Improving treatment with methotrexate in rheumatoid arthritis—Development of a multimedia patient education program and the MiRAK, a new instrument to evaluate methotrexate-related knowledge

Towards a consensus for nurse education of methotrexate for people with rheumatic and musculoskeletal diseases: A scoping review

INTRODUCTION

Patient education (PE) is a key role of nurses, which includes providing information, training, and support about methotrexate (MTX), an anchor drug in rheumatology. However, there is a wide variation in the access to rheumatology nurse consultations in Europe, and there is a lack of consensus regarding the delivery, context and timing of PE in these cases. This study aimed to provide a comprehensive overview of the existing research on nurse education of MTX for children/youth and adults with Rheumatic and Musculoskeletal Diseases (RMDs).

METHODS

This scoping review was conducted in accordance with Arksey and O'Malley's framework. A search on PubMed (MEDLINE), Scopus and Cochrane Database, and CINAHL, from inception until March 2022 was conducted. Articles on PE with a focus on MTX exclusively were included. Published and unpublished studies, from any world region, conducted with a qualitative, quantitative, or mixed-methods design and focused on defined research questions, were eligible for inclusion. Broad inclusion criteria were used if a research paper on PE focused on MTX for people with RMDs (PE or patient engagement, self-management, medication knowledge, or health literacy in patients). The reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Extension for Scoping Reviews (PRISMA-ScR) checklist. Two independent reviewers performed standardized data extraction and synthesis.

RESULTS

From 292 references identified, the total number of studies which met the inclusion criteria was relatively small (n = 14). The results identified that knowledge of MTX improves when education by nurses is provided.

CONCLUSION

This scoping review showed that there is no universal worldwide strategy for MTX education of children/youths and adults with RMDs. However, PE regarding MTX can be delivered in different forms, resulting in better satisfaction and adherence. More randomized controlled trials with powered samples are required.

Development and validation of a self-administered questionnaire measuring essential knowledge in patients with rheumatoid arthritis

To develop and validate a questionnaire assessing patient knowledge in rheumatoid arthritis (RA). Knowledge considered essential for patients with RA was identified through a series of Delphi rounds among rheumatologists, health professionals (HPs), patients, and then reformulated to construct the knowledge questionnaire. Cross-sectional multicenter validation was performed in 12 rheumatology departments to assess internal validity (Kuder–Richardson coefficient), external validity, acceptability, reproducibility (Lin’s concordance correlation coefficient) and sensitivity to change (difference in total score before and after patient education sessions). Associations between patient variables and knowledge levels were evaluated. RAKE (RA Knowledge questionnairE) is a self-administered 45-item questionnaire scored 0–100, with a 32-item short-form survey assessing knowledge of disease, comorbidity, pharmacological treatments, non-pharmacological treatments, self-care and adaptative skills. Of 130 patients included in the validation study, 108 were women. Acceptability was good with < 5% missing data. Internal validity coefficient was 0.90. Mean (standard deviation) long-form score was 72.8 ± 17.8, with lower scores in comorbidity and self-care and higher scores in adaptive skills. Reproducibility was good (0.86 [0.80; 0.92]). RAKE score was positively correlated with the patients’ level of education and the HPs’ opinion on the patients’ knowledge. RAKE score showed good sensitivity to change: 66.8 ± 16.4 then 83.8 ± 12.7, representing a hedges effect size of 1.14 [95% CI 0.73; 1.55]. RAKE is an updated questionnaire assessing essential knowledge for patients with RA to enhance self-management according to current guidelines and the patients’ perspective. RAKE can usefully inform patient education interventions, routine care and research.

