Allowing error covariances between 6 pairs of items within the same dimension resulted in an improved and acceptable fit of both the current model and the model with a separate upper and lower body component.

CONCLUSION

This study generally supports the factorial validity of the AIMS2-SF and suggests the use of separate scores for upper and lower body limitations. Further research is needed to resolve the issue of high error correlations associated with particular items.

Factors associated with physical activity of patients with osteoarthritis of the lower limb

OBJECTIVE

In patients with osteoarthritis (OA), moderate physical activity (PA) can reduce the progress of joint damage. PA is therefore an important target of in the non-surgical treatment of OA. To know about factors associated with PA can increase the success of interventions aiming at increasing PA. The aim of the study was to determine predictors of PA in patients suffering from OA to the hip or to the knee.

METHODS

In total, 1250 outpatients from 75 general practices were consecutively approached, 1021 returned questionnaires containing sociodemographic data, and short forms of the International Physical Activity Questionnaire (IPAQ), the Arthritis Impact Measurement Scale and the Patient Health Questionnaire to assess concomitant depression. A hierarchical stepwise multiple linear regression analysis with the IPAQ continuous score as dependent variable was performed.

RESULTS

Comparison of our findings with General population suggests that the overall PA of OA patients is decreased. Main predictors of PA were physical limitation to the lower body (beta = -0.179; P = 0.001), social contacts (P = -0.134; P < 0.001), pain (beta =-0.120; P = 0.001), age (beta = -0.110; P = 0.004) and the body mass index (beta =-0.043; P < 0.001).

CONCLUSION

The findings emphasize the influence of physical as well as psychosocial factors on PA of patients with OA and should help to tailor future interventions more appropriately. Further research is needed to determine if these tailored interventions will result in better compliance and in increased PA.

Case management of arthritis patients in primary care: a cluster-randomized controlled trial

OBJECTIVE

To assess whether providing information on arthritis self-management through general practitioners (GPs) increases the quality of life in patients with osteoarthritis and whether additional case management provided by practice nurses shows better results.

METHODS

We conducted a pragmatic, cluster-randomized, controlled, 3-arm trial that included 1,021 patients from 75 primary care practices in Germany. GPs were randomized to intervention group I, group II, or a control group. GPs of both intervention groups participated in 2 peer group meetings. In intervention group II, additional case management was conducted via telephone by a practice nurse. The primary outcome was change in quality of life, assessed by the German version of the Arthritis Impact Measurement Scales Short Form (AIMS2-SF). Secondary outcomes were health service utilization, prescriptions, and physical activity. Data were controlled for depression using the Patient Health Questionnaire 9 as a potential confounder.

RESULTS

Of 1,125 administered questionnaires, 1,021 were analyzed. Compared with the control group, no significant changes occurred in intervention group I with respect to the primary outcome. Performed radiographs decreased significantly (P = 0.050), whereas prescriptions of acetaminophen increased significantly (P < 0.001). In intervention group II, significant changes in the AIMS2-SF dimensions social (P < 0.001), symptom (P = 0.048), and lower body (P = 0.049) were identified. Radiographs (P = 0.031) and orthopedic referrals (P = 0.044) decreased whereas prescriptions of pain relievers increased significantly.

CONCLUSION

Improving the quality of life in patients with arthritis using arthritis self-management seems challenging. Simply providing this information through GPs is not sufficient but combining it with case management seems to be a promising approach.

Family practice nurses supporting self-management in older patients with mild osteoarthritis: a randomized trial

Background

Supporting self-management intends to improve life-style, which is beneficial for patients with mild osteoarthritis (OA). We evaluated a nurse-based intervention on older OA patients' self-management with the aim to assess its effects on mobility and functioning.

Methods

Randomized controlled trial of patients (≥ 65 years) with mild hip or knee OA from nine family practices in the Netherlands. Intervention consisted of supporting patients' self-management of OA symptoms using a practice-based nurse. Outcome measures were patients' mobility, using the Timed Up and Go test (TUG), and patient reported functioning, using an arthritis specific scale (Dutch AIMS2 SF).

