Role and modalities of information and education in the management of patients with rheumatoid arthritis: development of recommendations for clinical practice based on published evidence and expert opinion

[Standards of care for people with rheumatoid arthritis in Europe : Translation and comments of the eumusc.net recommendations supported by EULAR performed by a national task force of the professional organisations DGRh and VRA supported by "Deutsche Rheumaliga"]

In a joint initiative by the boards of the German Society for Rheumatology (DGRh) and the Association of Rheumatology Clinics (VRA) the European "standards of care" for rheumatoid arthritis, recently suggested by the European Musculoskeletal Conditions Surveillance and Information Network (eumusc.net) and supported by the European League Against Rheumatism (EULAR), were translated and annotated. The recommendations include aspects of the management of the disease, actual medical care, and access to information - this includes all types of support people with RA need, and, last but not least communication of the necessary knowledge. Furthermore, health care structures such as the availability of medical staff with relevant expertise are also important.

A survey of people with foot problems related to rheumatoid arthritis and their educational needs

Background

Up to 50% of people with rheumatoid arthritis (RA) have foot symptoms at diagnosis, hence early foot health intervention is recommended and this should include patient education. This study identifies, for the first time, the foot health education (FHE) needs of people with RA.

Methods

An online survey of people with RA (n = 543) captured quantitative data in relation to the aims, methods of delivery, content, timing and accessibility of FHE.

Results

The majority concurred about the aims of FHE. Verbal delivery and websites were the most common methods. Written and verbal FHE were perceived to be the most effective methods. The point of diagnosis was the preferred time to receive it. Lack of access to FHE included minimal focus on foot health during consultations by both health practitioners and patients with RA. Participant gender, age, disease duration and living situation had a statistically significant influence on the results.

Conclusion

Foot health education is rarely considered within the medical consultation. There is a lack of patient and/or health professional awareness of this need with a detrimental impact on foot health. Patients require health professionals to identify their foot education health needs. Tailored foot health education should begin at initial diagnosis.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-017-0193-6) contains supplementary material, which is available to authorized users.

Foot Health Education for People with Rheumatoid Arthritis: '…. A Game of Chance…' - A Survey of Patients' Experiences

OBJECTIVE

Up to 90% of people with rheumatoid arthritis (RA) experience foot problems leading to reduced function, mobility, quality of life and social participation, and impacts on body image, but these can be improved with general foot care, orthoses, footwear and patient education. Foot health patient education is lacking, so the aim of the present study was to identify the foot health educational needs of people with RA in relation to its content, timing, mode of delivery and the perceived barriers to its provision.

METHODS

People with RA completed an online survey and provided free-text comments for thematic analysis.

RESULTS

A total of 249 people completed the free-text section of the survey. Five main themes emerged: 'Forgotten feet'; 'Too little, too late'; 'Lacks and gaps'; 'I am my feet' and 'Game of chance'.

CONCLUSION

Foot pathology in people with RA has a bio-psychosocial impact on their lives. Foot health and related information appears to be considered rarely within the medical consultation. Access to foot health information and services is limited owing to a lack of patient and/or health professional awareness, with a detrimental impact on the prognosis of their foot health. The importance of foot health in people with RA should be reinforced for patients and health professionals alike. Opportunities to discuss foot health within the medical consultation should be provided regularly. Copyright © 2015 John Wiley & Sons, Ltd.

Patient-mediated knowledge translation (PKT) interventions for clinical encounters: a systematic review

BACKGROUND

Patient-mediated knowledge translation (PKT) interventions engage patients in their own health care. Insight on which PKT interventions are effective is lacking. We sought to describe the type and impact of PKT interventions.

METHODS

We performed a systematic review of PKT interventions, defined as strategies that inform, educate and engage patients in their own health care. We searched MEDLINE, EMBASE and the Cochrane Library from 2005 to 2014 for English language studies that evaluated PKT interventions delivered immediately before, during or upon conclusion of clinical encounters to individual patients with arthritis or cancer. Data were extracted on study characteristics, PKT intervention (theory, content, delivery, duration, personnel, timing) and outcomes. Interventions were characterized by type of patient engagement (inform, activate, collaborate). We performed content analysis and reported summary statistics.

