What do patients prefer? A multinational, longitudinal, qualitative study on patient-preferred treatment outcomes in early rheumatoid arthritis

Experiences of shifts in physiotherapy for rheumatoid arthritis over time - an autoethnography

INTRODUCTION

Several shifts in physiotherapy treatment of patients with rheumatoid arthritis (RA) have occurred over time.

OBJECTIVE

This paper aims to identify shifts in physiotherapy practice for patients with RA based on the author's work experiences from the 1980s until today at two Norwegian rheumatism hospitals, and to explore why shifts may have happened.

METHODS

A narrative was developed by describing events making a difference, categorizing, and ordering them with the help of narrative analysis and a sensitizing analytic lens on discourses.

RESULTS

The storyline from the 1980s to approximately the turn of the millennium is called 'Shifts determined mainly by clinical context-driven events' which occurred in response to medical advances and physiotherapists' clinical experiences. These shifts were later justified by physiotherapists' research in the clinical context. The other storyline covers mainly the 2000s and is called 'Shifts increasingly determined by events beyond clinical physiotherapy context.' They include adjustments to further medical advances and implementation of biopsychosocial understanding of disease at the hospital, and to external research-based recommendations, health reforms, and economy.

CONCLUSION

These processes have moved physiotherapy practice at the hospital from mainly providing individualized remedial and rehabilitative physiotherapy for the purpose to normalize physical function to an increasing focus on generic health measures for the purposes of health promotion and cardiovascular disease prevention. However, this shift may not fully match the complex needs presented by patients in disease remission with unrelenting fatigue and work inability and those who have multiple functional challenges and comorbidities.

Sociodemographic and clinical variables associated with negative illness perception in patients newly diagnosed with rheumatoid arthritis, axial spondyloarthritis, or psoriatic arthritis-a survey based cross-sectional study

When newly diagnosed with inflammatory arthritis (IA), acquiring self-management skills is beneficial, to enhance quality of life. The personal beliefs and mental representations patients hold about their illness, known as illness perception, significantly influence the development of these skills. Recognizing characteristics that affect illness perception is key to identifying patients requiring additional support for the development of self-management skills. This study aimed at identifying the sociodemographic and clinical characteristics associated with a negative illness perception. This cross-sectional study was based on survey data from patients diagnosed for ≤ 2 years. The Brief Illness Perception Questionnaire (B-IPQ) was used to measure illness perception. After psychometric testing, we divided the B-IPQ into two domains: (1) a control domain and (2) a consequence domain. We performed logistic regression analyses with multiple imputations. A total of 1,360 patients (61% females) were included. Among them, 64%, 20%, and 16% were diagnosed with rheumatoid arthritis, psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), respectively. Younger patients with lower socioeconomic status, a diagnosis of PsA or axSpA, high disease activity (OR 3.026, CI 2.208;4.147), severe physical disability (OR 4.147. CI 2.883;6.007), severe pain (OR 3.034, CI 1.991;4.622), and severe fatigue (OR 2.612, CI 1.942;3.513) were significantly more likely to report having a negative illness perception. Younger patients with a higher symptom burden, increased disease activity, lower socioeconomic status, and a diagnosis of PsA or axSpA may require additional attention and support in rheumatology clinical practice to aid in the development of their self-management skills.

Effectiveness and feasibility of a mobile health self-management intervention in rheumatoid arthritis: study protocol for a pragmatic multicentre randomised controlled trial (AEGORA)

BACKGROUND

Rheumatoid arthritis (RA) considerably impacts patients' lives. Patients' confidence in their ability to manage this impact, or self-efficacy, can be supported with self-management interventions. One approach is to use mobile health (mHealth) applications, which can additionally provide insight into disease impact by remotely monitoring patient-reported outcomes. However, user engagement with mHealth-apps is variable, and concerns exist that remote monitoring might make patients overly attentive to symptoms.

METHODS

App-based Education and GOal setting in RA (AEGORA) is a multicentre, pragmatic randomised controlled trial investigating an mHealth-based self-management intervention to improve self-efficacy and remotely monitor disease impact in patients with RA. The intervention is provided via an adapted version of the application Sidekick (Sidekick Health, Reykjavik, Iceland) and consists of education, goal setting, lifestyle advice, and remote assessment of the Rheumatoid Arthritis Impact of Disease (RAID) questionnaire. Across two centres, 120 patients will be recruited and randomised (2:1:1) to usual care or intervention group A/B (study app with weekly/monthly prompts to complete the RAID, respectively). Outcomes are assessed at baseline and after 4-6 months. The primary endpoint is a clinically important improvement (≥ 5.5/110) in the Arthritis Self-Efficacy Scale in the combined intervention group compared to usual care. Secondary endpoints are (a) non-inferiority regarding pain catastrophising, as a measure of symptom hypervigilance; (b) superiority regarding the RAID, sleep quality, and physical activity; and (c) participant engagement with the study app. Finally, the relationship between engagement, prompted frequency of RAID questionnaires, and the primary and secondary outcomes will be explored.

