Focusing on care research: A challenge and an opportunity

Nonpharmacologic interventions need outcomes for evaluating complex interventions in rheumatic diseases

INTRODUCTION

Nonpharmacologic interventions are themselves complex and are often combined with drugs and other interventions in the treatment of rheumatic diseases. Therefore, overall strategies for treatment are complex interventions. These should be evaluated regarding their processes and outcomes.

METHODS

The CARE network, an international organization of health professionals (physicians and nonphysicians) and patients conducted a survey in 2008 to identify core outcomes in the ICF perspective, completed with a second survey (2009-2010) with patients in routine practice. These surveys have provided new information about domains to investigate as a basis for evaluating complex interventions.

RESULTS

Outcome Measures in Rheumatology Clinical Trials (OMERACT) participants in this Special Interest Group agreed that current outcomes used in pharmacological research are not sufficient if the nonpharmacologic independent or combined contributions are to be assessed; other domains need to be addressed. This is an area of interest for further development.

CONCLUSION

Recommendations are proposed to develop research in the area of outcome for evaluation of complex interventions in rheumatic diseases.

Does the content really matter? A study comparing structure, process, and outcome of team rehabilitation for patients with inflammatory arthritis in two different clinical settings

OBJECTIVES

To provide a thorough description of team rehabilitation care and compare the structure, process, and outcomes in two specialized arthritis rehabilitation settings.

METHODS

Patients with inflammatory arthritis scheduled for inpatient rehabilitation in seven specialized rehabilitation centres and three rheumatology hospital departments in Norway were included consecutively in a prospective cohort study. Patients completed questionnaires at admission, at discharge, and at a 6-month follow-up, and kept a diary regarding structure and process variables during the rehabilitation stay.

RESULTS

Eighty patients in rehabilitation centres and 73 in hospital departments were included and 80% responded to the 6-month follow-up questionnaire. The two clinical settings differed significantly with regard to structure variables such as cost, referral of patients, length of stay, and number of health professionals involved, and most process variables reflecting treatment modalities. The most remarkable difference was in the amount of individual intervention compared with group intervention. Despite significant improvements in most outcomes at discharge, the scores deteriorated towards baseline level 6 months later. There was a trend towards more significant improvement during rehabilitation for patients at rehabilitation centres whereas patients at hospitals had more prolonged improvement.

CONCLUSIONS

Team rehabilitation for inflammatory arthritis in two different clinical settings differed across most variables for structure and process, but few significant differences in outcome were found. Considering the substantial differences in cost, there is an urgent need for consensus concerning which patients should receive rehabilitation in which setting. Future research on the development and evaluation of methods for prolonging the beneficial effects of rehabilitation is needed.

Rheumatology care: Involvement in medical decisions, received information, satisfaction with care, and unmet health care needs in patients with rheumatoid arthritis and ankylosing spondylitis

OBJECTIVE

To examine levels of received information, involvement in medical decisions, and satisfaction with care, to explore factors related to current involvement in medical decisions, and to assess patients' unmet health care needs related to their disease.

METHODS

A total of 1,193 patients with rheumatoid arthritis and ankylosing spondylitis completed self-reported health status questionnaires, including registration of sociodemographic data and questions about rheumatology care. Separate questions addressed information received, involvement in decisions, and satisfaction with care. Aspects of unmet health were assessed by an open-ended question.

RESULTS

The majority of patients reported medium to high levels of received information, involvement in medical decisions, and satisfaction with care. High involvement in medical decisions was univariately associated with high levels of perceived information and satisfaction, as well as with lower age and a good health status. In the multivariate analyses, patient satisfaction (odds ratio [OR] 4.21) and a high level of received information (OR 7.85), age (OR 0.99), and >12 years of formal education (OR 1.46) remained as significant predictors to current involvement. Nearly one-third reported a variety of unmet health care needs, and this report was associated with poor health.

CONCLUSION

The results indicate a need for a more flexible and patient centered care model, in which patients to a larger degree can decide which services they need and how these services should be delivered.

Effectiveness of the primary therapist model for rheumatoid arthritis rehabilitation: A randomized controlled trial

OBJECTIVE

To compare the primary therapist model (PTM), provided by a single rheumatology-trained primary therapist, with the traditional treatment model (TTM), provided by a physical therapy (PT) and/or occupational therapy (OT) generalist, for treating patients with rheumatoid arthritis (RA).

METHODS

Eligible patients were adults requiring rehabilitation treatment who had not received PT/OT in the past 2 years. Participants were randomized to the PTM or TTM group. The primary outcome was defined as the proportion of clinical responders who experienced a > or =20% improvement in 2 of the following measures from baseline to 6 months: Health Assessment Questionnaire, pain visual analog scale, and Arthritis Community Research and Evaluation Unit RA Knowledge Questionnaire.

RESULTS

Of 144 consenting patients, 33 (10 PTM participants, 23 TTM participants) dropped out without completing any followup assessment, leaving 111 for analysis (63 PTM participants, 48 TTM participants). The majority were women (PTM 87.3%, TTM 79.2%), with a mean age of 54.2 years and 56.8 years for the PTM and TTM groups, respectively. Average disease duration was 10.6 years and 13.2 years for each group, respectively. At 6 months, 44.4% of patients in the PTM group were clinical responders versus 18.8% in the TTM group (chi(2) = 8.09, P = 0.004).

CONCLUSION

Compared with the TTM, the PTM was associated with better outcomes in patients with RA. The results, however, should be interpreted with caution due to the high dropout rate in the TTM group.

Evolution of team care and evaluation of effectiveness

PURPOSE OF REVIEW

This paper describes the evolution and modern development of rheumatologic team care, reviews and defines methods of evaluation and assessment of rheumatologic team care, summarizes recent research, and discusses possible future directions for the refinement of and research in rheumatologic team care.

RECENT FINDINGS

The modern concept of multiprofessional team care for patients with rheumatic diseases has been evolving over more than 50 years. Research interest in rheumatologic team care is increasing, as is evidenced in international congresses and research networks addressing team care. Over the past decade, several studies of the effects and effectiveness of multiprofessional team care have been published. Few recent publication, however, have focused on team care because of a lack of optimal methods for studying team care and a lower priority for research in this area.

SUMMARY

Team care in the care, treatment, and rehabilitation of patients with rheumatologic diseases has a long and strong tradition in many countries. The role of team care is clinically relevant, and interest in the evidence-based evaluation and development of team care is growing. The International Classification of Functioning, Disability, and Health is a useful framework for examining the effects and effectiveness of team care. There is also a need for research and development with other outcome measures to analyze the different factors acting within team care. Furthermore, more specific studies of the effectiveness of team care are needed.