RESULTS

Of 694 retrieved studies, 16 were deemed eligible (5 arthritis, 11 cancer; 12 RCTs, 4 cohort studies; 7 low, 3 uncertain, 6 high risk of bias). PKT interventions included print material in 10 studies (brochures, booklets, variety of print material, list of websites), electronic material in 10 studies (video, computer program, website) and counselling in 2 studies. They were offered before, during and after consultation in 4, 1 and 4 studies, respectively; as single or multifaceted interventions in 10 and 6 studies, respectively; and by clinicians, health educators, researchers or volunteers in 4, 3, 5 and 1 study, respectively. Most interventions informed or activated patients. All studies achieved positive impact in one or more measures of patient knowledge, decision-making, communication and behaviour. This was true regardless of condition, PKT intervention, timing, personnel, type of engagement or delivery (single or multifaceted). No studies assessed patient harms, or interventions for providers to support PKT intervention delivery. Two studies evaluated the impact on providers of PKT interventions aimed at patients.

CONCLUSIONS

Single interventions involving print material achieved beneficial outcomes as did more complex interventions. Few studies were eligible, and no studies evaluated patient harms, or provider outcomes. Further research is warranted to evaluate these PKT interventions in more patients, or patients with different conditions; different types of PKT interventions for patients and for providers; and potential harms associated with interventions.

Randomised study versus control group of customised therapeutic education for patients in follow-up for rheumatoid arthritis

OBJECTIVE

We have evaluated customized objectives, predefined during a therapeutic education session for rheumatoid arthritis (RA).

METHODS

Fifty-four RA patients were randomised into patient therapeutic education (PTE) group versus waiting list (WL). The final comparative evaluation involved solving 3 predefined problems.

RESULTS

Fifty-four were evaluated after 6 months. The main criterion was defined for all three of the chosen themes at 76.9% in the PTE group and 42.4% in the WL group. Among the other positively evaluated criteria were: less corticotherapy, more occupational therapy, more demand for social aid, more physical activity, knowledge of the recognition of an RA attack and how to cope with it. On the other hand, knowledge of the treatments did not differ between the 2 groups nor did the RAPID scores, fatigue, stiffness, depression, compliance, number of consultations and hospitalisations. Patient satisfaction was excellent (between 85.3 and 93.9%).

CONCLUSION

This study is a good illustration of the position occupied and value of PTE in solving the problems specific to each RA case, the resulting high level of patient satisfaction and its independently complementary aspects relative to the purely medical treatment of RA. Customized PTE could better respond to specific patients problems in RA.

Development of patient-centred standards of care for rheumatoid arthritis in Europe: the eumusc.net project

Objective

The eumusc.net project is a European Union (EU) commission and European League Against Rheumatism (EULAR)funded project that aims to facilitate equal standards for musculoskeletal health in all EU countries. One work-package was to develop evidence-based and patient-centred standards of care (SOC), for rheumatoid arthritis (RA) understandable for patients and professionals across Europe.

Method

A review of documents covering clinical practice ‘guidelines’ and SOC for RA was conducted. The obtained documents were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) criteria, and all recommended methods to treat RA were extracted. Based on this information, a three-round Delphi exercise was performed including a consensus group meeting of 21 researchers and patient representatives.

Results

16 patient-centred SOC were formulated including a lay version in the format of a checklist. An example is SOC 3: ‘People with RA should receive a treatment plan developed individually between them and their clinician at each visit.’ The corresponding checklist question reads: ‘Have I received a treatment plan which includes an explanation of my management, expected goals and outcomes and important contact details?’

Conclusions

The SOC for RA will be available in all 23 official European languages and contribute to more unified treatment approaches in Europe.

Foot health education for people with rheumatoid arthritis: the practitioner's perspective

Background

Patient education is considered to be a key role for podiatrists in the management of patients with rheumatoid arthritis (RA). Patient education has undoubtedly led to improved clinical outcomes, however no attempts have been made to optimise its content or delivery to maximise benefits within the context of the foot affected by rheumatoid arthritis. The aim of this study was to identify the nature and content of podiatrists' foot health education for people with RA. Any potential barriers to its provision were also explored.

