Determinants of Perceived Health Nonimprovement in Early Rheumatoid Arthritis Patients With Favorable Treatment Outcomes

OBJECTIVE

To explore the association between achieving favorable clinical outcomes and patients' perceived change in overall health status after 12 months of treat-to-target in patients with early rheumatoid arthritis (RA) and to identify determinants of subjective nonimprovement.

METHODS

Baseline and 12-month data of patients included in the Dutch Rheumatoid Arthritis Monitoring remission induction cohort study with at least a moderate response (by European League Against Rheumatism criteria) after 1 year were selected for analysis. Logistic regression analysis was used to identify factors associated with nonimproved perceived overall health status at 12 months.

RESULTS

At 12 months, 75 of 210 patients (35%) did not consider their health to have improved despite having achieved favorable clinical outcomes. Relative change from baseline in pain (Wald = 20.20; P < 0.01) and fatigue (Wald = 5.58; P = 0.02) was independently associated with nonimproved perceived overall health status. The results were similar when only patients with ≤1 swollen joint were analyzed. An improvement of 55% in pain measured on a visual analog scale was found to discriminate reasonably well between patients who considered their health to have improved versus patients who did not, with an area under the receiver operating characteristic curve of 0.70 (95% confidence interval 0.61-0.78).

CONCLUSION

These results demonstrate that clinical improvements do not equate with improved subjective health for all patients. The association of nonimprovement with changes in pain and fatigue suggest that it might be worthwhile to monitor and address pain and fatigue in addition to and independently of disease activity in early RA.

Expert evaluations of fatigue questionnaires used in rheumatoid arthritis: a Delphi study among patients, nurses and rheumatologists in the Netherlands

OBJECTIVES

Evaluating fatigue items from traditional questionnaires and a new scale (BRAF-MDQ) by experts in rheumatoid arthritis (RA). This evaluation was part of a study to select fatigue items to develop an item bank for a Dutch computer-adaptive test (CAT) for RA. Experts' opinions were incorporated since they are essential for content validity of measurement instruments.

METHODS

The 60 items of the SF-36 subscale vitality, FACIT-F, POMS subscale fatigue/inertia, MAF and the recently developed BRAF-MDQ were evaluated by rheumatologists, nurses and RA patients in a Delphi procedure. Items were selected for development of the item bank/CAT if rated as adequate by at least 80% of the participants (when 50% or less they were excluded). On the basis of participants' comments, remaining items were re-worded and re-evaluated in the following round. The procedure stopped when all items were selected or rejected.

RESULTS

Ten rheumatologists, 20 nurses and 15 RA patients participated. After the first round, 40% of the traditional items and 60% of the BRAF-MDQ items were directly selected and 3 items of the traditional questionnaires and 1 item of the BRAF-MDQ were directly excluded. Remaining items were re-worded, eight of which were presented for re-evaluation in the second round. Finally, 90% of the items from the traditional questionnaires and 95% of the items from the new BRAF-MDQ were included in our item pool.

CONCLUSIONS

Fifty-five of the 60 items (92%) from fatigue questionnaires proved to have good content validity and were feasible for use in the Netherlands, some after adaptation.

A review of instruments to assess illness representations in patients with rheumatic diseases

OBJECTIVE

Critical appraisal of instruments to assess illness representations in rheumatology.

METHODS

A first search (MEDLINE, EMBASE, PsycINFO) identified articles describing development of instruments assessing illness representations. A second search identified articles applying them in rheumatology. Appraisal was performed using checklists.

RESULTS

Five instruments were identified: the Illness Perception Questionnaire (IPQ), the Revised Illness Perception Questionnaire (IPQ-R), the Illness Cognition Questionnaire (ICQ), the Implicit Models of Illness Questionnaire (IMIQ) and the Meaning of Illness Questionnaire (MIQ). The number of items varied from 18 to 70. Internal consistency was good. Construct validity was moderate to good for all instruments, but was not tested for the IMIQ. Predictive validity was assessed for the ICQ and IPQ and was low to moderate. Sensitivity to change was tested for ICQ and was good. Applications in rheumatology are increasing. Significant relationships with different outcomes and additional evidence for predictive validity were found.

CONCLUSIONS

Five instruments that assess illness representations can be used in rheumatology. The number of subscales and items vary. The ICQ and IPQ are most extensively validated and have been most frequently applied in rheumatology. Illness representations have relevant associations with self-report and objective outcomes. They should be considered when exploring health in rheumatology.

