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Prothero L, Cartwright M, Lorencatto F, Burr JM, Anderson J, Gardner P, Presseau J, Ivers N, Grimshaw JM, Lawrenson JG. Barriers and enablers to diabetic retinopathy screening: a cross-sectional survey of young adults with type 1 and type 2 diabetes in the UK. BMJ Open Diabetes Res Care 2022; 10:10/6/e002971. [PMID: 36418058 PMCID: PMC9685243 DOI: 10.1136/bmjdrc-2022-002971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/28/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Diabetic retinopathy screening (DRS) attendance in young adults (YAs) is consistently below recommended levels. The aim of this study was to identify barriers and enablers of DRS attendance among YAs in the UK living with type 1 (T1D) and type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS YAs (18-34 years) were invited to complete an anonymous online survey in June 2021 assessing agreement with 30 belief statements informed by the Theoretical Domains Framework (TDF) of behavior change describing potential barriers/enablers to DRS. RESULTS In total, 102 responses were received. Most had T1D (65.7%) and were regular attenders for DRS (76.5%). The most salient TDF domains for DRS attendance were 'Goals', with 93% agreeing that DRS was a high priority, and 'Knowledge', with 98% being aware that screening can detect eye problems early.Overall, 67.4% indicated that they would like greater appointment flexibility (Environmental context/resources) and 31.3% reported difficulties getting time off work/study to attend appointments (Environmental context/resources). This was more commonly reported by occasional non-attenders versus regular attenders (59.1% vs 23.4%, p=0.002). Most YAs were worried about diabetic retinopathy (74.3%), anxious when receiving screening results (63%) (Emotion) and would like more support after getting their results (66%) (Social influences). Responses for T1D and T2D were broadly similar, although those with T2D were more likely have developed strategies to help them to remember their appointments (63.6% vs 37.9%, p=0.019) (Behavioral regulation). CONCLUSIONS Attendance for DRS in YAs is influenced by complex interacting behavioral factors. Identifying modifiable determinants of behavior will provide a basis for designing tailored interventions to improve DRS in YAs and prevent avoidable vision loss.
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Affiliation(s)
- Louise Prothero
- Anglia Ruskin University - Rivermead Campus, Chelmsford, UK
- City, University of London, London, UK
| | | | | | | | | | - Philip Gardner
- United Kingdom Department of Health and Social Care, London, UK
| | | | - Noah Ivers
- University of Toronto, Toronto, Ontario, Canada
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Prothero L, Lawrenson JG, Cartwright M, Crosby‐Nwaobi R, Burr JM, Gardner P, Anderson J, Presseau J, Ivers N, Grimshaw JM, Lorencatto F. Barriers and enablers to diabetic eye screening attendance: An interview study with young adults with type 1 diabetes. Diabet Med 2022; 39:e14751. [PMID: 34837256 PMCID: PMC9304253 DOI: 10.1111/dme.14751] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/09/2021] [Accepted: 11/25/2021] [Indexed: 11/30/2022]
Abstract
AIM The aim of this study was to identify barriers and enablers of diabetic eye screening (DES) attendance amongst young adults with diabetes living in the United Kingdom. METHODS Semistructured qualitative interviews with adults aged 18-34 years with diabetes. Participants were purposively sampled to aim for representation across gender, geographical locations, diabetes type, years since diabetes diagnosis and patterns of attendance (i.e. regular attenders, occasional non-attenders, regular non-attenders). Data were collected and analysed using the Theoretical Domains Framework (TDF) to explore potential individual, sociocultural and environmental influences on attendance. Data were analysed using a combined deductive and inductive thematic analysis approach. Barriers/enablers were mapped to behaviour change techniques (BCTs) to identify potential strategies to increase attendance. RESULTS Key barriers to attendance reported by the sample of 29 study participants with type 1 diabetes, fell within the TDF domains: [Knowledge] (e.g. not understanding reasons for attending DES or treatments available if diabetic retinopathy is detected), [Social Influences] (e.g. lack of support following DES results), [Social role and Identity] (e.g. not knowing other people their age with diabetes, feeling 'isolated' and being reluctant to disclose their diabetes) and [Environmental Context and Resources] (e.g. lack of appointment flexibility and options for rescheduling). Enablers included: [Social Influences] (e.g. support of family/diabetes team), [Goals] (e.g. DES regarded as 'high priority'). Many of the reported barriers/enablers were consistent across groups. Potential BCTs to support attendance include Instructions on how to perform the behaviour; Information about health consequences; Social support (practical) and Social comparison. CONCLUSIONS Attendance to diabetic eye screening in young adults is influenced by a complex set of interacting factors. Identification of potentially modifiable target behaviours provides a basis for designing more effective, tailored interventions to help young adults regularly attend eye screening and prevent avoidable vision loss.