DISCUSSION

The AEGORA trial aims to study the effectiveness of mHealth-based, multicomponent self-management support to improve self-efficacy in the context of RA, while providing potentially valuable insights into temporal disease activity dynamics and the feasibility and possible negative effects of remote symptom monitoring in this population.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05888181. Retrospectively registered on March 23, 2023. Study inclusion started on March 3, 2023.

Defining independence: A scoping review by the OMERACT patient perspective of remission in rheumatoid arthritis group

AIMS

The Outcome Measures in Rheumatology Trials (OMERACT) Remission in Rheumatoid Arthritis (RA) patient perspective working group has previously found that patients prioritised independence, pain, and fatigue as key domains of remission in RA. However, there is currently no clear definition of independence. Consequently, this scoping review aimed to explore how independence is represented in the RA literature.

METHODS

A comprehensive search of the EMBASE, Medline, and PsycInfo databases was performed for publications that used independence or autonomy as a disease activity measure, description of disease in remission or treatment outcome. Papers were included if they involved adult participants and were written in English, with no restrictions on study design or publication year. Two reviewers (TK and AC, AT or BJ) independently screened the abstracts. A thematic approach was applied to derive common definitions and descriptions of independence.

RESULTS

660 articles were identified, of which 58 (25 qualitative, 28 quantitative, one mixed, and four reviews) met the inclusion criteria. 86% of total participants were female. Ten publications referenced remission. Independence took many forms; in addition to physical and functional capability, it was described in relation to work, social activities, autonomy in healthcare, and household activities. Four common themes describing independence were identified: 1. A return to a state before arthritis. 2. Being physically and functionally able. 3. A sense of freedom without needing to rely on others. 4. Having control over the organisation of one's life.

CONCLUSION

Although independence is frequently mentioned in the RA literature, it has various meanings, lacks a consistent definition, and is a concept rarely applied to remission. It is multi-factorial, exceeding functional ability alone, and contextualised within sociodemographic and disease factors. This scoping review provides common descriptions of independence to inform future qualitative work towards the development of an outcome measure of independence for the assessment of RA in remission.

Perspectives on Treatment of Inflammatory Bowel Disease in Older Patients: Applying Gut-Feeling in an Evidence-Based Era?

Background: The older inflammatory bowel disease (IBD) population is challenging to treat because of heterogeneity in characteristics related to frailty. The authors aimed to study factors contributing to the difference in treatment between older and younger patients with IBD and the relation between frailty and therapy goals, from the perspectives of both professionals and patients with IBD. Methods: Semi-structured interviews in 15 IBD professionals and 15 IBD patients aged ≥65 years. Results: Professionals had 1–20 years of experience, and three practiced in an academic hospital. Patients were aged 67–94 years and had a disease duration between 2 years and 62 years. The authors found that professionals aimed more often for clinical remission and less often for endoscopic remission in older compared with younger patients. Older patients also aimed for clinical remission, but valued objective confirmation of remission as a reassurance. Professionals sometimes opted for surgery earlier in the treatment course, while older patients aimed to prevent surgery. Professionals’ opinion on corticosteroids in older patients differed, while patients preferred to avoid corticosteroids. In professionals and patients, there was a shift towards goals related to frailty in patients with frailty. However, professionals did not assess frailty systematically, but judged frailty status by applying a clinical view. Conclusions: Many therapy goals differed between older and younger patients, in both professionals and patients. Professionals did not assess frailty systematically, yet aspects of frailty influenced therapy goals. This underlines the need for clinically applicable evidence on frailty in IBD, which could aid tailored treatment.

Disseminating and assessing implementation of the EULAR recommendations for patient education in inflammatory arthritis: a mixed-methods study with patients' perspectives

OBJECTIVES

To explore patients' agreement and reasons for agreement or disagreement with the EULAR recommendations for patient education (PE) for people with inflammatory arthritis (IA).

METHODS

This mixed-method survey collected data using snowball sampling. The survey had been translated into 20 languages by local healthcare professionals, researchers and patient research partners. It explored the degree to which patients with IA agreed with each recommendation for PE (0=do not agree at all and 10=agree completely) and their rationale for their agreement level in free text questions. Descriptive statistics summarised participants' demographics and agreement levels. Qualitative content analysis was used to analyse the free text data. Sixteen subcategories were developed, describing the reasons for agreement or disagreement with the recommendations, which constituted the categories.

RESULTS

The sample comprised 2779 participants (79% female), with a mean (SD) age 55.1 (13.1) years and disease duration 17.1 (13.3) years. Participants strongly agreed with most recommendations (median 10 (IQR: 9-10) for most recommendations). Reasons for agreement with the recommendations included the benefit of using PE to facilitate collaborative care and shared decision making, the value of flexible and tailored PE, and the value of gaining support from other patients. Reasons for disagreement included lack of resources for PE, not wanting information to be tailored by healthcare professionals and a reluctance to use telephone-based PE.

CONCLUSION

The EULAR recommendations for PE have been disseminated among patients with IA. Overall, agreement levels were very high, suggesting that they reflect patients' preferences for engaging in collaborative clinical care and using PE to facilitate and supplement their own understanding of IA. Reasons for not completely agreeing with the recommendations can inform implementation strategies and education of healthcare professionals.