Results

Fifty-one patients were randomized to the intervention group and 53 to the control group. Patient-reported functioning improved on four scales in the intervention group compared to one scale in the control group. However, this result was not significant. Mobility improved in both groups, without a significant difference between the two groups. There were no differences between the groups regarding consultations with family physicians or physiotherapists, or medication use.

Conclusion

A nurse-based intervention on older OA patients' self-management did not improve self-reported functioning, mobility or patients' use of health care resources.

Mapping hand functioning in hand osteoarthritis: comparing self-report instruments with a comprehensive hand function test

OBJECTIVE

To determine which self-report instruments best explain hand functioning measured by a generic comprehensive hand function test.

METHODS

Six questionnaires currently used in hand osteoarthritis (OA), namely, the Arthritis Impact Measurement Scales 2 Short Form (AIMS2-SF), the Australian/Canadian Osteoarthritis Hand Index (AUSCAN), the Cochin scale, the Functional Index of Hand OA (FIHOA), the Health Assessment Questionnaire (HAQ), and the Score for Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (SACRAH), were administered once in 100 patients with hand OA together with the Jebsen-Taylor Hand Function Test (JTHFT). In addition, 3 other hand function tests with short administration time were used: the Moberg Picking-Up Test (MPUT), the Button Test (BT), and grip strength. The Short Form 36 was used to describe health status. The relationship between the instruments and the JTHFT was determined by correlation analyses.

RESULTS

AIMS2-SF total scores had the highest raw correlation coefficient to the JTHFT, followed by AIMS2-SF upper body limitation subscale, SACRAH stiffness subscale, and SACRAH total score. If controlled for age, the HAQ had the highest correlation coefficient. Of the 3 short hand function tests, the MPUT showed the highest raw correlation coefficient to the JTHFT; if controlled for age, the BT had the highest correlation coefficient.

CONCLUSION

To comprehensively assess hand functioning in patients with hand OA, we recommend using both a self-report instrument used more generally in various arthritides and a self-report instrument specifically developed for hand OA. If a short test is preferred, we recommend using the MPUT or BT.

Health service utilization patterns of primary care patients with osteoarthritis

BACKGROUND

To assess factors associated with visits to GPs, orthopaedists, and non-physician practitioners of complementary medicine (alternative practitioners) by primary care patients with osteoarthritis (OA).

METHODS

Cross-sectional survey among 1250 consecutively addressed patients from 75 primary care practices in Germany. All patients suffered from OA of the knee or hip according to ACR criteria. They received questionnaires collecting sociodemographic data, data about health service utilisation, prescriptions, comorbidities. They also included established instruments as the Arthritis Impact Measurement Scale (AIMS2-SF) to assess disease-specific quality of life and the Patient Health Questionnaire (PHQ-9) to assess depression. Hierarchical stepwise multiple linear regression models were used to reveal significant factors influencing health service utilization.

RESULTS

1021 of 1250 (81.6%) questionnaires were returned. Nonrespondents did not differ from participants. Factors associated with health service use (HSU) varied between providers of care. Not being in a partnership, achieving a high score on the PHQ-9, increased pain severity reflected in the "symptom" scale of the AIMS2-SF, and an increased number of drug prescriptions predicted a high frequency of GP visits. The PHQ-9 score was also a predictor for visits to orthopaedists, as were previous GP contacts, a high score in the "symptom" scale as well as a high score in the "lower limb scale" of the AIMS2-SF. Regarding visits to alternative practitioners, a high score in the AIMS -"social" scale was a positive predictor as older people were less likely to visit them.

CONCLUSION

Our results emphasize the need for awareness of psychological factors contributing to the use of health care providers. Addressing the revealed factors associated with HSU appropriately may lead to decreased health care utilization. But further research is needed to assess how this can be done successfully.

Cultural adaptation and validation of a German version of the Arthritis Impact Measurement Scales (AIMS2)

OBJECTIVE

To validate a translated and culturally adapted version of the Arthritis Impact Measurement Scale (AIMS) 2 in primary care patients with osteoarthritis (OA) of the hip and knee.

METHOD

The AIMS2 was translated into German and culturally adapted. The questionnaire then was administered to 220 primary care patients with OA of the knee or hip. Two hundred and nine questionnaires were returned and analysed. Test-retest reliability was tested in 50 randomly selected patients, of those 42 completed the questionnaire after 2 weeks for a second time.

