Gap between short‐ and long‐term effects of patient education in rheumatoid arthritis patients: A systematic review

Objective

To systematically review educational or psychoeducational interventions for patients with rheumatoid arthritis focusing on long‐term effects, especially health status.

Methods

Two independent reviewers appraised the methodologic quality of the included randomized controlled trials, published between 1980 and July 2002.

Results

Validity scores of studies ranged from 3 to 9 (of 11). The 7 educational programs mainly improved knowledge and compliance in the short and long term, but there was no improvement in health status. All 4 psychoeducational programs improved coping behavior in the short term, 2 of them showing a positive long‐term effect on physical or psychological health variables.

Conclusion

Methodologically better‐designed studies had more difficulties demonstrating positive outcome results. Short‐term effects in program targets are generally observed, whereas long‐term changes in health status are not convincingly demonstrated. There is a need to find better strategies to enhance the transfer of short‐term effects into gains in health status.

     

Influence of coping skills on health‐related quality of life in patients with systemic lupus erythematosus

Objective

To identify coping strategies used by patients with systemic lupus erythematosus (SLE), and to assess the influence of main clinical and coping variables on health‐related quality of life (HRQOL).

Methods

We administered the Coping Orientation to Problems Experienced and the Short Form 36 questionnaire to a group of 144 patients with SLE and a group of 129 healthy controls. At the time of the psychological assessment, all patients underwent a complete clinical and laboratory evaluation.

Results

SLE patients had higher scores in acceptance (P < 0.001) and turning to religion (P = 0.05) and lower scores in planning (P = 0.001), suppression of competing activities (P = 0.010), restraint coping (P = 0.031), focusing on and venting of emotion (P = 0.009), and strategies focused on problem (P = 0.012) compared with controls. By means of linear regression analysis, HRQOL in SLE patients seemed to be influenced positively by restraint coping and positive reinterpretation and growth, and negatively by focusing on and venting of emotion, behavioral disengagement, and mental disengagement. When clinical variables were added to the multivariate analysis for coping strategies, more significant regression models that included joint pain were obtained.

Conclusion

In facing stressful situations, patients with SLE tend to use coping skills that are generally adopted for events perceived as nonmodifiable. Strategies that show a passive attitude and joint pain seem to impair these patients' HRQOL.

     

Health care utilization among rheumatoid arthritis patients referred to a rheumatology center: unequal needs,unequal care?

Objective

To quantify the utilization of health care by rheumatoid arthritis (RA) patients and to estimate the contribution of patient characteristics to the explanation of the use of care, in order to evaluate whether those in need of care actually receive care.

Methods

A questionnaire survey and a clinical examination were conducted among patients with RA referred to a rheumatology center. Health care utilization was assessed for medical care, allied health care, psychosocial care, and home care. The influence of sociodemographic variables and clinical and health characteristics on health care utilization was assessed by means of logistic regression.

Results

Multivariate analyses showed that, for all types of services, disease‐related factors explained most of the utilization. However, some sociodemographic variables (age, sex, and living situation) were also related to the utilization of care.

Conclusion

Most patients received the care they needed. However, for the elderly with RA, problems in access to allied health care and psychosocial care exist.

     

Quality of well‐being in older people with osteoarthritis

Objective

To examine the sensitivity of the Quality of Well‐Being Scale (QWB) as a measure of health‐related quality of life (HRQOL) in people with osteoarthritis (OA).

Methods

The QWB was administered, along with the Arthritis Impact Measurement Scale (AIMS) and other health measures. Health care utilization data were also obtained.

Results

People with OA had a mean QWB score of 0.643. The QWB scores were significantly correlated with total AIMS scores, self‐rated health status, health care costs, depression scores, and most AIMS subscales. In addition, changes in QWB scores after 1 year were significantly correlated with changes in total AIMS scores and some AIMS subscales.

Conclusion

The QWB appears to be a useful and sensitive generic, utility‐based measure of HRQOL in people with OA.