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Affiliation(s)
| | | | | | | | | | - Philip Gardner
- Office for Health Improvement and DisparitiesDepartment of Health and Social CareLondonUK
| | - John Anderson
- Homerton University Hospital NHS Foundation TrustLondonUK
| | | | - Noah Ivers
- Women’s College Research InstituteTorontoOntarioCanada
| | - Jeremy M. Grimshaw
- Ottawa Hospital Research InstituteOttawaOntarioCanada
- Department of MedicineUniversity of OttawaOttawaOntarioCanada
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Prothero L, Lorencatto F, Cartwright M, Burr JM, Gardner P, Anderson J, Presseau J, Ivers N, Grimshaw JM, Lawrenson JG. Perceived barriers and enablers to the provision of diabetic retinopathy screening for young adults: a cross-sectional survey of healthcare professionals working in the UK National Diabetic Eye Screening Programme. BMJ Open Diabetes Res Care 2021; 9:9/2/e002436. [PMID: 34740918 PMCID: PMC8573632 DOI: 10.1136/bmjdrc-2021-002436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 10/07/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Diabetic retinopathy screening (DRS) attendance in young adults is consistently below recommended levels. The aim of this study was to conduct a survey of screening providers in the UK Diabetic Eye Screening Programme (DESP) to identify perceived barriers and enablers to DRS attendance in young adults and elicit views on the effectiveness of strategies to improve screening uptake in this population. RESEARCH DESIGN AND METHODS Members of the British Association of Retinal Screening (n=580) were invited to complete an anonymous online survey in July 2020 assessing agreement with 37 belief statements, informed by the Theoretical Domains Framework (TDF) of behavior change, describing potential barrier/enablers to delivering DRS for young adults and further survey items exploring effectiveness of strategies to improve uptake of DRS. RESULTS In total, 140 (24%) responses were received mostly from screener/graders (67.1%). There was a high level of agreement that the DESP had a role in improving attendance in young adults (96.4%) and that more could be done to improve attendance (90.0%). The most commonly reported barriers related to TDF domains Social influences and Environmental context and resources including lack of integration of DRS with other processes of diabetes care, which limited the ability to discuss diabetes self-management. Other barriers included access to screening services and difficulties with scheduling appointments. Less than half (46.4%) of respondents reported having a dedicated strategy to improve screening uptake in young adults. Strategies perceived to be effective included: screening within the community; prompts/reminders and integrating eye screening with other diabetes services. CONCLUSIONS Screening providers were concerned about screening uptake in young adults, although many programs lacked a dedicated strategy to improve attendance. Problems associated with a lack of integration between DRS with other diabetes care processes were identified as a major barrier to providing holistic care to young adults and supporting diabetes self-management.
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Affiliation(s)
- Louise Prothero
- School of Health Sciences, City, University of London, London, UK
| | | | | | - Jennifer M Burr
- School of Medicine, University of St Andrews, St Andrews, UK
| | | | - John Anderson
- Diabetes and Endocrinology, Homerton University Hospital, London, UK
- Barts and The London School of Medicine and Dentistry, Blizard Institute, London, UK
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Noah Ivers
- Women's College Research Institute, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - John G Lawrenson
- School of Health Sciences, City, University of London, London, UK
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Scott DL, Ibrahim F, Hill H, Tom B, Prothero L, Baggott RR, Bosworth A, Galloway JB, Georgopoulou S, Martin N, Neatrour I, Nikiphorou E, Sturt J, Wailoo A, Williams FMK, Williams R, Lempp H. Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme. Programme Grants Appl Res 2021. [DOI: 10.3310/pgfar09080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Rheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.
Objectives
To (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.
Design
Observational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.
Setting
Observational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).
Participants
Patients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.
Interventions
Intensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.
Main outcome measures
Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR < 2.60) was the treatment target. Other outcomes included fatigue (measured on a 100-mm visual analogue scale), disability (as measured on the Health Assessment Questionnaire), harms and resource use for economic assessments.