Methods

A focus group was conducted. The audio dialogue was recorded digitally, transcribed verbatim and analysed using a structured, thematic approach. The full transcription was verified by the focus group as an accurate account of what was said. The thematic analysis framework was verified by members of the research team to ensure validity of the data.

Results

Twelve members (all female) of the north west Podiatry Clinical Effectiveness Group for Rheumatology participated. Six overarching themes emerged: (i) the essence of patient education; (ii) the content; (iii) patient-centred approach to content and timing; (iv) barriers to provision; (v) the therapeutic relationship; and (vi) tools of the trade.

Conclusion

The study identified aspects of patient education that this group of podiatrists consider most important in relation to its: content, timing, delivery and barriers to its provision. General disease and foot health information in relation to RA together with a potential prognosis for foot health, the role of the podiatrist in management of foot health, and appropriate self-management strategies were considered to be key aspects of content, delivered according to the needs of the individual. Barriers to foot health education provision, including financial constraints and difficulties in establishing effective therapeutic relationships, were viewed as factors that strongly influenced foot health education provision. These data will contribute to the development of a patient-centred, negotiated approach to the provision of foot health education for people with RA.

Therapeutic foot health education for patients with rheumatoid arthritis: a narrative review

PURPOSE

Foot health interventions such as foot orthoses for people with rheumatoid arthritis (RA) reduce pain, improve function and improve overall quality of life. Additionally, patient education (PE) is considered essential in achieving good outcomes with interventions such as foot orthoses, footwear and self-care. The aim of this literature review was to identify evidence in relation to the content, use and delivery of PE in the management of RA foot problems.

METHODS

An electronic search of the following databases was performed: PubMed, CINAHL, AMED, Medline and the Cochrane Library, between March 2000 and March 2010. In order to be included, studies had to be published in English, involve adults (>18 years) with RA, and assist in answering the research question. No publications regarding PE for the management of foot health-related problems in RA were found. However, other key terms emerged that embraced PE for people with RA and informed a further search. Thirty-two papers met the inclusion criteria and were reviewed with regard to the subject area, content of the paper, methodological issues and their key findings.

RESULTS

The present review provides evidence for the effectiveness of PE for people with RA delivered via a staged approach, with the content and timing of education provision being driven by the needs of the patient.

CONCLUSIONS

The effect of PE delivered from a podiatric context needs to be explored, and the nature and requirements of PE for individuals with RA-related foot problems from a patient and practitioner perspective requires investigation. Alternative and innovative ways of providing PE and, potentially, self-management need to be investigated and defined.

Protocol: developing a conceptual framework of patient mediated knowledge translation, systematic review using a realist approach

Background

Patient involvement in healthcare represents the means by which to achieve a healthcare system that is responsive to patient needs and values. Characterization and evaluation of strategies for involving patients in their healthcare may benefit from a knowledge translation (KT) approach. The purpose of this knowledge synthesis is to develop a conceptual framework for patient-mediated KT interventions.

Methods

A preliminary conceptual framework for patient-mediated KT interventions was compiled to describe intended purpose, recipients, delivery context, intervention, and outcomes. A realist review will be conducted in consultation with stakeholders from the arthritis and cancer fields to explore how these interventions work, for whom, and in what contexts. To identify patient-mediated KT interventions in these fields, we will search MEDLINE, the Cochrane Library, and EMBASE from 1995 to 2010; scan references of all eligible studies; and examine five years of tables of contents for journals likely to publish quantitative or qualitative studies that focus on developing, implementing, or evaluating patient-mediated KT interventions. Screening and data collection will be performed independently by two individuals.

Conclusions

The conceptual framework of patient-mediated KT options and outcomes could be used by healthcare providers, managers, educationalists, patient advocates, and policy makers to guide program planning, service delivery, and quality improvement and by us and other researchers to evaluate existing interventions or develop new interventions. By raising awareness of options for involving patients in improving their own care, outcomes based on using a KT approach may lead to greater patient-centred care delivery and improved healthcare outcomes.

