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Hao Y, Oon S, Nikpour M. Efficacy and safety of treat-to-target strategy studies in rheumatic diseases: A systematic review and meta-analysis. Semin Arthritis Rheum 2024; 67:152465. [PMID: 38796922 DOI: 10.1016/j.semarthrit.2024.152465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND The concept of treat-to-target (T2T), a treatment strategy in which treatment is directed to reach and maintain a defined goal such as remission or low disease activity (LDA), has been explored for several diseases including rheumatic diseases such as rheumatoid arthritis (RA). However, a comprehensive review of T2T in all rheumatic diseases has not recently been undertaken. OBJECTIVE To perform a systematic review and meta-analysis of the efficacy and safety of a T2T strategy in the management of adult patients with inflammatory rheumatic diseases. METHODS PUBMED, EMBASE and CINAHL were searched from January 1990 to December 2023 using key words related to a T2T strategy and rheumatic diseases; T2T strategy clinical trials or observational studies were included. Clinical, physical function and radiologic outcomes, cost-effectiveness, and adverse events (AEs) of the T2T strategies were investigated and a random-effect meta-analysis was conducted for the most commonly used outcomes in RA studies. RESULTS The search identified 7896 studies, of which 66 fit inclusion criteria, including 50 in RA, 3 in psoriatic arthritis (PsA), 1 in spondyloarthritis (SpA) and 12 in gout. For the studies comparing a T2T strategy with usual care (UC) in RA, 83.3% (20/24) showed a T2T strategy could achieve significantly better clinical outcomes, and the meta-analysis showed that patients treated with a T2T strategy were more likely to be in remission (pooled RR: 1.68 (1.47-1.92), p<0.001] and achieve DAS-28 response (pooled standardised mean difference (SMD): 0.47 (0.26-0.69), P<0.001] at 1 year than patients treated with UC. Sensitivity analyses showed that a T2T strategy with a predefined treatment protocol had better clinical efficacy than that without protocol. In terms of improving physical function and health-related quality of life (HRQoL), 11/19 (57.9%) studies found a T2T strategy was significantly more likely to achieve these than UC, with the meta-analysis for the mean change of HAQ score supporting this conclusion (pooled SMD: 1.48 (0.46-2.51), p=0.004). Five out of 9 studies (55.6%) demonstrated greater benefit regarding radiographic progression from a T2T strategy. In terms of cost-effectiveness and AEs, 2/2 studies found a T2T strategy was more cost-effective than UC and 8/8 studies showed no tendency for AEs to occur more often with a T2T strategy. For the studies in PsA and SpA, a T2T strategy was also demonstrated to be more effective than UC in clinical and functional benefits, but not in radiologic outcomes. All gout studies showed that sUA level could be controlled more effectively with a T2T strategy, and 2 studies revealed that the T2T strategy could inhibit erosion development or crystal deposition. CONCLUSIONS For patients with active RA, a T2T strategy has been shown in mulitple studies to increase the likelihood of achieving clinical response and improving HRQoL without increasing economic costs and AEs. Limited studies have shown clinical and functional benefits from T2T strategies in active PsA and SpA. A T2T strategy has also been found to improve clinical and radiologic outcomes in gout. T2T trials in other rheumatic diseases are lacking.
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Affiliation(s)
- Yanjie Hao
- The University of Melbourne at St Vincent's Hospital, 29 Regent Street, Fitzroy, VIC 3065, Australia
| | - Shereen Oon
- The University of Melbourne at St Vincent's Hospital, 29 Regent Street, Fitzroy, VIC 3065, Australia; Department of Rheumatology, St. Vincent's Hospital Melbourne, 35 Victoria Parade, Fitzroy, VIC 3065, Australia.
| | - Mandana Nikpour
- The University of Melbourne at St Vincent's Hospital, 29 Regent Street, Fitzroy, VIC 3065, Australia; Department of Rheumatology, St. Vincent's Hospital Melbourne, 35 Victoria Parade, Fitzroy, VIC 3065, Australia; Sydney MSK Research Flagship Centre, The University of Sydney School of Public Health, Room 132, Edward Ford Building, Fisher Road, University of Sydney, NSW 2006, Australia; Royal Prince Alfred Hospital Institute of Rheumatology and Orthopedics, 59 Missenden Rd, Camperdown NSW 2050, Australia.