Therapeutic education improves rheumatoid arthritis patients' knowledge about methotrexate: a single center retrospective study

To assess, by means of a questionnaire, the effectiveness of a therapeutic education session on rheumatoid arthritis patients' knowledge about methotrexate. Retrospective study of data collected in routine care. STROBE guidelines were used. Rheumatoid arthritis patients treated with methotrexate had a therapeutic education session conducted by a rheumatology nurse at time 0 and 6 months after. They completed a questionnaire to assess their knowledge about methotrexate before the first therapeutic education session and 6 and 12 months after. A score from 0 to 100 was calculated based on 20 questions. A total of 66 patients were enrolled (50 women), with a mean age of 57 years, median disease duration of 4 years, and methotrexate treatment duration of 2 years. The knowledge score improved 6 months after the first therapeutic education session and was unchanged at 12 months. Significant improvement was observed in knowledge about the need for contraception, the contraindication of trimethoprim, the maximum dose not to be exceeded, reduction in alcohol consumption, and the value of combining folic acid with methotrexate. Knowledge about the risk of hypersensitivity pneumonitis did not improve. Skills related to the need for and timing of laboratory testing and contraception were evaluated using two role-playing situations. None of the skills improved. A therapeutic education session improves patients' knowledge about methotrexate at 6 months.

Effect of Moxibustion on HIF-1α and VEGF Levels in Patients with Rheumatoid Arthritis

Background

Moxibustion has a therapeutic effect of reducing swelling and relieving pain in patients with rheumatoid arthritis (RA) but its mechanism is uncertain.

Objective

To evaluate the effect of moxibustion on serum levels of hypoxia-inducible factor-1α (HIF-1α) and vascular endothelial growth factor (VEGF) in patients with RA and to explore the possible mechanism of moxibustion.

Methods

This study involved 46 RA patients who had fulfilled the inclusion criteria and were randomly assigned to a treatment group and a control group in an equal ratio. The control group was treated with methotrexate or leflunomide, while the treatment group received methotrexate or leflunomide and moxibustion at ST 36 (Zusanli), BL 23 (Shenshu), and Ashi points. Patients' clinical symptoms, RA-associated serum markers, and serum levels of TNF-α, IL-1β, HIF-1α, and VEGF were compared in the two groups before and after intervention. Statistical analysis was performed using SPSS 21.0 statistical software.

Results

37 of 46 RA patients eventually completed the whole treatment course. Compared with the control group, the treatment group significantly improved the clinical symptoms (P < 0.05) but with no significant differences in RA-associated serum markers (P > 0.05). There were significant differences in TNF-α and IL-1β among the groups after 8 weeks of treatment (P < 0.05). HIF-1α and VEGF were decreased in the treatment group after therapy (P < 0.05). VEGF was reduced in the control group (P < 0.05), while HIF-1α was not significantly improved (P > 0.05). The reductions of HIF-1α and VEGF in the treatment group were superior to the control group (P < 0.05).

Conclusions

Moxibustion enhanced the anti-inflammatory and analgesic effects of conventional medicine and can enhance the effect of conventional medicine, downregulating HIF-1α/VEGF contents to inhibit angiogenesis.

Development of a methotrexate educational guide/information/monitoring booklet for inflammatory arthritis

INTRODUCTION

There are over 40,000 people living in Ireland with inflammatory arthritis (IA), a condition that is potentially destructive in nature and can have personal, social and economic consequences. Although we have witnessed dramatic changes in the treatment of IA in the last two decades, methotrexate (MTX) remains the first-line treatment for patients with a diagnosis of IA. Despite the fact that MTX is so commonly prescribed, there is a lack of educational materials both for healthcare professionals (HCPs) and patients. The aim of the present study was to develop a suite of MTX material for patients.

METHODS

A comprehensive literature review of MTX (evidence, educational materials and practice guidelines) in the treatment of IA was undertaken. The content of the documents was developed, and the format and structure of the documents were agreed. A tailored patient educational guide, information/monitoring booklet and alert card were designed to address the lack of educational materials for this condition. A national pilot study of the documents was conducted (a postal questionnaire for patients and electronic survey for clinical nurse specialists). Results and recommendations were incorporated into the final documents. These documents were also incorporated into the National Clinical Care Programme-rheumatology-methotrexate pathway.

RESULTS

A 26-page evidence-based educational guide was produced to support the HCP in educating patients taking MTX, in conjunction with a patient information/monitoring booklet and alert card to support the patient.