Participation in online patient support groups endorses patients' empowerment

OBJECTIVE

Although much has been expected of the empowering effect of taking part in online patient support groups, there is no direct evidence thus far for the effects of participation on patient empowerment. Hence our exploring to what extent patients feel empowered by their participation in online support groups, and which processes that occur in these groups are related to the empowering outcomes.

METHODS

An online questionnaire was completed by 528 individuals who were active in online groups for patients with breast cancer, fibromyalgia and arthritis.

RESULTS

The respondents felt empowered in several ways by their participation. The empowering outcomes that were experienced to the strongest degree were 'being better informed' and 'enhanced social well-being'. No significant differences in empowering outcomes between diagnostic groups were found. The empowering outcomes could only be predicted in a modest way by the processes that took place in the online support groups.

CONCLUSION

This study indicates that participation in online support groups can make a valuable contribution to the empowerment of patients.

PRACTICE IMPLICATIONS

Health care providers should acquaint their patients with the existence of online support groups and with the benefits that participation in these groups can offer.

Psychometric properties of the Rheumatoid Arthritis Disease Activity Index (RADAI) in a cohort of consecutive Dutch patients with RA starting anti-tumour necrosis factor treatment

OBJECTIVES

To examine the psychometric properties of the self-administered Dutch Rheumatoid Arthritis Disease Activity Index (RADAI) and its short form (RADAI-SF) in patients with rheumatoid arthritis starting anti-tumour necrosis factor treatment.

METHOD

Internal consistency was assessed with Cronbach's alpha. A confirmatory factor analysis (CFA) was carried out to test the single-factor structure. Construct validity was examined by correlating RADAI and RADAI-SF scores with Disease Activity Score in 28 joints (DAS28). Internal responsiveness was evaluated with the paired t test and the standardised response mean (SRM). External responsiveness was assessed with receiver operating characteristic analysis and the SRM, using the EULAR response criterion as external criterion. Change scores were correlated with changes in DAS28.

RESULTS

At baseline and after 3 months' treatment, respectively, 191 and 171 patients completed the RADAI. The internal consistency of the RADAI and the RADAI-SF was satisfactory. CFAs confirmed the single-factor structure of both RADAI versions, but the short form provided the best model fit. Moderate correlations were found with the DAS28. SRMs of the RADAI and the RADAI-SF were, respectively, 0.76 and 0.80. Both versions had moderate accuracy to distinguish responders from non-responders. Changes scores were moderately correlated with DAS28 change scores.

CONCLUSIONS

This study showed satisfactory psychometric properties of the Dutch version of the RADAI. Omission of the tender joint count (RADAI-SF) produced comparable results and is justified for research purposes. The tender joint count might be useful as additional clinical information in patient management.

Cost-effectiveness of Spa treatment for fibromyalgia: general health improvement is not for free

OBJECTIVES

To estimate the cost-effectiveness of an adjuvant treatment course of spa treatment compared with usual care only in patients with fibromyalgia syndrome (FM).

METHODS

134 patients with FM, selected from a rheumatology outpatient department and from members of the Dutch FM patient association were randomly assigned to a 2(1/2) week spa treatment course in Tunisia or to usual care only. Results are expressed as quality-adjusted life years (QALYs) for a 6-month as well as a 12-month time horizon. Utilities were derived form the Short Form 6D (SF-6D) scores and the visual analogue scale (VAS) rating general health. Costs were reported from societal perspective. Mean incremental cost per patient and the incremental cost utility ratio (ICER) were calculated; 95% confidence intervals (CIs) were estimated using double-sided bootstrapping.

RESULTS

The data of 128 (55 spa and 73 controls) of the 134 patients (96%) could be used for analysis. Improvement in general health was found in the spa group until 6 months of follow-up by both the SF-6D (AUC 0.32 vs 0.30, P < 0.05) and the VAS (AUC 0.23 vs 0.19, P < 0.01). After 1yr no significant between-group differences were found. Mean incremental cost of spa treatment was 1311 Euro per patient (95% CI 369-2439), equalling the cost of the intervention (thalassotherapy including airfare and lodging), or 885 Euro per patient based on a more realistic cost estimate.

CONCLUSIONS

The temporary improvement in quality of life due to an adjuvant treatment course of spa therapy for patients with FM is associated with limited incremental costs per patient.

