E-health to improve work functioning in employees with rheumatoid arthritis in rheumatology practice: a feasibility study

Patients' Experiences of Digital Health Interventions for the Self-Management of Chronic Pain: Systematic Review and Thematic Synthesis

BACKGROUND

Research regarding the effectiveness of digital health interventions (DHIs) for people living with chronic pain is widely documented, although it is often measured against changes in clinical outcomes. To gain a comprehensive understanding of the full impact of DHIs, it is vital to understand the experience of individuals who are using them. An exploration of qualitative data regarding the experience of people living with chronic pain engaging with DHIs could provide a more in-depth account of how individuals interact and engage with such tools, uncovering the overall impact DHIs can have on the lives of people living with chronic pain.

OBJECTIVE

This qualitative systematic review and thematic synthesis aimed to appraise and synthesize relevant qualitative evidence on patients' experiences of engaging with DHIs for the self-management of chronic pain symptoms.

METHODS

A systematic literature search of qualitative and mixed methods studies published between 2013 and 2023 was conducted across 6 databases: MEDLINE, PubMed, Embase, CINAHL, PsycINFO, and Scopus. Eligible studies included adult patients aged ≥18 years with a chronic pain diagnosis (ie, >12 weeks) reporting on the experience of engaging in a DHI for the self-management of chronic pain. The Critical Appraisal Skills Program checklist for qualitative research was used to appraise each study. Following a 3-step inductive thematic synthesis approach, the researcher performed line-by-line coding of each eligible article to identify descriptive themes. Through iterative evaluation of the descriptive themes, analytical themes that facilitated a deeper understanding of the data were derived.

RESULTS

In total, 37 qualitative and mixed methods studies were included in the review. Thematic synthesis revealed three overarching themes encompassing five subthemes: (1) personal growth, with 2 subthemes (gaining new insights and renewed mindset); (2) active involvement, with 3 subthemes (motivation, improved access, and health care decision-making); and (3) connectedness and support.

CONCLUSIONS

A positive experience with DHIs among people living with chronic pain is achieved through an improved understanding of their condition, greater self-awareness of how symptoms impact their lives, and an increase in motivation to play an active role in their health care. DHIs promote the confidence and independence of people living with chronic pain, as well as facilitate a sense of ongoing support between routine appointments. However, DHIs may disempower people living with chronic pain by placing too much focus on their pain and should be used as an adjunct to existing care as opposed to replacing in-person appointments. To appropriately meet the needs of people living with chronic pain, the content and features of DHIs should be personalized. Development of future DHIs should use a co-design approach involving key stakeholders to ensure the needs of people living with chronic pain are met.

TRIAL REGISTRATION

PROSPERO CRD42023445100; https://www.crd.york.ac.uk/PROSPERO/view/CRD42023445100.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/52469.

Evidence for telemedicine heterogeneity in rheumatic and musculoskeletal diseases care: a scoping review

Telemedicine and digital health represent alternative approaches for clinical practice; indeed, its potential in healthcare services for prevention, diagnosis, treatment, rehabilitation, and disease monitoring is widely acknowledged. These are all crucial issues to consider when dealing with chronic Rheumatic and Musculoskeletal Diseases (RMDs). The aim was to determine the current state of telemedicine in the field of rheumatology, considering the tools and devices in use as well as the Patient Reported Outcomes. A scoping review was performed following the PRISMA-ScR, retrieving articles through five databases from 1990 to 2022. Inclusion criteria were as follows: (I) adult patients with RMDs, (II) original research papers in the English language with available abstracts, and (III) telehealth and telemedicine are provided as healthcare services. Within the 62 included studies, multiple tools of telemedicine were used: 21/62 websites/online platforms, 18/62 mobile applications, 16/62 telephone contacts, 5/62 video-consultations, and 1/62 wearable devices. Outcomes were classified based on the economic, clinical, and humanistic framework. Clinical outcomes assessed through digital tools were pain, disease activity, and serum uric acid levels. Humanistic outcomes have been grouped according to four categories (e.g., mental and physical function, health management, and health perception). The heterogeneity of digital tools in the field of rheumatology highlights the challenge of implementing reliable research into clinical practice. Effective telerehabilitation models have been presented, and the use of a tight control strategy has also been mentioned. Future research should focus on establishing studies on other RMDs as well as summarizing and formulating clinical guidelines for RMDs. Key Points • Evidence for the usefulness of telemedicine and digital health for managing and monitoring rheumatic and musculoskeletal diseases is progressively increasing. • Several digital tools effectively measure clinical and humanistic and patient reported outcomes in rheumatic and musculoskeletal diseases. • Integrating diverse digital tools in rheumatology is challenging yet promising. • Future research should focus on developing standardized recommendations for practical use of telemedicine in daily practice.

