Primary therapist model for patients referred for rheumatoid arthritis rehabilitation: A cost‐effectiveness analysis

Objective

To estimate the incremental cost‐effectiveness (ICE) of services from a primary therapist compared with traditional physical therapists and/or occupational therapists for managing rheumatoid arthritis (RA), from the societal perspective.

Methods

Patients with RA were randomly assigned to the primary therapist model (PTM) or traditional treatment model (TTM) for ～6 weeks of rehabilitation treatment. Health outcomes were expressed in terms of quality‐adjusted life years (QALYs), measured with the EuroQol instrument at baseline, 6 weeks, and 6 months. Direct and indirect costs, including visits to health professionals, use of investigative tests, hospital visits, use of medications, purchases of adaptive aids, and productivity losses incurred by patients and their caregivers, were collected monthly.

Results

Of 144 consenting patients, 111 remained in the study after the baseline assessment: 63 PTM (87.3% women, mean age 54.2 years, disease duration 10.6 years) and 48 TTM (79.2% women, mean age 56.8 years, disease duration 13.2 years). From a societal perspective, PTM generated higher QALYs (mean ± SD 0.068 ± 0.22) and resulted in a higher mean cost ($6,848 Canadian, interquartile range [IQR] $1,984–$9,320) compared with TTM (mean ± SD QALY ?0.017 ± 0.24; mean costs $6,266, IQR $1,938–$10,194) in 6 months, although differences were not statistically significant. The estimated ICE ratio was $13,700 per QALY gained (95% nonparametric confidence interval ?$73,500, $230,000).

Conclusion

The PTM has potential to be an alternative to traditional physical/occupational therapy, although it is premature to recommend widespread use of this model in other regions. Further research should focus on strategies to reduce costs of the model and assess the long‐term economic consequences in managing RA and other rheumatologic conditions.

     

Effect of a high‐intensity weight‐bearing exercise program on radiologic damage progression of the large joints in subgroups of patients with rheumatoid arthritis

Objective

To investigate whether a high‐intensity exercise program accelerates the rate of radiologic damage of the large joints in predefined subgroups of patients with rheumatoid arthritis.

Methods

The data of 277 participants in a 2‐year randomized controlled trial, comparing the effects of high‐intensity exercises with usual care, were used. Linear regression analysis was used to test which predefined variables at baseline (age, disease duration, disease activity, physical capacity, functional ability, joint damage) modified the effect of high‐intensity exercise on the progression of radiologic damage of the large joints over 24 months.

Results

Baseline radiologic joint damage was the only variable associated with the effect of high‐intensity exercise on joint damage progression in large joints. In a subgroup of 218 patients with no or little joint damage (defined as Larsen score ≤5; 80% of our study population) the proportions of patients with an increase in joint damage were similar for the exercise and usual‐care group (35% versus 36%, risk ratio [RR] 1.0 [0.7–1.4]; P = not significant), whereas, in a subgroup of 59 patients who already had extensive damage of large joints (defined as Larsen score >5) the proportion was significantly higher in the exercise group (85% versus 48%, RR 1.8 [1.2–2.6]; P < 0.05).

Conclusion

High‐intensity weight‐bearing exercises appear to accelerate joint damage progression in patients with preexisting extensive damage. Patients with extensive large joint damage should, therefore, be advised to refrain from activities excessively loading the damaged joints.

     

Adherence and satisfaction of rheumatoid arthritis patients with a long‐term intensive dynamic exercise program (RAPIT program)

Objective

To evaluate adherence and satisfaction of patients with rheumatoid arthritis (RA) in a long‐term intensive dynamic exercise program.

Methods

A total of 146 RA patients started an intensive (strength and endurance training for 75 minutes, twice a week, for 2 years) exercise program (Rheumatoid Arthritis Patients In Training) aimed at improving physical fitness. Program attendance and satisfaction were examined. Additional assessments at baseline were done to find possible predictors of attendance.