Patients with breast cancer feel empowered by their participation in online support groups

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Background: People often join support groups when they find themselves in stressful circumstances such as serious health conditions. With the increase in the availability and popularity of the Internet, the opportunity to join support groups online has arisen. Ever since the rise of online support groups, much is expected of the potential empowering effect of taking part in these groups for patients. However, thus far, there is no direct evidence. Therefore the purpose of this study was to explore if and how people with breast cancer feel empowered by their participation in online support groups and which processes that take place in online support groups contribute to these outcomes. Methods: We have sent a posting with a link to an online survey to 7 online support groups for patients with breast cancer. In total 214 participants responded to the request to fill in the survey. Results: The majority of the respondents were women (n=211). The mean age of the respondents was 46 years (SD 8.9 years). The respondents were diagnosed 3 years ago on average, with a range of 0 to 15 years. The respondents felt empowered in several ways by their participation. First of all, most respondents (74%) felt better informed. They indicated that as a result of their participation, they had received adequate information to deal with their disease (60%). Additionally, most participants felt more confident in the relation with their physician. The participants indicated that they knew better which questions to ask their physician (69%) and that they felt better prepared for a consult with their physician (61%). For some of the respondents, participation in an online support group enabled easier acceptation of the disease (48%) and helped them to “open up” about their disease (49%). The main processes that contributed to these outcomes were: exchanging information, comparing with other participants and encountering social support. Conclusions: This study suggests that participation in online support groups can make a valuable contribution to the emergence of empowered patients, who set their own health agendas and who take control of their own health status, as is deemed necessary in the current transformation towards a modern health care consumer model.

No significant financial relationships to disclose.

Can we assess baseline pain and global health retrospectively?

OBJECTIVE

To study the agreement between patients' actual baseline assessments of pain and global health before treatment and retrospective assessments collected 2 weeks after treatment.

METHODS

Data were collected in a prospective study of 200 rheumatology outpatients treated with a local corticosteroid injection. At baseline and 2-week follow-up, localized pain and global health were assessed on 100 mm visual analogue scales. The follow-up questionnaire was extended with a retrospective assessment of pain and global health before treatment.

RESULTS

At follow-up patients slightly overestimated the severity of pain and global health before treatment. Actual and retrospective assessments were adequately correlated (pain: r(r(r(s) = 0.73; global health: r(s) = 0.67). Bland-Altman analysis showed that both pain and global health were characterized by high intra-individual variation between actual and retrospective assessments, with the 95% limits of agreement (-37.3 to 32.3 mm for pain and -49.7 to 37.8 mm for global health) far exceeding proposed values for minimal clinically important differences.

CONCLUSION

Over a 2-week interval, patients' retrospective assessments of baseline pain and global health are fairly accurate and adequately correlated with actual baseline scores. At the group level, retrospective assessments can provide acceptable data on baseline pain and global health. The wide variability between actual and retrospective assessments, however, indicates that even over short time intervals there is poor individual agreement between the two methods.

Validation of a Dutch translation of the fibromyalgia impact questionnaire

OBJECTIVES

To validate a Dutch translation of the fibromyalgia impact questionnaire (FIQ).

MATERIALS AND METHODS

Data were taken from two randomized clinical trials on Spa treatment and venlafaxine in fibromyalgia (FM). Participants completed the Dutch FIQ and a set of validated questionnaires for general health (RAND-36), depression (Beck depression inventory, BDI), pain (McGill pain questionnaire, MPQ) and fatigue (checklist individual strength, CIS). Internal consistency within the FIQ item 'physical functioning' was studied using Cronbach's alpha. Test-retest reliability was studied with intra-class-correlation (ICC) in a subsample of 76 control subjects over a 3 month period without specific intervention. Construct validity was evaluated by correlating the FIQ to other questionnaires. Sensitivity to change was studied using standardized response means (SRM).

RESULTS

The study sample consisted of 213 women and 11 men (mean age 47 yrs, mean disease duration 11 yrs). Cronbach's alpha for the item 'physical functioning' was 0.91, indicating high internal consistency. Test-retest reliability was acceptable, with ICC ranging from 0.45 for 'morning tiredness' to 0.71 for 'physical function'. FIQ correlated significantly with the RAND-36, with Spearman's rho ranging from -0.60 to -0.70 for items measuring the same concept. Similar patterns of correlation were seen with MPQ, BDI and CIS. Sensitivity to change was sufficient, with SRM after Spa treatment ranging from 0.3 for 'work days missed' to 0.9 for 'days felt good'. Similar SRM were found in the venlafaxine trial for patients reporting general improvement.

