Arthritis Education Research Articles

Pain Self-Management in Individuals With Chronic Musculoskeletal Pain During Lebanon's Overlapping Crises

ObjectivesWith Lebanon facing multiple crises simultaneously, it is important to understand how Lebanese adults with chronic musculoskeletal pain (CMP) are self-managing their pain amidst challenging circumstances. This study aimed to describe the pain self-management strategies Lebanese adults with CMP are using, as measured by the Arthritis Pain Self-Management Inventory (APSI), and to determine how helpful they perceive these strategies to be for pain relief. A secondary aim was to translate, culturally adapt, and validate the APSI in Lebanese adults with CMP. MethodsA descriptive design was used and a convenience sample of 154 Lebanese adults with CMP completed the Arabic version of the APSI and self-report measures of pain intensity and sociodemographic and clinical characteristics. ResultsThe APSI demonstrated acceptable content and cultural validity in Lebanese adults with CMP. Self-directed arthritis education was the strategy used by the largest number of participants, although it was perceived as the second least helpful for pain relief. The second and third most common strategies used were rest/relaxation, warm baths, and maintaining a healthy weight. The most helpful strategy was maintaining a healthy weight, followed by watching religious television, music therapy, and the use of braces or splints. ConclusionsLebanese adults with CMP should actively participate in their pain management plan and be educated on the various strategies they could use to effectively self-manage their pain.

Correlation analysis of outcomes assessed by patients and healthcare professionals: Exploration in adherence and education in Rheumatoid Arthritis

Correlation analysis of outcomes assessed by patients and healthcare professionals: Exploration in adherence and education in Rheumatoid Arthritis

A person-centered approach to characterizing longitudinal ambulatory impairment in Parkinson's disease

Loss of ambulation is common and highly variable in Parkinson’s disease (PD), and poorly understood from the perspectives of those with PD. Gaining insights to the anticipated perceived trajectories and their drivers, will facilitate patient-centered care. Latent class growth analysis, a person-centered mixture modelling approach, was applied to 16,863 people with PD stratified by early (N = 8612; < 3 years), mid (N = 6181; 3–10 years) and later (N = 2070; > 10 years) disease to discern clusters with similar longitudinal patterns of self-reported walking difficulty, measured by EuroQoL 5D-5L that is validated for use in PD. There were four clusters in early and mid-disease strata, with a fifth identified in later disease. Trajectories ranged from none to moderate walking difficulty, with small clusters with severe problems. The percentage of subjects with moderate (early = 17.5%, mid = 26.4%, later = 32.5%) and severe (early = 3.8%, mid = 7.4%, later = 15.4%) walking difficulty at baseline increased across disease duration groups. The trajectories tended to be stable with variability in moderate and severe groups. Across strata, clusters with moderate to severe problems were associated with more severe impairment, depression, anxiety, arthritis, higher BMI, lower income, and lower education, but no consistent race or gender differences. The findings reveal distinct longitudinal patterns in perceived difficulties in walking in PD.

OA41 Online MDT patient education for early inflammatory arthritis

Abstract Background/Aims Patient education in early inflammatory arthritis (EIA) promotes understanding and engagement with treatment, empowering patients to use self-management in their long-term health condition. It is embedded in national guidance and audit. Individual appointments are time consuming, and groups sessions became impossible during the COVID-19 pandemic. Our education sessions have evolved to a monthly online meeting which aims to be engaging, effective and time efficient. Methods Face-to-face group education afternoons were previously embedded into our early arthritis pathway. Presentations and opportunities for questions were given by a rheumatology consultant, nurse, physiotherapist, podiatrist and occupational therapist. Sessions lasted 2 hours and local charity representatives attended. Group education sessions completely stopped with the COVID-19 pandemic restrictions. This successful MDT model was moved to a monthly Microsoft Teams meeting and condensed to 1 hour. Sessions continue to consist of five short presentations, introduction to charity representatives and opportunity for questions. Following the session, all patients received links to videos of the talks for future reference, contact details for the MDT and local charities, and a link to download our local rheumatology self management app. Patients who are unable to attend also receive this content by email. Patient feedback was gathered through an online questionnaire. Results Attendance has increased over time with 75% of our new EIA patients now attending each month. Feedback from 16 patients rated 75% of all talks as extremely useful or useful. 89% are interested in attending future meetings. 93% had already used or plan to use our rheumatology self management app. Positive patient feedback included: “the whole team were brilliant giving advice and answering questions”, “nice to see the specialists' faces, and to get the feeling they really cared”, and “a perfectly sensible and productive way to introduce all the options for help and support”. Some patients did not feel confident to ask questions in the meeting. Email and telephone advice lines were signposted. Attendance was increased by 40% by a short telephone reminder of the appointment. Conclusion An online meeting has proven to be a time efficient and effective way of providing multidisciplinary education and introducing self management. A short time investment from each MDT member gives breadth to the education. Inviting all newly diagnosed early arthritis patients and encouraging attendance by a short telephone call has maximised reach. Ensuring all patients are sent presentation videos to re-watch and the self referral details further facilitates self management. The format could easily be adapted to other patient education events. Disclosure C. Gwynne: None. S. Gilbard: None. Z. Weller: None. M. Clemence: None. C. Parsons: None. R. Penford: None.

