Effectiveness and cost-effectiveness of comprehensive rehabilitation programs

Effects of an exercise programme for chronically ill and mobility-restricted elderly with structured support by the general practitioner's practice (HOMEfit) - study protocol of a randomised controlled trial

BACKGROUND

Exercise programmes can be administered successfully as therapeutic agents to patients with a number of chronic diseases and help to improve physical functioning in older adults. Usually, such programmes target either healthy and mobile community-dwelling seniors or elderly individuals living in nursing institutions or special residences. Chronically ill or mobility-restricted individuals, however, are difficult to reach when they live in their own homes.A pilot study has shown good feasibility of a home-based exercise programme that is delivered to this target group through cooperation between general practitioners and exercise therapists. A logical next step involves evaluation of the effects of the programme.

METHODS/DESIGN

The study is designed as a randomised controlled trial. We plan to recruit 210 patients (≥ 70 years) in about 15 general practices.The experimental intervention (duration 12 weeks)-a multidimensional home-based exercise programme-is delivered to the participant by an exercise therapist in counselling sessions at the general practitioner's practice and on the telephone. It is based on methods and strategies for facilitating behaviour change according to the Health Action Process Approach (HAPA). The control intervention-baseline physical activities-differs from the experimental intervention with regard to content of the counselling sessions as well as to content and frequency of the promoted activities.Primary outcome is functional lower body strength measured by the "chair-rise" test. Secondary outcomes are: physical function (battery of motor tests), physical activity (step count), health-related quality of life (SF-8), fall-related self-efficacy (FES-I), and exercise self-efficacy (SSA-Scale).The hypothesis that there will be differences between the two groups (experimental/control) with respect to post-interventional chair-rise time will be tested using an ANCOVA with chair-rise time at baseline, treatment group, and study centre effects as explanatory variables. Analysis of the data will be undertaken using the principle of intention-to-treat.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17727272.

Does the content really matter? A study comparing structure, process, and outcome of team rehabilitation for patients with inflammatory arthritis in two different clinical settings

OBJECTIVES

To provide a thorough description of team rehabilitation care and compare the structure, process, and outcomes in two specialized arthritis rehabilitation settings.

METHODS

Patients with inflammatory arthritis scheduled for inpatient rehabilitation in seven specialized rehabilitation centres and three rheumatology hospital departments in Norway were included consecutively in a prospective cohort study. Patients completed questionnaires at admission, at discharge, and at a 6-month follow-up, and kept a diary regarding structure and process variables during the rehabilitation stay.

RESULTS

Eighty patients in rehabilitation centres and 73 in hospital departments were included and 80% responded to the 6-month follow-up questionnaire. The two clinical settings differed significantly with regard to structure variables such as cost, referral of patients, length of stay, and number of health professionals involved, and most process variables reflecting treatment modalities. The most remarkable difference was in the amount of individual intervention compared with group intervention. Despite significant improvements in most outcomes at discharge, the scores deteriorated towards baseline level 6 months later. There was a trend towards more significant improvement during rehabilitation for patients at rehabilitation centres whereas patients at hospitals had more prolonged improvement.

CONCLUSIONS

Team rehabilitation for inflammatory arthritis in two different clinical settings differed across most variables for structure and process, but few significant differences in outcome were found. Considering the substantial differences in cost, there is an urgent need for consensus concerning which patients should receive rehabilitation in which setting. Future research on the development and evaluation of methods for prolonging the beneficial effects of rehabilitation is needed.

"It is about taking grips and not let myself be ravaged by my body": a qualitative study of outcomes from in-patient multidisciplinary rehabilitation for patients with chronic rheumatic diseases

PURPOSE

To explore how patients experience the process and personal impact of deriving outcomes from a rheumatological rehabilitation program.

METHODS

Semi-structured interviews were conducted with 23 patients with inflammatory rheumatic diseases approximately 2 months after a 4-week hospital based multidisciplinary rehabilitation program. A thematic analysis was applied.