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Nkhoma KB, Cook A, Giusti A, Farrant L, Petrus R, Petersen I, Gwyther L, Venkatapuram S, Harding R. A systematic review of impact of person-centred interventions for serious physical illness in terms of outcomes and costs. BMJ Open 2022; 12:e054386. [PMID: 35831052 PMCID: PMC9280891 DOI: 10.1136/bmjopen-2021-054386] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/20/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Person-centred care (PCC) is being internationally recognised as a critical attribute of high-quality healthcare. The International Alliance of Patients Organisations defines PCC as care that is focused and organised around people, rather than disease. Focusing on delivery, we aimed to review and evaluate the evidence from interventions that aimed to deliver PCC for people with serious physical illness and identify models of PCC interventions. METHODS Systematic review of literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched AMED, CINAHL, Cochrane Library, Embase, Medline, PsycINFO, using the following key concepts: patient/person-centred care, family centred care, family based care, individualised care, holistic care, serious illness, chronic illness, long-term conditions from inception to April 2022. Due to heterogeneity of interventions and populations studied, narrative synthesis was conducted. Study quality was appraised using the Joanna Briggs checklist. RESULTS We screened n=6156 papers. Seventy-two papers (reporting n=55 different studies) were retained in the review. Most of these studies (n=47) were randomised controlled trials. Our search yielded two main types of interventions: (1) studies with self-management components and (2) technology-based interventions. We synthesised findings across these two models:Self-management component: the interventions consisted of training of patients and/or caregivers or staff. Some studies reported that interventions had effect in reduction hospital admissions, improving quality of life and reducing costs of care.Technology-based interventions: consisted of mobile phone, mobile app, tablet/computer and video. Although some interventions showed improvements for self-efficacy, hospitalisations and length of stay, quality of life did not improve across most studies. DISCUSSION PCC interventions using self-management have some effects in reducing costs of care and improving quality of life. Technology-based interventions improves self-efficacy but has no effect on quality of life. However, very few studies used self-management and technology approaches. Further work is needed to identify how self-management and technology approaches can be used to manage serious illness. PROSPERO REGISTRATION NUMBER CRD42018108302.
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Affiliation(s)
- Kennedy Bashan Nkhoma
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, King's College London, London, UK
| | - Amelia Cook
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Alessandra Giusti
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Lindsay Farrant
- School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Ruwayda Petrus
- School of Applied Human Sciences, University of KwaZulu-Natal College of Humanities, Durban, South Africa
| | - I Petersen
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Liz Gwyther
- School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | | | - Richard Harding
- Department of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Krause* D, Mai* A, Denz R, Johow J, Reese JP, Westerhoff B, Klaaßen-Mielke R, Timmesfeld N, Rittstieg A, Saracbasi-Zender E, Günzel J, Klink C, Schmitz E, Fendler C, Raub W, Böddeker S, Dybowski F, Hübner G, Menne HJ, Lakomek HJ, Sarholz M, Trampisch U, J. Trampisch H, Braun J. The Structured Delegation of Medical Care Services for Patients With Inflammatory Rheumatic Diseases. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:157-164. [PMID: 35101166 PMCID: PMC9215273 DOI: 10.3238/arztebl.m2022.0109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/05/2021] [Accepted: 01/12/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND In some areas of Germany, there is a shortage of specialist physicians for patients with inflammatory rheumatic diseases. Delegating certain medical care services to qualified, specialized rheumatological assistants (SRAs) might be an effective way to supplement the available capacity for specialized medical care. METHODS Patients under stable treatment for rheumatoid arthritis (RA) or psoriatic arthritis (PsA) were included in this trial, which was designed to demonstrate, in a first step, the non-inferiority of a form of care involving delegation of physicians' tasks to SRAs (team-based care), in comparison to standard care, with respect to changes in disease activity at one year. "Non-inferiority," in this context, means either superiority or else an irrelevant extent of inferiority. In a second step, in case non-inferiority could be shown, the superiority of team-based care with respect to changes in patients' health-related quality of life would be tested as well. Disease activity was measured with the Disease