Design and development of an e-learning patient education program for self-management support in patients with rheumatoid arthritis

To develop an e-learning education program targeting patients with rheumatoid arthritis. The development process involved content specification and creative design. It was theoretically framed within theories of multimedia learning and entertainment-education and empirically based on evidence of patient education in rheumatoid arthritis and focus group discussions with stakeholders. We conducted a feasibility test among ten patients to assess the acceptability and usability of the program, and to identify areas to be adjusted. The following themes for educational needs were found in focus group discussions: “Knowledge of rheumatoid arthritis,” he disease course and prognosis,” “Medical treatment,” “A new life situation” and “Daily life with rheumatoid arthritis.” Based on this, an e-learning program covering the disease course, examinations, treatment, and daily life, was created. It combines animations, videos, podcasts, text, speech, and tests. Test persons found the program feasible—that is, clear in content and easy to understand with a suitable pace and coherence between graphics, speech, and text. This e-learning program is based on solid theoretical knowledge that meets users' needs and is easy to use. This study contributes to the innovation of health care by the development of a new digital tool for patient education.

Design and Development of an e-Learning Patient Education Program for Self-management Support in Patients With Rheumatoid Arthritis

Background Patient education is integral to the treatment and care of patients with rheumatoid arthritis. Furthermore, change is taking place in the organization of health care systems because of a demographic shift toward aging populations and advancements in digital technologies, allowing for new interventions. However, evidence on how to provide web-based patient education within arthritis is limited. Objective This study aimed to develop an e-learning education program targeting patients with rheumatoid arthritis. Methods The development involved content specification and creative design with contributions from the investigators, patient research partners, and experts in communication, digital design, and e-learning. It was theoretically framed within theories of self-management and behavior change, multimedia learning, and entertainment education and empirically based on the evidence of patient education in rheumatoid arthritis and focus group discussions with patients, nurses, and rheumatologists. Finally, we conducted a feasibility test among 10 patients to assess the acceptability and usability of the program to identify areas to be adjusted. Results The 5 following themes for educational needs were found in focus group discussions: “Knowledge of rheumatoid arthritis,” “The disease course and prognosis,” “Medical treatment,” “A new life situation,” and “Daily life with rheumatoid arthritis.” Based on these themes, a didactic and entertaining e-learning program with a simple user interface was created. It consists of 3 modules covering the disease course, examinations, treatment, and daily life with rheumatoid arthritis. It combines animations, videos, podcasts, text, speech, and tests. The patients who tested the program found it to be feasible—that is, clear in content and easy to understand with a suitable pace and coherence between graphics, speech, and text. Conclusions This e-learning program is based on solid theoretical knowledge that meets users’ needs and is easy to use. Our study describes possible elements integrated in the development of web-based educational tools that can guide future development processes.

Assessing acceptability and identifying barriers and facilitators to implementation of the EULAR recommendations for patient education in inflammatory arthritis: a mixed-methods study with rheumatology professionals in 23 European and Asian countries

ObjectivesTo disseminate and assess the level of acceptability and applicability of the European Alliance of Associations for Rheumatology (EULAR) recommendations for patient education among professionals in rheumatology across Europe and...

