A comparison of follow-up regimes in rheumatoid arthritis

Patient-Initiated Follow-Up (PIFU) as reorganized support for increased patient involvement - focus group discussions among patients' with inflammatory arthritis

Background

Inflammatory Arthritis is characterized by lifelong medical treatment and an unpredictable trajectory because of the fluctuating nature of the diseases. Proactive disease management is recommended, which includes close monitoring of disease activity that traditionally has been ensured by outpatient visits to rheumatologists at various fixed intervals. Internationally, there is a growing interest in how healthcare systems can be more flexible, individual-oriented and increasingly involve patients with lifelong diseases in their own treatment and care. We aimed to explore how patients with Inflammatory Arthritis with low disease activity or remission (DAS-CRP < 2.9) experience patient involvement in a reorganized follow-up care based on flexibility and patient-initiated contact.

Methods

We conducted a qualitative study based on four mixed group discussions focused on patients with inflammatory arthritis (rheumatoid arthritis [n = 21], axial spondyloarthritis [n = 3] and psoriatic arthritis [n = 1]) participating in a reorganized follow-up care. Changes in follow-up included access to a nurse and patient-initiated follow-up (PIFU). The analysis was based on content analysis. The reporting adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Results

In total, 25 patients (20 females (80%), mean age 61.8 [range 28–79]) participated. We identified three categories. 1) Patient-Initiated Follow-Up do not affect patients’ perceived support in disease control; this refers to patients’ experience of more time available through better resource utilization, as well as trust that access to professional support would be available whenever needed. The category 2) Information is valued by patients to delineate responsibilities in a new patient role reflects patients’ uncertainty in the transition to PIFU, combined with confusion about the distribution of responsibilities. 3) Patients need both extended perspectives of their arthritis and focused dialogue is about expanding patients’ understanding of their arthritis by interaction over time with both a rheumatologist and a rheumatology nurse in a focused dialogue to involve the patient.

Conclusions

Patients participating in PIFU welcome the flexibility and involvement. However, patients need relevant information to act adequately within a new patient role. Interaction with both rheumatologists and nurses, combined with sufficient time for dialogue, broaden patients’ perspective, make opportunities for action visible, and contribute to patients’ ability to participate in follow-up care.

Patient-initiated appointments compared with standard outpatient care for rheumatoid arthritis: a randomised controlled trial

OBJECTIVES

To test the hypothesis that implementing a patient-initiated system of care could improve clinical outcome in rheumatoid arthritis (RA) using disease activity guided management.

METHODS

An 18-month controlled blinded end point two-centre study with 131 patients with RA randomised to intervention (n=64) or control (n=67). The intervention group participants were guaranteed appointments to a rheumatologist within 10 working days if they subjectively experienced a flare in disease activity. The control group participants were booked in advance according to guidelines. Independent assessments were performed in the two groups at 0, 3, 6, 12 and 18 months. Outcome measures included: Disease Activity Score 28 (DAS28), a Visual Analogue Scale (satisfaction with care, confidence in care), number of appointments with a rheumatologist.

RESULTS

DAS28 decreased. Median satisfaction and confidence in care were >90 mm on Visual Analog Scale. Median number of appointments was 3. There were no significant differences between the groups among these outcomes. Visits in the intervention group more often resulted in change of treatment than in the control group (p<0.001).

CONCLUSIONS

Patient-initiated care was neither better nor inferior to traditional care in terms of outcomes analysed. Patient-initiated appointments can safely be used in everyday outpatient care of RA to empower the patient, if disease activity guided management is applied. Further research should investigate if this intervention can target a subgroup of patients and hence also result in released resources.

Effectiveness of the primary therapist model for rheumatoid arthritis rehabilitation: A randomized controlled trial

OBJECTIVE

To compare the primary therapist model (PTM), provided by a single rheumatology-trained primary therapist, with the traditional treatment model (TTM), provided by a physical therapy (PT) and/or occupational therapy (OT) generalist, for treating patients with rheumatoid arthritis (RA).

METHODS

Eligible patients were adults requiring rehabilitation treatment who had not received PT/OT in the past 2 years. Participants were randomized to the PTM or TTM group. The primary outcome was defined as the proportion of clinical responders who experienced a > or =20% improvement in 2 of the following measures from baseline to 6 months: Health Assessment Questionnaire, pain visual analog scale, and Arthritis Community Research and Evaluation Unit RA Knowledge Questionnaire.