Informing Digital Programs for Lupus Self-Management Education: A Systematic Scoping Review

OBJECTIVE

We describe the characteristics, content, and effectiveness of digital self-management (SM) education programs for lupus and other chronic conditions to identify gaps and inform the improvement of future programs in lupus.

METHODS

Three bibliographic databases were searched for articles published between May 2012 and April 2022. The search was cast to capture the breadth of digital SM education programs in the following conditions: lupus, epilepsy, fibromyalgia, multiple sclerosis, sickle cell anemia, Sjögren syndrome, psoriatic arthritis, and rheumatoid arthritis. Title and abstract screening, as well as full-text review, was conducted by two independent reviewers. Data extraction was first completed by one author charting all studies and then, a second time, by four members of the research team charting collaboratively.

RESULTS

Of the 1,969 articles identified through the search, 14 met inclusion criteria. Two additional articles were included following bibliography review. The 16 articles represented 12 unique digital SM education programs. Programs covered five conditions: epilepsy (n = 3), fibromyalgia (n = 2), multiple sclerosis (n = 4), lupus (n = 1), and rheumatoid arthritis (n = 2). Most programs were asynchronous and internet-based (n = 9) with a prescribed sequence of content (n = 8). Peer, technical, or specialist support was offered in seven programs. Most programs demonstrated statistically significant improvement of symptoms in the intervention group (n = 8).

CONCLUSION

This scoping review summarizes the current landscape for digital SM education programs in lupus and similar conditions. In lupus, further investigation will fill in the gaps around digital SM education needs, user experience, and evaluation of outcomes.

Future challenges in rheumatology - is telemedicine the solution?

The COVID-19 pandemic has become an unprecedented facilitator of rapid telehealth expansion within rheumatology. Due to demographic shifts and workforce shortages in the future, new models of rheumatology care will be expected to emerge, with a growing footprint of telehealth interventions. Telehealth is already being used to monitor patients with rheumatic diseases and initial studies show good results in terms of safety and disease progression. It is being used as a tool for appointment prioritization and triage, and there is good evidence for using telehealth in rehabilitation, patient education and self-management interventions. Electronic patient-reported outcomes (ePROs) offer a number of long-term benefits and opportunities, and a routine collection of ePROs also facilitates epidemiological research that can inform future healthcare delivery. Telehealth solutions should be developed in close collaboration with all stakeholders, and the option of a telehealth visit must not deprive patients of the possibility to make use of a conventional 'face-to-face' visit. Future studies should especially focus on optimal models for rheumatology healthcare delivery to patients living in remote areas who are unable to use or access computer technology, and other patient groups at risk for disparity due to technical inequity and lack of knowledge.

Effects of e-health interventions on health outcomes in patients with rheumatoid arthritis: a systematic review and meta-analysis

AIMS AND OBJECTIVES

To evaluate the effects of e-health interventions on disease activity, self-efficacy, pain and quality of life among patients with rheumatoid arthritis (RA).

BACKGROUND

Prior systematic reviews have only reported the quality and features of e-health interventions in patients with RA. However, the effect of e-health interventions in patients with RA is unclear.

DESIGN

Systematic review and meta-analysis.

METHODS

This review was conducted following the PRISMA guideline. We searched 5 databases, including PubMed, EMBASE, CINAHL, Scopus and the Cochrane library. The risk of bias was assessed using the Cochrane risk of bias tool. The quality of the evidence was assessed via the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. Using a random-effects model adopted the standardised mean difference (SMD) with a 95% confidence interval (CI). A chi-squared test and an I² test were used to assess heterogeneity. Subgroup analyses were conducted based on different controls.

RESULTS

A total of 9 randomised control trials were included in this study. Compared with the control group, disease activity of the e-health group significantly decreased (SMD with 95% CI: -.17 [-.30, -.04], p = .01, I²  = 1%). Meanwhile, trials with usual care control had a larger effect on disease activity (SMD with 95% CI: -.21 [-.40, -.02], p = .03, I²  = 38%). The effect of e-health interventions on self-efficacy was controversial; pain and quality of life were negative in the currently included studies. The quality of evidence was rated as low for disease activity and very low for pain, self-efficacy and quality of life.