Results

Median (interquartile range) age and disease duration of the patients were 54 (45–61) and 5 (3–10) years, respectively. After 2 years, 118 (81%) patients still participated in an exercise class. The median attendance rate of all patients was 74%. Low attendance was weakly associated with high disease activity, low functional ability, and low quality of life at baseline but not with the severity of joint damage at baseline. At the end, 78% of all participants would (strongly) recommend the program to other RA patients.

Conclusion

Adherence and satisfaction of RA patients with an intensive dynamic exercise program over a prolonged time can be high. Disease severity parameters do not strongly predict the compliance of participants in an intensive exercise program.

     

The long‐term cost‐effectiveness of obesity prevention interventions: systematic literature review

Obesity prevention provides a major opportunity to improve population health. As health improvements usually require additional and scarce resources, novel health technologies (interventions) should be economically evaluated. In the prevention of obesity, health benefits may slowly accumulate over time and it can take many years before an intervention has reached full effectiveness. Decision‐analytic simulation models (DAMs), which combine evidence from diverse sources, can be utilized to evaluate the long‐term cost‐effectiveness of such interventions. This literature review summarizes long‐term economic findings (defined as ≥40 years) for 41 obesity prevention interventions, which had been evaluated in 18 cost‐utility analyses, using nine different DAMs. Interventions were grouped according to their method of delivery, setting and risk factors targeted into behavioural (n = 21), community (n = 12) and environmental interventions (n = 8). The majority of interventions offered good value for money, while seven were cost‐saving. Ten interventions were not cost‐effective (defined as >50,000 US dollar), however. Interventions that modified a target population's environment, i.e. fiscal and regulatory measures, reported the most favourable cost‐effectiveness. Economic findings were accompanied by a large uncertainty though, which complicates judgments about the comparative cost‐effectiveness of interventions.     

Long-term follow-up of a high-intensity exercise program in patients with rheumatoid arthritis

The aims of this study were to describe rheumatoid arthritis patients’ compliance with continued exercise after participation in a 2-year supervised high-intensity exercise program and to investigate if the initially achieved effectiveness and safety were sustained. Data were gathered by follow-up of the participants who completed the 2-year high-intensity intervention in a randomized controlled trial (Rheumatoid Arthritis Patient In Training study). Eighteen months thereafter, measurements of compliance, aerobic capacity, muscle strength, functional ability, disease activity, and radiological damage of the large joints were performed. Seventy-one patients were available for follow-up at 18 months, of whom 60 (84%) were still exercising (exercise group: EG), with average similar intensity but at a lower frequency as the initial intervention. Eleven patients (16%) reported low intensity or no exercises (no-exercise group: no-EG). Patients in the EG had better aerobic fitness and functional ability, lower disease activity, and higher attendance rate after the initial 2-year intervention. At follow-up, both groups showed a deterioration of aerobic fitness and only patients in the EG were able to behold their muscle strength gains. Functional ability, gained during the previous participation in high-intensity exercises, remained stable in both groups. Importantly, no detrimental effects on disease activity or radiological damage of the large joints were found in either group. In conclusion, the majority of the patients who participated in the 24-month high-intensity exercise program continued exercising in the ensuing 18 months. In contrast to those who did not continue exercising, they were able to preserve their gains in muscle strength without increased disease activity or progression of radiological damage.     

Using internet technology to deliver a home‐based physical activity intervention for patients with rheumatoid arthritis: A randomized controlled trial

Objective

To compare the effectiveness of 2 Internet‐based physical activity interventions for patients with rheumatoid arthritis (RA).

Methods

A total of 160 physically inactive patients with RA who had a computer with Internet access were randomly assigned to an Internet‐based physical activity program with individual guidance, a bicycle ergometer, and group contacts (individualized training [IT] group; n = 82) or to an Internet‐based program providing only general information on exercises and physical activity (general training [GT] group; n = 78). Outcome measures included quantity of physical activity (questionnaire and activity monitor), functional ability, quality of life, and disease activity (baseline, 3, 6, 9, and 12 months).

