Patient-centred care in established rheumatoid arthritis

Belonging, happiness, freedom and empowerment-a qualitative study of patients' understanding of health in early rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory joint disease, that influences patients' health in different ways, including physical, social, emotional, and psychological aspects. The goal of rheumatology care is to achieve optimal health and personalised care and therefore, it is essential to understand what health means for patients in the early course of RA. The aim of this study was to describe the understanding of health among patients with early RA.

METHODS

The study had a descriptive qualitative design with a phenomenographic approach. Phenomenography is used to analyse, describe, and understand various ways people understand or experience a phenomenon, in this study, patients' understandings of health. Individual semi-structured interviews were conducted with 31 patients (22 women and nine men, aged (38-80) with early RA, defined as a disease duration of < 1 year, and disease-modifying anti-rheumatic drugs (DMARDs) for 3-7 months. The phenomenographic analysis was conducted in 7 steps, and the outcome space presents the variation in understanding and the interrelation among categories. In accordance with the European Alliance of Associations for Rheumatology's (EULAR) recommendations, a patient research partner participated in all phases of the study.

RESULTS

The analysis revealed four main descriptive categories: 'Health as belonging' was described as experiencing a sense of coherence. 'Health as happiness' was understood as feeling joy in everyday life. 'Health as freedom' was understood as feeling independent. 'Health as empowerment' was understood as feeling capable. Essential health aspects in early RA are comprised of a sense of coherence, joy, independence, and the capability to manage everyday life.

CONCLUSIONS

This study revealed that patients' perception of health in early RA encompasses various facets, including a sense of belonging, happiness, freedom, and empowerment. It highlighted that health is multifaceted and personal, emphasizing the importance of acknowledging this diversity in providing person-centred care. The findings can guide healthcare professionals to deepen patients' participation in treatment goals, which may lead to better treatment adherence and health outcomes.

Development of a web-based patient decision aid for myopia laser correction method

BACKGROUND

In the context of healthcare centered on the patient, Patient Decision Aids (PtDAs) acts as an essential instrument, promoting shared decision-making (SDM). Considering the prevalent occurrence of myopia, the objective of this study is to furnish exhaustive and easily comprehensible information to assist patients in making well-informed decisions about their options for myopia laser correction.

METHOD

The research team developed a decision guide for myopia patients considering laser correction, aiming to facilitate informed decisions. The study followed the first four stages of the IPDAS process model: "scope/scoping," "design," "prototype development," and "alpha testing." Ten semi-structured interviews with patients (n = 6) and corneal specialist ophthalmologists (n = 4) were conducted to understand the challenges in selecting a laser correction method. Online meetings with 4 corneal specialists were held to discuss challenging cases. A comparison table of harms and benefits was created. The initial prototype was developed and uploaded on the internet portal. User feedback on software and text aspects was incorporated into the final web software, which was reviewed by a health education expert for user-friendliness and effectiveness.

RESULT

Educational needs assessment revealed concerns such as pain, daily life activities, return to work, the potential need for glasses ('number return'), eye prescription stability, and possible complications. These shaped the decision aid tool's content. Expert consensus was achieved in several areas, with some items added or extended. In areas lacking consensus, comments were added for clarity. Five clients assessed the web app (PDAIN), rating it 46/50 in user-centricity, 47/50 in usability, and 45/50 in accuracy and reliability, totaling 138/150. Post-piloting, software errors were documented and rectified. During the trial phase, five myopic users interacted with the software, leading to modifications. User feedback indicated the tool effectively enhanced understanding and influenced decision-making.

CONCLUSION

PDAIN, serves as a facilitative tool in the process of selecting a corneal laser correction method for myopic patients. It enabling Nearsighted patients to make informed decisions.

Update of the guidelines for the pharmacological treatment of rheumatoid arthritis by the Mexican College of Rheumatology 2023

OBJECTIVE

To develop updated guidelines for the pharmacological management of rheumatoid arthritis (RA).

METHODS

A group of experts representative of different geographical regions and various medical services catering to the Mexican population with RA was formed. Questions based on Population, Intervention, Comparison, and Outcome (PICO) were developed, deemed clinically relevant. These questions were answered based on the results of a recent systematic literature review (SLR), and the evidence's validity was assessed using the GRADE system, considered a standard for these purposes. Subsequently, the expert group reached consensus on the direction and strength of recommendations through a multi-stage voting process.

RESULTS

The updated guidelines for RA treatment stratify various therapeutic options, including different classes of DMARDs (conventional, biologicals, and JAK inhibitors), as well as NSAIDs, glucocorticoids, and analgesics. By consensus, it establishes the use of these in different subpopulations of interest among RA patients and addresses aspects related to vaccination, COVID-19, surgery, pregnancy and lactation, and others.

CONCLUSIONS

This update of the Mexican guidelines for the pharmacological treatment of RA provides reference points for evidence-based decision-making, recommending patient participation in joint decision-making to achieve the greatest benefit for our patients. It also establishes recommendations for managing a variety of relevant conditions affecting our patients.

Bridge the gap caused by public health crises: medical humanization and communication skills build a psychological bond that satisfies patients

BACKGROUND

Patient satisfaction is an important outcome domain of patient-centered care. Medical humanization follows the patient-centered principle and provides a more holistic view to treat patients. The COVID-19 pandemic posed significant barriers to maintaining medical humanization. However, empirical study on the relationship between medical humanization and patient satisfaction is clearly absent.

OBJECTIVES

We examined the mediation effects of communication on the relationship between medical humanization and patient satisfaction when faced with a huge public health crisis like the COVID-19 pandemic, and the moderation effect of medical institutional trust on the mediation models.

METHODS

A cross-sectional survey study was performed. A final sample size of 1445 patients was surveyed on medical humanization, communication, patient satisfaction and medical institutional trust.

RESULTS

All correlations were significantly positive across the main variables (r = 0.35-0.67, p < 0.001 for all) except for medical institutional trust, which was negatively correlated with the medical humanization (r=-0.14, p < 0.001). Moderated mediation analysis showed that the indirect effect of medical humanization on patient satisfaction through communication was significant (b = 0.22, 95% CI: 0.18 ~ 0.25). Medical institutional trust significantly moderated the effect of medical humanization on patient satisfaction (b=-0.09, p < 0.001) and the effect of medical humanization on communication (b= -0.14, p < 0.001).

CONCLUSION

Medical humanization positively influence patient satisfaction, communication mediated the association between medical humanization and patient satisfaction, and medical institutional trust negatively moderated the effects of medical humanization on patient satisfaction and communication. These findings suggest that humanistic communication contributes to patient satisfaction in the face of a huge public health crisis, and patients' evaluation of satisfaction is also regulated by rational cognition.

How do patients with rheumatoid arthritis perceive their self-care and self-care support? A mixed-method study

AIM

To explore self-care and needs and preferences towards tailored self-care support of patients with rheumatoid arthritis at the outpatient clinic.

DESIGN

A sequential explanatory mixed method design.

METHODS

The Self-Care of Chronic Illness Inventory questionnaire, two focus groups and six semi-structured interviews were conducted between November 2021 and April 2023. Questionnaires of 107 patients were descriptively analysed. Subsequently, 11 patients and 2 healthcare professionals participated in the focus groups and 6 patients in the interviews, which were thematically analysed.

RESULTS

Quantitative and qualitative data corresponded and showed that patients perform various self-care activities at an adequate level and have strategies to exert control and reduce symptoms. One key theme emerged: 'Not only being the person with rheumatoid arthritis' (RA) as patients primarily aim to get on with their lives. Nine subthemes covered self-care activities for maintaining health including staying physically active, finding the right medication and dose and adapting their diet. Patients differed in how they self-monitored their symptoms. Recognizing symptoms and finding strategies to manage symptoms included the process of body listening in which patient seek and try different strategies to find what works for them and incorporate routines. Patients experienced positive effects of a warm or cold environment. Patients felt the need for practical and emotional support from others and preferred having credible information.

CONCLUSION

Patients perform adequate self-care including a diversity of self-care activities to get on with their lives and have strategies to reduce and control the symptoms and impact of RA.

IMPLICATIONS

Tailoring self-care support to patients' individual needs and preferences is necessary to help patients cope with the erratic nature of the disease and maintain their quality of life. Healthcare providers need to provide practical and emotional support and use credible information to allow patients to make self-care decisions to manage their lives.

REPORTING METHODS

Quantitative finding are reported according to the STROBE guidelines and qualitative finding are reported according to the COREQ guidelines.