The sources of disease-related information for Estonia's rheumatoid arthritis patients: a qualitative study

OBJECTIVE

To describe rheumatoid arthritis patients' perceptions of being informed and of the value of the information obtained.

BACKGROUND

About the accessibility of the disease-specific information to the patients, a prerequisite for any kind of the patient empowerment, can be considered as a priority area for investigation.

DESIGN

Six focus groups (involving 27 patients) were conducted. For analysing the data, thematic analysis was applied.

RESULTS

The participants referred to the media and the Internet, in-patient units, physicians at out-patient consultations, patients organisations, fellow patients and their own experience as the sources of disease-related information. The information delivered by the physicians was valued highest; satisfaction with the information received from the in-patient units was expressed. The knowledge acquired through the experience was mentioned as being important for coping with the disease. The media was an easily accessible information channel, although the information from this source was less trusted. The access to the Internet was seen as being limited for certain patients groups. The availability of physician-delivered information was described as unsatisfactory due to the organisation of information transmittal in out-patient settings.

CONCLUSIONS

The results indicated the current balance of information sources as being incongruous with the provision of systematic and reliable disease-related information. The available information may also be qualitatively incomplete.

RELEVANCE TO CLINICAL PRACTICE

Recognition of the weak and strong points of the structure of information provision is valuable when considering the development of educational opportunities for rheumatoid arthritis patients.

Canadian recommendations for use of methotrexate in patients with rheumatoid arthritis

OBJECTIVE

To develop recommendations for the use of methotrexate (MTX) in patients with rheumatoid arthritis.

METHODS

Canadian rheumatologists who participated in the international 3e Initiative in Rheumatology (evidence, expertise, exchange) in 2007-2008 formulated 5 unique Canadian questions. A bibliographic team systematically reviewed the relevant literature on these 5 topics. An expert committee consisting of 26 rheumatologists from across Canada was convened, and a set of recommendations was proposed based on the results of systematic reviews combined with expert opinions using a nominal group consensus process.

RESULTS

The 5 questions addressed drug interactions, predictors of response, strategies to reduce non-serious side effects, variables to assess clinical response, and incorporating patient preference into decision-making. The systematic review retrieved 93 pertinent articles; this evidence was presented to the expert committee during the interactive workshop. After extensive discussion and voting, a total of 9 recommendations were formulated: 2 on drug interactions, 1 on predictors of response, 2 on strategies to reduce non-serious side effects, 3 on variables to assess clinical response, and 1 on incorporating patient preferences into decision-making. The level of evidence and the strength of recommendations are reported. Agreement among panelists ranged from 85% to 100%.

CONCLUSION

Nine recommendations pertaining to the use of MTX in daily practice were developed using an evidence-based approach followed by expert/physician consensus with high level of agreement.

Characteristics and development of therapeutic patient education in rheumatoid arthritis: analysis of the 2003-2008 literature

OBJECTIVE

The aim of this study is to point out the recent characteristics and developments of therapeutic patient education (TPE) in rheumatoid arthritis through an analysis of the international articles published from 2003 to 2008.

METHOD

Studies were selected from major databases, using the following keywords: rheumatoid arthritis, patient education, self-management, programs. Three authors independently reviewed each study and selected the data using the patient education research categories (PERC). Articles consistently related to patient education in rheumatoid arthritis (37 among 109) were included.

RESULTS

The selected articles have been published in 23 scientific journals. The majority of them concern TPE for adult patients with rheumatoid arthritis. TPE is delivered in several structures and group education represents the most widespread educational strategy mainly provided by a multiprofessional team. There are two types of programs: educational, aiming to make the patient competent in the daily management of his disease and psycho-educational ones, aiming to improve coping and to decrease stress, anxiety and depression. Twenty-eight studies show the effectiveness of TPE on the basis of bio-clinical, educational, psychosocial, economical criteria, but the majority of these positive results are observed in short-term. Barriers to TPE are linked to cultural and socio-economic factors.