Results

The proportion of physically active patients was significantly greater in the IT than in the GT group at 6 (38% versus 22%) and 9 months (35% versus 11%; both P < 0.05) regarding a moderate intensity level for 30 minutes in succession on at least 5 days a week, and at 6 (35% versus 13%), 9 (40% versus 14%), and 12 months (34% versus 10%; all P < 0.005) regarding a vigorous intensity level for 20 minutes in succession on at least 3 days a week. In general, there were no statistically significant differences regarding changes in physical activity as measured with an activity monitor, functional ability, quality of life, or disease activity.

Conclusion

An Internet‐based physical activity intervention with individually tailored supervision, exercise equipment, and group contacts is more effective with respect to the proportion of patients who report meeting physical activity recommendations than an Internet‐based program without these additional elements in patients with RA. No differences were found regarding the total amount of physical activity measured with an activity monitor.

     

Cost-utility and cost-effectiveness analyses of a long-term, high-intensity exercise program compared with conventional physical therapy in patients with rheumatoid arthritis

OBJECTIVE: To estimate the cost utility and cost effectiveness of long-term, high-intensity exercise classes compared with usual care in rheumatoid arthritis (RA) patients. METHODS: RA patients (n = 300) were randomly assigned to either exercise classes or UC; followup lasted for 2 years. Outcome measures were quality-adjusted life years (QALYs) according to the EuroQol (EQ-5D), Short Form 6D (SF-6D), and a transformed visual analog scale (VAS) rating personal health; functional ability according to the Health Assessment Questionnaire (HAQ) and McMaster Toronto Arthritis Patient Preference Interview (MACTAR); and societal costs. RESULTS: QALYs in both randomization groups were similar according to the EQ-5D and SF-6D, but were in favor of usual care according to the VAS (annual difference 0.037 QALY; 95% confidence interval [95% CI] 0.002, 0.069). Functional ability was similar according to the HAQ, but in favor of the exercise classes according to the MACTAR (annual difference 2.9 QALY; 95% CI 0.9, 4.9). Annual medical costs of the exercise program were estimated at 780 per participating patient (1 approximately $1.05). The increase per patient in total medical costs of physical therapy was estimated at 430 (95% CI 318, 577), and the increase in total societal costs at 602 (95% CI -490, 1,664). For societal willingness-to-pay equal to 50,000 per QALY, usual care had better cost utility than exercise classes, and significantly so according to the VAS. CONCLUSION: From a societal perspective and without taking possible preventive health effects into account, long-term, high-intensity exercise classes provide insufficient improvement in the valuation of health to justify the additional costs.     

Long‐term efficacy of therapy in patients with fibromyalgia: A physical exercise‐based program and a cognitive‐behavioral approach

Objective

To analyze the long‐term efficacy of 2 interventions for female fibromyalgia (FM) patients: 1) cognitive‐behavioral therapy (CBT), and 2) a physical exercise (PE)–based strategy.

Methods

We conducted a prospective, long‐term, randomized, parallel clinical trial. The outcome variables are physical activity, aerobic capacity, and results of the Fibromyalgia Impact Questionnaire (FIQ), Short Form 36, Beck Anxiety and Depression Inventory, Chronic Pain Self‐Efficacy Scale, and Chronic Pain Coping Inventory. All were measured at baseline, posttreatment, 6 months, and 1 year. The duration of both treatments was 8 weeks.

Results

Some items of the FIQ and some strategies to cope with pain improved significantly in both groups after treatment. All variables measuring functional capacity improved significantly in the PE group, whereas only physical activity of the vertebral column improved in the CBT group. There were no differences in anxiety, depression, and self efficacy after treatment in either group. After 1 year of followup, most of the parameters had returned to baseline values in both groups. However, in the PE group, functional capacity remained significantly better.

Conclusions

PE and CBT improve clinical manifestations in FM patients only for short periods of time. Improvement in self efficacy and physical fitness are not associated with improvement in clinical manifestations.

     

Cost effectiveness of combined spa–exercise therapy in ankylosing spondylitis: A randomized controlled trial

Objective

To evaluate the cost effectiveness and cost utility of a 3‐week course of combined spa therapy and exercise therapy in addition to standard treatment consisting of antiinflammatory drugs and weekly group physical therapy in ankylosing spondylitis (AS) patients.