WHAT DOES THIS PAPER ADD

Patients perform various self-care activities at an adequate level and have strategies to exert control and reduce symptoms. Patients primarily aim to continue their lives and not being seen as the person with rheumatoid arthritis. Healthcare professionals need to provide practical and emotional support and use credible information to inform patients' self-care decision-making.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Experience and perceptions among rheumatoid arthritis patients following a telehealth-delivered dietary intervention: a qualitative study

The effects of dietary modifications have been assessed in people living with rheumatoid arthritis (RA) with consistent benefits reported from clinical trials. However, the lived experience of making and sustaining positive dietary changes for people with RA remains unknown. The aim of this qualitative study was to explore the experiences of adults with RA and their perceptions of a 12-week telehealth-delivered dietary intervention and to assess the acceptability of the programme. Qualitative data was collected via four online focus groups with participants who had just completed a 12-week dietary intervention programme delivered through telehealth methods. Thematic analysis was used to code and summarize the identified key themes. Twenty-one adults with RA (47.5 ± 12.3 years, 90.5% females) were included in this qualitative study. Overarching themes included: (a) motivation to join the programme, (b) benefits of the programme, (c) factors influencing adherence to dietary prescription, and (d) advantages and disadvantages of telehealth. The study demonstrated that a dietary intervention delivered through telehealth methods by a Registered Dietitian (RD) appears to be well-accepted and may be used to complement face-to-face care for people with RA. The identified factors influencing the adoption of a healthier eating pattern will aid in the development of future dietary interventions for a RA population.

'I Prefer To Die at Home With Dignity': Perceptions of Death Rituals Among Religious Muslim Kidney and Liver Transplant Patients With COVID-19

BACKGROUND

Kidney and liver transplant recipients may be at a high risk of contracting acute COVID-19 due to chronic immunosuppression and comorbidities. These patients receive combinations of immunosuppressive drugs, altering their innate and adaptive immunity, thus, rendering them more susceptible to bacterial and viral infections and higher mortality. Kidney and liver transplant recipients frequently exhibit one or several risk factors, increasing the risk for unfavorable outcomes.

METHODS

This qualitative study explores perceptions of religious rituals and practices relating to COVID-19 deaths among Muslim kidney and liver transplant recipients during the first, second, third, and fourth waves, focusing on their tendency to unlawfully refuse to be hospitalized due to their objection to certain guidelines that prevent or restrict religious practices and traditions. A qualitative study based on interviews with 35 older, religious Muslim liver and kidney transplant recipients was conducted face-to-face and on Zoom.

RESULTS

Our findings indicated the absence of acceptable and respectful death rites for the deceased in the event of death from COVID-19, spurring the refusal of older, religious Muslim transplant recipients in Israel to be hospitalized after contracting COVID-19.

CONCLUSIONS

To address these concerns, health authorities and religious leaders must collaborate to find solutions that satisfy the requirements of both the health system and the religious Muslim community.

Psychological support and patient-centered care for patients with rheumatoid arthritis: Nurses' opinions and practice in Japan

AIM

To investigate nurses' opinions and practices regarding psychological support and patient-centered care (PCC) for patients with rheumatoid arthritis.

METHOD

Registered nurses engaged in rheumatic care in Japan were asked to complete the questionnaire regarding nurses' perceived necessity, understanding, and implementation of psychological support, and six patient supports related to PCC, using a seven-point Likert scale. Correlation on practice between psychological support and PCC was evaluated.

RESULTS

A total of 53 nurses participated. Nurses indicated high necessity of providing psychological support, whereas implementation was statistically significantly lower than necessity and motivation. Nurses' answers showed significantly lower implementation compared with understanding regarding basic concepts of psychological support: listening, empathy, acceptance, open questions, and closed questions. Most nurses (54.7%) sometimes provided psychological support, followed by often (34.0%), always (5.7%), and not at all (5.6%). Perceived necessity of PCC was rated high. However, its implementation was significantly lower than necessity for all evaluated cares, such as patients' need-based support and support to patients' families, related to PCC. Positive correlations were observed between the implementation of psychological support and PCC. Nurses stressed the importance of psychological support for patient education and shared decision-making.

CONCLUSION

This preliminary study indicated that most nurses considered psychological support and PCC necessary, but their implementation was relatively low. As psychological support is also crucial to shared decision-making, in addition to PCC, barriers to its implementation should be addressed to improve patients' outcomes and quality of life.

Physical function and severe side effects matter most to patients with RA (< 5 years): a discrete choice experiment assessing preferences for personalized RA treatment

AIM

Early assessment of patient preferences has the potential to support shared decisions in personalized precision medicine for patients with rheumatoid arthritis (RA). The aim of this study was to assess treatment preferences of patients with RA (< 5 years) with previous experience of inadequate response to first-line monotherapy.

METHOD

Patients were recruited (March-June 2021) via four clinics in Sweden. Potential respondents (N = 933) received an invitation to answer a digital survey. The survey included an introductory part, a discrete choice experiment (DCE) and demographic questions. Each respondent answered 11 hypothetical choice questions as part of the DCE. Patient preferences and preference heterogeneity were estimated using random parameter logit models and latent class analysis models.

RESULTS

Patients (n = 182) assessed the most important treatment attributes out of physical functional capacity, psychosocial functional capacity, frequency of mild side effects and likelihood of severe side effects. In general, patients preferred a greater increase in functional capacity and decreased side effects. However, a substantial preference heterogeneity was identified with two underlying preference patterns. The most important attribute in the first pattern was the 'likelihood of getting a severe side effect'. Physical functional capacity was the most important attribute in the second pattern.

CONCLUSION

Respondents focused their decision-making mainly on increasing their physical functional capacity or decreasing the likelihood of getting a severe side effect. These results are highly relevant from a clinical perspective to strengthen communication in shared decision making by assessing patients' individual preferences for benefits and risks in treatment discussions.

A dyadic exploration of support in everyday life of persons with RA and their significant others

BACKGROUND

Support from significant others is important for participation in everyday life for persons with rheumatoid arthritis (RA). Meanwhile, significant others also experience limitations.

AIMS

To explore how support is expressed by persons with RA and significant others, and how support relates to participation in everyday life of persons with RA.

MATERIAL AND METHODS

Sixteen persons with RA and their significant others participated in individual semi-structured interviews. The material was analyzed using dyadic analysis.

RESULTS

Persons with RA and significant others reported that RA and support had become natural parts of everyday life, especially emotional support. The reciprocal dynamics of support were also expressed as imperative. Also, support from people outside of the dyads and well-functioning communication facilitated everyday life.

CONCLUSIONS

Significant others and the support they give are prominent factors and facilitators in everyday life of persons with RA. Concurrently, the support persons with RA provide is important, along with support from outside of the dyads.

SIGNIFICANCE

The results indicate that the interaction between persons with RA and the social environment is central to gain insight into how support should be provided for optimal participation in everyday life. Significant others can preferably be more involved in the rehabilitation process.

Factors Associated With Household Work Limitations in Mexican Patients With Rheumatoid Arthritis: The Impact of the Disease on Women's Life

BACKGROUND

Little attention has been given to the impact of rheumatoid arthritis (RA) on domestic work, which remains the domain of women, particularly in the Latin American region. The study identified factors associated with RA-related household work limitations (HOWL) in Mexican for women with long-standing disease.

METHODS

This cross-sectional study was performed between September 2020 and April 2022, in patients from the recent-onset RA cohort (initiated in 2004). At study entry, patients had standard rheumatic assessments and were administered the HOWL questionnaire, a survey to assess family responsibilities, household work characteristics, and the patient's economic dependency, and the family APGAR index to assess family function. Multiple logistic regression analysis identified variables associated with RA-related HOWL.

RESULTS

Data from 114 female RA patients were analyzed. Overall, at cohort entry, patients were middle-aged (median, 37.5 years), with 12 years of education, and the minority (n = 42 [39.3%]) were married or living together. Patients were representative of typical patients with recent-onset disease and had significant disease activity. At study entry, the patients had 12 (7-16) years of disease duration, and their disease was under control. The median (interquartile range) HOLW-Q score was 0.67 (0-3.33), and 33 patients (28.9%) had RA-related HOWL. Receiving financial support for family living expenses, requiring assistance for activities of daily living, and DAS28 (Disease Activity Score, 28 joints evaluated) were associated with RA-related HOWL; meanwhile, a better Short-Form 36 score at disease onset was protective.

CONCLUSIONS

Domestic work in Mexican RA women might be impacted by social determinants, health-related quality of life at disease onset, and current disease activity status.

Development of a web-based decision aid for initiating biological or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) in axial spondyloarthritis

OBJECTIVES

To develop a web-based evidence-based decision aid to support shared decision-making in patients with axial spondyloarthritis (axSpA) who face a treatment decision to initiate or switch a biological or targeted synthetic disease modifying antirheumatic drug (b/tsDMARDs).

METHODS

Through an iterative process, we systematically developed a decision aid based on evidence from the literature, explorative needs assessment interviews among patients and care providers, and input from experts of the SpA working group of the Dutch Society for Rheumatology and professionals on patient information employed at the Dutch Arthritis Society. The usability, ease of use and feasibility of the pilot version were tested among stakeholders and feedback was used to adapt the decision aid. Finally, a multifaceted strategy was used to introduce the decision aid in clinical practice.