     

Quality of life,social support,and knowledge of disease in women with rheumatoid arthritis

Objective

To examine the relationships between the quality of life (QOL) of women with rheumatoid arthritis (RA) and 1) their perceived levels of social support and 2) their primary caregivers' knowledge of RA and its treatment.

Methods

Women aged 40–60 years with established RA completed validated questionnaires on health status (Arthritis Impact Measurement Scales 2) and satisfaction with the levels of social support from their primary caregiver (Significant Others Scale A). In addition, both the caregivers and patients independently completed questionnaires that were designed to elicit knowledge of RA and its treatment.

Results

Fifty‐eight patients and their primary caregivers completed the questionnaires. Analysis of the patients' health status demonstrated widespread biopsychosocial impairments. Arthritis pain, identified as the poorest health status dimension, was associated with the lowest levels of satisfaction, and received the highest priority for health status improvement. In contrast, the patients reported highest levels of satisfaction with social support from family and friends. Positive associations between social support variables and a number of QOL measures were observed. Both the caregivers and the patients displayed limited knowledge of RA and its treatment. Associations between the levels of knowledge and the patients' QOL measures were not observed.

Conclusion

In this study of women with RA and their caregivers, a limited knowledge of disease did not appear to impact QOL measures. However, failure to detect an association between knowledge of disease and QOL may have been influenced by a combination of the relatively small study numbers and insufficient variation in caregivers' knowledge, such that a floor effect existed.

     

Economic evaluation of multidisciplinary rehabilitation after primary total knee arthroplasty based on a randomized controlled trial

Objective

To conduct an economic evaluation of a multidisciplinary, biopsychosocial outpatient rehabilitation program implemented 2–4 months after total knee arthroplasty (TKA), compared with conventional orthopedic care.

Methods

After surgery, 86 patients were randomized to a multidisciplinary rehabilitation group (n = 44) or a conventional orthopedic care group (n = 42). Alongside the randomized controlled trial, we estimated the costs of rehabilitation, health care resource use, and community support. Information about resource use was collected by means of a questionnaire together with data from hospital records. The primary outcome (effectiveness) measure was change in self‐reported functional capacity and the secondary measure was quality‐adjusted life years (QALYs) gained during the 12‐month followup. Cost‐effectiveness was assessed from between‐group differences in costs, change in functional capacity, and QALYs gained.

Results

Both protocols of providing rehabilitation services turned out to be equally effective, but the conventional orthopedic care protocol was unequivocally cost saving: the saving was €1,830 per patient (95% confidence interval ?548, 3,623) using the available direct cost data.

Conclusion

Multidisciplinary rehabilitation for unselected osteoarthritis patients in the subacute period of recovery after TKA is not a cost‐effective use of health care resources. Similar rehabilitation protocols cannot be recommended for clinical pathways of TKA in the future.

     

Acute low back pain self‐management intervention for urban primary care patients: Rationale,design, and predictors of participation

Objectives

To describe the rationale and design of a self‐management program for low‐income, urban, primary care patients with acute low back pain. Issues related to recruitment and protocol delivery, and attendance patterns and predictors of program attendance are described.

Methods

Two hundred eleven adult patients (73% female; 60% African American) were recruited from primary care neighborhood health centers. Focus groups were conducted for program development, and participants then completed a baseline interview and were randomized into groups receiving either usual care or a self‐management intervention.

Results

Twenty‐nine percent of the intervention group attended the self‐management class. Significant predictors of attendance included being older, reporting less income, and not working for pay. Attendees did not differ from nonattendees on back pain severity, symptoms, health‐related quality of life, self‐management processes, or satisfaction with care.

Conclusion

Effective minimal‐contact behavioral interventions are needed to reach larger portions of the patient population.

     

Mental health status and leisure‐time physical activity contribute to fatigue intensity in patients with spondylarthropathy

Objective

To examine the relationship between disease‐related variables, leisure‐time physical activity (LTPA), and mental health status with fatigue severity in patients with spondylarthropathy (SpA).