RESULTS

Overarching themes were increased dignity and self-respect. Initial uncertainty regarding illness management was exchanged with confident coping and of becoming an active agent in ones own life. Strategies and coping tools tried out during the rehabilitation stay, do by their experienced effect become primary sources of gained insight into illness and symptom manifestation. Both elements give a sense of control and influence self-confidence and motivation to engage in self-management. The process from gained insight and experienced effect of coping tools, to active self management, is however, not automatic. Psychological factors play a key role, and there is a need to take individual psychological themes into account and tailor interventions accordingly.

CONCLUSIONS

Specialized multidisciplinary rehabilitation is an ongoing active process, in which psychological factors play a key role and must be accounted for. Well targeted rehabilitation has the potential to create outcomes of major personal impact.

Autoimmune diseases and rehabilitation

This review gives an overview of the rehabilitation of autoimmune diseases. After general remarks on rehabilitation, the effects of acute and chronic exercises on inflammatory markers are summarized. Most of the available literature deals with rheumatoid arthritis (RA) and multiple sclerosis (MS), and therefore, rehabilitation of these diseases is described in more detail. Exercise is the main component in the rehabilitation of patients with RA and aims at increasing physical capacity, muscle strength, aerobic endurance, cardiovascular fitness and functional abilities, and helps to prevent secondary deconditioning due to reduced activity levels. Since MS causes a wide range of symptoms, the rehabilitation of these patients requires a multidisciplinary approach and encompasses physiotherapy, exercise therapy, hippotherapy, cognitive rehabilitation, psychological therapy, strategies to improve fatigue and coping programs. The ultimate goal of rehabilitation is to enable patients with chronic conditions to reach and maintain their optimal physical, sensory, intellectual, psychological and social functional levels, and to attain independence and self-determination as far as possible.

Can cost utility evaluations inform decision making about interventions for low back pain?

BACKGROUND CONTEXT

Low back pain (LBP) is associated with high health-care utilization and lost productivity. Numerous interventions are routinely used, although few are supported by strong evidence. Cost utility analyses (CUAs) may be helpful to inform decision makers.

PURPOSE

To conduct a systematic review of CUAs of interventions for LBP.

STUDY DESIGN

Systematic review.

METHODS

A search strategy combining medical subject headings and free text related to LBP and health economic evaluations was executed in MEDLINE. Cost utility analyses combined with randomized controlled trials for LBP were included. Studies that were published before 1998, non-English, decision analyses, and duplicate reports were excluded. Search results were evaluated by two reviewers, who extracted data independently related to clinical study design, economic study design, direct cost components, utility results, cost results, and CUA results.

RESULTS

The search produced 319 citations, and of these 15 met eligibility criteria. Most were from the United Kingdom (n=8), published in the past 3 years (n=12), studied chronic LBP or radiculopathy (n=13), and had a follow-up >12 months (n=13). Combined, there were 33 study groups who received a mean 2.1 interventions, most commonly education (n=17), exercise therapy (n=13), spinal manipulation therapy (n=7), surgery (n=7), and usual care from a general practitioner (n=7). Mean baseline utility was 0.57, improving to 0.67 at follow-up; the mean difference in utility improvement between study groups was 0.04. Based on available data and converted to US dollars, the cost per quality-adjusted life year ranged from $304 to 579,527 dollars, with a median of 13,015 dollars.

CONCLUSIONS

Few CUAs were identified for LBP, and there was heterogeneity in the interventions compared, direct cost components measured, indirect costs, other methods, and results. Reporting quality was mixed. Currently published CUAs do not provide sufficient information to assist decision makers. Future CUAs should attempt to measure all known direct cost components relevant to LBP, estimate indirect costs such as lost productivity, have a follow-up period sufficient to capture meaningful changes, and clearly report methods and results to facilitate interpretation and comparison.

Cost of Finnish statutory inpatient rehabilitation and its impact on functional and work capacity of patients with early rheumatoid arthritis: experience from the FIN‐RACo trial

OBJECTIVE

To explore the cost of the statutory inpatient rehabilitation system in Finland and its impact on the functional and work capacity of patients with early rheumatoid arthritis (RA).