RESULTS

The decision aid consists of (1) consultation support instructions in the context of disease control and treatment needs, (2) an overview of available treatment options for axSpA, (3) detailed information on b/tsDMARDs and an interactive option grid that facilitates comparison of characteristics and (4) a final check supporting patients to deliberate on the decision to initiate or switch a b/tsDMARD. Rheumatologists introduced the decision aid in several Dutch rheumatology settings and the Dutch Arthritis Society posted it on their website, social media and in their monthly newsletter.

CONCLUSION

We developed an evidence-based decision aid to support axSpA patients who face a treatment decision to initiate or switch a b/tsDMARD and introduced this in clinical practice.

A multidisciplinary-led early arthritis service to manage client-identified participation restrictions in early inflammatory arthritis: A qualitative study of service user and staff perspectives

BACKGROUND

The impact of inflammatory arthritis (IA) on occupational performance and on participation in meaningful life roles is recognised. However, limited research has explored how clinical services support broader life impact and participation restrictions associated with early disease as part of routine healthcare. This exploratory study was undertaken to describe how a novel multidisciplinary-led early arthritis service approach addresses client-identified participation restrictions in early IA.

METHODS

Qualitative Description (QD) approaches were used to explore perspectives of staff and clients of these multidisciplinary-led early arthritis services in Ireland. Data were gathered using focus groups with staff, and individual semi-structured interviews with clients. Transcripts were analysed using thematic analysis.

RESULTS

Fifteen staff working in these services participated in the focus groups and 43 clients with IA participated in interviews (female n = 31); diagnosis duration ranged from 5 to 24 months. Participants described how the multidisciplinary-led service had a clear remit to address participation alongside traditional symptom management and provided automatic, immediate access to interventions focussed on identification and management of participation restrictions experienced in early disease. The service model utilised a delivery approach that allowed for ease of early access to a full multidisciplinary team and prolonged support. The most significant feature of the service approach was 'the centrality of the client' which influenced a person-centred approach to identification of needs and priorities for interventions.

CONCLUSION

Findings indicate the role and value of this innovative multidisciplinary approach in addressing client-identified participation restrictions in routine clinical practice that is positively regarded by clients and staff.

Patient Experienced Symptom State in rheumatoid arthritis: sensitivity to change in disease activity and impact

OBJECTIVES

The Patient Experienced Symptom State (PESS) is a single-question, patient-reported outcome that is validated to assess global disease impact in RA. This study addresses its sensitivity to change, and reliability.

METHODS

Disease activity, disease impact in the seven domains of RA Impact of Disease (RAID) and PESS were assessed in patients with RA from the NOR-DMARD registry, at two visits, 6 months apart. The PESS over the last week was scored at five levels, from 'very bad' to 'very good'. Disease impact and disease activity were compared between patients who improved, maintained or worsened PESS over time, through one-way analysis of variance, with post hoc Bonferroni correction. Correlations between changes in these parameters were assessed through Spearman's correlation coefficient. Sensitivity to change was assessed by standardized response mean (SRM) between the two visits. Reliability was analysed through intraclass correlation coefficient (ICC) between the two visits in patients with stable disease activity and impact.

RESULTS

In 353 patients [76.8% females, mean (s.d.) 9.9 (9.6) years disease duration], improvement in PESS level was associated with substantial improvements in mean impact in all domains as well as disease activity (P <0.02). PESS change was moderately to strongly correlated with RAID domains and disease activity (rho: 0.4-0.7). PESS was responsive to change (SRM: 0.65, 95% CI: 0.54, 0.76), particularly among RAID responders (SRM: 1.79, 95% CI: 1.54, 1.99). PESS was moderately reliable in patients with stable condition (ICC: 0.72, 95% CI: 0.52, 0.83).

CONCLUSION

PESS is valid, feasible, reliable and responsive, representing an opportunity to improve the assessment of disease impact with minimal questionnaire burden.

Treat-to-target in rheumatoid arthritis: a real-world study of the application and impact of treat-to-target within the wider context of patient management, patient centricity and advanced therapy use in Europe

BACKGROUND

While treat-to-target (T2T) is endorsed for the management of rheumatoid arthritis (RA), data on the degree of implementation in clinical practice are limited. This study investigated the use of T2T for RA in a real-world setting across Europe.

METHODS

The Adelphi RA Disease-Specific Programme was a point-in-time survey of rheumatologists and their consulting patients with RA conducted between January and October 2020 in Belgium, France, Germany, Italy, Spain and the UK. Rheumatologists completed an attitudinal survey, and a record form for their next 10-12 consulting patients, who were invited to voluntarily complete a patient-reported questionnaire. Data collected included clinical characteristics, treatment patterns and attitudes towards T2T.

RESULTS

Overall, 316 rheumatologists provided data for 3120 patients, of whom 1108 completed the questionnaire. While 86.1% of rheumatologists estimated using T2T principles in clinical practice, only 66.6% of patients were reported by their physician to be managed using a T2T approach. Achieving disease remission was the most commonly reported treatment goal identified by rheumatologists (79.7%), followed by symptom control (47.8%) and reducing impact on quality of life (44.5%). 40.8% of rheumatologists and their patients were in agreement that a treatment goal had been set. When there was agreement on treatment goals, we observed better patient satisfaction, engagement and treatment success.

CONCLUSIONS

Despite recommendations, the T2T approach in RA appears to be suboptimally implemented in clinical practice. This highlights the importance of patient-centricity in the decision-making process to define meaningful targets and select appropriate treatments to improve disease outcomes.

'You don't want to be seen as a burden' experiences of working with early inflammatory arthritis: a qualitative study

PURPOSE

To describe the impact of early inflammatory arthritis on work participation.

MATERIALS AND METHODS

Thirty individuals (24 women) of working age (age 18-69 years) with inflammatory arthritis (<2 years duration) who were in paid employment or fulltime education were interviewed using qualitative description methodology. Data was analysed using thematic analysis.

RESULTS

Half of participants (n = 15) reported work disability within the first two-years of diagnosis. Five descriptive themes were identified that explained the early impact of IA on participation in paid employment. These themes were: (i) altered capacity for work; (ii) work comes first; (iii) the invisible burden; (iv) the disclosure effect; and (v) a reconstructed work future.

CONCLUSION

The scale of early work disability appears to be higher than previously understood. Although early medical intervention has improved disease management, significant work-based restrictions requiring intervention remain. Internalised and invisible work-related anxieties present early in the disease and need to be acknowledged and addressed by healthcare providers.IMPLICATIONS FOR REHABILITATIONEarly inflammatory arthritis causes significant challenges in work ability, and early work-based participation restrictions are present despite early use of drug therapy.Assessment of the client's subjective experience, including understanding the invisible burden, is an important aspect in determining the types of work interventions required.Disclosure of diagnosis in the work environment is associated with anxiety and fear, however, disclosure is influential in supporting capacity to retain work participation and should be included in work interventions.Routine healthcare should include early interventions to address work-based restrictions and supporting work retention to avoid work disability.

Portuguese adaptation and validation of a patient-reported experience measure for patients with rheumatoid arthritis: A protocol study

Background:

There is a growing attention to patient-reported experience measures in assessing the quality of care in patient-centered care models. A specific patient-reported experience measure for patients with rheumatoid arthritis (RA) has been developed in the United Kingdom—Commissioning for Quality in Rheumatoid Arthritis Patient-Reported Experience Measure. This patient-reported experience measure might be feasible to be used in Portugal, yet an adaptation and validation process is needed. Therefore, the aims of this study will be to translate and cross-culturally adapt the Portuguese version of the Commissioning for Quality in Rheumatoid Arthritis Patient-Reported Experience Measure, evaluate its content and face validity through a qualitative approach, and evaluate its psychometric properties through a clinical field testing.

Methods:

This study is based on a multimethod approach combining qualitative and quantitative approaches. This study will include patients with RA from a single rheumatology center. Three sequential phases are planned: Commissioning for Quality in Rheumatoid Arthritis Patient-Reported Experience Measure translation and cultural adaptation, Commissioning for Quality in Rheumatoid Arthritis Patient-Reported Experience Measure content and face validity assessed through 2 focus groups with at least 10 patients, and the Commissioning for Quality in Rheumatoid Arthritis Patient-Reported Experience Measure field testing through a cross-sectional study with 50 patients.

Conclusions:

By involving patients with RA in the validation and implementation of the Commissioning for Quality in Rheumatoid Arthritis Patient-Reported Experience Measure, we expect to demonstrate the usefulness of this specific patient-reported experience measure to improve health care provided to patients with RA.

Beyond Empowerment in Rheumatology Care

In this issue of The Journal of Rheumatology, Carluzzo et al¹ explored different factors that contribute to the empowerment of individuals with arthritis. The study used data obtained from 12,560 US participants in the Live Yes! INSIGHTS program, based on sociodemographic information and patient-reported outcome measures (PROMs) about physical and mental health, emotional support, and empowerment.