RESULTS

Of 144 consenting patients, 33 (10 PTM participants, 23 TTM participants) dropped out without completing any followup assessment, leaving 111 for analysis (63 PTM participants, 48 TTM participants). The majority were women (PTM 87.3%, TTM 79.2%), with a mean age of 54.2 years and 56.8 years for the PTM and TTM groups, respectively. Average disease duration was 10.6 years and 13.2 years for each group, respectively. At 6 months, 44.4% of patients in the PTM group were clinical responders versus 18.8% in the TTM group (chi(2) = 8.09, P = 0.004).

CONCLUSION

Compared with the TTM, the PTM was associated with better outcomes in patients with RA. The results, however, should be interpreted with caution due to the high dropout rate in the TTM group.

Outcomes of patients with rheumatoid arthritis receiving rehabilitation

PURPOSE OF REVIEW

Rehabilitation, including physical therapy and occupational therapy, complements drug therapy in the management of symptoms in patients with rheumatoid arthritis. Approximately 26% of patients with rheumatoid arthritis receive a referral for rehabilitation by rheumatologists. This review summarizes findings on the effectiveness and economic outcomes of physical therapy and occupational therapy in managing rheumatoid arthritis.

RECENT FINDINGS

Studies evaluating the outcomes of various service delivery models for physical therapy and occupational therapy demonstrate improvements, especially in physical function, among people with rheumatoid arthritis. A recent pilot study examining the primary therapist model also suggests that the primary therapist model may be a viable option for delivering rheumatoid arthritis rehabilitation services. However, the evidence on other alternative models such as the physical therapy/occupational therapy practitioner model is limited. Only a few economic evaluations have been performed, and among those, none examine the cost-effectiveness of different service models.

SUMMARY

Systematically interpreting the findings of service delivery models in rehabilitation is challenging because of the wide range of interventions and outcome measures used. A thorough understanding of the value of different rehabilitation models will require the guidance of a sound evaluation framework. Future clinical trials should consider including a component for evaluating cost-effectiveness. Such knowledge can contribute to evidence-informed resource allocation.

Patient initiated outpatient follow up in rheumatoid arthritis: six year randomised controlled trial

OBJECTIVES

To determine whether direct access to hospital review initiated by patients with rheumatoid arthritis would result in improved clinical and psychological outcome, reduced overall use of healthcare resources, and greater satisfaction with care than seen in patients receiving regular review initiated by a rheumatologist.

DESIGN

Two year randomised controlled trial extended to six years.

SETTING

Rheumatology outpatient department in teaching hospital.

PARTICIPANTS

209 consecutive patients with rheumatoid arthritis for over two years; 68 (65%) in the direct access group and 52 (50%) in the control group completed the study (P = 0.04).

CLINICAL OUTCOME

pain, disease activity, early morning stiffness, inflammatory indices, disability, grip strength, range of movement in joints, and bone erosion. Psychological status: anxiety, depression, helplessness, self efficacy, satisfaction, and confidence in the system. Number of visits to hospital physician and general practitioner for arthritis.

RESULTS

Participants were well matched at baseline. After six years there was only one significant difference between the two groups for the 14 clinical outcomes measured (deterioration in range of movement in elbow was less in direct access patients). There were no significant differences between groups for median change in psychological status. Satisfaction and confidence in the system were significantly higher in the direct access group at two, four, and six years: confidence 9.8 v 8.4, 9.4 v 8.0, 8.7 v 6.9; satisfaction 9.3 v 8.3, 9.3 v 7.7, 8.9 v 7.1 (all P < 0.02). Patients in the direct access group had 38% fewer hospital appointments (median 8 v 13, P < 0.0001).

CONCLUSIONS

Over six years, patients with rheumatoid arthritis who initiated their reviews through direct access were clinically and psychologically at least as well as patients having traditional reviews initiated by a physician. They requested fewer appointments, found direct access more acceptable, and had more than a third fewer medical appointments. This radical responsive management could be tested in other chronic diseases.

Occupational therapy for rheumatoid arthritis

BACKGROUND

For persons with rheumatoid arthritis (RA) the physical, personal, familial, social and vocational consequences are extensive. Occupational therapy (OT), with the aim to facilitate task performance and to decrease the consequences of rheumatoid arthritis for daily life activities, is considered to be a cornerstone in the management of rheumatoid arthritis. Till now the efficacy of occupational therapy for patients with rheumatoid arthritis on functional performance and social participation has not been systematically reviewed.

OBJECTIVES

To determine whether OT interventions (classified as comprehensive therapy, training of motor function, training of skills, instruction on joint protection and energy conservation, counseling, instruction about assistive devices and provision of splints) for rheumatoid arthritis patients improve outcome on functional ability, social participation and/or health related quality of life.

SEARCH STRATEGY

Relevant full length articles were identified by electronic searches in Medline, Cinahl, Embase, Amed, Scisearch and the Cochrane Musculoskeletal group Specialised Register. The reference list of identified studies and reviews were examined for additional references. Date of last search: December 2002.