CONCLUSION

The Dutch FIQ is a valid instrument for measuring health status in FM, showing sufficient reliability, construct validity and responsiveness.

Spa treatment for primary fibromyalgia syndrome: a combination of thalassotherapy, exercise and patient education improves symptoms and quality of life

OBJECTIVES

To study the effect of a combination of thalassotherapy, exercise and patient education in people with fibromyalgia.

METHODS

Patients with fibromyalgia, selected from a rheumatology out-patient department and from members of the Dutch fibromyalgia patient association, were pre-randomized to receive either 2(1/2) weeks of treatment in a Tunisian spa resort, including thalassotherapy, supervised exercise and group education (active treatment) or treatment as usual (control treatment). Primary outcome measure was health-related quality of life, measured with the RAND-36 questionnaire. Secondary measures included the Fibromyalgia Impact Questionnaire, the McGill Pain Questionnaire, the Beck Depression Inventory, tender point score and a 6-min treadmill walk test.

RESULTS

Fifty-eight participants receiving the active treatment reported significant improvement on RAND-36 physical and mental component summary scales. For physical health, differences from the 76 controls were statistically significant after 3 months, but not after 6 and 12 months. A similar pattern of temporary improvement was seen in the self-reported secondary measures. Tender point scores and treadmill walk tests improved more after active treatment, but did not reach significant between-group differences, except for walk tests after 12 months.

CONCLUSIONS

A combination of thalassotherapy, exercise and patient education may temporarily improve fibromyalgia symptoms and health-related quality of life.

Sensitivity to change of AIMS2 and AIMS2-SF components in comparison to M-HAQ and VAS-pain

OBJECTIVE

To examine sensitivity to change of Dutch versions of AIMS2 (arthritis impact measurement scales-2) and AIMS2-SF (short form) components, in comparison with M-HAQ (modified health assessment questionnaire) and the 100 mm visual analogue scale for pain (VAS-pain) in patients with rheumatoid arthritis.

METHODS

218 patients participated in a study on patient education. Participants completed the Dutch AIMS2, M-HAQ, and VAS-pain at baseline and after one year; 165 completed both assessments. The education programme did not have any effect on health status. Patients were classified according to change over one year in their responses to the AIMS2 question about general health perception: improved health (n = 32), no change (n = 101), and poorer health (n = 32). Changes in scores over one year were tested with paired t tests, and standardised response means were calculated for AIMS2 and AIMS2-SF components, M-HAQ total score, and VAS-pain in the three classifications of change in health perception.

RESULTS

AIMS2 and AIMS2-SF physical, symptom, and affect components showed similar sensitivity to change. The physical and symptom components performed better than M-HAQ and VAS-pain. AIMS2 and AIMS2-SF social interaction and role components were not sensitive to changes in general health perception. The role component was only applicable in 63 patients, because the others were unemployed, disabled, or retired.

CONCLUSIONS

AIMS2-SF is a good alternative to the AIMS2 long form for the assessment of health status in rheumatoid arthritis, and is preferable to M-HAQ and VAS-pain. Use of the AIMS2-SF makes it easier and less costly to collect data and reduces the burden on patients.

Perceptions about perceived functional disabilities and pain of people with rheumatoid arthritis: differences between patients and their spouses and correlates with well-being

OBJECTIVE

In this study we examined the differences in perceptions of the patient's health status between rheumatoid arthritis (RA) patients and their spouses, and correlates of these differences with patients' and spouses' well-being.

METHODS

A sample of 188 couples with one member receiving treatment for RA were selected from the rheumatology clinics in Twente, The Netherlands. The mean age of both RA patients and spouses was 56 years. Respondents completed questionnaires, including estimations of both patients and spouses on the patient's functional disabilities and pain, and scales on affect and marital commitment for patients and spouses.

RESULTS

Differences in estimations of patients and spouses were considerable. Both over- and underestimations of the patient's functional disabilities by the spouse were associated with the patient's poorer mental health status. Overestimations of the patient's functional disabilities were associated with poorer mental health among spouses.

CONCLUSION

It is essential that any support intended by the spouse is in accordance with the patient's needs. If the patient's condition is misperceived by the spouse, this can lead to ineffective and inappropriate support being given.