Methods

Sixty‐six SpA patients completed questionnaires assessing disease activity (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI]), functional ability (Bath Ankylosing Spondylitis Functional Index), and health‐related quality of life (Short Form 36). LTPA patterns, demographics, and disease‐related data were obtained by interview. A clinical examination determined tender point count. Fatigue was assessed with the BASDAI fatigue item.

Results

The mean BASDAI fatigue score was 5.5 (SD = 2.7) with 59% of the sample obtaining a score ≥5. Disease activity, functional disability, and worse mental health contributed to greater fatigue (R² = 0.56). The relationship between exercise duration and fatigue intensity was moderated by mental health status. For patients with poorer mental health scores, exercise did not influence fatigue severity. However, for patients reporting better mental health status, engaging in more LTPA decreased fatigue severity.

Conclusion

In addition to increased disease activity and functional disability, greater fatigue severity in SpA is associated with poorer mental health status. Integrating regular leisure physical activity into the comprehensive treatment of SpA may be useful for modulating fatigue.

     

Identification of case complexity and increased health care utilization in patients with rheumatoid arthritis

Objectives To document biopsychosocial profiles of patients with rheumatoid arthritis (RA) by means of the INTERMED and to correlate the results with conventional methods of disease assessment and health care utilization.

Methods

Patients with RA (n = 75) were evaluated with the INTERMED, an instrument for assessing case complexity and care needs. Based on their INTERMED scores, patients were compared with regard to severity of illness, functional status, and health care utilization.

Results

In cluster analysis, a 2‐cluster solution emerged, with about half of the patients characterized as complex. Complex patients scoring especially high in the psychosocial domain of the INTERMED were disabled significantly more often and took more psychotropic drugs. Although the 2 patient groups did not differ in severity of illness and functional status, complex patients rated their illness as more severe on subjective measures and on most items of the Medical Outcomes Study Short Form 36. Complex patients showed increased health care utilization despite a similar biologic profile.

Conclusions

The INTERMED identified complex patients with increased health care utilization, provided meaningful and comprehensive patient information, and proved to be easy to implement and advantageous compared with conventional methods of disease assessment. Intervention studies will have to demonstrate whether management strategies based on INTERMED profiles can improve treatment response and outcome of complex patients.

     

Long‐term morbidity,mortality, and economics of rheumatoid arthritis

Objective

To estimate the morbidity, mortality, and lifetime costs of care for rheumatoid arthritis (RA).

Methods

We developed a Markov model based on the Arthritis, Rheumatism, and Aging Medical Information System Post‐Marketing Surveillance Program cohort, involving 4,258 consecutively enrolled RA patients who were followed up for 17,085 patient‐years. Markov states of health were based on drug treatment and Health Assessment Questionnaire scores. Costs were based on resource utilization, and utilities were based on visual analog scale–based general health scores.

Results

The cohort had a mean age of 57 years, 76.4% were women, and the mean duration of disease was 11.8 years. Compared with a life expectancy of 22.0 years for the general population, this cohort had a life expectancy of 18.6 years and 11.3 quality‐adjusted life years. Lifetime direct medical care costs were estimated to be $93,296. Higher costs were associated with higher disability scores.

Conclusion

A Markov model can be used to estimate lifelong morbidity, mortality, and costs associated with RA, providing a context in which to consider the potential value of new therapies for the disease.

     

A disease‐specific self‐help program compared with a generalized chronic disease self‐help program for arthritis patients

Objective

Both the Arthritis Self‐Management Program (ASMP) and the generic Chronic Disease Self‐Management Program (CDSMP) have been shown to be successful in improving conditions in patients with arthritis. This study compared the relative effectiveness of the 2 programs for individuals with arthritis.

Methods

Patients whose primary disease was arthritis were randomized to the ASMP (n = 239) or to the CDSMP (n = 116). Analyses of covariance were used to compare the outcome measures for the 2 programs at 4 months and 1 year. Measures included quality of life outcomes (self reported, health distress, disability, activity limitation, global health, pain, and fatigue), health behaviors (practice of mental stress management, stretching and strength exercise, aerobic exercise), self efficacy, and health care utilization (physician visits and hospitalizations).