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

ObjectivesTo explore patients’ agreement and reasons for agreement or disagreement with the EULAR recommendations for patient education (PE) for people with inflammatory arthritis (IA).MethodsThis mixed-method survey collected data using snowball...

Cost and Quality of Life Outcomes of the STepped Exercise Program for Patients With Knee OsteoArthritis Trial

ObjectivesThis study aimed to evaluate the cost-effectiveness of the randomized clinical trial STEP-KOA (STepped Exercise Program for patients with Knee OsteoArthritis). MethodsThe trial included 230 intervention and 115 control participants from 2 Veterans Affairs (VA) medical centers. A decision tree simulated outcomes for cohorts of patients receiving arthritis education (control) or STEP-KOA (intervention), which consisted of an internet-based exercise training program (step 1), phone counseling (step 2), and physical therapy (step 3) according to patient’s response. Intervention costs were assessed from the VA perspective. Quality of life (QOL) was measured using 5-level EQ-5D US utility weights. Incremental cost-effectiveness ratios (ICERs) were calculated as the difference in costs divided by the difference in quality-adjusted life-years (QALYs) between arms at 9 months. A Monte Carlo probabilistic sensitivity analysis was used to generate a cost-effectiveness acceptability curve. ResultsThe adjusted model found differential improvement in QOL utility weights of 0.042 (95% confidence interval 0.003-0.080; P=.03) for STEP-KOA versus control at 9 months. In the base case, STEP-KOA resulted in an incremental gain of 0.028 QALYs and an incremental cost of $279 per patient for an ICER of $10 076. One-way sensitivity analyses found the largest sources of variation in the ICER were the impact on QOL and the need for a VA-owned tablet. The probabilistic sensitivity analysis found a 98% probability of cost-effectiveness at $50 000 willingness-to-pay per QALY. ConclusionsSTEP-KOA improves QOL and has a high probability of cost-effectiveness. Resources needed to implement the program will decline as ownership of mobile health devices increases.

POS0267-HPR IDENTIFYING MEANINGFUL AND DETECTABLE CHANGE FROM THE PATIENT PERSPECTIVE ACROSS COMMON FATIGUE MEASURES IN RHEUMATOID ARTHRITIS