Methods

A total of 120 Dutch outpatients with AS were randomly allocated into 3 groups of 40 patients each. Group 1 was treated in a spa resort in Bad Hofgastein, Austria; group 2 in a spa resort in Arcen, The Netherlands. The control group stayed at home and continued their usual activities and standard treatment during the intervention weeks. After the intervention, all patients followed weekly group physical therapy. The total study period was 40 weeks. Effectiveness of the intervention was assessed by functional ability using the Bath Ankylosing Spondylitis Function Index (BASFI). Utilities were measured with the EuroQoL (EQ‐5D_utility). A time‐integrated summary score defined the clinical effects (BASFI‐area under the curve [AUC]) and utilities (EQ‐5D_utility‐AUC) over time. Both direct (health care and non‐health care) and indirect costs were included. Resource utilization and absence from work were registered weekly by the patients in a diary. All costs were calculated from a societal perspective.

Results

A total of 111 patients completed the diary. The between‐group difference for the BASFI‐AUC was 1.0 (95% confidence interval [95% CI] 0.4–1.6; P = 0.001) for group 1 versus controls, and 0.6 (95% CI 0.1–1.1; P = 0.020) for group 2 versus controls. The between‐group difference for EQ‐5D_utility‐AUC was 0.17 (95% CI 0.09–0.25; P < 0.001) for group 1 versus controls, and 0.08 (95% CI 0.00–0.15; P = 0.04) for group 2 versus controls. The mean total costs per patient (including costs for spa therapy) in Euros (€) during the study period were €3,023 for group 1, €3,240 for group 2, and €1,754 for the control group. The incremental cost‐effectiveness ratio per unit effect gained in functional ability (0–10 scale) was €1,269 (95% CI 497–3,316) for group 1, and €2,477 (95% CI 601–12,098) for group 2. The costs per quality‐adjusted life year gained were €7,465 (95% CI 3,294–14,686) for group 1, and €18,575 (95% CI 3,678–114,257) for group 2.

Conclusion

Combined spa–exercise therapy besides standard treatment with drugs and weekly group physical therapy is more effective and shows favorable cost‐effectiveness and cost‐utility ratios compared with standard treatment alone in patients with AS.

     

Effects of shoulder arthroplasty and exercise in patients with rheumatoid arthritis

The aim of this study was to examine pain and shoulder function in patients with rheumatoid arthritis (RA) before and after shoulder arthroplasty and postoperative exercise. Twenty-four patients (26 shoulders) were consecutively included in a multicentre study. Before surgery, at discharge from hospital and after 3 and 6 months, perceived shoulder function and shoulder pain were assessed by visual analogue scales, activities of daily living by the Modified Health Assessment Questionnaire (M-HAQ) and shoulder range of motion (ROM) by a goniometer. All patients showed considerable pain reduction at discharge from hospital (p<0.001). In those with intact rotator cuff and biceps tendon (n=13) improvements were found after 6 months in active and passive abduction and flexion ROMs (p<0.01) and in M-HAQ (p<0.001). Such improvements were not found in those with torn soft tissue (n=12). Preoperatively, abduction and flexion motor deficits (passive ROM >active ROM) were found for the total group (p=0.001). Less flexion motor deficit was found in the intact soft tissue than in the torn soft tissue group after 3 (p=0.002) and 6 months (p<0.001). No group difference was found with respect to abduction motor deficit. In conclusion, pain relief was obtained by all patients. Improvements in ROMs and activities of daily living were influenced by the state of the soft tissue.Sources of support: From EXTRA-funds from the Norwegian Foundation for Health and Rehabilitation     

The impact of lifestyle behaviours,physical activity and smoking on morbidity and mortality in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is associated with pain, disability and increased risk of developing comorbidities and premature mortality. While these poor outcomes have improved in line with advances in the treatment of RA, they still persist to some degree today. Physical activity and smoking are two areas of patients’ lives where changes may have a substantial impact on the poor outcomes associated with RA. Physical activity in RA has been well studied, with many randomised trials indicating the benefits of physical activity on pain and disability. A number of observational studies have assessed the impact of smoking on RA, also indicating the benefits of quitting smoking on RA-related outcomes, but with less consistent findings, potentially due to epidemiological challenges (e.g. collider bias, recall bias). There are also a number of barriers preventing patients making these positive lifestyle changes, such as lack of time and motivation, lack of knowledge and advice, as well as disease-specific barriers, such as pain and fatigue.     