Back to Basics: Prioritizing Communication as a Key Instrument in Managing Rheumatoid Arthritis

Patients with rheumatoid arthritis (RA) have come to experience a tremendous increase in therapeutic options with disease-modifying antirheumatic drugs (DMARDs).¹ After decades of dissatisfying drug therapy results with conventional synthetic DMARDs (csDMARDs) only, the introduction of the first tumor necrosis factor inhibitors in the late 1990s has revolutionized RA treatment.².

A meta-synthesis of qualitative studies on stress urinary incontinence in women for the development of a Core Outcome Set: A systematic review

OBJECTIVE

Given the high variation of perceptions of women with stress urinary incontinence (SUI), qualitative meta-synthesis in this field appears warranted. We aimed to synthesize evidence on women's experiences of SUI by analyzing qualitative data.

METHODS

A literature search of Medline, Embase, Scopus, PsycInfo, and CINAHL databases was performed by a CHORUS Working Group, from inception to August 2020. Qualitative studies on women's perspectives on SUI were included. Thematic analysis was used as a conceptual approach to analyze the data and develop a set of overarching themes. The quality of studies was assessed based on the Critical Appraisal Skills Program tool.

RESULTS

Seven studies were included. Six themes encompassing women's perspectives on SUI emerged: experiencing SUI, awareness of SUI, treatments for SUI, sexuality, communication, and psychosocial effects. The quality appraisal of the studies showed good coherence.

CONCLUSION

This study revealed six overarching themes, of which treatment had the highest prevalence. Assessment of women's perceptions of SUI in the context of a qualitative meta-synthesis may inform policy and practice around this condition, may guide and help set research priorities, and will ideally contribute to the development of a Core Outcome Set for SUI.

Patients' Perceptions of Person-Centered Care in Early Rheumatoid Arthritis: A Qualitative Study

Objective

Most research on patient experiences of rheumatoid arthritis (RA) care is performed with patients who have established RA and less often with patients with early RA. Experiences of and expectations about health care may change over time, which is why the aim was to explore patients’ perceptions of person‐centered care (PCC) early in the RA disease course.

Methods

Thirty‐one patients with early RA were interviewed in this qualitative study. An abductive qualitative content analysis was conducted based on the framework of McCormack and McCance (1,2). The four constructs, prerequisites, care environment, person‐centered processes, and person‐centered outcomes, constituted the four categories in the deductive part of the study. An inductive analysis generated 11 subcategories exploring the content of PCC.

Results

For patients with early RA, PCC was described in terms of 1) prerequisites including being treated with respect, meeting dedicated health care professionals, and meeting professional competence; 2) care environment including having access to a multidisciplinary team, having access to health care, and encountering a supportive organization; 3) person‐centered processes including being listened to, being supported, and being involved in decision‐making; and 4) person‐centered outcomes including being satisfied with received health care and achieving optimal health.

Conclusion

Genuine PCC is important for patients early in the RA disease course, supporting the implementation of a person‐centered approach during all stages in the health care system. This study contributes to information about how to further develop person‐centeredness in rheumatology care.

Guided internet-based cognitive-behavioral therapy for patients with rheumatic conditions: A systematic review

CONTEXT

Rheumatic conditions have a large impact on both patients and society. Many patients experience adjustment problems, such as symptoms of anxiety and depression and sleep problems, contributing to high healthcare costs. Internet-based cognitive-behavioral therapy (iCBT) has shown to support patients with somatic conditions in coping with their disease, with therapist-guided iCBT usually showing larger effects than unguided iCBT. However, the specific relevance of guided iCBT for rheumatic conditions has not been reviewed yet, which could have important implications for implementation.

OBJECTIVES

The objective of our review was to give an overview of evaluations of guided iCBT for rheumatic conditions, including physical, psychological, and impact on daily life outcomes.

METHODS

This review is registered with PROSPERO with registration number CRD42020154911. The review followed PRISMA guidelines and included an assessment of risk of bias. PubMed, PsycINFO, Embase, Cochrane Library, Web of Science, and Emcare were searched until 5 October 2020. Inclusion criteria were: patients ≥18 years old with a rheumatic condition, randomized controlled trial, accessible full-text English article, original data, inclusion of psychological, and/or physical and/or impact outcomes, and therapist-guided iCBT. Study and sample characteristics, as well as clinical variables were extracted.

RESULTS

A systematic search identified 6089 studies, of which 8 trials were included, comprising of 1707 participants in total. Significant medium to large between-group effects were found for psychological outcomes (depression, anxiety, catastrophizing, self-efficacy) and impact on daily life outcomes (impact on daily life, quality of life), whilst results for physical outcomes (pain intensity, fatigue) were mixed.

CONCLUSION

Whilst more research is warranted, for instance regarding physical outcomes, cost-effectiveness, safety of the intervention, and moderators of iCBT success, our results show that guided iCBT could be an important addition to medical treatment for rheumatic conditions. Guided iCBT can improve psychological and impact on daily life outcomes in patients with rheumatic conditions, which is promising for iCBT implementation in clinical practice.