Focusing illusion, adaptation and EQ-5D health state descriptions: the difference between patients and public

BACKGROUND

Patients tend to assign higher utilities to health states compared with the general public. Several explanations have been given for this difference including focusing illusion -, caused in part by the sparseness of a health state description such as the EQ-5D -, and adaptation.

OBJECTIVE

We investigated whether patients and the public differ in which dimensions they find important. Furthermore, we compared whether the dimensions named by patients and the public obtained higher rankings of importance compared with the predefined EQ-5D dimensions. Within each nominated dimension we investigated whether the public used a more negative frame compared with patients. In addition, adaptation was investigated by comparing patients with high levels of adaptation and patients with low levels of adaptation.

DESIGN

Data were collected using semistructured interviews among 124 patients with rheumatoid arthritis and 64 members of the public. Participants indicated which aspects are important to them when they think about their life having rheumatoid arthritis and rated the importance of these aspects and of the EQ-5D dimensions.

RESULTS

In contrast to patients, the public named more often aspects related to sports and mobility, leisure activities and work and framed these aspects negatively. Compared with self-rated dimensions, the public ranked the EQ-5D dimensions as more important whereas patients found both groups of aspects equally important. Patients who showed higher levels of adaptation did not differ significantly from patients with lower levels.

CONCLUSION

The public is focused on life domains that are negatively influenced by the described health state whereas patients are focused on both the positive and negative aspects of their lives.

Rasch analysis of Dutch-translated version of the Foot Impact Scale for rheumatoid arthritis

OBJECTIVE

To translate the foot impact scale for RA (FIS-RA) to the dutch target language and to evaluate its internal construct validity using rasch analysis.

METHODS

Forward and backward translations of the original English version of the FIS-RA scale, combined with synthesis techniques and expert committee review, were undertaken to produce a final Dutch version with two subscales for impairment/footwear (FIS-RA(IF)) and activity/participation (FIS-RA(AP)). The pre-final version was field tested in RA patients to investigate face and content validity. FIS-RA questionnaires were completed by 207 Dutch RA patients. Rasch analysis tested the data for overall fit to the model, item and person fit, unidimensionality, differential item function (DIF) by age, gender and disease duration, targeting, reliability and local response dependency. Item deletion and re-analysis were planned, where Rasch model assumptions were violated.

RESULTS

The FIS-RA(IF) (P < 0.0001) and FIS-RA(AP) (P < 0.0001) subscales did not fit the overall Rasch model. Misfitting items, DIF by age, gender and disease duration, and local response dependency were observed in both subscales. Item thresholds showed good coverage over both scales although a floor effect was observed for the FIS-RA(AP) subscale. The person separation index was 0.81 and 0.92 for the FIS-RA(IF) and FIS-RA(AP) subscales, respectively. Both subscales were not unidimensional. Item deletion and repeat Rasch analysis produced two subscales that fitted the Rasch model and were unidimensional.

CONCLUSION

A Dutch language version of the FIS-RA questionnaire was successfully developed using Rasch analysis. Subscales for impairment/footwear and activity/participation showed good construct validity and were unidimensional.

Effect of adaptive abilities on utilities, direct or mediated by mental health?

Background

In cost-utility analyses gain in health can be measured using health state utilities. Health state utilities can be elicited from members of the public or from patients. Utilities given by patients tend to be higher than utilities given by members of the public. This difference is often suggested to be explained by adaptation, but this has not yet been investigated in patients. Here, we investigate if, besides health related quality of life (HRQL), persons' ability to adapt can explain health state utilities. Both the direct effect of persons' adaptive abilities on health state utilities and the indirect effect, where HRQL mediates the effect of ability to adapt, are examined.

Methods

In total 125 patients with Rheumatoid Arthritis were interviewed. Participants gave valuations of their own health on a visual analogue scale (VAS) and time trade-off (TTO). To estimate persons' ability to adapt, patients filled in questionnaires measuring Self-esteem, Mastery, and Optimism. Finally they completed the SF-36 measuring HRQL. Regression analyses were used to investigate the direct and mediated effect of ability to adapt on health state utilities.

Results

Persons' ability to adapt did not add considerably to the explanation of health state utilities above HRQL. In the TTO no additional variance was explained by adaptive abilities (Δ R² = .00, β = .02), in the VAS a minor proportion of the variance was explained by adaptive abilities (Δ R² = .05, β = .33). The effect of adaptation on health state utilities seems to be mediated by the mental health domain of quality of life.

Conclusions

Patients with stronger adaptive abilities, based on their optimism, mastery and self-esteem, may more easily enhance their mental health after being diagnosed with a chronic illness, which leads to higher health state utilities.

The ParkinsonNet concept: development, implementation and initial experience

The quality and efficiency of allied health care in Parkinson's disease (PD) must be improved. We have developed the ParkinsonNet concept: a professional regional network within the catchment area of hospitals. ParkinsonNet aims to: (1) improve PD-specific expertise among allied health personnel, by training a selected number of therapists according to evidence-based guidelines; (2) enhance the accuracy of referrals by neurologists; (3) boost patient volumes per therapist, by stimulating preferred referral to ParkinsonNet therapists; and (4) stimulate collaboration between therapists, neurologists, and patients. We describe the procedures for developing a ParkinsonNet network. Our initial experience with this new concept is promising, showing an increase in PD-specific and a steady rise in the patient volume of individual therapists.