The Lived Experiences of Iranian Patients with Rheumatoid Arthritis: A Qualitative Research

BACKGROUND

Rheumatoid Arthritis (RA) is a chronic inflammatory disease that affects various systems of the body. The present study was conducted with the aim to explain the lived experiences of Iranian patients with RA.

MATERIALS AND METHODS

According to the research question, the phenomenological research approach was used. The participants were selected through purposive sampling, and sampling was continued until data saturation was achieved. The data was collected by conducting unstructured interviews and using an audio recorder. To interpret the data, an interpretive/hermeneutic approach was implemented using Van Manen's method. In addition, Lincoln and Guba's criteria were used to evaluate data robustness.

RESULTS

A total of 24 participants participated in the study. Overall, 145 basic concept codes were extracted which were classified into the four main themes of self-management with the participation of the family, spiritual resilience in the face of existing problems, the tendency to hide the disease, and the fear of an uncertain future.

CONCLUSIONS

It is recommended that care providers use the findings of this study to develop care plans in the various aspects of the physical, mental, social, and spiritual needs of patients with RA based on their concerns and deep experiences. It is also suggested that other qualitative research approach methodologies such as grounded theory for explaining the process of patient care and providing an appropriate model, or action research for solving the problems of hospitalized patients through suitable care at home be implemented.

Patient involvement in rheumatoid arthritis care to improve disease activity-based management in daily practice: A randomized controlled trial

OBJECTIVE

To evaluate the effect of an intervention to improve disease activity-based management of RA in daily clinical practice by addressing patient level barriers.

METHODS

The DAS-pass strategy aims to increase patients' knowledge about DAS28 and to empower patients to be involved in treatment (decisions). It consists of an informational leaflet, a patient held record and guidance by a specialized rheumatology nurse. In a Randomized Controlled Trial, 199 RA patients were randomized 1:1 to intervention or control group. Outcome measures were patient empowerment (EC-17; primary outcome), attitudes towards medication (BMQ), disease activity (DAS28) and knowledge about DAS28.

RESULTS

Our strategy did not affect EC-17, BMQ, or DAS28 use. However it demonstrated a significant improvement of knowledge about DAS28 in the intervention group, compared to the control group. The intervention had an additional effect on patients with low baseline knowledge compared to patients with high baseline knowledge.

CONCLUSION

The DAS-pass strategy educates patients about (the importance of) disease activity-based management, especially patients with low baseline knowledge.

PRACTICE IMPLICATIONS

The strategy supports patient involvement in disease activity-based management of RA and can be helpful to reduce inequalities between patients in the ability to be involved in shared decision making.

Death From COVID-19, Muslim Death Rituals and Disenfranchised Grief - A Patient-Centered Care Perspective

In Islam, religious directives regarding death are derived from the Quran and Islamic tradition, but there is a variety of death rituals and practices, lived by Muslims across contexts and geographies. This narrative study explored the dynamics of death and bereavement resulting from COVID-19 death among religious Muslims in Israel. Narrative interviews were conducted with 32 religious Muslims ages 73-85. Findings suggest several absent death rituals in COVID-19 deaths (i.e., the physical and spiritual purification of the body, the shrouding of the body, the funeral, and the will). Theoretically, this study linked death from COVID-19 with patient-centered care, highlighting disenfranchised grief due to the clash of health authority guidelines with religious death practices. Methodologically, this narrative study voices the perspectives of elder religious Muslims in Israel. Practically, this study suggests ways to implement the cultural perspective in COVID-19 deaths and enable a healthy bereavement process.

Towards a Better Implementation of Treat-to-Target Strategy in Rheumatoid Arthritis: A Comparison of Two Real-World Cohorts

Introduction

Treat-to-target (T2T) strategy has been the core of rheumatoid arthritis (RA) management for over a decade, although it implementation has varied distinctly in real practices. We report here our investigation of the differences in disease activity and target achievement of two patient cohorts with different T2T implementations.

Methods

Data of the CENTRA (Collaboratively intENsive Treat-to-target in RA) and TARRA (Treat-to-TARget in RA) cohorts were used. The CENTRA cohort is a RA cohort prospectively followed up by a fixed team with tight control, while the TARRA is a longitudinal observational cohort followed up by a rheumatologist with casual control. Patients from the two cohorts were matched 1:3 by propensity score matching. The primary outcome was the Simplified Disease Activity Index (SDAI) at the 1-year follow-up.

Results

Included in this analysis were 102 patients from the CENTRA cohort and 271 patients from the TARRA cohort. Both groups were comparable in terms of age, gender, disease course, and seropositivity. At the end of the 1-year follow-up, the SDAI of patients in the CENTRA cohort was significantly lower than that of patients in the TARRA cohort (2.1 vs. 3.4; p < 0.001). A similar result was obtained based on the generalized estimating equation (GEE) model (p = 0.009). In addition, more patients in the CENTRA cohort achieved SDAI-defined remission compared to the TARRA cohort [72 (70.6%) vs. 134 (49.4%); p < 0.001].

Conclusion

Patients with RA may benefit more from a tight control T2T strategy with closer follow-up and appropriate education compared with those with a casual T2T strategy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-022-00441-0.

A Serious Puzzle Game to Enhance Adherence to Antirheumatic Drugs in Patients With Rheumatoid Arthritis: Systematic Development Using Intervention Mapping

Background

Patients’ implicit attitudes toward medication need and concerns may influence their adherence. Targeting these implicit attitudes by combining game-entertainment with medication-related triggers might improve medication adherence in patients with rheumatoid arthritis (RA).

Objective

The aim of this study was to describe the systematic development of a serious game to enhance adherence to antirheumatic drugs by using intervention mapping.

Methods

A serious game was developed using the intervention mapping framework guided by a multidisciplinary expert group, which proceeded along 6 steps: (1) exploring the problem by assessing the relationship between medication adherence and implicit attitudes, (2) defining change objectives, (3) selecting evidence-based behavior change techniques that focused on adjusting implicit attitudes, (4) designing the intervention, (5) guaranteeing implementation by focusing on intrinsic motivation, and (6) planning a scientific evaluation.

Results

Based on the problem assessment and guided by the Dual-Attitude Model, implicit negative and illness-related attitudes of patients with RA were defined as the main target for the intervention. Consequently, the change objective was “after the intervention, participants have a more positive attitude toward antirheumatic drugs.” Attention bias modification, evaluative conditioning, and goal priming were the techniques chosen to implicitly target medication needs. These techniques were redesigned into medication-related triggers and built in the serious puzzle game. Thirty-seven patients with RA tested the game at several stages. Intrinsic motivation was led by the self-determination theory and addressed the 3 needs, that is, competence, autonomy, and relatedness. The intervention will be evaluated in a randomized clinical trial that assesses the effect of playing the serious game on antirheumatic drug adherence.

Conclusions

We systematically developed a serious game app to enhance adherence to antirheumatic drugs among patients with RA by using the intervention mapping framework. This paper could serve as a guideline for other health care providers when developing similar interventions.

The Role of Self-management in Inflammatory Arthritis

Self-management in inflammatory arthritis (IA) is a multi-component and complex intervention, presenting an unmet need in the care of people with IA. The ability to self-manage in IA is an essential component of care that goes beyond drug therapy and allows the patient to work on managing the practical, physical and psychological impacts of disease. Self management is useful to support an individual to achieve and maintain independence. Healthcare professionals should be given adequate guidance and professional training to support patients in self-management of their disease. Recently, the European Alliance of Associations for Rheumatology (EULAR) produced guidelines for the implementation of self-management strategies in patients with inflammatory arthritis,1 this editorial discusses the key recommendations in the guidelines.

Are We Transitioning Toward Person-centered Practice on Self-management Support? An Explorative Case Study Among Rheumatology Outpatient Clinic Nurses in Norway

Introduction

There are only a few studies investigating nurses’ views on self-management in the care of patients with rheumatic diseases.

Objective

The aim of this study is to explore how Norwegian rheumatology outpatient nurses describe their ways of supporting patients’ self-management focusing on the core dimensions of person-centered self-management support.

Methods

Ten individual semistructured interviews with rheumatology outpatient nurses were conducted in Norway from March to September 2017. The interviews were audiorecorded and transcribed verbatim. NVIVO was used to support a systematic analysis of themes and patterns.

Results

Nurses’ views on self-management support fell into three approaches; (1) narrowly biomedically orientated, (2) biomedically and holistic, and (3) person-centered. The nurse's views of self-management support varied and did not fully align with the core dimensions of person-centered practice.

Conclusion

The findings indicate that the biomedical paradigm continues to influence Norwegian rheumatology outpatient clinic nurses’ approach to self-management support. If person-centered principles of self-management support are to be translated into standard nursing practice, including identifying and supporting patient-defined self-management goals and processes, there is a need to challenge established structures in health care systems.