Activity Score 28, and health-related quality of life with the EQ-5D-5L. This was a randomized, multicenter, rater-blinded trial with two treatment arms (team-based care and standard care). The statistical analysis was performed with mixed linear models (DRKS00015526). RESULTS From September 2018 to June 2019, 601 patients from 14 rheumatological practices and 3 outpatient rheumatological clinics in the German states of North Rhine-Westphalia and Lower Saxony were randomized to either team-based or standard care. Team-based care was found to be non-inferior to standard care with respect to changes in disease activity (adjusted difference = -0.19; 95% confidence interval [-0.36; -0.02]; p <0.001 for non-inferiority). Superiority with respect to health-related quality of life was not demonstrated (adjusted difference = 0.02 [-0.02; 0.05], p = 0.285). CONCLUSION Team-based care, with greater integration of SRAs, is just as good as standard care in important respects. Trained SRAs can effectively support rheumatologists in the care of stable patients with RA or PsA.
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Affiliation(s)
- Dietmar Krause*
- *The authors contributed equally to this paper
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Anna Mai*
- *The authors contributed equally to this paper
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | - Robin Denz
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | - Johannes Johow
- Coordination Center for Clinical Trials of Philipps University Marburg
| | - Jens-Peter Reese
- Institute of Clinical Epidemiology and Biometry, Julius Maximilian University Würzburg
| | | | - Renate Klaaßen-Mielke
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | - Nina Timmesfeld
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | - Annette Rittstieg
- *The authors contributed equally to this paper
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | | | - Judith Günzel
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Claudia Klink
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Elmar Schmitz
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Claas Fendler
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Wolf Raub
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Stephanie Böddeker
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Friedrich Dybowski
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Georg Hübner
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Hans-Jürgen Menne
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Heinz-Jürgen Lakomek
- Johannes Wesling Minden Hospital, Germany, Department of Rheumatology and Physical Medicine
| | | | - Ulrike Trampisch
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | - Hans J. Trampisch
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | - Jürgen Braun
- The Ruhr District Rheumatology Center, Ruhr University Bochum
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Hoeper JR, Zeidler J, Meyer SE, Gauler G, Steffens-Korbanka P, Welcker M, Wendler J, Schuch F, von Hinüber U, Schwarting A, Witte T, Meyer-Olson D, Hoeper K. Effect of nurse-led care on outcomes in patients with ACPA/RF-positive rheumatoid arthritis with active disease undergoing treat-to-target: a multicentre randomised controlled trial. RMD Open 2021; 7:rmdopen-2021-001627. [PMID: 33863842 PMCID: PMC8055148 DOI: 10.1136/rmdopen-2021-001627] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/02/2021] [Accepted: 04/05/2021] [Indexed: 01/03/2023] Open
Abstract
Objective To determine the non-inferiority of nurse-led care (NLC) in patients with anticitrullinated protein antibody (ACPA)-positive and/or rheumatoid factor (RF)-positive rheumatoid arthritis (RA) with active disease who are starting disease-modifying antirheumatic drug therapy, following treat-to-target (T2T) recommendations. Methods A multicentre, pragmatic randomised controlled trial was conducted to assess clinical effectiveness, anxiety, depression and patient satisfaction following a non-inferiority design. The participants were 224 adults with ACPA/RF-positive RA who were randomly assigned to either NLC or rheumatologist-led care (RLC). The primary outcome was the Disease Activity Score in 28 Joints measured with C reactive protein (DAS28-CRP) assessed at baseline and after 3, 6, 9 and 12 months. A DAS28-CRP difference of 0.6 was set as the non-inferiority margin. Mean differences between the groups were assessed following per-protocol and intention-to-treat strategies. Results Demographic data and baseline characteristics of patients in the NLC group (n=111) were comparable to those of patients in the RLC group (n=113). The improvement in disease activity (change in DAS28-CRP, primary outcome) over the course of 12 months was significant in both groups (p<0.001). No significant differences were observed between the NLC and RLC groups (p=0.317). Non-inferiority of NLC was shown for the primary outcome and all secondary outcomes. Conclusion This study supported the non-inferiority of NLC in managing T2T and follow-up care of patients with RA with moderate to high disease activity and poor prognostic factors in addition to RLC. Trial registration number DRKS00013055.