SELECTION CRITERIA

Controlled (randomized and non-randomized) and other than controlled studies (OD) addressing OT for RA patients were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

The methodological quality of the included trials was independently assessed by two reviewers. Disagreements were resolved by discussion. A list proposed by Van Tulder et al. (Van Tulder 1997) was used to assess the methodological quality. For outcome measures, standardized mean differences were calculated. The results were analysed using a best evidence synthesis based on type of design, methodological quality and the significant findings of outcome and/or process measures.

MAIN RESULTS

Thirty-eight out of 58 identified occupational therapy studies fulfilled all inclusion criteria. Six controlled studies had a high methodological quality. Given the methodological constraints of uncontrolled studies, nine of these studies were judged to be of sufficient methodological quality. The results of the best evidence synthesis shows that there is strong evidence for the efficacy of "instruction on joint protection" (an absolute benefit of 17.5 to 22.5, relative benefit of 100%) and that limited evidence exists for comprehensive occupational therapy in improving functional ability (an absolute benefit of 8.7, relative benefit of 20%). Indicative findings for evidence that "provision of splints" decreases pain are found (absolute benefit of 1.0, relative benefit of 19%).

REVIEWER'S CONCLUSIONS

There is evidence that occupational therapy has a positive effect on functional ability in patients with rheumatoid arthritis.

Patient-initiated hospital follow-up for rheumatoid arthritis

OBJECTIVES

To evaluate the clinical efficacy, cost and acceptability of a shared care system of patient- or general practitioner (GP)-initiated hospital review in rheumatoid arthritis (RA).

METHODS

A 2-yr randomized controlled trial of routine rheumatologist-initiated review was compared with a shared care system. Shared care patients had no routine follow-up but patients or GPs initiated access to rapid review by the multidisciplinary team via a nurse-run helpline. Control patients had a rheumatologist-initiated medical review at intervals of 3-6 months. Clinical and psychological status, resource use, and patient and GP satisfaction and confidence were assessed. Three-monthly clinical data were assessed (blind) for safety monitoring, with failure set at a 20% increase in pain, disability or disease activity.

RESULTS

Two hundred and nine established RA patients participated, of whom 182 were evaluable. Safety-net failures were not different between groups. Shared care patients had less pain (24 months, 3.9 cm on a 10-cm visual analogue scale vs 4.8 cm for controls; P: < 0.05), a smaller increase in pain over 2 yr (+ 0.4 cm vs +1.6 cm for controls; P: < 0.01), greater self-efficacy (6, 15, 18, 21 months, P: < 0.05), used 33.5% less resources (208 ponds sterling per patient per year vs 313 pound sterling for controls; P: < 0.001) and were more confident in the system (6, 9, 12, 18, 21, 24 months, P: < 0.01 to P: < 0.001).

CONCLUSIONS

A patient-initiated system for hospital review over 2 yr offers some clinical benefit compared with the traditional system, using fewer resources and attracting greater patient confidence. Longer-term assessment of the system would be appropriate.

Managing early presentation of rheumatoid arthritis. Systematic overview

OBJECTIVE

To describe evidence-based management of patients presenting to family physicians with typical signs and symptoms of recent onset of rheumatoid arthritis (RA).

STUDY SELECTION

Articles for critical review were included if relevant to primary care management of early RA (less than 1 year duration). Sources included MEDLINE from 1966 to December 1995, the reference library of the Arthritis Community Research and Evaluation Unit, and conference abstracts.

FINDINGS

Evidence from randomized, controlled trials supports the short-term benefit of nonsteroidal anti-inflammatory drugs, disease-modifying agents for rheumatic diseases, intravenous pulse corticosteroid therapy, intra-articular therapy, aerobic exercise, patient education, psychologic intervention, home physiotherapy, home occupational therapy, and rehabilitation programs. Some evidence favours acetaminophen for analgesia, low-dose oral corticosteroids for symptom control, and referral to a rheumatologist. Evidence for rest, ice, and heat for symptom control is conflicting and based on low-quality studies.

CONCLUSION

Family physicians play an important role in establishing early and accurate diagnosis of RA, coordinating therapy, and providing ongoing support, education, and monitoring to patients and their families.