Patient Empowerment and Associations with Disease Activity and Pain-Related and Lifestyle Factors in Patients With Rheumatoid Arthritis

BACKGROUND

Empowerment is important to patients with rheumatoid arthritis (RA) because most care is in the form of self-management. The aim was to study levels of empowerment and associated variables in patients with RA and to investigate longitudinal clinical data in patients with low and high empowerment.

METHODS

A postal survey was sent in 2017 to patients with RA from the BARFOT (Better Anti-Rheumatic Pharmacotherapy) cohort that included questions about disease activity, pain-related factors, lifestyle habits, and contained the Swedish Rheumatic Disease Empowerment Scale (SWE-RES-23). The 844 patients who answered the SWE-RES-23 made up the cohort of the present study. Differences in level of empowerment between groups (low, moderate, and high empowerment) were analyzed with ANOVA. Logistic regression analysis was used to study variables associated with low empowerment. Thirdly, we performed comparisons in longitudinal data (15 years) of disease activity, pain, and physical function between the three empowerment groups (low, moderate, and high empowerment).

RESULTS

Patients with low empowerment (n = 282) were significantly older, more often women, and reported worse pain-related factors and physical function and lower moderate and vigorous physical activity compared with those with high empowerment (n = 270). An analysis of longitudinal data found that patients with low empowerment had worse pain and physical function at all time points.

CONCLUSION

Patients with low empowerment have more pain-related symptoms, poorer physical function, and are less physically active. To promote patient empowerment in rehabilitation interventions it is important to identify and support self-management.

Identification of Five Quality Needs for Rheumatology (Text Analysis and Literature Review)

Background: While the use of the term "quality" in industry relates to the basic idea of making processes measurable and standardizing processes, medicine focuses on achieving health goals that go far beyond the mere implementation of diagnostic and therapeutic processes. However, the quality management systems used are often simple, self-created concepts that concentrate on administrative processes without considering the quality of the results, which is essential for the patient. For several rheumatic diseases, both outcome and treatment goals have been defined. This work summarizes current mainstreams of strategies with published quality efforts in rheumatology. Methods: PubMed, Cochrane Library, and Web of Science were used to search for studies, and additional manual searches were carried out. Screening and content evaluation were carried out using the PRISMA-P 2015 checklist. After duplicate search in the Endnote reference management software (version X9.1), the software Rayyan QCRI (https://rayyan.qcri.org) was applied to check for pre-defined inclusion and exclusion criteria. Abstracts and full texts were screened and rated using Voyant Tools (https://voyant-tools.org/). Key issues were identified using the collocate analysis. Results: The number of selected publications was small but specific (14 relevant correlations with coefficients >0.8). Using trend analysis, 15 publications with relative frequency of keywords >0.0125 were used for content analysis, revealing 5 quality needs. The treat to target (T2T) initiative was identified as fundamental paradigm. Outcome parameters required for T2T also allow quality assessments in routine clinical work. Quality care by multidisciplinary teams also focusing on polypharmacy and other quality aspects become essential, A global software platform to assess quality aspects is missing. Such an approach requires reporting of multiple outcome parameters according to evidence-based clinical guidelines and recommendations for the different rheumatic diseases. All health aspects defined by the WHO (physical, mental, and social health) have to be integrated into the management of rheumatic patients. Conclusion: For the future, quality projects need goals defined by T2T based initiatives in routine clinical work, secondary quality goals include multidisciplinary cooperation and reduction of polypharmacy. Quality indicators and standards in different health systems will provide new information to optimize patients' care in different health systems.

Monitoring of rheumatoid arthritis: a patient survey on disease insight and possible added value of an innovative inflammation monitoring device

To enable patients with rheumatoid arthritis (RA) and their healthcare professionals to choose the optimal treatment, it is crucial to accurately assess the current state of inflammatory activity. The objectives of this study were to (1) investigate the perspective of RA patients on their insight into the current status of their disease, and to (2) investigate the patients’ perspective on the possible added value of a monitoring device based on optical spectral transmission—called the HandScan—that measures the location and severity of joint inflammation. A survey was distributed online among patients with RA in the Netherlands. Four-hundred and eight patients with RA completed the survey. Of these, 298 (73%) felt they have sufficient insight into their current disease status. Most respondents perceived either a large (n = 242; 59%) or small (n = 148; 36%) added value of the HandScan in their monitoring process, mostly because the device provides additional knowledge on the presence of inflammation. This perceived added value was higher for respondents experienced with the device (n = 46; p = .04). Respondents preferred monitoring with the device on every (n = 192; 47%) or most (n = 171; 42%) visits to the outpatient clinic, or even more often than on every visit (n = 17; 4%). Monitoring RA using an optical spectral transmission device is seen by patients as a possibly valuable addition to the monitoring process of inflammatory activity during visits to an outpatient clinic. Their main reason was that the device can increase insight into their current disease status. More insight may support patients in discussing treatment options with their rheumatologist.

Underground COVID-19 Home Hospitals for Haredim: Non-Compliance or a Culturally Adapted Alternative to Public Hospitalization?

This thematic study analyzed the experiences of Jewish Haredi (Lithuanian) patients in underground home hospitals during the second wave of COVID-19 in Israel. This minority comprises 12.6% of the Israeli population. Participants were 30 members of this hidden population, ages 59-78. Haredi complied with community directives rather than with the national directive of hospitalizing COVID-19 patient only at public hospitals. Compliance with community directives was driven by a distrust in health authorities and clinicians at public hospitals; by the preference of patient-centered care, a desired approach of care that public hospitals fail to implement; by the need to sustain beliefs, values, and traditions; by community leadership; and by the need to conserve political power. While health authorities view underground home hospitals as demonstrating non-compliance with the national directive, Haredi leaders view underground home hospitals as demonstrating a self-sufficient, patient-centered care alternative to public hospitalizations. Considering the benefits of patient-centered care and the growth of the multi-cultural global landscape, we call upon health authorities to explore the accommodation of patient-centered care for COVID-19 patients and the designing of an adaptive multi-cultural policy that address multi-cultural aspects of religious minorities as key to health promotion. We propose ways to implement multi-cultural policies.

The mode of delivery and content of communication strategies used in mandatory and non-mandatory biosimilar transitions: a systematic review with meta-analysis

Effective patient-provider communication is crucial to promote shared decision-making. However, it is unclear how to explain treatment changes to ensure patient acceptance, such as when transitioning from a bio-originator to a biosimilar. This review investigates communication strategies used to educate patients on transitioning to biosimilars and explores whether the willingness to transition and treatment persistence differs for the delivery (verbal or written) and the amount of information provided. MEDLINE, Embase, Scopus, and relevant conference databases were systematically searched. Communication strategies from 33 studies (88% observational cohort studies) published from 2012 to 2020 were synthesized and willingness to transition, persistence, and subjective adverse events explored. Patients only received information verbally in 11 studies. The remaining 22 studies also provided written information. Cost-saving was the main reason provided for the transition. Patients were most willing to transition when receiving written and verbal information (χ² = 5.83, p = .02) or written information that only addressed a few (3-5) concerns (χ² = 16.08, p < .001). There was no significant difference for persistence or subjective adverse events (p's > .05). Few randomized controlled trials have been conducted. Available data shows more willingness to transition when patients received written and verbal information. Initial documents should contain basic information and consultations or telephone calls used to address concerns.

Centers of Excellence Implementation for Treating Rheumatoid Arthritis in Colombia: A Cost-Analysis

Background

Health systems need to optimize the use of resources, especially in high-cost diseases as rheumatoid arthritis (RA). We aimed to evaluate the efficiency of using centers of excellence (CoE) as a strategy for improving RA treatment in Colombia.

Methods

A cost description analysis was carried out using the standard costing technique. We estimated the costs of medical consultations, laboratories, images, and medications for RA. Categories of care standards stratified by severity were defined using the disease activity score in 28 joints (DAS28). We evaluated the impact, in terms of costs (US dollars), for providing RA clinical care for a previously described cohort using the CoE approach. Statistical analyses were performed in Microsoft Excel^®, and R.

Results

Expenditure on therapeutic drugs increases as the severity of RA increases. Drugs represent 53.6% of the total cost for the low disease activity (LDA) stage, 75.2% for moderate disease activity (MDA), 88.5% for severe disease activity (SDA) and 97% for SDA with biologic treatment (SDA+Biologic). Treating 968 patients would cost US$612,639 (US$487,978-1,220,160) at baseline, per year. After a year of follow-up at the CoE, treating the same patients would cost US$388,765 (US$321,710-708,476), which implies potential cost-savings of up to US$223,874 per year.

Conclusion

The strategy of providing clinical care for RA through CoE can save US$231.3 per patient-per year. The results of our study show that CoE could greatly impact the public policies dealing with treatment of RA in Colombia. Applying the CoE model in our country would both improve health outcomes, as well as being more efficient in terms of costs.