RESULTS

Item-scale correlations were reasonably good as well as the discriminative power of separate scales. The assessment of internal consistency reliability also revealed satisfactory values; Cronbach's alpha was 0.77 or higher for all scales. The test-retest reliability, estimated in an intraclass correlation coefficient (ICC), exceeded 0.90, except the "social activities" scale (0.87). Since only patients with OA of the lower limb were enrolled, substantial floor effects occurred in the "arm function" (28.2%) and the "hand and finger function" scale (29.2%). The principal factor analysis confirmed the postulated three-factor structure with a physical, physiological and social dimension, explaining 48.5%, 13.9% and 6.8% of the variation, respectively. External validity was assessed by calculating correlations to the Western Ontario and MacMaster (WOMAC) osteoarthritis questionnaire a pain visual analogue scale (VAS) and the Kellgren score as well as to disease duration. Spearman's "R" achieved satisfactory values for the corresponding WOMAC scales and the pain-VAS. Correlations with disease duration as well as with the radiological grading were low.

CONCLUSION

The GERMAN-AIMS2 is a reliable and valid instrument to assess the quality of life (QoL) in primary care patients suffering from OA.

Evaluation of a culturally adapted German version of the Patient Assessment of Chronic Illness Care (PACIC 5A) questionnaire in a sample of osteoarthritis patients

OBJECTIVE

The chronic care model and the 5A approach have achieved widespread acceptance and reflect the core elements of patient-centred care in chronic diseases, including arthritis. Appropriate assessment tools are indispensable to assess whether provided care is in alignment with these evidence-based conceptual frameworks of care. The aim of this study was to examine the validity of a translated and culturally adapted version of the Patient Assessment of Chronic Illness Care (PACIC 5A) questionnaire among osteoarthritis (OA) patients.

METHODS

Of 300 administered questionnaires, 236 (78.6%) were returned. Established statistical approaches were used in order to assess psychometric properties. Test-retest reliability was tested in 75 randomly selected patients who received the questionnaire a second time after 2 weeks. The EUROPEP questionnaire was used in order to address external validity.

RESULTS

Scale internal consistency was confirmed with values ranging from 0.52 to 0.97 for Pearson's r. Internal consistency reliability was satisfying: Cronbach's alpha was 0.78 or higher for all scales. Test-retest reliability (intraclass correlation coefficient) exceeded 0.77. Correlations with the EUROPEP, which is not organized according to a conceptual approach to care, were only strong in corresponding scales.

CONCLUSIONS

The PACIC 5A is a reliable and valid instrument to assess the congruency of care to the chronic care model of OA patients. Its use is encouraged in quality improvement projects but also in further research.

Osteoarthritis and functional disability: results of a cross sectional study among primary care patients in Germany

BACKGROUND

The aim of the study was to determine factors associated with functional disability in patients with OA.

METHODS

1250 questionnaires were distributed to OA outpatients from 75 general practices; 1021 (81.6%) were returned. Questionnaires included sociodemographic data, the short form of the Arthritis Impact Measurement Scale (AIMS2-SF), and the Patient Health Questionnaire (PHQ-9) to assess concomitant depression. A hierarchical stepwise multiple regression analysis with the AIMS2-SF dimension "lower body" as dependent was performed.

RESULTS

Main factors associated with functional disability were depression symptoms, as reflected in a high score of the PHQ-9 (beta = 0.446; p < 0.0009), pain as reflected in the AIMS2-SF symptom scale (beta = 0.412; p = 0.001), and few social contacts (beta = 0.201; p < 0.042). A high body mass index was associated with lower functional ability (beta = 0.332; p = 0.005) whereas a higher educational level (beta = -0.279; p = 0.029) predicted less impairment. Increased age was a weak predictor (beta = 0.178; p = 0.001) of disability. With a p of 0.062 the radiological severity according to the grading of Kellgren and Lawrence slightly surpassed the required significance level for remaining in the final regression model.

CONCLUSION

The results emphasize that psychological as well as physical factors need to be addressed similarly to improve functional ability of patients suffering from OA. More research with multifaceted and tailored interventions is needed to determine how these factors can be targeted appropriately.