Outcome in adults with juvenile idiopathic arthritis. Comparison of the DUTCH-AIMS2 between JIA and RA

OBJECTIVES

To compare outcome in adult patients with JIA in childhood with outcome in young adults with RA and to evaluate the use of the DUTCH-AIMS2 in adult JIA patients

METHODS

A questionnaire containing the DUTCH-AIMS2 to assess health outcomes (answers ranging from 0-10: 0=best) was sent to 142 adults with JIA (18-40 years). These health outcomes were compared with those of 34 young RA patients (< or = 40 years) from former studies. The DUTCH-AIMS2 was tested for its reliability and validity in adult JIA patients.

RESULTS

The response rate was 71%. Disease duration of JIA patients (mean 19.2+/-9.5 years) was longer than in young RA patients (mean 7.8+/-5.3 years). RA patients scored worse than JIA patients in all health status areas with the exception of mobility. The mean health outcome scores were low for all groups (< or = 4.80). The internal consistency and the validity of the DUTCH-AIMS2 were satisfactory.

CONCLUSIONS

Overall, the health outcome of oligoarticular and polyarticular adult JIA and young RA patients was quite good. The DUTCH-AIMS2 can be used as an instrument in outcome studies in JIA patients.

Psychometric properties of a Dutch short form of the Arthritis Impact Measurement Scales 2 (Dutch-AIMS2-SF)

OBJECTIVE

To evaluate the reliability and validity of a Dutch version of the Arthritis Impact Measurement Scales 2 short form (AIMS2-SF) and examine the agreement between the AIMS2 and AIMS2-SF in rheumatoid arthritis (RA) patients.

METHODS

Data were collected from 587 RA patients from three studies. Patients completed the Dutch-AIMS2, Modified Health Assessment Questionnaire (M-HAQ), and Visual Analogue Scale for pain (VAS-pain), and clinical data were collected to calculate the Disease Activity Score 28 (DAS28). Short-form component scores were calculated from the AIMS2 long-form data. In addition, a Modified Symptom component score was calculated by replacing item 42 with item 38 as was suggested by Haavardsholm et al. [7] for the Norwegian version.

RESULTS

The internal consistency of the Physical, Symptom and Affect components was good (Cronbach's alpha= 0.75-0.87), moderate for the Role component (alpha=0.62) but rather low for the Social Interaction (0.51) component. Replacing item 33 with item 31 of the long-form AIMS2 increased internal consistency for the Social Interaction component to 0.63. Test-retest reliability of the AIMS2-SF components was high (intraclass correlation coefficients >0.70). Mean scores of the AIMS2-SF were generally close to those from the AIMS2, but the limits of agreement were rather wide. Both the Modified Symptom and Modified Social Interaction components showed better agreement than the original short-form components. Plots of differences between AIMS2 and AIMS2-SF against the mean of the two scores for the five components showed that the differences varied over the range of the measurements. Factor analysis confirmed the three-factor structure, with a physical, psychological and social dimension that has been found for the Dutch-AIMS2 long form. Correlations of the AIMS2-SF components with M-HAQ total score, functional class, VAS-pain and DAS28 were very similar to the correlations for the original AIMS2.

CONCLUSION

The Dutch-AIMS2-SF, with Modified Symptom and Social Interaction components has good psychometric properties, similar to those of the Dutch-AIMS2 long form.

Patient education for adults with rheumatoid arthritis

BACKGROUND

Because of the unpredictability people with arthritis face on a daily basis, patient education programmes have become an effective complement to traditional medical treatment giving people with arthritis the strategies and the tools necessary to make daily decisions to cope with the disease.

OBJECTIVES

To assess the effectiveness of patient education interventions on health status in patients with rheumatoid arthritis.

SEARCH STRATEGY

We searched MEDLINE, EMBASE and PsycINFO and the Cochrane Controlled Trials Register. A selection of review articles (see references) were examined to identify further relevant publications. There was no language restriction.

SELECTION CRITERIA

Randomised controlled trials (RCT's) evaluating patient education interventions that included an instructional component and a non-intervention control group; pre- and post-test results available separately for RA, either in the publication or from the studies' authors; and study results presented in full, end-of-study report.