Patient Perspectives on Outcome Domains of Medication Adherence Trials in Inflammatory Arthritis: An International OMERACT Focus Group Study

OBJECTIVE

To describe the perspectives of patients with inflammatory arthritis (IA) on outcome domains of trials evaluating medication adherence interventions.

METHODS

Adult patients (≥ 18 yrs) with IA taking disease-modifying antirheumatic drugs from centers across Australia, Canada, and the Netherlands participated in 6 focus groups to discuss outcome domains that they consider important when participating in medication adherence trials. We analyzed the transcripts using inductive thematic analysis.

RESULTS

Of the 38 participants, 23 (61%) had rheumatoid arthritis and 21 (55%) were female. The mean age was 57.3 ± (SD 15.0) years. Improved outcome domains that patients wanted from participating in an adherence trial were categorized into 5 types: medication adherence, adherence-related factors (supporting adherence; e.g., medication knowledge), pathophysiology (e.g., physical functioning), life impact (e.g., ability to work), and economic impact (e.g., productivity loss). Three overarching themes reflecting why these outcome domains matter to patients were identified: how taking medications could improve patients' emotional and physical fitness to maintain their social function; how improving knowledge and confidence in self-management increases patients' trust and motivation to take medications as agreed with minimal risk of harms; and how respect and reassurance, reflecting health care that values patients' opinions and is sensitive to patients' individual goals, could improve medication-taking behavior.

CONCLUSION

Patients value various outcome domains related to their overall well-being, confidence in medication use, and patient-healthcare provider relationships to be evaluated in future adherence trials.

2021 EULAR recommendations for the implementation of self-management strategies in patients with inflammatory arthritis

Background

An important but often insufficient aspect of care in people with inflammatory arthritis (IA) is empowering patients to acquire a good understanding of their disease and building their ability to deal effectively with the practical, physical and psychological impacts of it. Self-management skills can be helpful in this regard.

Objectives

To develop recommendations for the implementation of self-management strategies in IA.

Methods

A multidisciplinary taskforce of 18 members from 11 European countries was convened. A systematic review and other supportive information (survey of healthcare professionals (HCPs) and patient organisations) were used to formulate the recommendations.

Results

Three overarching principles and nine recommendations were formulated. These focused on empowering patients to become active partners of the team and to take a more proactive role. The importance of patient education and key self-management interventions such as problem solving, goal setting and cognitive behavioural therapy were highlighted. Role of patient organisations and HCPs in promoting and signposting patients to available resources has been highlighted through the promotion of physical activity, lifestyle advice, support with mental health aspects and ability to remain at work. Digital healthcare is essential in supporting and optimising self-management and the HCPs need to be aware of available resources to signpost patients.

Conclusion

These recommendations support the inclusion of self-management advice and resources in the routine management of people with IA and aim to empower and support patients and encourage a more holistic, patient-centred approach to care which could result in improved patient experience of care and outcomes.

Association between Health Literacy, Patient Activation, and Functional Capacity in Individuals with Rheumatoid Arthritis

Objectives:

To describe health literacy, patient activation, and functional capacity in individuals with rheumatoid arthritis and to evaluate the associations of health literacy and activation level with functional capacity.

Methods:

A cross-sectional study involving patients with rheumatoid arthritis was carried out at the rheumatology service of a teaching hospital. Health literacy was assessed by applying the short version of the Test of Functional Health Literacy in Adults. Patient Activation was measured by using the summarized version of the Patient Activation Measure. The Health Assessment Questionnaire was applied to evaluate functional capacity. Sociodemographic and clinical variables were also collected to carried out univariate and multivariate analyses by using logistic regression.

Results:

The sample was composed of 179 patients, of whom 90.5% (n = 162) were women. The participants’ average age was 58.3 ± 11.4 years. The prevalence of patients with inadequate or marginal health literacy was high (67%). In contrast, 74% of the patients showed high activation levels. The average score on the Health Assessment Questionnaire was 1.08 ± 0.7. Adequate health literacy was negatively associated with higher Health Assessment Questionnaire scores (OR = 0.42; 95% CI 0.20 – 0.86; p = 0.018), and high activation levels were negatively associated with moderate to severe functional limitation (level 3/moderate activation level – OR = 0.24; 95% CI 0.10 – 0.56; p = 0.001; level 4/high activation level – OR = 0.22; 95% CI 0.08 – 0.50; p = 0.000).

Conclusion:

Health professionals must be aware of health literacy and activation levels of patients with rheumatoid arthritis, given that interventions to improve them represent an opportunity to increase functional capacity.

Psychometric characteristics of the health care empowerment questionnaire in a sample of patients with arthritis and rheumatic conditions

Background

Patient empowerment can improve health‐related outcomes and is important in chronic conditions, such as arthritis. This study aimed to validate the Health Care Empowerment Questionnaire (HCEQ), a patient‐reported experience measure of empowerment, for use with patients with arthritis and other rheumatic diseases.

Methods

The HCEQ measures Patient Information Seeking (or Involvement in Decisions) and Healthcare Interaction Results (or Involvement in Interactions) and asks respondents to answer questions in two ways: whether they feel something happened and its importance to them. Face validity was assessed through qualitative data (n = 8, nominal group technique; n = 55, focus groups). Measure structure was assessed through confirmatory factor analysis (CFA); internal consistency was also assessed (n = 9226). Test‐retest reliability was assessed with sub‐sample of participants (n = 182).

Results

We found adequate face validity of the HCEQ for patients with arthritis. The CFA indicated good fit to the data for the two‐factor structure of the HCEQ (RMSEA = 0.075; CFI = 0.987; TLI = 0.978; SRMR = 0.026). Internal consistency was strong (α=0.94 for both subscales). Test‐retest reliability was moderate for Patient Information Seeking (ICC=0.67) and good for Healthcare Interaction Results (ICC=0.77).

Conclusions

The HCEQ, with modifications, demonstrated promising psychometric properties within this sample, laying the foundation for further assessment. This work supports the HCEQ as an appropriate instrument for examining experiences with and perceived importance of empowerment in individuals with arthritis and other rheumatic conditions.

Patient Contribution

Patients contributed to the assessment of face validity. As a measure of patient empowerment, the HCEQ’s use can enable further participation of patients in health care.

Qualitative Research in Rheumatology: An Overview of Methods and Contributions to Practice and Policy

Patient-centered care is widely advocated in rheumatology. This involves collaboration among patients, caregivers, and health professionals and is particularly important in chronic rheumatic conditions because the disease and treatment can impair patients' health and well-being. Qualitative research can systematically generate insights about people's experiences, beliefs, and attitudes, which patients may not always express in clinical settings. These insights can address complex and challenging areas in rheumatology, such as treatment adherence and transition to adult healthcare services. Despite this, qualitative research comprises 1% of studies published in top-tier rheumatology journals. A better understanding about the effect and role, methods, and rigor of qualitative research is needed. This overview highlights the recent contributions of qualitative research in rheumatology, summarizes the common approaches and methods used, and outlines the key principles to guide appraisal of qualitative studies.

Clinical Outcomes of Patients with Rheumatoid Arthritis Treated in a Disease Management Program: Real-World Results

Background

Care models can affect the clinical outcome of patients with rheumatic and musculoskeletal diseases.

Objective

We aimed to compare how an innovative model of a rheumatoid arthritis disease-management program can improve the clinical outcomes of patients compared to a conventional assessment approach.

Methods

We performed a retrospective analysis of real-world data from clinical records of a cohort of 5078 patients diagnosed with rheumatoid arthritis who were followed up at the Center of Excellence in Rheumatoid Arthritis vs the clinical outcomes reported in the Colombian National Registry of Rheumatoid Arthritis.

Results

We found significant differences in the diagnosis and follow-up between the specialized Center program and the usual care reported by the Colombian National Registry (p<0.005), including the evaluation of rheumatoid factor, Anti-citrullinated antibodies Disease Activity Score, Health Assessment Questionnaire, number of visits to the rheumatologist, and clinical outcomes measured by the level of disease activity. In addition, when comparing the Center's clinical outcomes - from baseline to the last follow-up, we found an improvement in the level of disease activity, with patients classified in remission increasing from 20.8% to 58.5% (p<0.005), and a reduction in those with high disease activity from 18% to 4.7% (p<0.005).

Conclusion

Real-world evidence showed that patients with rheumatoid arthritis who underwent follow-up under an innovative disease-management model improved their clinical outcomes compared with those patients in a conventional assessment program. These results could suggest a way of improving health policies for patients with rheumatoid arthritis.