Results
Evaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p < 0.001]. Disability (as measured on the Health Assessment Questionnaire) decreased when intensive management patients achieved remission (difference –0.40, 95% confidence interval –0.57 to –0.22) and these differences were considered clinically relevant. However, in all intensive management patients reductions in the Health Assessment Questionnaire scores were less marked (difference –0.1, 95% confidence interval –0.2 to 0.0). The numbers of serious adverse events (intensive management n = 15 vs. standard care n = 11) and other adverse events (intensive management n = 114 vs. standard care n = 151) were similar. Economic analysis showed that the base-case incremental cost-effectiveness ratio was £43,972 from NHS and Personal Social Services cost perspectives. The probability of meeting a willingness-to-pay threshold of £30,000 was 17%. The incremental cost-effectiveness ratio decreased to £29,363 after including patients’ personal costs and lost working time, corresponding to a 50% probability that intensive management is cost-effective at English willingness-to-pay thresholds. Analysing trial baseline predictors showed that remission predictors comprised baseline DAS28-ESR, disability scores and body mass index. A 6-month extension study (involving 95 intensive management patients) showed fewer remissions by 18 months, although more sustained remissions were more likley to persist. Qualitative research in trial completers showed that intensive management was acceptable and treatment support from specialist nurses was beneficial.
Limitations
The main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.
Conclusion
The benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.
Future work
Further research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.
Trial registration
Current Controlled Trials ISRCTN70160382.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David L Scott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Fowzia Ibrahim
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Harry Hill
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Brian Tom
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Louise Prothero
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Rhiannon R Baggott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | | | - James B Galloway
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Sofia Georgopoulou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Naomi Martin
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Isabel Neatrour
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Jackie Sturt
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK
| | - Allan Wailoo
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Frances MK Williams
- Twin Research and Genetic Epidemiology, School of Life Course Sciences, King’s College London, St Thomas’ Hospital, London, UK
| | - Ruth Williams
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
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Scott D, Ibrahim F, Hill H, Tom B, Prothero L, Baggott RR, Bosworth A, Galloway JB, Georgopoulou S, Martin N, Neatrour I, Nikiphorou E, Sturt J, Wailoo A, Williams FMK, Williams R, Lempp H. The clinical effectiveness of intensive management in moderate established rheumatoid arthritis: The titrate trial. Semin Arthritis Rheum 2020; 50:1182-1190. [PMID: 32931984 PMCID: PMC7390769 DOI: 10.1016/j.semarthrit.2020.07.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/21/2020] [Accepted: 07/28/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Many trials have shown that intensive management is effective in patients with early active rheumatoid arthritis (RA). But its benefits are unproven for the large number of RA patients seen in routine care who have established, moderately active RA and are already taking conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs). The TITRATE trial studied whether these patients also benefit from intensive management and, in particular, achieve more remissions. METHODS A 12-month multicentre individually randomised trial compared standard care with monthly intensive management appointments which was delivered by specially trained healthcare professionals and incorporated monthly clinical assessments, medication titration and psychosocial support. The primary outcome was 12-month remission assessed using the Disease Activity Score for 28 joints using ESR (DAS28-ESR). Secondary outcomes included fatigue, disability, harms and healthcare costs. Intention-to-treat multivariable logistic- and linear regression analyses compared treatment arms with multiple imputation used for missing data. RESULTS 459 patients were screened and 335 were randomised (168 intensive management; 167 standard care); 303 (90%) patients provided 12-month outcomes. Intensive management increased DAS28-ESR 12-month remissions compared to standard care (32% vs 18%, p = 0.004). Intensive management also significantly increased remissions using a range of alternative remission criteria and increased patients with DAS28-ESR low disease activity scores. (48% vs 32%, p = 0.005). In addition it substantially reduced fatigue (mean difference -18; 95% CI: -24, -11, p<0.001). There was no evidence that serious adverse events (intensive management =15 vs standard care =11) or other adverse events (114 vs 151) significantly increase with intensive management. INTERPRETATION The trial shows that intensive management incorporating psychosocial support delivered by specially trained healthcare professions is effective in moderately active established RA. More patients achieve remissions, there were greater improvements in fatigue, and there were no more harms.