[Conservative treatment of hip and knee osteoarthritis: a systematic, step-by-step treatment strategy]

In the Netherlands the current, conservative management of osteoarthritis of the hip and knee is heterogeneous and suboptimal. Existing guidelines only provide indications for certain interventions, but they do not provide recommendations about the sequence of these treatments. A step-by-step treatment strategy has now been developed in addition to the guidelines. Its aim is to optimize and clarify the conservative policy for osteoarthritis. In addition, communication between patients and professionals and between professionals themselves must be encouraged. According to the treatment strategy, relatively advanced interventions are considered only after simpler interventions have had insufficient results. A care booklet has also been developed that contains information for patients about osteoarthritis, treatment options, healthcare professionals and the treatment strategy.

[Practice guideline 'Diagnosis and treatment of rheumatoid arthritis']

Treatment early in the course of the disease, along with early diagnosis, has a positive influence on clinical outcome in patients with rheumatoid arthritis (RA). Therapeutic strategies, including the use of 'disease-modifying antirheumatic drug' (DMARD) combinations, have proved effective, with relatively few side effects. New insights into the pathophysiology of RA have lead to the development of novel therapeutic agents that have been demonstrated to be highly effective. Patients should be monitored intensively with respect to the effect of therapy on reduction of disease activity, followed by modification of therapeutic strategy in the case of a suboptimal treatment response. Various non-pharmacological interventions, such as exercise therapy and patient education, are available to help patients to cope with the consequences of the disease. Optimizing treatment of RA by means of this approach will help to realize the goal of current therapy: to achieve and sustain remission and, thereby, an optimal functional level.

Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: randomized controlled trial

BACKGROUND AND PURPOSE

In many physical therapy programs for subjects with adhesive capsulitis of the shoulder, mobilization techniques are an important part of the intervention. The purpose of this study was to compare the effectiveness of high-grade mobilization techniques (HGMT) with that of low-grade mobilization techniques (LGMT) in subjects with adhesive capsulitis of the shoulder.

SUBJECTS

One hundred subjects with unilateral adhesive capsulitis lasting 3 months or more and a > or =50% decrease in passive joint mobility relative to the nonaffected side were enrolled in this study.

METHODS

Subjects randomly assigned to the HGMT group were treated with intensive passive mobilization techniques in end-range positions of the glenohumeral joint, and subjects in the LGMT group were treated with passive mobilization techniques within the pain-free zone. The duration of treatment was a maximum of 12 weeks (24 sessions) in both groups. Subjects were assessed at baseline and at 3, 6, and 12 months by a masked assessor. Primary outcome measures included active and passive range of motion and shoulder disability (Shoulder Rating Questionnaire [SRQ] and Shoulder Disability Questionnaire [SDQ]). An analysis of covariance with adjustments for baseline values and a general linear mixed-effect model for repeated measurements were used to compare the change scores for the 2 treatment groups at the various time points and over the total period of 1 year, respectively.

RESULTS

Overall, subjects in both groups improved over 12 months. Statistically significant greater change scores were found in the HGMT group for passive abduction (at the time points 3 and 12 months), and for active and passive external rotation (at 12 months). A statistically significant difference in trend between both groups over the total follow-up period of 12 months was found for passive external rotation, SRQ, and SDQ with greater change scores in the HGMT group.

DISCUSSION AND CONCLUSION

In subjects with adhesive capsulitis of the shoulder, HGMTs appear to be more effective in improving glenohumeral joint mobility and reducing disability than LGMTs, with the overall differences between the 2 interventions being small.

Impact of adhesive capsulitis and economic evaluation of high-grade and low-grade mobilisation techniques

The purpose of this study was to estimate the impact of adhesive capsulitis on costs and health and to compare the cost-utility of high-grade and low-grade mobilisation techniques. In a randomised controlled trial, 92 patients with adhesive capsulitis received either high-grade mobilisation techniques or low-grade mobilisation techniques and were followed for one year. Outcome measures were quality adjusted life years (QALYs) according to the Short Form 6D (SF-6D) and societal costs estimated from cost questionnaires. Estimated costs and QALYs in both randomisation groups were similar, except for the number of treatment sessions (18.6 for high-grade mobilisation techniques versus 21.5 for low-grade mobilisation techniques), with an estimated cost difference of 105 euros in favour of high-grade mobilisation techniques (p = 0.001, 95% CI 43 euros to 158 euros). In the entire sample, the average valuation of health improved from 0.597 at baseline to 0.745 after a year. The burden due to adhesive capsulitis was estimated at 0.048 QALY and 4,521 euros per patient. About half these costs were due to absenteeism which, during the first quarter, amounted to 38% of the total working hours. In conclusion, the cost-utility analysis does not allow for an evidence-based recommendation on the preferred treatment. Based on the clinical outcome measures, high-grade mobilisation techniques are still preferred to low-grade mobilisation techniques. The estimated substantial burden, both to the patient and to society, suggests that effective early treatment of adhesive capsulitis is warranted to attempt to accelerate recovery.