CONCLUSION

A large number of studies still assess the positive effects of TPE. Nowadays, the problems of short-term efficacy of TPE and the cultural and social barriers to this practice have become a major issue for research.

Quality and impact of information about interventional rheumatology: a study in 119 patients undergoing fluoroscopy-guided procedures

OBJECTIVE

To evaluate the quality of patient information about fluoroscopy-guided rheumatologic procedures, and to look for an impact on the patient's experience of the procedure.

METHODS

One hundred and nineteen patients completed questionnaires before and after undergoing fluoroscopy-guided interventions. We looked for associations between the information supplied by the rheumatologist who recommended the procedure and pain, anxiety, awareness of potential complications, and the match between patient expectations and actual experience.

RESULTS

62.8% of patients reported receiving information about the procedure. Only 20.5% reported receiving specific information about potential adverse events, although 80.9% felt this information would have been useful. Most patients (74.8%) would have liked to receive additional information. Only 10.1% patients were given written information. Mean (+/-SD) anticipated pain severity as assessed in the waiting room before the procedure on a 0-10 scale was 4.5+/-2.4 in women and 4.2+/-2.3) in men. Actual pain severity during the procedure as assessed on the same scale was 2.7+/-2.6 in women and 2.2+/-1.6 in men. The level of information about the procedure did not influence anticipated or actual pain severity. Anxiety was reported by 59.8% patients and was more common in women (P<0.001), in patients given written information (P=0.05), and in patients undergoing their first intervention (P=0.05). Information was perceived as alleviating anxiety by 69.9% patients, and 77.3% of patients felt they would experience less anxiety if they had the procedure a second time. Only 21.2% patients were able to name a potential adverse event, and this proportion was not influenced by receiving written information. A mismatch between expectations about the procedure or its duration and actual experience was reported by 17 (17/69, 24.6%) and 34 (34/98, 34.7%) patients, respectively, with no significant differences across study subgroups.

CONCLUSION

Information about interventional rheumatology procedures is required for ethical principles and legislation. Patients increasingly expect detailed information, which may increase the likelihood that the procedure unfolds smoothly. Our results indicate a need for optimizing patient information. Standardized written material deserves to be evaluated as a means of better meeting the informational needs of patients.

Recommendations of the French Society for Rheumatology. TNFalpha antagonist therapy in rheumatoid arthritis

OBJECTIVES

To develop recommendations for TNFalpha-antagonist therapy in patients with rheumatoid arthritis (RA) seen in everyday practice, under the aegis of the French Society for Rheumatology.

METHOD

We used the methods recommended by the French Agency for Healthcare Accreditation and Evaluation, the AGREE collaboration, and the European League against Rheumatism (EULAR). The recommendations focus on patient selection, monitoring, and treatment adjustments.

RESULTS

Criteria for selecting patients eligible for TNFalpha-antagonist treatment of RA include: 1) a definitive diagnosis of RA; 2) disease activity for longer than 1 month, including presence of objective signs of inflammation; or radiographic progression; 3) previous failure of methotrexate in the highest tolerated dosage or of another disease-modifying antirheumatic drug in patients with contraindications to methotrexate; 4) absence of contraindications to TNFalpha-antagonist therapy. When starting TNFalpha-antagonist therapy 1) a thorough baseline evaluation should be conducted; 2) any of the three available agents can be used, as no differences in efficacy have been identified in patient populations; 3) concomitant methotrexate therapy is recommended regardless of the TNFalpha antagonist used; and 4) patients should receive standardized follow-up at regular intervals. Treatment adjustments should be based on the following: 1) the treatment objective is achievement of a EULAR response; 2) when such a response is not achieved, the dosage or dosing interval can be changed, or the patient can be switched to another TNFalpha antagonist; 3) in patients who experience intolerance to a TNFalpha antagonist, another TNFalpha antagonist may be tried, depending on the nature of the adverse event; 4) occurrence of a remission should lead to a reduction in symptomatic medications, most notably glucocorticoids where used; in the event of a prolonged remission, either the TNFalpha antagonist or the concomitant disease-modifying antirheumatic drug may be reduced.

CONCLUSION

These recommendations are intended to help physicians use TNFalpha antagonists in their everyday practice with RA patients. They do not constitute regulations.