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Affiliation(s)
- David Scott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Fowzia Ibrahim
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom.
| | - Harry Hill
- ScHARR Health Economics and Decision Science, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, United Kingdom
| | - Brian Tom
- MRC Biostatistics Unit, University of Cambridge, Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge Biomedical Campus, Cambridge, CB2 0SR, United Kingdom
| | - Louise Prothero
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Rhiannon R Baggott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Ailsa Bosworth
- National Rheumatoid Arthritis Society (NRAS), Switchback Office Park, Gardner Rd, Maidenhead, SL6 7RJ, United Kingdom
| | - James B Galloway
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Sofia Georgopoulou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Naomi Martin
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Isabel Neatrour
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Jackie Sturt
- Department Of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom
| | - Allan Wailoo
- ScHARR Health Economics and Decision Science, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, United Kingdom
| | - Frances M K Williams
- Twin Research & Genetic Epidemiology, School of Life Course Sciences, King's College London, St Thomas' Hospital, London SE1 7EH, United Kingdom
| | - Ruth Williams
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
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Prothero L, Barley E, Galloway J, Georgopoulou S, Sturt J. Corrigendum to ``The evidence base for psychological interventions for rheumatoid arthritis: A systematic review of reviews'' [International Journal of Nursing Studies Volume 82, June 2018, Pages 20-29]. Int J Nurs Stud 2020; 107:103581. [DOI: 10.1016/j.ijnurstu.2020.103581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Prothero L, Sturt J, de Souza S, Lempp H. Intensive management for moderate rheumatoid arthritis: a qualitative study of patients' and practitioners' views. BMC Rheumatol 2019; 3:12. [PMID: 30976751 PMCID: PMC6437952 DOI: 10.1186/s41927-019-0057-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 02/26/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The TITRATE trial seeks to test whether intensive management is valuable in achieving disease remission in moderately active rheumatoid arthritis. Intensive management is a complex intervention consisting of: 1) 12 x monthly appointments, 2) tailored 'treatment support' based on motivational interviewing techniques, 3) optimised medication (including the opportunity for biologics), 4) provision of a Patient Handbook, and 5) shared treatment planning. This study aims to understand: a) patients' and practitioners' views on the feasibility and acceptability of intensive management, and b) patients' and practitioners' experience of receiving/providing intensive management. METHODS A qualitative study, nested within a randomised controlled trial. Participants were patients (n = 15) in the intensive management arm of the trial and rheumatology practitioners (n = 16) providing the intensive management intervention, from 18/42 clinics across England. Data were collected via semi-structured interviews and analysed using thematic analysis and iterative categorization. RESULTS Monthly appointments were largely acceptable to both groups who cited several treatment benefits (e.g. regular review of medication, practitioners built close relationships with patients). Practitioners were 'fairly confident' using the motivational interviewing techniques. Learning to pace was the most commonly reported self-management technique that patients and healthcare professionals worked on together, followed by gaining control over pain and fatigue. Practitioners liked having the option to offer biologics to patients with moderate RA. Most patients found the optimised medication (following monthly joint assessment) helpful and side-effects experienced were resolved. Variation existed in the extent to which patients engaged with the Patient Handbook and shared treatment planning, with those who did engage doing so in the early stages. CONCLUSIONS Feedback from patient participants about the intensive management intervention was positive. They found increased medication helpful. Continuity of care with the same healthcare professional at regular intensive management sessions, and the treatment support provided, were highly rated. Feedback from practitioners indicated that intensive management training is feasible. Evidence from the interviews showed that some practitioners applied motivational interviewing techniques during standard care appointments and they would like the opportunity to address lifestyle issues with patients.
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Affiliation(s)
- Louise Prothero
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King’s College London, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ UK
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, 57 Waterloo Road, London, SE1 8WA UK
| | - Jackie Sturt
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, 57 Waterloo Road, London, SE1 8WA UK
| | - Savia de Souza
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King’s College London, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ UK
| | - Heidi Lempp
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King’s College London, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ UK
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Abstract
The nature of physician-patient interaction can have a significant impact on patient outcomes through information-sharing and disease-specific education that can enhance patients' active involvement in their care. The aim of this systematic review was to examine all the empirical evidence pertaining to aspects of physician-patient communication and its impact on patient outcomes. A systematic search of five electronic databases (MEDLINE, PsycINFO, EMBASE, CINAHL, and Web of Science) was undertaken from earliest record to December 2016. Studies were eligible if they: (1) included adult participants (18 years or over) with a diagnosis of a rheumatic condition; (2) were of quantitative, qualitative or mixed methods design; (4) were surveys, observational and interventional studies; (5) were published in the English language; and (6) reported findings on either various physician-patient communication aspects alone or in combination with physical and psychological outcomes. Searches identified 455 papers. Following full-text retrieval and assessment for eligibility and quality, ten studies were included in the review; six quantitative, one mixed methods, and three qualitative papers. Higher levels of trust in the physician and active patient participation in the medical consultation were linked to lower disease activity, better global health, less organ damage accrual, greater treatment satisfaction with fewer side effects from the medication, more positive beliefs about control over the disease, and about current and future health. Future research could focus on the design and implementation of interventions incorporating communications skills and patient-education training.