Exercise therapy after coronary artery bypass graft surgery: a randomized comparison of a high and low frequency exercise therapy program

BACKGROUND

Postoperative exercise therapy aims at recovering, as soon as possible, independence in the basic physical activities; but the type, intensity, and therefore the costs of the programs, vary widely. The aim of this study was to compare the effectiveness of a low frequency (once daily, not in the weekend) program with a high frequency (twice daily, including the weekend) one and to assess whether the latter would yield sufficient benefit for the patient to justify higher costs in material and personnel (physiotherapists) after uncomplicated coronary artery bypass graft (CABG) surgery.

METHODS

Two-hundred and forty-six patients were randomly allocated to either a low or high frequency exercise program. Endpoints were the functional level as measured by the achievement of five activity milestones, the patient's independence (functional independence measures [FIM]) as assessed by a structured interview, the amount of daily physical activity (activity monitor), and patient satisfaction (questionnaire). Except for patient satisfaction, all measurements were done in the first week after surgery.

RESULTS

Patients with the high frequency exercise program achieved functional milestones faster than patients with the low frequency exercise program (p = 0.007). The frequency of the exercise program had no influence on functional independence as measured with the FIM or quantity of physical activity. The satisfaction degree was greater in the high frequency group (p = 0.032), although the low frequency group was not dissatisfied.

CONCLUSIONS

A high frequency exercise program leads to earlier performance of functional milestones and yields more satisfaction after uncomplicated CABG surgery and this should lead to an earlier discharge. On the other hand, if the shortage of physiotherapists remains unchanged or even increases, the low frequency program also yields excellent functional results, albeit at the cost of a somewhat longer hospital stay: but it would allow a sensible redistribution of the physiotherapists activity towards complicated and, therefore, more demanding patients.

Multidisciplinary team care and outcomes in rheumatoid arthritis

PURPOSE OF REVIEW

Comprehensive rehabilitation, involving a team of health professionals from various disciplines, is widely used as an adjunct to pharmacological and surgical treatment in patients with rheumatoid arthritis (RA). Studies on the effectiveness and costs of such programs, as well as on developments regarding outcome measures and quality improvement in this particular field are reviewed.

RECENT FINDINGS

Recent studies confirm that defined day patient multidisciplinary programs are equally effective as inpatient team care programs. It appears that similar effects, at lower costs, may be achieved by clinical nurse specialists coordinating multidisciplinary care in an outpatient setting. With respect to outcome measures on effectiveness of multidisciplinary team care, the use of function-specific and patient-oriented outcome measures is advocated. Moreover, the use of tools and procedures to enhance the role of the patient in the team care process and communication among health professionals may yield important leads for the improvement of the effectiveness and quality of multidisciplinary team care.

SUMMARY

Comprehensive inpatient and day patient programs prove to be equally effective in patients with rheumatoid arthritis, while the employment of alternative forms of comprehensive care, such as care coordinated by a clinical nurse specialist, is promising. With respect to future research, challenges are related to the development and selection of adequate outcome measures, the enhancement of mutual communication, and a further definition and extension of the role of the patient in the team care process.

Rehabilitation of people with rheumatoid arthritis

Rehabilitation, as an adjunct to pharmacological and surgical therapies in patients with rheumatoid arthritis (RA), aims to minimize the consequences of the disease. For a systematic assessment of the consequences of disease, an appropriate definition and evaluation of the goals of therapy and interventions, and an active partnership with the patient, a structured approach to rehabilitation management is needed.Despite widespread positive clinical experience with rehabilitative interventions, the scientific evidence of their effectiveness is, in general, scanty, owing to a lack of studies with sufficient methodological quality. Further well-designed clinical studies are warranted with respect to several interventions where evidence is falling short.

Managing chronic disease: evidence-based medicine or patient centred medicine?

Chronic diseases are recognized as a leading cause of mortality, morbidity, health care utilization and cost. A constant tailoring of care to the actual needs of individual patients, complexity and long duration are the distinguishing features of chronic disease management. Given the rapid development and high use of services providing complex management, the number of controlled clinical trials in this field is limited. The information from the few available controlled clinical trials may be difficult to interpret, mainly due to a large variety in the interventions being studied, differences in 'control treatments' and a confined set of outcome measures that are used. The ethical issue with this observation is, that in the absence of randomised clinical trial information on clinical effectiveness and in consequence of the lack of additional data that are crucial for therapeutic decisions in the process of caring, specific patient groups, such as patients with chronic diseases, may become disadvantaged. The scarcity and incompleteness of controlled trial information can partly be explained by difficulties in conducting this type of research in the field of chronic disease management. To avoid that patients with chronic diseases become disadvantaged, the use of alternative designs such as observational studies to evaluate chronic disease management must be accepted and supported. Moreover, in chronic disease management the process of caring needs to emphasized and appraised appropriately. For that purpose, new measurement methods, focussing on concepts of caring that are not included in the majority of current clinical trials, need to be developed.