MAIN RESULTS

Twenty-four studies with relevant data were included. We found significant effects of patient education at first follow-up for scores on disability, joint counts, patient global assessment and psychological status. Physician global assessment was not assessed in any of the included studies. The two separate dimensions of psychological status: anxiety and depression showed no significant effects, nor did the dimensions of pain and disease activity. At final follow up no significant effects of patient education were found.

REVIEWER'S CONCLUSIONS

Patient education as provided in the studies reviewed here had moderate short-term effects on patient global assessment, and small short-term effects on disability, joint counts and psychological status. There were no long-term benefits.

Effects of increased and deregulated expression of cell division genes on the morphology and on antibiotic production of streptomycetes

This paper describes the effects of increased expression of the cell division genes ftsZ, ftsQ, and ssgA on the development of both solid- and liquid-grown mycelium of Streptomyces coelicolor and Streptomyces lividans. Over-expression of ftsZ in S. coelicolor M145 inhibited aerial mycelium formation and blocked sporulation. Such deficient sporulation was also observed for the ftsZ mutant. Over-expression of ftsZ also inhibited morphological differentiation in S. lividans 1326, although aerial mycelium formation was less reduced. Furthermore, antibiotic production was increased in both strains, and in particular the otherwise dormant actinorhodin biosynthesis cluster of S. lividans was activated in liquid- and solid-grown cultures. No significant alterations were observed when the gene dosage of ftsQ was increased. Analysis by transmission electron microscopy of an S. coelicolor strain overexpressing ssgA showed that septum formation had strongly increased in comparison to wild-type S. coelicolor, showing that SsgA clearly influences Streptomyces cell division. The morphology of the hyphae was affected such that irregular septa were produced with a significantly wider diameter, thereby forming spore-like compartments. This suggests that ssgA can induce a process similar to submerged sporulation in Streptomyces strains that otherwise fail to do so. A working model is proposed for the regulation of septum formation and of submerged sporulation.

The general public's knowledge and perceptions about rheumatic diseases

OBJECTIVE

In the Netherlands, the mass media pay little attention to rheumatic diseases. For this reason, it might be assumed that in general people know very little about rheumatic diseases and thus have an unrealistic image of them. The purpose of this study was to gain insight into the general public's knowledge and perceptions regarding rheumatic diseases in the Netherlands.

METHODS

A questionnaire was sent by mail to a random sample of 1800 Dutch homes; the response was 658. Questions mainly focused on knowledge, attitudes, behavioural intentions and use of the mass media with regard to rheumatic diseases.

RESULTS

The respondents gave the right answer to a mean of 8.2 statements out of 17 true/false statements regarding factual knowledge of rheumatic diseases. Respondents particularly underestimated the prevalence of rheumatic diseases and were unaware of several rheumatic disorders. Most respondents had rarely used the mass media to gain information about rheumatic diseases, but they did show a moderate interest in acquiring information. Knowledge correlated positively with the respondents' level of education, acquaintance with rheumatic patients, and use of the mass media. Knowledge correlated negatively with the idea that rheumatic patients are themselves able to influence the course of their disease. In general, respondents judged rheumatic diseases to be rather serious but did not feel very frightened or vulnerable of becoming a rheumatic patient. Fear of rheumatic diseases correlated positively with interest in information about rheumatic diseases, intentions of visiting a doctor if experiencing rheumatic complaints and helping rheumatic patients in daily life.

CONCLUSIONS

This study found that the public in general do not know very much about rheumatic diseases, but they do have a moderate desire for more information about them. Furthermore, they do not feel frightened of being confronted with a rheumatic disorder. More information about rheumatic diseases in the media might lead to better knowledge and perception of rheumatic diseases among the general public.

Media coverage of chronic diseases in the Netherlands

OBJECTIVE

Little is known about the quantity or quality of information on rheumatic diseases provided by the mass media. The aim of this study was to gain insight into the media coverage of rheumatic diseases compared with other chronic diseases in the Netherlands.

MATERIALS AND METHODS

Newspaper articles, magazine articles, and medical television programs that appeared or were broadcast during a 1-year period, and contained information on rheumatic diseases, heart disease, cancer, chronic lung disease, or diabetes mellitus, were selected for content analysis. For each article and program, it was determined whether coverage concentrated on treatment, influence of lifestyle, scientific progress, or disease consequences. It was also determined whether professional experts and patients were featured.