Osteoarthritis: quality of life, comorbidities, medication and health service utilization assessed in a large sample of primary care patients

Objective

To assess the gender related impact of osteoarthritis (OA) on quality of life (QoL) and health service utilization (HSU) of primary care patients in Germany.

Methods

Cross sectional study with 1250 OA patients attending 75 primary care practices from March to May 2005. QoL was assessed using the GERMAN-AIMS2-SF. Data about comorbidities, prescriptions, health service utilization, and physical activity were obtained by questioning patients or from the patients' medical files. Depression was assessed by means of the Patient Health Questionnaire (PHQ-9).

Results

1021 (81.7%) questionnaires were returned. 347 (34%) patients were male. Impact of OA on QoL was different between gender: women achieved significantly higher scores in the AIMS 2-SF dimensions lower body (p < 0.01), symptom (p < 0.01), affect (p < 0.01) and work (p < 0.05). Main predictors of pain and disability were a high score in the "upper body "scale of the AIMS2-SF (beta = 0.280; p < 0.001), a high score in the PHQ-9 (beta = 0.214; p < 0.001), duration of OA (beta = 0.097; p = 0.004), age (beta = 0.090; p = 0.023) and the BMI (beta = 0.069; p = 0.034). Predictors of pain and disability did not differ between gender. 18.8 % of men and 19.7% of women had a concomitant depression. However, no gender differences occurred. Women visited their GP (mean 5.61 contacts in 6 months) more often than men (mean 4.08; p < 0.01); visits to orthopedics did not differ between gender.

Conclusion

The extent to which OA impacts men and women differs in primary care patients. This might have resulted in the revealed differences in the pharmacological treatment and the HSU. Further research is needed to confirm our findings and to assess causality.

Concepts important to patients with psoriatic arthritis are not adequately covered by standard measures of functioning

OBJECTIVE

To explore whether the concepts important to patients with psoriatic arthritis (PsA) are covered by self-report instruments assessing functioning.

METHODS

We conducted a qualitative focus group study with PsA patients about their problems in daily functioning. Focus groups were tape recorded and transcribed verbatim. The transcribed texts were divided into meaning units, and concepts contained in these meaning units were extracted. Self-report instruments assessing functioning in PsA were identified in a structured literature search. Using the International Classification of Functioning, Disability and Health (ICF) as a common frame of reference, we determined whether each concept identified in the focus groups was covered by each of the instruments.

RESULTS

Thirty-one patients participated in 6 focus groups. The following 9 instruments were included in the present analysis: Arthritis Impact Measurement Scale Short Form; Bath Ankylosing Spondylitis Disease Activity Index; Disabilities of the Arm, Shoulder, and Hand Questionnaire; Dermatology Quality of Life Index; Dougados Functional Index; Health Assessment Questionnaire (HAQ); HAQ-S (HAQ adapted for spondylarthropathies); PsA-specific Quality of Life Instrument; and Short Form 36 Health Survey. Of the 54 concepts identified in 590 meaning units in the transcribed data, 19 concepts (35%) were not covered by any of the instruments. Of these, 11 concepts that were linked to the ICF component environmental factors were not covered by any of the instruments, whereas all concepts linked to the ICF component activities and participation were covered by at least 1 of the instruments (but no single instrument covered all concepts).

CONCLUSION

The impact of environmental factors, attitudes towards individuals with health problems, and loss of leisure time may represent important aspects addressing participation that are currently not covered in the instruments assessing functioning in PsA.

Osteoarthritis of the knee and hip: a comparison of factors associated with physical activity