In- and out-patient rehabilitation in rheumatoid arthritis. A controlled, open, longitudinal, cost-effectiveness study

Twenty-six patients with rheumatoid arthritis (RA) participated either in a 21 day, community sponsored, in-patient multidisciplinary rehabilitation program (N = 20) or; received traditional, out-patient physiotherapy designed by the patient's rheumatologist (N = 6). Clinical assessments were made (prior to, immediately after, and 6 months after rehabilitation) to evaluate the response to these two quite different rehabilitative measures that included: functional classification, joint score index, subjective VAS of pain, HAQ, pain disability index, Comprehensible psychopathological rating scale, hemoglobin, and CRP measurements. Economic assessments included salary, direct and community sponsored costs, for rehabilitation and costs for sick days and production losses. No clear-cut differences between the two rehabilitation modes were detected. Both modes showed improvement in different assessment parameters; patients with higher education and, therefore, with a less joint-disturbing work profile appeared to profit more from an extensive in-patient rehabilitation program. Patients with less education and a more manually-oriented working profile, did worse and had a higher tendency to seek medical pensioning, in spite of rehabilitative measures. As the total costs for out-patient rehabilitation only add up to 15.8% of the total costs for in-patient rehabilitation, this study setting cautiously suggests that out-patient rehabilitation might be an acceptable alternative to individualized patient groups that might not compromise clinical and vocational outcome. Larger patient groups are needed, however, to confirm these findings.

Effects of occupational therapy home service on patients with rheumatoid arthritis

Because there is little information about the efficacy of home occupational therapy, we decided to assess the effects of a home service on patients with rheumatoid arthritis. 105 patients aged 18-70 years, on stable medical therapy, were randomised to receive a 6-week comprehensive programme of occupational therapy (experimental group, 53 patients) or to receive no such treatment (control group, 52). At 6 weeks, control patients received the experimental regimen, and experimental patients were continued on treatment as needed up to 12 weeks. Outcomes were measured at baseline, 6, and 12 weeks with a global functional capacity score (functional score). At 6 weeks the functional score for the experimental group was significantly higher than that for the control group (mean difference = 8.1, 95% Cl 1.7 to 15.8, p = 0.012). Control patients at 12 weeks showed a similar improvement to experimental patients at 6 weeks, and between 6 and 12 weeks the experimental patients were stable. Occupational therapy leads to a statistically significant and clinically important improvement in function in patients with rheumatoid arthritis.

Severe disability in rheumatoid arthritis: assessment following comprehensive rehabilitation

26 patients with rheumatoid arthritis (RA) who presented with severe disability to a rheumatology unit were reviewed following comprehensive rehabilitation. This comprised in-patient evaluation, alteration in drug therapy, physical and occupational therapy and in many cases, orthopaedic surgery. Sustained benefit is observed 4-6 years later in terms of disease activity and functional class. The greatest improvement in functional class was noted in those patients who underwent joint replacement.

Rehabilitation for rheumatoid arthritis patients. A controlled trial

For 1 year we obtained questionnaire and clinical measures from 2 cohorts of rheumatoid arthritis patients: 49 experimental patients who were admitted for an average of 13 days to a university-based rheumatology rehabilitation unit, and 43 control patients who received care from rheumatologists associated with another teaching hospital. At 1 year, after controlling for groups differences, the experimental patients demonstrated significant (P less than 0.05) improvement compared with control patients in several functional status, mental health, and disease activity measures.

Functional capacity and treatment data from a community based study of patients with rheumatoid arthritis

A community based study of rheumatoid arthritis was undertaken to determine patient characteristics and the patterns of treatment. Three hundred and eighty subjects were visited in their homes throughout Tasmania (pop. 430 000) by a research team. The median age of the sample was 60 years (interquartile range (IR) 49-69), with a female predominance of 2.65 to 1. The average onset age was 41 years (IR 30-53). Prescribing data indicated that polypharmacy was not common in the community, and that the use of slow acting antirheumatic drugs (SAARDs) and oral corticosteroids was not widespread. At the time of the study 26% of subjects were assayed fully functional--class I of the American Rheumatism Association's (ARA) functional classifications. The functional capacity data provided evidence that the spectrum of rheumatoid arthritis found in the community differed from that found in specialist rheumatology clinics.

The use of questionnaires in the evaluation of the functional capacity in rheumatoid arthritis

The functional capacity of 46 patients with rheumatoid arthritis was assessed by means of two systems of investigation. Three different questionnaires were used. One set of each was filled out by the patient himself; the other with the help of the occupational therapist. The results obtained were tested for their reliability. In addition they were also compared to the Ritchie-Index (method of simple measurement of disease activity) of thirty patients. The disability of each patient could be assessed with sufficient precision. A correlation to the Ritchie-Index was also registered.

Are hospital assessments of daily living activities valid?

The level of functional achievement gained during a rehabilitation programme provides the basis for supplying aids and requesting community services on discharge. In a study of follow up regimes for patients with rheumatoid arthritis a comparison was made between functional assessments in hospital before discharge and at home shortly after discharge. A small number of the activities assessed showed a significant change at home and these changes were all towards a lower level of independence.