Background:Different tools are commonly used to assess fatigue in RA including single items (visual analogue (VAS), numeric rating (NRS), and Likert scales), SF-36 Vitality, and PROMIS. Evidence is needed to identify scores that reflect meaningful change to patients to interpret fatigue results in trials and for clinical care.Objectives:To use symptom-specific and RA change anchors to estimate meaningful and detectable change scores from the patient perspective across several fatigue measures.Methods:Stable RA patients (ACR/EULAR 2010 criteria) were recruited from 3 academic clinical practices across the Southern, Mid-Atlantic, and Northeastern United States. Scales were administered at 2 consecutive visits to capture PROs including fatigue. We also asked a fatigue-specific change question (How would you rate your fatigue since the last visit?). Response options were a lot better, a little better, the same, a little worse, and a lot worse. An RA disease activity change question followed a similar format. We compared mean change between visits across fatigue and RA change categories for the Fatigue NRS, Fatigue 5-point Likert (none to very severe), SF36 Vitality, and PROMIS Fatigue 4a, 7a, and 8a.Results:The sample included 282 patients with stable RA who completed questionnaires 4.6 (SD 2.4) months apart. Patients were mostly white (78%) women (82%) with RA duration of 13 (11) years. At V1, most were in CDAI LDA (57%) or MDA (30%) with 5% in REM and 8% in HDA states. Using the Fatigue change anchor, 6% were a lot better, with mean change ranging from |1-11|points across scales (Table 1); among 13% a little better, smaller changes |0.4 to 5|were reported. Across all measures score changes for meaningful and minimal improvement were numerically larger for improvement than worsening.Fatigue Change CategoriesLot Better 6%Little Better 13%Same 49%Little Worse 22%Lot Worse 10%NMeanSDNMeanSDNMeanSDNMeanSDNMeanSDFatigue 11 point NRS19-2.22.437-0.72.3137-0.51.9610.41.9261.32.1Fatigue 5-point Likert19-0.81.236-0.41.21370.00.9600.20.9270.61.2SF36 Vitality (0-100)1911.216.1364.913.71370.310.659-3.215.326-11.416.6PROMIS Fatigue 7a19-5.98.537-2.67.51380.06.462-0.36.5274.38.3PROMIS Fatigue 8a19-6.110.237-2.77.1138-0.37.1621.36.9275.611.0PROMIS Fatigue 4a19-6.89.937-3.38.2138-0.47.4601.27.2275.211.5Using the RA change categories, more people rated their RA as at least a little better compared with fatigue (28% vs. 19%, respectively) at the second visit (Table 2). Similar patterns were evident across RA change categories, though score changes associated with improvement and worsening were about half those observed using fatigue change anchors.RA Disease Activity Change CategoriesLot Better13%Little Better15%Same42%Little Worse21%Lot Worse9%NMeanSDNMeanSDNMeanSDNMeanSDNMeanSDFatigue 11 point NRS36-0.82.343-0.62.7117-0.21.958-0.21.9260.72.2Fatigue 5-point Likert35-0.31.242-0.31.11180.11.0580.10.8260.31.3SF36 Vitality (0-100)356.417.4433.813.0117-0.612.957-3.711.325-6.017.0PROMIS Fatigue 7a37-1.69.543-1.57.4118-0.37.0590.55.6261.37.5PROMIS Fatigue 8a37-2.19.543-1.79.01180.17.6590.74.8263.011.4PROMIS Fatigue 4a36-2.79.643-2.39.01180.18.1590.45.6252.612.0Conclusion:The score change associated with meaningful improvement and worsening between visits on commonly used fatigue scales was much larger with fatigue vs. RA change categories. More people rated their RA improved as compared with fatigue at the 2nd visit. Symptom-specific anchors are likely to offer more relevant change scores associated with meaningful improvement and worsening than RA change anchors. These estimates offer new information about meaningful and detectable improvement and worsening on common measures for trialists, researchers, and clinicians monitoring fatigue in people with RA.Acknowledgements:The primary research data included within this report were acquired through funding in part from a PCORI Methods Award (SC14-1402-10818). This work was also supported by the NIH through the Rheumatic Diseases Resource-based Core Center (P30-AR053503 Core D, and P30-AR070254, Core B), the Camille Julia Morgan Arthritis Research and Education Fund, and the Rheumatoid Arthritis Discovery Fund.Disclosure of Interests:None declared

Physical Therapy Use, Costs, and Value for Latent Classes of Good vs Poor Outcome in Patients Who Catastrophize About Their Pain Prior to Knee Arthroplasty

ObjectiveTo examine use, costs, and value of physical therapy (PT) among subgroups. DesignWe conducted an observational study of data from a randomized trial of a pain coping skills intervention. Good and poor outcome subgroups were determined based on Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) Pain and Physical Function scores. The use and costs of PT care as well as changes in WOMAC Pain and Physical Function scores over 4 time periods during a 1-year follow-up were reported. We compared the number of PT visits, total PT costs, and cost per 1-unit improvement in WOMAC scores for the 2 latent subgroups. SettingFive academic medical centers. ParticipantsPatients who catastrophized about their pain prior to knee arthroplasty (N=384). InterventionsPain coping skills training, arthritis education, and usual care. Main Outcome MeasuresThe WOMAC Pain Scale was the primary outcome. ResultsThe value of PT was lower and the cost of PT was higher for poor vs good outcome subgroups beginning 2 months after knee arthroplasty. For example, during the 2- to 6-month period, participants in the poor outcome subgroup incurred a PT cost of $5181.22 per 1-unit improvement in WOMAC Pain compared with $437.87 per 1-unit improvement in WOMAC Pain for the good outcome subgroup (P<.001). From the 6- to 12-month period, WOMAC scores worsened for the poor outcome subgroup, indicating no benefit from PT. ConclusionsPatients in 2 latent classes demonstrated clinically important differences in value of PT. Future research should identify rehabilitation-based interventions that reduce utilization and enhance effectiveness for patients at high risk for poor outcome.

Editorial introductions

Editorial introductions

Stepped Exercise Program for Patients With Knee Osteoarthritis : A Randomized Controlled Trial.