Assessing utility values in rheumatoid arthritis: A comparison between time trade‐off and the EuroQol

Objective

To compare the utility values and quality‐adjusted life years (QALYs) obtained by the Time Trade‐Off instrument (TTO) and the EuroQol‐5D (EQ‐5D) in patients with rheumatoid arthritis (RA); to analyze the association between utility values and Disease Activity Score 28 (DAS28) and Health Assessment Questionnaire (HAQ).

Methods

We conducted a longitudinal, prospective, 1‐year study of RA patients selected randomly from 10 rheumatology clinics. TTO and EQ‐5D were administered at 4 scheduled visits.

Results

The study sample comprised 300 RA patients (82% women, mean age 59 years, mean disease duration 10.3 years). A total of 260 patients completed both the TTO and the EQ‐5D at baseline, and the mean ± SD TTO scores were significantly higher than the EQ‐5D scores (0.81 ± 0.22 versus 0.53 ± 0.35, P < 0.0001). The intraclass correlation coefficient (ICC) for the utility methods was 0.19. Data about changes in both TTO and EQ‐5D scores during the study year were available in 163 patients. These changes tended to be larger in the TTO scores than the EQ‐5D scores (mean ± SD 0.05 ± 0.25 versus ?0.005 ± 0.35, P = 0.054). The ICC for the mean changes in the utility scores was 0.24. Patients obtained a mean ± SD of 0.04 ± 0.20 QALYs based on TTO scores and 0.004 ± 0.27 based on EQ‐5D scores (P = 0.12). At baseline, the EQ‐5D scores were highly correlated with the HAQ (r = ?0.74) and moderately correlated with the DAS28 (r = ?0.47), whereas the TTO correlated poorly with both the HAQ and DAS28. Correlation between the mean change in the EQ‐5D and in the HAQ was moderate (r = ?0.55).

Conclusion

TTO and EQ‐5D do not yield the same utility values. The results suggest that the EQ‐5D is more representative of RA status than the TTO, a valuable conclusion when addressing economic evaluations in RA.

     

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.

     

Minimal disease activity,remission, and the long‐term outcomes of rheumatoid arthritis

Objective

To determine the prevalence of minimal disease activity (MDA) and remission in patients with rheumatoid arthritis (RA), to assess the effect of anti–tumor necrosis factor (anti‐TNF) therapy on MDA, and to determine the extent to which MDA status improves long‐term outcomes.

Methods

Using the Patient Activity Scale (PAS) as a surrogate, we assessed the prevalence of MDA and remission in 18,062 patients with RA using the newly developed Outcome Measures in Rheumatology Clinical Trials (OMERACT) criteria for MDA.

Results

MDA was noted in 20.2% of 18,062 patients and persistent MDA, operationally defined as having MDA during ≥2 consecutive 6‐month observation periods, occurred in 13.5% of 7,433 patients followed longitudinally. Disease activity at remission levels was noted in 7%. Among patients with MDA, 82% received disease‐modifying antirheumatic drugs or biologic agents. Following anti‐TNF initiation, the cumulative probability of achieving MDA at 2 and 6 years was 4.1% and 7.6%, respectively, and persistent MDA probabilities were 2.7% and 4.5%, respectively. Regardless of RA duration, patients with MDA had substantially better outcomes, including a 10‐fold reduction in work disability and an approximately 2‐fold reduction in total joint replacement and mortality.

Conclusion

Remission remains uncommon in RA, and the prevalence of new remission in community practice is substantially lower than noted in published trials of biologic therapy. On average, persons with MDA appear to have persistently mild RA. This might be the effect of milder RA and/or more effective treatment in early RA. The PAS had satisfactory levels of agreement with the full MDA criteria and appears suitable for use in clinical and epidemiologic research.