Results

Both programs showed positive results. The disease‐specific ASMP appeared to have advantages over the more generic CDSMP for patients with arthritis at 4 months. These advantages had lessened slightly by 1 year.

Conclusion

The disease‐specific ASMP should be considered first where there are sufficient resources and participants. However, both programs had positive effects, and the CDSMP should be considered a viable alternative.

     

Perceived self‐efficacy gained from,and health effects of,a rehabilitation program after hip joint replacement

Objective

To examine whether a routine multidisciplinary inpatient rehabilitation program can increase patient self‐efficacy, and to investigate the effects of high self‐efficacy at admission, and increases in self‐efficacy, on health changes in patients who undergo such rehabilitation after hip joint replacement.

Methods

Participants in this longitudinal study were 1,065 patients who underwent inpatient rehabilitation after hip joint replacement. Questionnaires were administered at admission, discharge, and 6‐month followup. The main outcome variables were disability, pain, depressive symptomatology, and self‐efficacy to cope with disability and pain.

Results

Significant improvements from admission to discharge from the inpatient rehabilitation program in disability, pain, depressive symptoms, and self‐efficacy were found. In addition, higher levels of self‐efficacy at admission and larger increases in self‐efficacy over the course of the program predicted larger health changes (i.e., greater decreases in disability, pain, and depressive symptoms). Results were generally similar for health changes from discharge to 6‐month followup.

Conclusion

A routine multidisciplinary inpatient rehabilitation program after hip joint replacement can result in enhanced self‐efficacy.

     

Relationship of pain‐coping strategies and pain‐specific beliefs to pain experience in children with juvenile idiopathic arthritis

Objective

To examine whether pain‐specific beliefs and coping strategies of patients with juvenile idiopathic arthritis (JIA) independently predict their reported pain, while controlling for relevant demographic variables, disease activity, and parent‐rated disability. To compare use of pain‐coping strategies and pain‐related beliefs of a selected subgroup of patients with high pain and low disease activity (high pain group) with the remaining patients.

Methods

Children with JIA (n = 56) completed the Pain Coping Questionnaire, a revised version of the Survey of Pain Attitudes, and a 3‐week pain diary. The parents completed the Childhood Health Assessment Questionnaire (CHAQ). Second order principal component analyses were conducted in order to reduce the number of independent variables. Regression analyses of the dependent measure were performed. The use of coping strategies and health beliefs were compared using t‐tests for independent samples. Pearson's correlation coefficients were calculated to examine the direct associations between each individual coping and belief scale, and the pain measure.

Results

Only the CHAQ and the cognitive belief composite factor score made statistically significant contribution to the prediction of pain after controlling for other variables. Significant differences were found between the scores of high pain patients and the rest of the group for the health belief subscale of disability (mean ± SD 2.0 ± 0.6 and 1.2 ± 0.7, respectively), and for the health belief subscale of harm (mean ± SD 2.7 ± 0.6 and 1.8 ± 0.7, respectively). Significant correlations were obtained between the pain measure and the pain‐coping subscale of catastrophizing, the pain belief subscales of disability, harm, solicitude (inverse), control, and medical cure.

Conclusion

These results support a model of pain experience in patients with JIA where psychological factors are strongly influential. It may be efficient to focus behavioral interventions on a subgroup of children where the pain experience seems to be in discordance with the disease activity.

     

Unmet demands for health care among patients with rheumatoid arthritis: Indications for underuse?

Objective

To assess the prevalence of unmet health care demands among rheumatoid arthritis (RA) patients, and to determine if these unmet demands indicate underuse.

Methods

A total of 679 patients with RA participated in a questionnaire survey and clinical examination. Unmet health care demands and health care use were assessed for orthopedic care, allied health care, home care, and psychosocial care. Indications for underuse were determined by comparing health outcomes of patients with unmet health care demands and of health care users.