Evidence-based models are needed to deliver exercise-related services for knee osteoarthritis efficiently and according to patient needs. To examine a stepped exercise program for patients with knee osteoarthritis (STEP-KOA). Randomized controlled trial. (ClinicalTrials.gov: NCT02653768). 2 U.S. Department of Veterans Affairs sites. 345 patients (mean age, 60 years; 15% female; 67% people of color) with symptomatic knee osteoarthritis. Participants were randomly assigned in a 2:1 ratio to STEP-KOA or an arthritis education (AE) control group, respectively. The STEP-KOA intervention began with 3 months of an internet-based exercise program (step 1). Participants who did not meet response criteria for improvement in pain and function after step 1 progressed to step 2, which involved 3 months of biweekly physical activity coaching calls. Participants who did not meet response criteria after step 2 went on to in-person physical therapy visits (step 3). The AE group received educational materials via mail every 2 weeks. Primary outcome was Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Scores for the STEP-KOA and AE groups at 9 months were compared by using linear mixed models. In the STEP-KOA group, 65% of participants (150 of 230) progressed to step 2 and 35% (81 of 230) to step 3. The estimated baseline WOMAC score for the full sample was 47.5 (95% CI, 45.7 to 49.2). At 9-month follow-up, the estimated mean WOMAC score was 6.8 points (CI, -10.5 to -3.2 points) lower in the STEP-KOA than the AE group, indicating greater improvement. Participants were mostly male veterans, and follow-up was limited. Veterans in STEP-KOA reported modest improvements in knee osteoarthritis symptoms compared with the control group. The STEP-KOA strategy may be efficient for delivering exercise therapies for knee osteoarthritis. Department of Veterans Affairs, Health Services Research and Development Service.

Smartphone Apps Targeting Physical Activity in People With Rheumatoid Arthritis: Systematic Quality Appraisal and Content Analysis.

BackgroundRheumatoid arthritis (RA) is a disabling, inflammatory joint condition affecting 0.5%-1% of the global population. Physical activity (PA) and exercise are recommended for people with RA, but uptake and adherence tend to be low. Smartphone apps could assist people with RA to achieve PA recommendations. However, it is not known whether high quality, evidence-informed PA apps that include behavior change techniques (BCTs) previously identified as effective for PA adherence are available for people with RA.ObjectiveThis study aims to systematically identify apps that include goals to facilitate PA for adults with RA and assess app quality and content for the inclusion of relevant BCTs against recommendations for cardiorespiratory, resistance, flexibility, and neuromotor PA and exercise.MethodsA systematic search of the Apple App Store and Google Play Store in the United Kingdom was conducted to identify English language apps that promote PA for adults with RA. Two researchers independently assessed app quality (mobile app rating scale [MARS]; range 0-5) and content (BCT Taxonomy version 1, World Health Organization, the American College of Sports Medicine, and the European League against Rheumatism recommendations for PA). The completeness of reporting of PA prescription was evaluated using a modified version of the Consensus on Exercise Reporting Template (CERT; range 0-14).ResultsA total of 14,047 apps were identified. Following deduplication, 2737 apps were screened for eligibility; 6 apps were downloaded (2 on the Apple App Store and 4 on the Google Play Store), yielding 4 unique apps. App quality varied (MARS score 2.25-4.17). Only 1 app was congruent with all aspects of the PA recommendations. All apps completely or partially recommended flexibility and resistance exercises, 3 apps completely or partially advised some form of neuromotor exercise, but only 2 offered full or partial guidance on cardiorespiratory exercise. Completeness of exercise reporting was mixed (CERT scores 7-14 points) and 3-7 BCTs were identified. Two BCTs were common to all apps (information about health consequences and instruction on how to perform behavior). Higher quality apps included a greater number of BCTs and were more closely aligned to PA guidance. No published trials evaluating the effect of the included apps were identified.ConclusionsThis review identifies 4 PA apps of mixed quality and content for use by people with RA. Higher quality apps were more closely aligned to PA guidance and included a greater number of BCTs. One high-quality app (Rheumatoid Arthritis Information Support and Education) included 7 BCTs and was fully aligned with PA and exercise guidance. The effect of apps on PA adherence should be established before implementation.