CONCLUSIONS

These documents are now widely available and used in clinical practice in Ireland, providing patients with standardized, evidence-based information about MTX.

Identifying the unmet information and support needs of women with autoimmune rheumatic diseases during pregnancy planning, pregnancy and early parenting: mixed-methods study

Background

Autoimmune rheumatic diseases (ARDs) such as inflammatory arthritis and Lupus, and many of the treatments for these diseases, can have a detrimental impact on fertility and pregnancy outcomes. Disease activity and organ damage as a result of ARDs can affect maternal and foetal outcomes. The safety and acceptability of hormonal contraceptives can also be affected. The objective of this study was to identify the information and support needs of women with ARDs during pregnancy planning, pregnancy and early parenting.

Methods

This mixed methods study included a cross-sectional online survey and qualitative narrative interviews. The survey was completed by 128 women, aged 18–49 in the United Kingdom with an ARD who were thinking of getting pregnant in the next five years, who were pregnant, or had young children (< 5 years old). The survey assessed quality-of-life and information needs (Arthritis Impact Measurement Scale Short Form and Educational Needs Assessment Tool), support received, what women found challenging, what was helpful, and support women would have liked. From the survey participants, a maximum variation sample of 22 women were purposively recruited for qualitative interviews. Interviews used a person-centered participatory approach facilitated by visual methods, which enabled participants to reflect on their experiences. Interviews were also carried out with seven health professionals purposively sampled from primary care, secondary care, maternity, and health visiting services.

Results

Survey findings indicated an unmet need for information in this population (ENAT total mean 104.85, SD 30.18). Women at the pre-conception stage reported higher needs for information on pregnancy planning, fertility, giving birth, and breastfeeding, whereas those who had children already expressed a higher need for information on pain and mobility. The need for high quality information, and more holistic, multi-disciplinary, collaborative, and integrated care consistently emerged as themes in the survey open text responses and interviews with women and health professionals.

Conclusions

There is an urgent need to develop and evaluate interventions to better inform, support and empower women of reproductive age who have ARDs as they navigate the complex challenges that they face during pregnancy planning, pregnancy and early parenting.

Electronic supplementary material

The online version of this article (10.1186/s41927-018-0029-4) contains supplementary material, which is available to authorized users.

Producing an evidence-based treatment information website in partnership with people affected by multiple sclerosis

BACKGROUND AND AIMS

In earlier work, we identified that people affected by multiple sclerosis (MS) can have difficulty finding online treatment information that is up to date, trustworthy, understandable, and applicable to personal circumstances, but does not provoke confusion or negative emotional consequences. The objective was to develop online consumer summaries of MS treatment evidence (derived from Cochrane Reviews) that respond to identified treatment information needs of people affected by MS.

METHODS

A 2-phase mixed-methods project, conducted in partnership with consumers and an MS organisation. Phase 1 included review panels with consumers (Australians affected by MS) and health professionals to test paper-based treatment summaries before development, and pilot testing of the website. Phase 2 involved an online survey after website launch.

RESULTS

Eighty-three participants (85% affected by MS) took part. Phase 1 participants strongly endorsed key review summary components, including layering information, and additional sections to aid personal applicability. Participants additionally suggested questions for health professionals. Participants across both phases were receptive to the idea of being provided with Cochrane Review summaries online but were seeking other types of evidence and information, such as personal experiences and the latest experimental treatments, which could not be provided. While the small survey sample size (n = 58) limits application of the results to a broader population, the website was viewed favourably, as a useful, understandable, and trustworthy information source.

CONCLUSION

We describe a partnership approach to developing online evidence-based treatment information, underpinned by an in-depth understanding of consumers' information needs.

Medication Risk Communication in Rheumatology: Where Are We and Where Do We Go from Here?