Nonpharmacological treatments in early rheumatoid arthritis: clinical practice guidelines based on published evidence and expert opinion

OBJECTIVE

To develop clinical practice guidelines for the use of nonpharmacological treatments in patients with early rheumatoid arthritis (RA), using the evidence-based approach and expert opinion.

METHODS

A scientific committee used a Delphi prioritization procedure to select five questions. Evidence providing answers to the five questions was sought in the literature and presented to a panel of rheumatologists. The panel developed five detailed recommendations, filling gaps in evidence with their expert opinion. The strength of each recommendation was determined.

RESULTS

Of the 565 publications retrieved by the literature review, 198 were included in the analysis. The five recommendations on nonpharmacological treatments for early RA were validated by a final vote among all participants. The recommendations are as follows: (1) physicians may decide to provide joint protection education to patients with potentially severe early RA, with the knowledge that structured joint protection programs have not been found effective; (2) physical exercise and sports can be recommended to patients with early RA; muscle strength exercises are advisable; (3) in patients with early RA, metatarsal pain and/or foot alignment abnormalities should be looked for regularly, and appropriate insoles should be prescribed if needed; (4) dietary measures and nutritional supplements are not indicated as part of the treatment of early RA; (5) elimination diets, particularly those with low intakes of dairy products, should be discouraged in patients with early RA.

CONCLUSION

These recommendations should help to improve practice uniformity and, ultimately, to improve the management of RA.

Structural evaluation in the management of patients with rheumatoid arthritis: development of recommendations for clinical practice based on published evidence and expert opinion

OBJECTIVES

To develop French evidence-based recommendations for the structural evaluation of rheumatoid arthritis (RA) in everyday practice.

METHODS

A scientific committee selected 10 questions using the Delphi consensus procedure. Evidence-based responses to each question were sought by searching the PubMed and Ovid databases and the abstract databases for the 2002, 2003, and 2004 annual meetings of the French Society for Rheumatology, the EULAR, and the American College of Rheumatology. The following indexing terms were used: rheumatoid arthritis, arthritis, patient, diagnostic imaging, radiography, joint, erosion, and joint space width. All articles published in French or English prior to May 2004 were identified. The evidence from these articles was reported to a panel of 77 rheumatologists working in hospital or office practice. The panel developed detailed recommendations, filling gaps in evidence with their expert opinion. The strength of each recommendation was determined.

RESULTS

The 10 questions probed the structural evaluation of RA by plain radiography, magnetic resonance imaging (MRI), and ultrasonography, both for diagnostic and monitoring purposes. The literature search retrieved 673 publications, of which 166 were selected and reviewed. The panel developed 10 recommendations, one for each question, which were accepted by consensus.

CONCLUSION

Recommendations relative to the diagnosis or monitoring of structural involvement in patients with RA in everyday practice were developed. They should help to improve practice uniformity and, ultimately, to improve the management of RA.

Physical examination and laboratory tests in the management of patients with rheumatoid arthritis: development of recommendations for clinical practice based on published evidence and expert opinion

OBJECTIVES

To develop recommendations for the physical and laboratory-test follow-up of patients with rheumatoid arthritis (RA) seen in everyday practice, using evidence from the literature, supplemented with expert opinion when needed.

METHODS

A scientific committee selected 7-10 questions using the Delphi consensus procedure. Evidence-based responses to each question were sought in the literature and were then used by a panel to develop recommendations. To fill in gaps in knowledge from the literature, the panelists relied on their personal opinion.

RESULTS

The seven questions dealt with the physical and laboratory-test follow-up of RA and the factors predicting disease severity. The literature review identified 799 articles whose title and abstract suggested relevance to the study. Elimination of articles that provided no data on the study topic left 128 original articles. The panel developed seven recommendations, one for each question, which were accepted by consensus.

CONCLUSION

Recommendations about the physical and laboratory-test follow-up of patients with RA seen in everyday practice were developed. Because they constitute an objective foundation built by consensus among experts, should improve the uniformity and quality of care provided to RA patients in everyday practice.