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Affiliation(s)
- Sofia Georgopoulou
- Department of Psychology, University of East London, Arthur Edwards Building, Water Lane, Stratford, E15 4LZ UK
- Clinical Trials Group, Academic Department of Rheumatology, King’s College London, Faculty of Life Sciences and Medicine, 3rd Floor Weston Education Centre, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ UK
| | - Louise Prothero
- Clinical Trials Group, Academic Department of Rheumatology, King’s College London, Faculty of Life Sciences and Medicine, 3rd Floor Weston Education Centre, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ UK
| | - David P. D’Cruz
- Clinical Trials Group, Academic Department of Rheumatology, King’s College London, Faculty of Life Sciences and Medicine, 3rd Floor Weston Education Centre, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ UK
- Louise Coote Lupus Unit, 4th Floor Tower Wing, Guys Hospital, London, SE1 9RT UK
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Prothero L, Barley E, Galloway J, Georgopoulou S, Sturt J. The evidence base for psychological interventions for rheumatoid arthritis: A systematic review of reviews. Int J Nurs Stud 2018; 82:20-29. [PMID: 29573593 DOI: 10.1016/j.ijnurstu.2018.03.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 03/04/2018] [Accepted: 03/09/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Psychological interventions are an important but often overlooked adjunctive treatment option for patients with rheumatoid arthritis. Findings from systematic reviews of psychological interventions for this patient group are conflicting. A systematic review of reviews can explain inconsistencies between studies and provide a clearer understanding of the effects of interventions. OBJECTIVES To: 1) determine the effectiveness of psychological interventions in improving biopsychosocial outcomes for adults with rheumatoid arthritis, 2) determine the relationship between the intensity of the psychological interventions (number of sessions, duration of sessions, duration of intervention) on outcomes, and 3) assess the impact of comparator group (usual care, education only) on outcomes. DESIGN We conducted a systematic review of reviews using the following inclusion criteria: 1) randomised controlled trials of psychological interventions (including cognitive behavioural therapy, supportive counselling, psychotherapy, self-regulatory techniques, mindfulness-based cognitive therapy and disclosure therapy) provided as an adjunct to medication, 2) included rheumatoid arthritis patients aged ≥ 18 years, 3) reported findings for at least 1 of the primary outcomes: pain, fatigue, psychological status, functional disability and disease activity and 4) were published in English between January 2000 and March 2015 (updated January 2018). DATA SOURCES We searched in MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. Reference lists were searched for additional reviews. REVIEW METHODS Study selection and 50% of the quality assessments were performed by two independent reviewers. Methodological quality was measured using the Assessment of Multiple Systematic Reviews checklist. Data extraction was conducted by one reviewer using a predesigned data extraction form. RESULTS Eight systematic reviews met inclusion criteria (one review was excluded due to its low-quality score). Small post intervention improvements in patient global assessment, functional disability, pain, fatigue, anxiety and depression were observed. The effect on coping, self-efficacy and physical activity was greater. Improvements in depression, coping and physical activity were maintained (8.5-14 months). Interventions delivered over a longer period with a maintenance component appeared more effective. Attention, education, and placebo control groups produced some improvements but not as large as those produced by the psychological interventions. CONCLUSIONS Psychological interventions result in small to moderate improvements in biopsychosocial outcomes for patients with rheumatoid arthritis in addition to those achieved by standard care. Several priorities for future research were identified, including determining the cost effectiveness of non-psychologically trained health professionals delivering psychological interventions.