A practical guide to interpreting and applying systematic reviews of qualitative studies in rheumatology

While patient-centered care is widely advocated in the management of rheumatic diseases, it can be challenging to implement, particularly for patients with complex systemic conditions. Patient-centered care involves identifying and integrating the patient's experiences, attitudes, and preferences in decision-making. Qualitative research is used to describe patient perspectives and priorities that may not always be expressed in clinical settings. Systematic reviews of qualitative studies can provide new and more comprehensive evidence of patients' beliefs and priorities across different populations and healthcare settings and are increasingly being reported across medical specialties, including rheumatology. In rheumatology, they have been used to examine topics including medication-taking and adherence, coping with systemic sclerosis and conservative management and exercise in osteoarthritis. By referencing recent examples of systematic qualitative reviews in the rheumatology literature, this article will outline the methodology and methods used, and provide an approach to guide the appraisal of reviews. We aim to give the reader a practical understanding of systematic reviews of qualitative literature and elucidate how knowledge gained from such reviews can be applied to improve the care of patients with rheumatic conditions.

The Patient Experienced Symptom State (PESS): a patient-reported global outcome measure that may better reflect disease remission status

OBJECTIVES

In RA, Patient Acceptable Symptom State assesses disease from the patient's perspective, which does not correspond either to disease remission or to full control of disease impact. This study aims to explore the properties of a novel multilevel Patient Experienced Symptom State (PESS).

METHODS

This was a cross-sectional analysis of two datasets of patients with RA. PESS was assessed through the question: 'Consider how your RA has affected you. If you remain in the coming months as you have been the last week, how would you rate your condition?', with five levels (from 'very bad' to 'very good'). Construct validity of PESS was assessed against validated disease activity [DAS28, Simplified Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI)] and impact measures [RA Impact of Disease (RAID) and modified HAQ]. Multiple pairwise comparisons between groups and receiver-operating characteristic curves with Youden Index were performed.

RESULTS

A total of 1407 patients [74% female, mean (S.d.) age 53.5 (13.4) years, mean disease duration 14.3 (12.0) years and mean DAS28 3.0 (1.5)] were analysed. Overall, 16.3% considered themselves as being in 'very good', 21.6% in 'good' and 31.9% in 'acceptable' state. Disease activity and impact measures differed significantly across the five levels (P < 0.01). Cut-off values corresponding to 'good' and 'very good' PESS states were in the range of low disease activity/remission (for 'good' and 'very good': DAS28-ESR-4v ≤2.6/≤2.3; CDAI ≤5.0/≤3.1; SDAI ≤5.1/≤3.8, respectively) and very low disease impact (RAID domains all ≤1).

CONCLUSION

PESS 'very good' status corresponds to currently recommended targets for RA management and reflects full control of disease impact. PESS appears to be an easy-to-use and relevant measure in the evaluation of patients with RA.

The patient perspective of nurse-led care in early rheumatoid arthritis: A systematic review of qualitative studies with thematic analysis

INTRODUCTION

Management of rheumatoid arthritis has changed dramatically over the last decade and is characterised by early start of intensive treatment and tight monitoring of disease activity until remission. The role of nurse-led care at early stage of disease is not well understood.

AIMS

To develop an understanding of rheumatology nurse-led care from the perspective of patients with early rheumatoid arthritis.

METHODS

A systematic review of qualitative studies, reported in line with PRISMA checklist. In March 2019, the following databases were searched: MEDLINE, EMBASE, CINAHL, PsycINFO and OpenGrey. Studies were included if they: included adults with rheumatoid arthritis; were qualitative studies with data on patients' perspectives of nurse-led care; and published in peer-reviewed journals, in English, between 2010-2019. Due to few studies in early rheumatoid arthritis, inclusion was extended to adults with established rheumatoid arthritis. Two reviewers screened abstracts and full texts. Joanna Briggs Institute Critical Appraisal Tool was used for quality assessment. Thematic synthesis was conducted according to the framework of Thomas and Harden (2008).

RESULTS

The search identified 1034 records. After screening and assessing for eligibility, eight qualitative studies were included in the review (133 patients). Three themes were identified from the synthesis. Nurse-led care was seen to provide professional expertise in planning and delivery of care. A person-centred approach was used combined with good communication skills, thus creating a positive therapeutic environment. Nurse-led care was described as providing a sense of empowerment and psychological support.

CONCLUSION

Patients with rheumatoid arthritis are supportive of nurse-led care. They value its professionalism and person-centred approach which provide a sense of security and confidence.

RELEVANCE TO CLINICAL PRACTICE

The findings outline ingredients of nurse-led care that are important to patients. These can inform nurses' professional development plans, service improvement and the competence framework for rheumatology nursing.

A sanctuary from everyday life: rheumatology patients' experiences of in-patient multidisciplinary rehabilitation - a qualitative study

PURPOSE

To explore how rheumatology patients experience the personal impact of an inpatient rehabilitation stay and to elucidate the impact of contextual factors on the outcome.

METHODS

Exploratory qualitative individual interviews were conducted with 15 rheumatology patients (73% female) who had completed a two-week inpatient rehabilitation stay. Data collection, analysis and interpretation of data were performed within a phenomenological-hermeneutic framework inspired by Paul Ricoeur's interpretative philosophy.

RESULTS

The analysis derived one core theme, A sanctuary from everyday life, and five subthemes: (1) Being seen, heard and acknowledged as an equal and whole person; (2) Professional care and compassion; (3) Social relations and interactions between patients; (4) Individual rehabilitation, but challenges regarding shared decision making; and (5) Rehabilitation as a personal process but problems with coherence and transferability of learning to everyday life.

CONCLUSION

Patients experience inpatient rehabilitation as a sanctuary, in the following three ways; through individually planned multidisciplinary interventions at the hospital; recognition and compassion from the multidisciplinary staff and through social relationships and interactions with fellow patients. There is a need for improved coordination across primary and secondary health care, to ease coherence and transfer of learning to the patients' everyday lives.IMPLICATIONS FOR REHABILITATIONPatients can find peace and energy to care for themselves because they are away from everyday life when admitted for inpatient multidisciplinary rehabilitation.Patients need to be prepared for shared decision-making in order to be able to participate in formulating personal and meaningful goals for rehabilitation.There is a need for awareness of organisational and life transitions, to secure transfer of elements from the rehabilitation stay to the patient's everyday life.Rehabilitation professionals should be aware of the significance of fellow patients and facilitate and support the patient-patient relationships.

Educational needs of patients with rheumatic and musculoskeletal diseases attending a large health facility in Austria

INTRODUCTION

Patient education is an important part of the management of rheumatic and musculoskeletal diseases. Given that patients with diverse diseases do not have the same needs, it is crucial to assess the educational requirements of targeted groups to provide tailored educational interventions. The aim of our study was to assess educational needs of a large cohort of patients with different rheumatic and musculoskeletal diseases attending a health facility in Austria.

METHODS

We assessed educational needs, via an online survey of patients with fibromyalgia (FMS), rheumatoid arthritis (RA), and ankylosing spondylitis (AS) recruited from an Austrian health-care facility, using the Austrian version of the Educational Needs Assessment Tool (OENAT).

RESULTS

For our sample of 603 patients, AS (62%), RA (15%), and FMS (24%), there were no educational need differences for the domains of movements, disease process, and self-help measures. Patients with FMS had less need for pain management education and greater need for education about feelings, than other disease groups. Patients with RA had a greater need for education related to treatments than other groups, and patients with AS had a greater need for treatment education than patients with FMS. Patients with AS reported greater need for support system education than other patient groups.

CONCLUSION

Educational needs vary by disease groups, suggesting that health-care professionals should assess disease-specific needs for education to provide optimal assistance in disease management for patients.

Patients' experiences regarding self-monitoring of the disease course: an observational pilot study in patients with inflammatory rheumatic diseases at a rheumatology outpatient clinic in The Netherlands

OBJECTIVES

Self-monitoring the disease course is a relatively new concept in the management of patients with inflammatory rheumatic diseases (IRDs). The aims of this pilot study were to obtain patients' experiences with online self-monitoring, to assess information about the agreement between the disease course assessed with patient-reported outcome measures (PROMs) and an objectively measured Disease Activity Score 28 (DAS28) by the rheumatologist, and to assess adherence to predetermined PROM frequency intervals.

DESIGN

Observational study using qualitative and quantitative methods.

SETTING

The rheumatology outpatient clinic of a teaching hospital in The Netherlands (secondary care).

PARTICIPANTS

47 patients with an IRD who regularly attended the outpatient clinic.

METHODS

Patients completed PROMs by using an online self-monitoring program. Their experiences regarding self-monitoring were qualitatively assessed through a focus group discussion and telephone interviews using a thematic analysis approach. Adherence to the predefined PROM frequency (completed PROM assessments within the predetermined frequency) and the agreement between the DAS28 course and PROM values (Rheumatoid Arthritis Disease Activity Index-5 and the Rheumatoid Arthritis Impact of Disease (RAID)) were quantitatively assessed using descriptives.

RESULTS

Forty-seven patients participated, most of them diagnosed with rheumatoid arthritis (n=38, 80.9%). Three themes were identified: knowledge about and insight into the disease (activity), patient-professional interaction and functionality of the program. Mean adherence to the predetermined PROM frequency was 68.1%. The RAID showed the best agreement with the DAS28 course. Mean participation time was 350 days.