CONCLUSIONS

The effect of e-health interventions on disease activity was statistically significant. More well-designed randomised controlled trials are still needed to verify the effects in the future.

RELEVANCE TO CLINICAL PRACTICE

This study shows the potential value of e-health in improving health outcomes in patients with RA.

2018 update of the EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis

To update the European League Against Rheumatism (EULAR) recommendations for the role of the nurse in the management of chronic inflammatory arthritis (CIA) using the most up to date evidence. The EULAR standardised operating procedures were followed. A task force of rheumatologists, health professionals and patients, representing 17 European countries updated the recommendations, based on a systematic literature review and expert consensus. Higher level of evidence and new insights into nursing care for patients with CIA were added to the recommendation. Level of agreement was obtained by email voting. The search identified 2609 records, of which 51 (41 papers, 10 abstracts), mostly on rheumatoid arthritis, were included. Based on consensus, the task force formulated three overarching principles and eight recommendations. One recommendation remained unchanged, six were reworded, two were merged and one was reformulated as an overarching principle. Two additional overarching principles were formulated. The overarching principles emphasise the nurse's role as part of a healthcare team, describe the importance of providing evidence-based care and endorse shared decision-making in the nursing consultation with the patient. The recommendations cover the contribution of rheumatology nursing in needs-based patient education, satisfaction with care, timely access to care, disease management, efficiency of care, psychosocial support and the promotion of self-management. The level of agreement among task force members was high (mean 9.7, range 9.6-10.0). The updated recommendations encompass three overarching principles and eight evidence-based and expert opinion-based recommendations for the role of the nurse in the management of CIA.

Nurses' roles in the management of chronic inflammatory arthritis: a systematic review

In 2011 EULAR first published recommendations for the potential role of nurses in the management of patients with rheumatic diseases. To perform a literature update for the role of nurses in the management of chronic inflammatory arthritis (CIA) from 2010 to 2018. A systematic literature review (SLR) was performed according to the PRISMA guidelines, in accordance with the search strategies and eligibility criteria of the EULAR taskforce. The eligibility criteria were “inflammatory arthritis”, “interventions undertaken by nurses” and “relevant outcomes to answer the research questions”. Exclusion criteria were in itself contradictory outcomes, insufficient data, consideration if they did not clearly distinguish between nurses and health professionals or focused on chronic other than rheumatic diseases. Systematic reviews were classified as descriptive and excluded. Quality of selected trials was determined according to Oxford—levels of evidence 2009. A total of 48 articles and 10 abstracts were identified fulfilling the eligibility and exclusion criteria. Recommendation 1 has been well established in Europe so far. New evidence strengthens the recommendation 3, and—at least in part—recommendation 6. High evidence strengthens recommendation 4, especially for outpatients with low and stable disease activity. Some new evidence also exists for recommendations 7 and 8. This SLR reveals new evidence for the role of nurses in managing CIA patients since 2010, especially for RA-patients with low disease activity or in remission.

Telemedicine for patients with rheumatic diseases: Systematic review and proposal for research agenda

OBJECTIVE

To systematically review the scientific literature regarding tele-rheumatology and draw conclusions about feasibility, effectiveness, and patient satisfaction.

METHODS

PubMed, Scopus, and Cochrane database searches were performed (April 2016) using relevant MeSH and keyword terms for telemedicine and rheumatic diseases. Articles were selected if reporting outcomes for feasibility, effectiveness, and patient satisfaction and methodologically appraised using the Cochrane Collaboration's tool for assessing risk of bias and a modified version of CONSORT 2010 Statement.

RESULTS

A total of 177 articles were screened, 23 were selected for the present review but only 9 were RCTs. Five studies reported on feasibility, 14 effectiveness, and 9 satisfaction rates for different tele-rheumatology interventions grouped in synchronous (remotely delivered consultation) and asynchronous (remote disease activity assessment; tele-monitoring of treatment strategies or rehabilitation; and remotely delivered self-management programs). Seven studies (30.4%) were on rheumatoid arthritis, 2 (8.7%) were on systemic sclerosis (1 including also rheumatoid arthritis patients), 5 (21.7%) on fibromyalgia, 2 (8.7%) on osteoarthritis, 3 (13.0%) on juvenile idiopathic arthritis and 4 (17.4%) on mixed disease cohorts. Interventions and outcomes heterogeneity prevented meta-analysis of results. Overall, feasibility and patient satisfaction rates were high or very high across intervention types. Effectiveness was equal or higher than standard face-to-face approach in controlled trials which, however, were affected by small sample size and lack of blinding participants according to appraisal tools.