This paper reviews findings from recent research examining issues related to the risk communication process within the context of rheumatologic conditions. Five specific questions are addressed. First, to what extent do patients with rheumatic disorders exhibit adequate knowledge relevant to disease and medication risks and risk management? Second, what sources do patients use when attempting to find information about disease and medication risks and risk management? Third, what types of information about disease and medication risks and risk management do rheumatologists provide during routine office visits. Fourth, what governmental regulations attempt to increase consumer access to information about medication risks and risk management? Finally, what other educational resources are available to facilitate patient-provider communication concerning disease and medication risks and risk management? The findings reported identify gaps in patient knowledge concerning medication risks and risk management, highlight areas for improvement, and identify resources that may enhance medication risk communication.

The use of concept mapping in measurement development and evaluation: Application and future directions

The past decade has seen an increase of measurement development research in social and health sciences that featured the use of concept mapping as a core technique. The purpose, application, and utility of concept mapping have varied across this emerging literature. Despite the variety of uses and range of outputs, little has been done to critically review how researchers have approached the application of concept mapping in the measurement development and evaluation process. This article focuses on a review of the current state of practice regarding the use of concept mapping as methodological tool in this process. We systematically reviewed 23 scale or measure development and evaluation studies, and detail the application of concept mapping in the context of traditional measurement development and psychometric testing processes. Although several limitations surfaced, we found several strengths in the contemporary application of the method. We determined concept mapping provides (a) a solid method for establishing content validity, (b) facilitates researcher decision-making, (c) insight into target population perspectives that are integrated a priori, and (d) a foundation for analytical and interpretative choices. Based on these results, we outline how concept mapping can be situated in the measurement development and evaluation processes for new instrumentation.

The development of a questionnaire to evaluate rheumatoid arthritis patient's knowledge about methotrexate

AIMS AND OBJECTIVES

Assess knowledge concerning methotrexate in rheumatoid arthritis patients by means of a questionnaire.

BACKGROUND

Methotrexate is the standard drug for rheumatoid arthritis treatment. It has potentially serious side effects that can be largely prevented by making sure that patients are well informed and comply with prescription guidelines.

DESIGN

Cross-sectional survey.

METHODS

A questionnaire on methotrexate (mode of action, administration, drug interactions), side effects, monitoring and lifestyle implications was offered to all the rheumatoid arthritis patients treated with the drug seen between March and September 2013 in a large hospital in France.

RESULTS

One hundred and eighty-three patients (143 women), mean age 60 (13·5) years, with a median disease duration of 12 years [7-20] and treated with methotrexate for eight years [5-13] took part. Methotrexate was identified as a disease-modifying antirheumatic drug by 78% of the patients. The weekly administration method was well assimilated (97%); 67% indicated that the rationale for folic acid was to reduce treatment toxicity. Only 21% knew that trimethoprim was contraindicated. Half were aware of the haematologic risk and 36% were aware of the risk of hypersensitivity pneumonitis. There was knowledge concerning laboratory testing (80%), but 54% thought they were only being monitored for rheumatoid arthritis activity. Only 13% of the men, but 90% of the women, of childbearing age knew that contraception was essential, and 75% indicated that alcohol consumption should be limited. A low knowledge score correlated significantly with age and low educational level. It was independent of sex, duration of treatment for rheumatoid arthritis.

CONCLUSIONS

Rheumatoid arthritis patient's knowledge concerning methotrexate is poor, particularly for the most serious side effects (haematologic and hypersensitivity pneumonitis), interactions with trimethoprim, and in men, the need for contraception.

RELEVANCE TO CLINICAL PRACTICE

Patient knowledge concerning methotrexate should be regularly checked and supported using the different therapeutic education tools available, especially when patients are older people and have had limited schooling.

Education for patients with rheumatoid arthritis in Latin America and the Caribbean

Patient education is highly recommended in rheumatoid arthritis (RA) to support patient management. The challenge is to adhere to the recommendations for providing health education to RA patients in Latin American and the Caribbean (LAC) countries taking into account factors such as patient health illiteracy, lack of rheumatologists, and lack of resources including access to disease-modifying antirheumatic drugs (DMARDs). As existing educational material in regional languages is not readily available and inadequate, we propose developing a web-based educational program that would fulfill the requirements of most patients with RA across LAC countries with an emphasis on the correct and safe use of methotrexate.