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Affiliation(s)
- Juliana Rachel Hoeper
- Center for Health Economics Research Hannover (CHERH), Leibniz Universität Hannover, Hannover, Germany.,Rheumatologie and Immunologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Jan Zeidler
- Center for Health Economics Research Hannover (CHERH), Leibniz Universität Hannover, Hannover, Germany
| | - Sara Eileen Meyer
- Rheumatologie and Immunologie, Medizinische Hochschule Hannover, Hannover, Germany
| | | | | | | | - Jörg Wendler
- Internistische Praxisgemeinschaft, Rheumatologie, Erlangen, Germany
| | - Florian Schuch
- Internistische Praxisgemeinschaft, Rheumatologie, Erlangen, Germany
| | | | - Andreas Schwarting
- Division of Rheumatology and Clinical Immunology, University Hospital Mainz, Mainz, Germany.,ACURA Rheumatology Center Rhineland-Palatinate, Bad Kreuznach, Germany
| | - Torsten Witte
- Rheumatologie and Immunologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Dirk Meyer-Olson
- Rheumatologie and Immunologie, Medizinische Hochschule Hannover, Hannover, Germany.,Rheumatologie, m&i Fachklinik Bad Pyrmont, Bad Pyrmont, Germany
| | - Kirsten Hoeper
- Rheumatologie and Immunologie, Medizinische Hochschule Hannover, Hannover, Germany
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Sezgin MG, Bektas H. The effect of nurse-led care on fatigue in patients with rheumatoid arthritis: A systematic review and meta-analysis of randomised controlled studies. J Clin Nurs 2021; 31:832-842. [PMID: 34396605 DOI: 10.1111/jocn.16003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/19/2021] [Accepted: 08/03/2021] [Indexed: 01/09/2023]
Abstract
AIMS AND OBJECTIVES This study aimed to investigate the effect of nurse-led care on fatigue in patients with rheumatoid arthritis. BACKGROUND Evaluating the effect of nurse-led care on fatigue in patients with rheumatoid arthritis will be useful in planning appropriate nursing interventions to increase the functional status and quality of life of patients. DESIGN Systematic review and meta-analysis. METHODS A comprehensive literature review was conducted on the Cochrane Library, Web of Science, PubMed, EBSCOhost/CINAHL Complete, Springer Link, ProQuest, Science Direct and Ovid databases. The selected articles were examined by two independent ratters with the PICOS criteria, and the methodological quality of the studies included in the study was evaluated with the Quality Assessment Tool for Quantitative Studies. The Comprehensive Meta-Analysis 3 software was used in the analysis of the data. The study was conducted using the checklist for PRISMA. RESULTS This meta-analysis study included six of 1,445 randomised controlled trials. These six studies consisted of a total of 994 patients and provided education and psychosocial support through 30-minute to 2-hour consultations, visits and briefings. No significant publication bias was found in the main outcomes. According to the results of the meta-analysis, the fatigue in patients with rheumatoid arthritis decreased significantly in nurse-led care groups compared with control groups (Hedge's g = -0.18; 95% CI = -0.3 to -0.06). CONCLUSIONS The findings in this systematic review and meta-analysis indicated that nurse-led care played an important role in reducing fatigue in patients with rheumatoid arthritis. RELEVANCE TO CLINICAL PRACTICE Nurse-led care is an effective and appropriate method in reducing fatigue in patients with rheumatoid arthritis. The awareness of all health professionals about the importance of nurse-led care will increase. We recommend the implementation of nurse-led education and psychosocial support interventions to reduce the fatigue of patients with rheumatoid arthritis.