RESULTS

Nine hundred seventeen newspaper articles, 304 magazine articles, and 163 medical programs were found. Most dealt with cancer (43%) and heart disease (37%). The amount of media attention given to each of the five disease categories was found to correspond with mortality but not with prevalence. The contents of the articles and programs differed significantly according to disease topic. The main focus in rheumatic diseases was on patients' experiences, as well as regular and alternative medications. In heart disease and cancer, the main focus was on professional medical viewpoints, operations, and mortality, whereas in chronic lung disease and diabetes it was on treatments in the context of regular medications, scientific progress, and incurability. The influence of lifestyle on the disease process was mentioned most often in connection with diabetes, rheumatic disease, and chronic lung disease.

CONCLUSIONS

The amount of attention a disease category received from the media depended on its fatality rates and not on its prevalence. Heart disease and cancer were portrayed as being more serious than the more lingering diseases. Surprisingly, the proportion of articles and programs that included the influence of lifestyle in their coverage was lowest for cancer and heart disease. More frequent and more accurate coverage of chronic diseases, especially rheumatic diseases, is needed if their image is to be brought into line with their importance for and impact on the community.

Determinants of compliance with medication in patients with rheumatoid arthritis: the importance of self-efficacy expectations

In this study we examine which factors are related to compliance with medication in patients suffering from rheumatoid arthritis (RA).

PATIENTS

persons suffering recently developed, active RA, who cooperated in a randomized study on the effect of patient education. We analyzed the relation between adherence to Sulphasalazine therapy and personal factors, environmental influences, demographic factors, disease-related factors, and barriers to compliance. Moreover, a logistical regression analysis was performed on these factors, considering > or = 80% a high compliance, both with compliance as dependent factor. Only self-efficacy correlated with compliance (r = 0.58; P < 0.001). The logistical regression analysis identified self-efficacy as the only factor determining > or = 80% adherence (P = 0.01). Self-efficacy regarding the use of prescribed medication is related to compliance with this treatment. Further study is needed to determine the test characteristics of self-efficacy as a predictor for compliance with medication.

Fatigue in rheumatoid arthritis: the role of self-efficacy and problematic social support

OBJECTIVE

To examine the relationship of fatigue in people with rheumatoid arthritis (RA) with self-efficacy, positive and problematic aspects of social support, and demographic and disease-related variables.

METHOD

Out-patients with at least 5 yr RA were studied. Fatigue was measured with a visual analogue scale. Other variables included were: positive social support [Social Support List-Interactions (SSL12-I)] and problematic social support; self-efficacy towards coping with RA and towards mobilizing support; health status (Dutch-AIMS2); and laboratory tests: erythrocyte sedimentation rate (ESR), haemoglobin (Hb) and rheumatoid factor (RF); and disease duration.

RESULTS

A total of 229 out-patients were included. Fatigue correlated with all scales of the Dutch-AIMS2: with pain, physical function and affect (P < 0.001). There was no significant correlation with social support, but there was a highly significant correlation of fatigue with problematic social support (P < 0.001). Both forms of self-efficacy correlated strongly with fatigue: patients with high self-efficacy expectations towards coping with RA, and towards mobilizing the social network (P < 0.001), had less fatigue. In the regression analysis to explain the variation in fatigue, only pain, self-efficacy expectations towards coping with RA, and towards asking for help and problematic social support remained significant.

CONCLUSIONS

Fatigue can to a large extent (37%) be explained by pain, self-efficacy towards coping with RA, and towards asking for help and problematic social support. It is known that self-efficacy can be enhanced by self-management courses and it may thus be possible to improve fatigue.

A self-report Thompson articular index: what does it measure?

The aim of this study was to investigate the reliability and validity of the self-report Thompson articular index (ThAI) in Dutch patients with rheumatoid arthritis (RA). A rheumatologist assessed the ThAI in 43 patients with RA. Patients completed the self-report ThAI and the AIMS-2 questionnaire to assess physical function, pain, mood and level of tension. Blood samples were taken to measure the erythrocyte sedimentation rate (ESR). After 4 weeks, patients were sent a questionnaire for a repeat assessment of the self-report AI. The test-retest reliability of the self-report ThAI was adequate (ICC=0.83). There was low agreement between ThAI scores from patients and AI scores assessed by the rheumatologist (ICC=0.44). Self-report ThAI scores (mean=230.5) were significantly higher than the rheumatologist's scores (mean=110.8). Levels of agreement between patients and rheumatologist for individual joints were disappointing, ranging from 49% to 74% (Cohen's kappa from -0.02 to 0.48). The rheumatologist's ThAI scores correlated significantly with ESR (r=0.55) and physical function (r=0.44), but not with pain, mood or level of tension. Patients' scores correlated significantly with physical function (r=0.51), pain (r=0.43), and mood (r=0.36) but not with ESR or level of tension. In regression analyses the only significant predictor of the rheumatologist's ThAI scores was ESR, and for patients' scores physical function, thus showing that patients' responses are not confounded by mood or level of tension. In conclusion, the self-report ThAI is a reliable measure, but the validity is questionable because of the non-significant correlation with ESR and the low level of agreement between patients and rheumatologist. The results indicate that self-reported joint involvement is more closely related to physical function than to arthritic activity.