To assess factors associated with physical activity (PA) in a large sample of primary care patients, 1,250 outpatients from 75 general practices were approached consecutively. Of these, 1,021 (81.7%) returned short forms of the international physical activity questionnaire (IPAQ) and the arthritis impact measurement scale (AIMS2-SF). In addition, the patient health questionnaire (PHQ-9) was used to assess concomitant depression. A stepwise multiple linear regression analysis with the IPAQ score as dependent variable was performed separately for knee and hip patients. The impact of osteoarthritis (OA) on patients with an affected knee (594/58.2%) was more severe, as reflected in higher scores in the "symptom", "lower body", and "affect" scales of the AIMS2-SF (p < 0.01 for all). These patients were also less active than patients with OA to the hip (p = 0.02 for IPAQ score). Main predictors of PA [change in p(F) for all factors < or =0.001] in knee OA patients were physical limitation to the lower limb (R(2) = 0.180), social network (R(2) = 0.121), pain (R(2) = 0.111), body mass index (R(2) = 0.041), and age (R(2) = 0.032). Predictors for OA at the hip (427/41.8%) differed slightly [change in p(F) for all factors < or =0.003): physical limitation to the lower limb (R(2) = 0.162), pain (R(2) = 0.131), PHQ-9 score (R(2) = 0.092), social network (R(2) = 0.078), and disease duration (R(2) = 0.043). Our findings suggest that factors associated with PA differ depending on the localization of the OA. Our results may help to tailor future interventions more appropriately. Further research is needed to determine whether these tailored interventions will result in increased PA.

The impact of concomitant depression on quality of life and health service utilisation in patients with osteoarthritis

To assess the impact of concomitant depression on quality of life (QoL) and health service utilisation of patients with osteoarthritis (OA). Data were collected from 75 primary care practices in Germany. Totally, 1,250 patients were consecutively approached; 1,021 (81.7%) questionnaires were returned and analysed. Measures included sociodemographic data, the Arthritis Impact Measurement Scale (AIMS2-SF) and the Patient Health Questionnaire (PHQ-9) to assess depression. A PHQ-9 score > or = 15 was defined as reflecting depression. Patients with a depressive disorder achieved significantly (all P < 0.001) higher scores in all AIMS2-SF dimensions. They had more contacts to general practitioners (P < 0.01), orthopaedics (P < 0.01) and to providers of Complementary Alternative Medicine offered e.g. by healers. Concomitant depression aggravates the burden of OA significantly. This results in increased health service utilisation. Appropriate treatment of depression would appear not only to increase QoL but also to lower costs by decreasing health service utilisation.

Predictors of depression in a sample of 1,021 primary care patients with osteoarthritis

OBJECTIVE

Although there is a strong relationship between depression, chronic pain, and physical activity, there are few findings regarding the prevalence and predictors of depression in patients with osteoarthritis (OA). The goal of the present study was to assess the prevalence and severity of depression in a large sample of patients with OA and to reveal predictors of depression.

METHODS

Patients were approached consecutively in 75 general practices. Of 1,250 distributed questionnaires, 1,021 were returned and analyzed. Besides sociodemographic data, medication and comorbidities, depression, and arthritis were assessed using the Patient Health Questionnaire (PHQ-9) and the Arthritis Impact Measurement Scale. A stepwise multiple linear regression analysis with the PHQ-9 score as the dependent variable was performed.

RESULTS

On the PHQ-9, 19.76% of men and 19.16% of women achieved a score of >or=15, indicating at least a moderately severe depression. Significant sex differences could not be revealed. The strongest predictor for depression severity was perceived pain (beta = 0.243, P < 0.001) and few social contacts (beta = 0.218, P < 0.001). Further predictors were physical limitation of the lower body (beta = 0.157, P < 0.001) and upper body (beta = 0.163, P < 0.001), age (beta = -0.168, P < 0.001), and body mass index (beta = 0.080, P = 0.020).

CONCLUSION

These findings suggest an increased prevalence of depression among patients with OA and emphasize the need for recognition and appropriate treatment. Most of the revealed predictors are influenceable and should be potential targets in a comprehensive treatment of OA to interrupt the vicious circle of pain, physical limitation, and depression.

The assessment of disability associated with osteoarthritis

PURPOSE OF REVIEW

Disability (activity limitation) is an important and common health outcome for patients with osteoarthritis, making accurate measures essential. This paper explores self-report measures of activity limitation associated with osteoarthritis and reports on recent conceptual advances that impact on the measurement of activity limitation.