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Affiliation(s)
- Louise Prothero
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK; Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, 57 Waterloo Road, London, SE1 8WA, UK.
| | - Elizabeth Barley
- College of Nursing, Midwifery and Healthcare, University of West London, Boston Manor Road, Brentford, Middlesex, TW8 9GA, UK.
| | - James Galloway
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK.
| | - Sofia Georgopoulou
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK; School of Psychology, University of East London, Water Lane, London, E15 4LZ, UK.
| | - Jackie Sturt
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, 57 Waterloo Road, London, SE1 8WA, UK.
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Martin NH, Ibrahim F, Tom B, Galloway J, Wailoo A, Tosh J, Lempp H, Prothero L, Georgopoulou S, Sturt J, Scott DL. Does intensive management improve remission rates in patients with intermediate rheumatoid arthritis? (the TITRATE trial): study protocol for a randomised controlled trial. Trials 2017; 18:591. [PMID: 29221496 PMCID: PMC5723045 DOI: 10.1186/s13063-017-2330-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 11/16/2017] [Indexed: 01/26/2023] Open
Abstract
Background Uncontrolled active rheumatoid arthritis can lead to increasing disability and reduced quality of life over time. ‘Treating to target’ has been shown to be effective in active established disease and also in early disease. However, there is a lack of nationally agreed treatment protocols for patients with established rheumatoid arthritis who have intermediate disease activity. This trial is designed to investigate whether intensive management of disease leads to a greater number of remissions at 12 months. Levels of disability and quality of life, and acceptability and cost-effectiveness of the intervention will also be examined. Methods The trial is a 12-month, pragmatic, randomised, open-label, two-arm, parallel-group, multicentre trial undertaken at specialist rheumatology centres across England. Three hundred and ninety-eight patients with established rheumatoid arthritis will be recruited. They will currently have intermediate disease activity (disease activity score for 28 joints assessed using an erythrocyte sedimentation rate of 3.2 to 5.1 with at least three active joints) and will be taking at least one disease-modifying anti-rheumatic drug. Participants will be randomly selected to receive intensive management or standard care. Intensive management will involve monthly clinical reviews with a specialist health practitioner, where drug treatment will be optimised and an individualised treatment support programme delivered based on several principles of motivational interviewing to address identified problem areas, such as pain, fatigue and adherence. Standard care will follow standard local pathways and will be in line with current English guidelines from the National Institute for Health and Clinical Excellence. Patients will be assessed initially and at 6 and 12 months through self-completed questionnaires and clinical evaluation. Discussion The trial will establish whether the known benefits of intensive treatment strategies in active rheumatoid arthritis are also seen in patients with established rheumatoid arthritis who have moderately active disease. It will evaluate both the clinical and cost-effectiveness of intensive treatment. Trial registration Current Controlled Trials, ID: ISRCTN70160382. Registered on 16 January 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2330-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Naomi H Martin
- Academic Department of Rheumatology, King's College London, Weston Education Centre, Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK.
| | - Fowzia Ibrahim
- Academic Department of Rheumatology, King's College London, Weston Education Centre, Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK
| | - Brian Tom
- MRC Biostatistics Unit, Institute of Public Health, University Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK
| | - James Galloway
- Academic Department of Rheumatology, King's College London, Weston Education Centre, Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK
| | - Allan Wailoo
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Jonathan Tosh
- DRG Abacus, Manchester One, 53 Portland Street, Manchester, M1 3LF, UK
| | - Heidi Lempp
- Academic Department of Rheumatology, King's College London, Weston Education Centre, Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK
| | - Louise Prothero
- Academic Department of Rheumatology, King's College London, Weston Education Centre, Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK
| | - Sofia Georgopoulou
- Department of Physiotherapy, King's College London, 5th Floor, Addison House, Guy's Campus, London, SE1 1UL, UK
| | - Jackie Sturt
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK
| | - David L Scott
- Academic Department of Rheumatology, King's College London, Weston Education Centre, Cutcombe Road, Denmark Hill, London, SE5 9RJ, UK
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Kirresh OZ, Sturt J, Dennick K, Campbell R, Bearne L, Prothero L, Lempp H. O22. THE RELATIONSHIP BETWEEN PSYCHOLOGICAL DISTRESS AND RHEUMATOLOGICAL CONDITIONS: IS IT A DISEASE-SPECIFIC DISTRESS? Rheumatology (Oxford) 2017. [DOI: 10.1093/rheumatology/kex061.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Georgopoulou S, Prothero L, Lempp H, Galloway J, Sturt J. Motivational interviewing: relevance in the treatment of rheumatoid arthritis? Rheumatology (Oxford) 2016; 55:1348-56. [PMID: 26515960 PMCID: PMC5854032 DOI: 10.1093/rheumatology/kev379] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 09/17/2015] [Indexed: 11/13/2022] Open
Abstract
Advances in pharmacological treatment options in RA have led to a dramatic potential for improvement in patients' physical and psychological status. Despite advances, poor outcomes, including fatigue, pain, reduced physical activity and quality of life, are still observed. Reasons include non-adherence to medication, insufficient knowledge about the disease and lack of support in coping and effectively self-managing their condition. Motivational interviewing (MI) is a person-centred approach that relies on collaboration and empathy aiming to elicit a person's own motivation for behaviour change. It has been implemented in a variety of long-term conditions, addressing issues such as lifestyle changes with beneficial effects, but it is yet to be widely recognized and adopted in the field of rheumatology. This review will explain the techniques underpinning MI and the rationale for adopting this approach in rheumatology with the aim to increase medication adherence and physical activity and improve patients' coping strategies for pain and fatigue.