CONCLUSION

Telemedicine may provide a well-accepted way to remotely deliver consultation, treatment and monitoring disease activity in rheumatology. Higher quality RCTs demonstrating effectiveness of different tele-rheumatology interventions are needed.

Cancer@Work - a nurse-led, stepped-care, e-health intervention to enhance the return to work of patients with cancer: study protocol for a randomized controlled trial

BACKGROUND

Although the importance of work for patients with cancer is nowadays more acknowledged both in the literature as well as in cancer survivorship care, effective interventions targeting the return to work of these patients are still scarce. Therefore, we developed a nurse-led, stepped-care, e-health intervention aimed at enhancing the return to work of patients with cancer. The objective of this study is to describe the content of the intervention and the study design used to evaluate the feasibility and (cost) effectiveness of the intervention.

METHODS

We designed a multi-centre randomised controlled trial with a follow-up of 12 months. Patients who have paid employment at the time of diagnosis, are on sick leave and are between 18-62 years old will be eligible to participate. After patients have signed the informed consent form and filled in the baseline questionnaire, they are randomly allocated to either the nurse-led, stepped-care, e-health intervention called Cancer@Work, or care as usual. The primary outcome is sustainable return to work. Secondary outcomes are sick leave days, work ability, work functioning, quality of life, quality of working life and time from initial sick leave to full return to work without extensive need for recovery. The feasibility of the Cancer@Work intervention and direct and indirect costs will be determined. Outcomes will be assessed by questionnaires at 3, 6, 9 and 12 months of follow-up.

DISCUSSION

The results of this study will provide new insights into the feasibility and (cost) effectiveness of Cancer@Work, a nurse-led, stepped-care, e-health intervention for cancer patients aimed at enhancing their return to work. If proven effective, the intention is to implement the Cancer@Work intervention in usual psycho-oncological care.

TRIAL REGISTRATION

NTR (Netherlands Trial Registry): NTR5190 . Registered on 18 June 2015.

Enhancing the Return to Work of Cancer Survivors: Development and Feasibility of the Nurse-Led eHealth Intervention Cancer@Work

Background

It is important to enhance the return to work of cancer survivors with an appropriate intervention, as cancer survivors experience problems upon their return to work but consider it an essential part of their recovery.

Objective

The objective of our study was to develop an eHealth intervention to enhance the return to work of cancer survivors and to test the feasibility of the eHealth intervention with end users.

Methods

To develop the intervention we 1) searched the literature, 2) interviewed 7 eHealth experts, 3) interviewed 7 cancer survivors, 2 employers, and 7 occupational physicians, and 4) consulted experts. To test feasibility, we enrolled 39 cancer survivors, 9 supervisors, 7 occupational physicians, 9 general physicians and 2 social workers and gave them access to the eHealth intervention. We also interviewed participants, asked them to fill in a questionnaire, or both, to test which functionalities of the eHealth intervention were appropriate and which aspects needed improvement.

Results

Cancer survivors particularly want information and support regarding the possibility of returning to work, and on financial and legal aspects of their situation. Furthermore, the use of blended care and the personalization of the eHealth intervention were preferred features for increasing compliance. The first version of the eHealth intervention consisted of access to a personal and secure website containing various functionalities for cancer survivors blended with support from their specialized nurse, and a public website for employers, occupational physicians, and general physicians. The eHealth intervention appeared feasible. We adapted it slightly by adding more information on different cancer types and their possible effects on return to work.

Conclusions

A multistakeholder and mixed-method design appeared useful in the development of the eHealth intervention. It was challenging to meet all end user requirements due to legal and privacy constraints. The eHealth intervention appeared feasible, although implementation in daily practice needs to be subject of further research.

ClinicalTrial

Dutch Trial Register number (NTR): 5190; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5190 (Archived by WebCite at http://www.webcitation.org/6hm4WQJqC)

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