Editorial introductions

Editorial introductions

Participation in school and physical education in juvenile idiopathic arthritis in a Nordic long-term cohort study

BackgroundThe aim of the study was to describe school attendance and participation in physical education in school among children with juvenile idiopathic arthritis (JIA).MethodsConsecutive cases of JIA from defined geographical areas of Finland, Sweden and Norway with disease onset in 1997 to 2000 were followed for 8 years in a multi-center cohort study, aimed to be as close to population-based as possible. Clinical characteristics and information on school attendance and participation in physical education (PE) were registered.ResultsParticipation in school and in PE was lowest initially and increased during the disease course. Eight years after disease onset 228/274 (83.2%) of the children reported no school absence due to JIA, while 16.8% reported absence during the last 2 months due to JIA. Full participation in PE was reported by 194/242 (80.2%), partly by 16.9%, and none by 2.9%. Lowest participation in PE was found among children with ERA and the undifferentiated categories. Absence in school and PE was associated with higher disease activity measures at the 8-year visit. School absence > 1 day at baseline predicted use of disease-modifying anti-rheumatic drugs, including biologics (DMARDs) (OR 1.2 (1.1–1.5)), and non-remission off medication (OR 1.4 (1.1–1.7) 8 years after disease onset.ConclusionSchool absence at baseline predicted adverse long-term outcome. In children and adolescents with JIA participation in school activities is mostly high after 8 years of disease. For the minority with low participation, special attention is warranted to promote their full potential of social interaction and improve long-term outcome.

OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis

To update and expand upon prior Osteoarthritis Research Society International (OARSI) guidelines by developing patient-focused treatment recommendations for individuals with Knee, Hip, and Polyarticular osteoarthritis (OA) that are derived from expert consensus and based on objective review of high-quality meta-analytic data. We sought evidence for 60 unique interventions. A systematic search of all relevant databases was conducted from inception through July 2018. After abstract and full-text screening by two independent reviewers, eligible studies were matched to PICO questions. Data were extracted and meta-analyses were conducted using RevMan software. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence Profiles were compiled using the GRADEpro web application. Voting for Core Treatments took place first. Four subsequent voting sessions took place via anonymous online survey, during which Panel members were tasked with voting to produce recommendations for all joint locations and comorbidity classes. We designated non-Core treatments to Level 1A, 1B, 2, 3, 4A, 4B, or 5, based on the percentage of votes in favor, in addition to the strength of the recommendation. Core Treatments for Knee OA included arthritis education and structured land-based exercise programs with or without dietary weight management. Core Treatments for Hip and Polyarticular OA included arthritis education and structured land-based exercise programs. Topical non-steroidal anti-inflammatory drugs (NSAIDs) were strongly recommended for individuals with Knee OA (Level 1A). For individuals with gastrointestinal comorbidities, COX-2 inhibitors were Level 1B and NSAIDs with proton pump inhibitors Level 2. For individuals with cardiovascular comorbidities or frailty, use of any oral NSAID was not recommended. Intra-articular (IA) corticosteroids, IA hyaluronic acid, and aquatic exercise were Level 1B/Level 2 treatments for Knee OA, dependent upon comorbidity status, but were not recommended for individuals with Hip or Polyarticular OA. The use of Acetaminophen/Paracetamol (APAP) was conditionally not recommended (Level 4A and 4B), and the use of oral and transdermal opioids was strongly not recommended (Level 5). A treatment algorithm was constructed in order to guide clinical decision-making for a variety of patient profiles, using recommended treatments as input for each decision node. These guidelines offer comprehensive and patient-centered treatment profiles for individuals with Knee, Hip, and Polyarticular OA. The treatment algorithm will facilitate individualized treatment decisions regarding the management of OA.

Special treatment in rheumatology-cross-sectoral quality-oriented selective contracts

In the last 4years selective contracts according to §140a of the German Social Code Book V (SGBV) with three different health insurers were signed by the Professional Association of German Rheumatologists (BDRh) and from the beginning of the year 2018 by the management company of the association. The contracts were rolled out in five regions of Germany (Bavaria, Hesse, Mecklenburg-Western Pomerania, North Rhine and Saxony). Up to the end of 2018, 12,000 patients with chronic inflammatory rheumatic diseases were treated within the managed care of these contracts. The interface and the treatment pathways were initially consented with the associations of rheumatologists and general practitioners. The aim of the managed care was to provide the optimal quality in diagnostics and treatment and to improve management of rheumatic diseases. Quality indicators, such as treat-to-target principles, tight control, delegation to specially trained assistance personnel, patient education in rheumatoid arthritis (StruPi) and early arthritis consultation, are part of the managed care and are successfully promoted with incentive payments. Thus approximately 20% of the patients were enrolled for the first time in rheumatological care. The BDRh wants to promote the nationwide roll-out of this managed care in Germany with more participating health insurance funds.