METHODS

In the Finnish Rheumatoid Arthritis Combination-Therapy trial (FIN-RACo), 195 patients with recent-onset RA, 162 of them available for the work force, were randomly assigned to two different drug treatment strategies for 2 years. Otherwise, the patients received routine multidisciplinary care and, if their functional or work capacity was endangered, were referred to inpatient rehabilitation. After a 5-year follow-up, data on rehabilitation, sick leave, and RA-related disability pensions were obtained from official registers.

RESULTS

Of the 162 patients, 49 (30%) underwent inpatient rehabilitation at an average cost of EURO5400. The rehabilitated patients more often worked in white-collar jobs and had more pain and a worse Health Assessment Questionnaire (HAQ) score (1.0 vs. 0.78; p = 0.01) at baseline. Their HAQ scores remained higher throughout follow-up (p<0.001); no change appeared over inpatient periods [mean 0.01; 95% confidence interval (CI) -0.13 to 0.16]. No independent impact of rehabilitation on the HAQ score emerged in an adjusted generalized estimating equations (GEE) model (p = 0.55). Nor did any improvement in work capacity appear: average lost productivity (human capital approach) per patient-year was EURO10 155 (95% CI 6994-14 196) before and EUR 12 839 (95% CI 8589-19 139) after the start of rehabilitation.

CONCLUSION

For patients with recent-onset RA, the Finnish statutory inpatient rehabilitation system had no positive impact on either functional or work capacity during the first few years, despite its considerable cost.

Cross cultural aspects of rehabilitation in rheumatic diseases

PURPOSE OF REVIEW

The aim of this article is to describe progress in the understanding of the relationship between culture, race, ethnicity and similar factors as they pertain to rehabilitation and the rheumatic diseases. This review highlights important current issues and indicates areas for future study.

RECENT FINDINGS

There is very little published research in this area of rehabilitation medicine. Recent findings and observations indicate that there are many important cultural aspects of rehabilitation in the rheumatic diseases with several societal as well as individual implications. This is a rapidly growing area of work as it is being increasingly recognized that an understanding of these cross cultural issues is essential in order to be able to ensure the delivery of clinically and cost effective rehabilitation services which are client centred and consequently culturally appropriate. Although the interrelationship of culture, race, genetics, ethnicity, language, religion, history, geography, socioeconomic status and educational level is complex, studies are beginning to reveal the contributions of these factors to ensuring minimization of disability and high quality rehabilitation strategies.

SUMMARY

Although much neglected, the importance of cultural aspects of rehabilitation in rheumatic diseases is being increasingly recognized and understood. Issues that have been identified include the rehabilitation needs assessment of different ethnic groups, the development of culturally valid outcome measures and the implementation and evaluation of culturally competent multidisciplinary rehabilitation programs.

Active warming during emergency transport relieves acute low back pain

STUDY DESIGN

Prospective randomized blinded trial in a prehospital emergency system.

OBJECTIVES

To evaluate the effects of external active warming on acute back pain during rescue transport to hospital.

BACKGROUND DATA

Acute low back pain is one of the complaints that most often entails a visit to the physician or use of the emergency system. Superficial (e.g., hydrocolloid packs) and deep heating (e.g., ultrasound) can relieve acute low back pain in a clinical setting. Recent data showed significant benefit for patients in pain from minor trauma treated by active warming during emergency transport. Accordingly, we tested the hypothesis that active warming would reduce pain and anxiety in patients with acute low back pain being transported to a hospital.

METHODS

A total of 100 patients were included in our study. We selected only those suffering from acute pain > 60 mm on a visual analog scale in the lower back. Patients were randomly assigned to two groups: active warming with a carbon-fiber electric heating blanket (Group 1) versus passive warming with a woolen blanket (Group 2) during transfer to hospital. RESULTS.: Pain scores on arrival at the hospital differed significantly between Group 1 and Group 2 (P < 0.01). In Group 1, pain reduction from 74.2 +/- 8.5 mm VAS to 41.9 +/- 18.9 mm VAS (P < 0.01) was noted between departure from the emergency site and arrival at the hospital. Pain scores remained practically unchanged in Group 2 (73.3 +/- 11.9 mm VAS and 74.1 +/- 12.0 mm VAS).

CONCLUSIONS

Active warming reduces acute low back pain during rescue transport.