Depression and depressive symptoms in rheumatoid arthritis patients: an analysis of their occurrence and determinants

The objectives were to determine the differences in depressive symptoms and depression between rheumatoid arthritis (RA) and osteoarthritis (OA) patients, and to analyse the contribution of sociodemographic and clinical variables to depression in RA patients. The responses of 60 Egyptian RA patients and 40 patients with OA of the knees to the Symptom Checklist-90-R Depression subscale were compared. The proportions of patients from both groups confirmed by a psychiatric interview to be clinically depressed according to the DSM-III-R criteria were also compared. The contributions of sociodemographic and disease variables to depressive symptoms and clinical depression in RA patients were explored by multiple linear and logistic regression, respectively. RA patients showed significantly higher depression scores than OA patients (P = 0.001). The difference was unaffected by controlling for the effects of age, sex, disease duration and the sociodemographic covariates. A depressive disorder was clinically confirmed in 23% of RA patients and 10% of OA patients. The erythrocyte sedimentation rate (ESR), being unmarried and an urban residence were significant predictors of depressive symptoms (P < 0.05), while being unmarried (P < 0.05, OR = 2.1) and HAQ disability (P < 0.01, OR = 3.8) were significant predictors of clinical depression in RA patients. RA patients have significantly more depressive symptoms and tend to be more clinically depressed than OA patients. The contribution of some sociodemographic and clinical variables to depression in RA patients was modest, albeit significant.

The supply of and demand for informal and professional care for patients with rheumatoid arthritis

The objective of this study is to determine supply of, and demand for, informal care for rheumatoid arthritis (RA) patients and to evaluate the factors that contribute to the amounts of help needed and received from professional and informal care providers at home. Data were collected by questionnaire from 229 RA patients and 174 informal caregivers. Most of the help required is also received, though 24% of the patients did not receive help for one or more tasks. Most help given at home is by informal caregivers. The amount of help needed is related primarily to the patient's physical condition, sex, and self-efficacy expectations towards coping with RA. The amount of help received from informal caregivers is largely explained by the physical condition and the marital status of the patient, the sex of the caregiver, the patient's self-efficacy expectations towards coping with RA, and the age of the patient. The amount of help received from health professionals is related primarily to the marital status and the physical condition of the patient.

Effects of patient education on compliance with basic treatment regimens and health in recent onset active rheumatoid arthritis

OBJECTIVES

To determine the effects of patient education on compliance and on health in patients with active, recent onset rheumatoid arthritis (RA).

METHODS

A randomised, controlled, assessor blinded, one year trial. The experimental group followed an education programme. All patients started on sulphasalazine therapy. Compliance with sulphasalazine was measured by pill counting. Compliance rates with regimens of physical exercise, endurance activities, and energy conservation were measured by questionnaires. Compliance with prescriptions of joint protection was scored using a test for joint protection performance. Health was measured by a Disease Activity Score (function of erythrocyte sedimentation rate, Ritchie score, and number of swollen joints), C reactive protein, Dutch-AIMS scores, and M-HAQ scores, range of motion of shoulder, elbow, and knee joints. Parameters were scored at baseline and after three, six, and 12 months.

RESULTS

Sixty of 65 patients gave informed consent, five of them withdrew from follow up. Compliance with sulphasalazine exceeded 80% with no differences between groups. Compliance with physical exercise (at three months), energy conservation (at three and at 12 months), and joint protection (at three months) improved significantly more in the experimental group. The improvements of health were not different in the groups.

CONCLUSION

Compliance with sulphasalazine among patients with active, recent onset RA is high, whether formal patient education is followed or not. Compliance with physical exercise, energy conservation, and joint protection was increased by patient education. Formal patient education did not improve health status.