CONCLUSION

Patients were predominantly positive about online self-monitoring. They indicated that they gained more knowledge about their disease, felt less dependent on the healthcare professional and valued the insight into their long-term disease course. Barriers were mostly related to technical factors. Patients were able to and willing to self-monitor their disease, which could contribute to a more efficient allocation of outpatient consultations in the future.

Two parallel short forms to measure disease- and treatment-associated knowledge in rheumatoid arthritis: application of item response theory

Objective

The aim was to develop two disease- and treatment-related knowledge about RA (DataK-RA) short forms using item response theory-based linear optimal test design.

Methods

We used the open source Excel add-in solver to program a linear optimization algorithm to develop two short forms from the DataK-RA item bank. The algorithm was instructed to optimize precision (i.e. reliability) of the scores for both short forms, subject to a number of constraints that served to ensure that each short form would include unique items and that the short forms would have similar psychometric properties. Agreement among item response theory scores obtained from the different short forms was assessed using the Bland–Altman method and Student’s paired t-test. Construct validity and relative efficiency of the short forms was evaluated by relating the score to age, sex and educational attainment.

Results

Two short forms were derived from the DataK-RA item bank that satisfied all content constraints. Both short forms included 15 unique items and yielded reliable scores (r &gt; 0.70), with low ceiling and floor effects. The short forms yielded statistically indistinguishable mean scores according to Student’s paired t-test and Bland–Altman analysis. Scores on short forms 1 and 2 were associated with age, sex and educational attainment to a similar extent.

Conclusion

In this study, we developed two DataK-RA short forms with unique items, yet similar psychometric properties, that can be used to assess patients pre- and post-test interventions aimed at improving disease-related knowledge in RA patients.

Validation and implementation of a patient-reported experience measure for patients with rheumatoid arthritis and spondyloarthritis in the Netherlands

Objectives

To test the psychometric properties of the United Kingdom’s Commissioning for Quality in Rheumatoid Arthritis Patient-Reported Experience Measure (CQRA-PREM) in patients with spondyloarthritis (SpA) and rheumatoid arthritis (RA) and to implement this questionnaire in daily practice in the Netherlands.

Methods

After a forward-backward translation procedure into Dutch, the CQRA-PREM was tested into two quality registries in daily practice. Face validity was assessed with focus group interviews. Feasibility was evaluated through completion times and interpretability of domain scores through floor and ceiling effects. Internal consistency (Cronbach’s α coefficients) and homogeneity (corrected item-total correlations) were determined. Divergent validity was assessed by Spearman’s rank correlation coefficients (r_s) between the average scores of domains and outcome measures. The CQRA-PREM was implemented in daily practice, and the results were used in quality improvement cycles.

Results

Face validity of the CQRA-PREM was good. The CQRA-PREM was completed by 282 patients with SpA and 376 with RA. Median time to complete the CQRA-PREM was 4.7 min. Ceiling effects were found in three out of seven domains. Internal consistency of nearly all domains was considered good (0.65 ≤ α ≤ 0.95). Thresholds for homogeneity were exceeded within three domains (r_p > 0.7), suggesting item redundancy. Divergent validity showed that nearly all domains of the CQRA-PREM were at most weakly correlated with outcomes measures (− 0.3 ≤ r_s ≤ 0.3). The CQRA-PREM could identify areas of improvement for providing patient-centered care.

Conclusion

The CQRA-PREM has acceptable psychometric properties and has shown to be a useful tool in evaluating quality of care from the patients’ perspective in the Netherlands.

Trial registration

SpA-Net is registered in the Netherlands Trial Registry (NTR6740).

Key Points

• The Commissioning for Quality in Rheumatoid Arthritis Patient-Reported Experience Measure (CQRA-PREM) is a valid measure for assessing patient-centeredness of rheumatology care.

• The Dutch version of the CQRA-PREM shows acceptable psychometric properties.

• The CQRA-PREM shows to be a useful tool in Plan-Do-Check-Act quality improvement cycles in the Netherlands.

• The CQRA-PREM can be used for benchmarking and quality improvement of rheumatology services.

Electronic supplementary material

The online version of this article (10.1007/s10067-020-05076-6) contains supplementary material, which is available to authorized users.

What Matters Most to Patients and Rheumatologists? A Discrete Choice Experiment in Rheumatoid Arthritis

INTRODUCTION

To determine patient and rheumatologist preferences for rheumatoid arthritis (RA) treatment attributes in Spain and to evaluate their attitude towards shared decision-making (SDM).

METHODS

Observational, descriptive, exploratory and cross-sectional study based on a discrete choice experiment (DCE). To identify the attributes and their levels, a literature review and two focus groups (patients [P] = 5; rheumatologists [R] = 4) were undertaken. Seven attributes with 2-4 levels were presented in eight scenarios. Attribute utility and relative importance (RI) were assessed using a conditional logit model. Patient preferences for SDM were assessed using an ad hoc questionnaire.

RESULTS

Ninety rheumatologists [52.2% women; mean years of experience 18.1 (SD: 9.0); seeing an average of 24.4 RA patients/week (SD: 15.3)] and 137 RA patients [mean age: 47.5 years (SD: 10.7); 84.0% women; mean time since diagnosis of RA: 14.2 years (SD: 11.8) and time in treatment: 13.2 years (SD: 11.2), mean HAQ score 1.2 (SD: 0.7)] participated in the study. In terms of RI, rheumatologists and RA patients viewed: time with optimal QoL: R: 23.41%/P: 35.05%; substantial symptom improvement: R: 13.15%/P: 3.62%; time to onset of treatment action: R: 16.24%/P: 13.56%; severe adverse events: R: 10.89%/P: 11.20%; mild adverse events: R: 4.16%/P: 0.91%; mode of administration: R: 25.23%/P: 25.00%; and added cost: R: 6.93%/P: 10.66%. Nearly 73% of RA patients were involved in treatment decision-making to a greater or lesser extent; however, 27.4% did not participate at all.

CONCLUSION

Both for rheumatologists and patients, the top three decision-making drivers are time with optimal quality, treatment mode of administration and time to onset of action, although in different ranking order. Patients were willing to be more involved in the treatment decision-making process.

Appropriating and asserting power on inflammatory arthritis teams: A social network perspective

Background

Therapeutic interventions for people with inflammatory arthritis (IA) increasingly involve multidisciplinary teams and strive to foster patient‐centred care and shared decision making. Participation in health‐care decisions requires patients to assert themselves and negotiate power in encounters with clinicians; however, clinical contexts often afford less authority for patients than clinicians. This disadvantage may inhibit patients' involvement in their own health care.

Objective

To identify communication attributes, IA patients use to influence and negotiate their treatment with members of their health‐care network.

Method

A qualitative social network approach was used to analyse data from a larger study that investigated IA patients' overall experiences of multidisciplinary care. Fourteen patients with IA attended individual semi‐structured interviews. Researchers used thematic analysis to identify patterns of assertiveness and influence in the data.

Results

Participants experienced loss of identity, control and agency in addition to the physical symptoms of IA. However, they had a sense of personal responsibility for managing their health care. Perceptions of health‐care team support enhanced patients' influence in treatment negotiations. Notably, there appeared to be an underlying tension between being empowered or disempowered.

Discussion and conclusions

The findings have significant implications for treatment decision communication approaches to IA care. A social network perspective may provide a pathway for clinicians to better understand the complexities of communication with their patients. This approach may reduce unequal power dynamics that occur within clinician/patient interactions and afford people with IA agency, control and affirmation of identity within their health‐care network.

A pilot study examining patient preference and satisfaction for ava®, a reusable electronic injection device to administer certolizumab pegol

Background: Anti-tumor necrosis factor (anti-TNF) adherence is suboptimal. ava®, a reusable electromechanical self-injection device (e-Device) developed for certolizumab pegol (CZP) administration, aims to overcome some barriers to increase adherence. This study evaluates patient experience of the e-Device and its training materials and determines patient device preference.Methods: CZP-treated patients were recruited from the Netherlands, Denmark and Sweden. Patients completed a pre-injection Assessment of Self-Injection (ASI) questionnaire investigating self-injection perception. After training, patients administered 3 consecutive self-injections using the e-Device, patient experience of each was assessed using the post-injection ASI. An additional questionnaire evaluated training materials. After Injection 3, patients indicated their preference: the e-Device or their previous device.Results: 59 patients participated; most rated the e-Device highly for satisfaction, self-confidence and ease of use. The (negative) feelings and pain and skin reactions domains had low ratings. Post-injection ASI domain scores were similar following each of the 3 e-Device injections. Training materials were rated highly (video: 8.4/10; step-by-step guide: 8.4/10). 57.1% (32/56) patients preferred the e-Device over their previous self-injection device.Conclusions: Patients were satisfied with the e-Device and most preferred it over other self-injection devices. By improving patient experience, the e-Device may help increase medication adherence.