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Affiliation(s)
- Sofia Georgopoulou
- Academic Department of Rheumatology, Faculty of Life Sciences & Medicine and
| | - Louise Prothero
- Academic Department of Rheumatology, Faculty of Life Sciences & Medicine and
| | - Heidi Lempp
- Academic Department of Rheumatology, Faculty of Life Sciences & Medicine and
| | - James Galloway
- Academic Department of Rheumatology, Faculty of Life Sciences & Medicine and
| | - Jackie Sturt
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
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Prothero L, Georgopoulou S, de Souza S, Bosworth A, Bearne L, Lempp H. Patient involvement in the development of a handbook for moderate rheumatoid arthritis. Health Expect 2016; 20:288-297. [PMID: 27086728 PMCID: PMC5354020 DOI: 10.1111/hex.12457] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2016] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Self-management is a key recommendation for people with rheumatoid arthritis (RA). Educational materials may support self-management, and increasingly patients are becoming involved with the development of these materials. The TITRATE trial compares the effectiveness of intensive management to standard care in patients with moderate RA across England. As part of the intensive management intervention, participants are given a handbook. AIM AND OBJECTIVES The aim of this study was to develop a handbook to support the intensive management. The objectives were to: (i) involve patients in the identification of relevant information for inclusion in the TITRATE handbook; (ii) ensure the content of the handbook is acceptable and accessible. DESIGN We held an audio-taped workshop with RA patients. The transcript of the workshop was analysed using thematic content analysis. RESULTS Five main themes were identified as follows: 'rheumatoid arthritis treatment, perceptions of rheumatoid arthritis, the importance of individualized goals, benefits of self-management and the patient handbook'. Feedback from the workshop was incorporated into the handbook, and patients' anonymous testimonies were added. CONCLUSION This study demonstrates that patient contribution to the development of educational material to support intensive management of RA is both feasible and valuable. A qualitative evaluation of the use and impact of the handbook with patients and practitioners is planned on completion of the TITRATE trial.
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Affiliation(s)
- Louise Prothero
- Academic Department of Rheumatology, Clinical Trials Group, King's College London, Faculty of Life Sciences and Medicine, Weston Education Centre, London, UK
| | - Sofia Georgopoulou
- Academic Department of Rheumatology, Clinical Trials Group, King's College London, Faculty of Life Sciences and Medicine, Weston Education Centre, London, UK
| | - Savia de Souza
- Academic Department of Rheumatology, Clinical Trials Group, King's College London, Faculty of Life Sciences and Medicine, Weston Education Centre, London, UK
| | - Ailsa Bosworth
- National Rheumatoid Arthritis Society, Maidenhead, Berkshire, UK
| | - Lindsay Bearne
- Academic Department of Physiotherapy, Division of Health and Social Care Research, King's College London, London, UK
| | - Heidi Lempp
- Academic Department of Rheumatology, Clinical Trials Group, King's College London, Faculty of Life Sciences and Medicine, Weston Education Centre, London, UK
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Prothero L, Georgopoulou S, Galloway J, Williams R, Bosworth A, Lempp H. Patients’ and carers’ views and expectations about intensive management for moderate rheumatoid arthritis: a qualitative study. PSYCHOL HEALTH MED 2015; 21:918-25. [DOI: 10.1080/13548506.2015.1111394] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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