STepped exercise program for patients with knee OsteoArthritis (STEP-KOA): protocol for a randomized controlled trial

BackgroundPhysical therapy (PT) and other exercise-based interventions are core components of care for knee osteoarthritis (OA), but both are underutilized, and some patients have limited access to PT services. This clinical trial is examining a STepped Exercise Program for patients with Knee OsteoArthritis (STEP-KOA). This model of care can help to tailor exercise-based interventions to patient needs and also conserve higher resource services (such as PT) for patients who do not make clinically relevant improvements after receiving less costly interventions.Methods / DesignStep-KOA is a randomized trial of 345 patients with symptomatic knee OA from two Department of Veterans Affairs sites. Participants are randomized to STEP-KOA and Arthritis Education (AE) Control groups with a 2:1 ratio, respectively. STEP-KOA begins with 3 months of access to an internet-based exercise program (Step 1). Participants not meeting response criteria for clinically meaningful improvement in pain and function after Step 1 progress to Step 2, which involves bi-weekly physical activity coaching calls for 3 months. Participants not meeting response criteria after Step 2 progress to in-person PT visits (Step 3). Outcomes will be assessed at baseline, 3, 6 and 9 months (primary outcome time point). The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), and secondary outcomes are objective measures of physical function. Linear mixed models will compare outcomes between the STEP-KOA and AE control groups at follow-up. We will also evaluate patient characteristics associated with treatment response and conduct a cost-effectiveness analysis of STEP-KOA.DiscussionSTEP-KOA is a novel, efficient and patient-centered approach to delivering exercise-based interventions to patients with knee OA, one of the most prevalent and disabling health conditions. This trial will provide information on the effectiveness of STEP-KOA as a novel potential model of care for treatment of OA.Trial RegistrationClinicaltrials.gov, NCT02653768 (STepped Exercise Program for Knee OsteoArthritis (STEP-KOA)), Registered January 12, 2016.

Feasibility evaluation of a pain self-management app-based intervention among older people living with arthritic pain: study protocol

BackgroundOptimal management of chronic arthritic pain experienced by older adults involves applying active self-management strategies every day. Cost-effective and innovative strategies to help build older people’s pain self-management capability are required. This study protocol is designed to evaluate the feasibility, acceptability, and preliminary outcomes of a pain self-management app among older people living in the community with arthritic pain.Methods/designThis is a phase I feasibility study. A pre-post test study design will be used to trial a freely available pain self-management app named Rheumatoid Arthritis Information Support and Education (“RAISE”) for 14 days. Thirty community-dwelling older people living with arthritic pain who use a smartphone will be recruited from (1) various community-based social clubs/organizations/groups or (2) via Facebook groups with potentially high number of older members. In addition, snowballing sampling approach will also be utilized.These participants will trial the RAISE app, which was selected following a systematic evaluation of all available chronic pain apps by the investigator team. A face-to-face or telephone-based meeting will be organized with all consenting participants in order to seek their informed consent, download and set up the intervention app on their mobile device, be provided with app training, and complete the pre-test data (Time 1 (T1)). Participants will be asked to use the RAISE app as desired for 14 days. Post-test data collection (Time 2 (T2)) will occur on day 15. Data collected includes participant’s demographic and clinical information, pain scores, pain self-efficacy, and online technology self-efficacy. Participants will be invited to take part in a semi-structured telephone interview at T2 to explore their experiences of using the app.An evaluation of patterns of app use, recruitment, retention, attrition rates, and analysis of the missing data will inform the study and intervention feasibility. Preliminary outcomes are participant’s pain intensity and interference, pain self-efficacy, and online technology self-efficacy.DiscussionThis study will help us better understand the feasibility and acceptability of using this novel intervention among community-dwelling older people living with arthritic pain. The results will also help inform future pain app studies.Trial registrationAustralia New Zealand Clinical Trials Registry: ACTRN12617000921381.