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Affiliation(s)
- Merve Gozde Sezgin
- Department of Internal Medicine Nursing, Akdeniz University Faculty of Nursing, Antalya, Turkey
| | - Hicran Bektas
- Department of Internal Medicine Nursing, Akdeniz University Faculty of Nursing, Antalya, Turkey
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Britten N, Ekman I, Naldemirci Ö, Javinger M, Hedman H, Wolf A. Learning from Gothenburg model of person centred healthcare. BMJ 2020; 370:m2738. [PMID: 32873594 DOI: 10.1136/bmj.m2738] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Nicky Britten
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Inger Ekman
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
- Gothenburg University Centre for Person-Centred Care (GPCC), Gothenburg, Sweden
| | | | | | | | - Axel Wolf
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
- Gothenburg University Centre for Person-Centred Care (GPCC), Gothenburg, Sweden
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Bergsten U, Almehed K, Baigi A, Jacobsson LTH. A randomized study comparing regular care with a nurse-led clinic based on tight disease activity control and person-centred care in patients with rheumatoid arthritis with moderate/high disease activity: A 6-month evaluation. Musculoskeletal Care 2019; 17:215-225. [PMID: 31219668 PMCID: PMC6852576 DOI: 10.1002/msc.1403] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 11/20/2022]
Abstract
Introduction A recent survey showed that 27% of rheumatoid arthritis (RA) patients had inadequately controlled disease activity. Hence, there is a need for new strategies aiming at improving patient outcomes. The aim of the present study was to evaluate the effect of a nurse‐led clinic with frequent visits, treat‐to‐target and person‐centred care of patients with established RA and moderate‐to‐high disease activity compared with patients receiving regular care. Methods The study was a randomized, controlled trial over 26 weeks, with a nonrandomized extension to week 50. Patients were randomized to an intervention group (IG; nurse‐led clinic) based on person‐centred care, frequent visits and “treat to target”, or to a control group (CG) which visited the clinic according to care as usual. The primary outcome was the difference in the DAS28 change between the IG and the CG groups. Results A total of 332 patients were screened for eligibility, of which 70 were randomly assigned to either the IG (n = 36) or the CG (n = 34) group. The primary outcome was not met, although patients in the IG group tended to improve more than those in the CG group (difference: 0.43 (95% confidence interval [CI] –0.27, 1.13). In both the IG and CG groups, delta‐DAS28 improved significantly. The European League Against Rheumatology moderate or good response was achieved by 76% (95% CI 58, 89) in the IG and 49% (95% CI 32, 65) in the CG group. Conclusions Disease activity tended to improve more with the nurse‐led intervention compared with regular care, although the difference was not significant, probably partly due to the lack of statistical power.
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Affiliation(s)
- Ulrika Bergsten
- Research and Development Department at Region of Halland, Halmstad, Sweden
| | - Katarina Almehed
- Rheumatology Department, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Amir Baigi
- Research and Development Department at Region of Halland, Halmstad, Sweden
| | - Lennart T H Jacobsson
- Department of Rheumatology and Inflammation Research, University of Gothenburg, Goteborg, Sweden
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