Results

Of the 679 patients, 28.7% had an unmet demand for 1 of the 4 services: 13.4% for allied health care, 9.7% for orthopedic care, 9.4% for home care, and 6.2% for psychosocial care. Underuse of allied health care, home care and psychosocial care was observed.

Conclusion

Unmet demands for health care are frequent among RA patients. Most unmet demands indicate underuse. Health care professionals should therefore be more responsive to the demands of patients.

     

Use of alternative therapies by older adults with osteoarthritis

Objective

To examine the rates of use and expenditures on alternative therapies by adults with osteoarthritis (OA).

Methods

Adults with OA recruited from the community to participate in a randomized clinical trial recorded alternative and traditional health care use on postcard diaries. General and arthritis‐specific quality of life was assessed by questionnaires.

Results

More than 47% of participants reported using at least one type of alternative care during the 20‐week intervention period. Among alternative care consumers, the most commonly used treatments were massage therapy (57%), chiropractic services (20.7%), and nonprescribed alternative medications (17.2%). Four percent of subjects reported using only alternative care during the study period. Expenditures for alternative therapy averaged $1,127 per year, compared with $1,148 for traditional therapies.

Conclusion

Use of and expenditures for alternative care were high among this cohort of older adults with OA. Clinicians may want to inquire about use of these therapies before recommending treatments for this condition.

     

Performance of a generic health‐related quality of life measure in a clinic population with rheumatic disease

Objective

To assess the performance of a generic health‐related quality of life (HRQOL) measure in a rheumatology clinic population.

Methods

Participants (n = 619) with fibromyalgia, rheumatoid arthritis, or osteoarthritis receiving care from rheumatologists completed mailed questionnaires that included the Behavioral Risk Factor Surveillance System (BRFSS) HRQOL measure and condition‐specific measures assessing disability, pain, fatigue, and helplessness. The BRFSS assesses global health and number of days in the past 30 of poor physical or mental health or activity limitation. The overall sample was described, followed by comparison of adjusted scores on all HRQOL measures by diagnosis.

Results

Participants reported mild difficulty with activities of daily living, marked pain and fatigue, and moderate helplessness. Participants reported a mean of 8 or more days out of 30 of poor physical and mental health and activity limitations; more than 40% reported poor or fair health. Participants with fibromyalgia reported more ill health on condition‐specific measures and the BRFSS HRQOL measures than did participants with osteoarthritis or rheumatoid arthritis.

Conclusion

The BRFSS HRQOL measure is a brief, easily administered, generic health indicator that shows differences among rheumatic disease diagnoses.

     

Impairment and impact of pain in female patients with Ehlers‐Danlos syndrome: A comparative study with fibromyalgia and rheumatoid arthritis

Objective

The purpose of this study was to investigate functional impairment and the impact of pain in patients with Ehlers‐Danlos syndrome, hypermobility type (EDS‐HT), and to compare the burden of disease with that in women with fibromyalgia (FM) and rheumatoid arthritis (RA).

Methods

A total of 206 female patients were compared (72 with EDS‐HT, 69 with FM, and 65 with RA). Functional impairment was assessed with the Sickness Impact Profile (SIP), and the psychosocial impact of chronic pain was quantified with the Multidimensional Pain Inventory (MPI). Data on symptoms were collected.

Results

SIP results showed clinically relevant health‐related dysfunction in all groups. Significantly poorer physical, psychosocial, and overall function was found in the EDS‐HT group compared with the RA group. In comparison with the FM group, the EDS‐HT group reported similar physical and overall function, but better psychosocial function. T scores from the MPI revealed significantly higher levels of pain severity and life interference due to pain, and a lower level of perceived life control, in the EDS‐HT group compared to the RA group. In contrast, the EDS‐HT group showed significantly lower levels of pain severity, life interference, and affective distress in comparison with the FM group. Social support for help in coping with pain was similar between the 3 groups.

Conclusion

EDS‐HT is associated with a consistent burden of disease, similar to that of FM and worse than that of RA, as well as a broad impact of chronic pain on daily life, which needs to be addressed in the health care system.