RECENT FINDINGS

The Western Ontario and McMaster Universities Osteoarthritis Index and the Short Form-36, the most commonly used measures to assess activity limitation, continue to be validated in osteoarthritis. There has been little consensus, however, about which measure to use across different types of osteoarthritis. While new measures have been developed to assess activity limitation, it remains unclear whether or not these are an improvement over existing measures. The International Classification of Functioning, Disability and Health is becoming an important consideration. Commonly used measures do not map directly onto individual constructs of this classification, however a new measure for Japanese people with knee osteoarthritis was developed based on these constructs.

SUMMARY

There have been significant developments in the conceptual approach to measuring activity limitation. Measures are needed that operationalize activity limitation as defined by the International Classification of Functioning, Disability and Health (within or ideally across cultures), providing a common underlying construct for measures and hence facilitating comparability across studies.

Comparison of AIMS2-SF, WOMAC, x-ray and a global physician assessment in order to approach quality of life in patients suffering from osteoarthritis

Background

Chronic diseases like osteoarthritis (OA) substantially affect different dimensions of quality of life (QoL). The aim of the study was to reveal possible factors which mainly influence general practitioners (GPs) assessment of patients' QoL.

Methods

220 primary care patients with OA of the knee or the hip treated by their general practitioner for at least one year were included. All GPs were asked to assess patients' QoL based on the patients' history, actual examination and existing x-rays by means of a visual analog scale (VAS scale), resulting in values ranging from 0 to 10. Patients were asked to complete the McMaster Universities Osteoarthritis Index (WOMAC) and the Arthritis Impact Measurement Scale2 Short Form (AIMS2-SF) questionnaire.

Results

Significant correlations were revealed between "GP assessment" and the AIMS2-SF scales "physical" (rho = 0.495) and "symptom" (rho = 0.598) as well as to the "pain" scale of the WOMAC (rho = 0.557). A multivariate ordinal regression analysis revealed only the AIMS2-SF "symptom" scale (coefficient beta = 0.2588; p = 0.0267) and the x-ray grading according to Kellgren and Lawrence as significant influence variables (beta = 0.6395; p = 0.0004).

Conclusion

The results of the present study suggest that physicians' assessment of patients' QoL is mainly dominated by physical factors, namely pain and severity of x-ray findings. Our results suggest that socioeconomic and psychosocial factors, which are known to have substantial impact on QoL, are underestimated or missed. Moreover, the overestimation of x-ray findings, which are known to be less correlated to QoL, may cause over-treatment while important and promising targets to increase patients' QoL are missed.

Rationale, design and conduct of a comprehensive evaluation of a primary care based intervention to improve the quality of life of osteoarthritis patients. The PraxArt-project: a cluster randomized controlled trial [ISRCTN87252339]

BACKGROUND

Osteoarthritis (OA) has a high prevalence in primary care. Conservative, guideline orientated approaches aiming at improving pain treatment and increasing physical activity, have been proven to be effective in several contexts outside the primary care setting, as for instance the Arthritis Self management Programs (ASMPs). But it remains unclear if these comprehensive evidence based approaches can improve patients' quality of life if they are provided in a primary care setting.

METHODS/DESIGN

PraxArt is a cluster randomised controlled trial with GPs as the unit of randomisation. The aim of the study is to evaluate the impact of a comprehensive evidence based medical education of GPs on individual care and patients' quality of life. 75 GPs were randomised either to intervention group I or II or to a control group. Each GP will include 15 patients suffering from osteoarthritis according to the criteria of ACR. In intervention group I GPs will receive medical education and patient education leaflets including a physical exercise program. In intervention group II the same is provided, but in addition a practice nurse will be trained to monitor via monthly telephone calls adherence to GPs prescriptions and advices and ask about increasing pain and possible side effects of medication. In the control group no intervention will be applied at all. Main outcome measurement for patients' QoL is the GERMAN-AIMS2-SF questionnaire. In addition data about patients' satisfaction (using a modified EUROPEP-tool), medication, health care utilization, comorbidity, physical activity and depression (using PHQ-9) will be retrieved. Measurements (pre data collection) will take place in months I-III, starting in June 2005. Post data collection will be performed after 6 months.

DISCUSSION

Despite the high prevalence and increasing incidence, comprehensive and evidence based treatment approaches for OA in a primary care setting are neither established nor evaluated in Germany. If the evaluation of the presented approach reveals a clear benefit it is planned to provide this GP-centred interventions on a much larger scale.