G.J. Tijhuis

Cost effectiveness and cost utility analysis of multidisciplinary care in patients with rheumatoid arthritis: a randomised comparison of clinical nurse specialist care, inpatient team care, and day patient team care

Objective: To assess the relative cost effectiveness of clinical nurse specialist care, inpatient team care, and day patient team care. Methods: Incremental cost effectiveness analysis and cost utility analysis, alongside a prospective randomised controlled trial with two year follow up. Included were patients with rheumatoid arthritis (RA) with increasing difficulty in performing activities of daily living over the previous six weeks. Quality of life and utility were assessed by the Rheumatoid Arthritis Quality of Life questionnaire, the Short Form-6D, a transformed rating scale, and the time tradeoff. A cost-price analysis was conducted to estimate the costs of inpatient and day patient hospitalisations. Other healthcare and non-healthcare costs were estimated from cost questionnaires. Results: 210 patients with RA (75% female, median age 59 years) were included. Aggregated over the two year follow up period, no significant differences were found on the quality of life and utility instruments. The costs of the initial treatment were estimated at €200 for clinical nurse specialist care, €5000 for inpatient team care, and €4100 for day patient team care. Other healthcare costs and non-healthcare costs were not significantly different. The total societal costs did not differ significantly between inpatients and day patients, but were significantly lower for the clinical nurse specialist patients by at least €5400. Conclusions: Compared with inpatient and day patient team care, clinical nurse specialist care was shown to provide equivalent quality of life and utility, at lower costs. Therefore, for patients with health conditions that allow for any of the three types of care, the preferred treatment from a health-economic perspective is the care provided by the clinical nurse specialist.

Long-Term Physical Functioning and Its Association With Somatic Comorbidity and Comorbid Depression in Patients With Established Rheumatoid Arthritis: A Longitudinal Study

To describe long‐term physical functioning and its association with somatic comorbidity and comorbid depression in patients with established rheumatoid arthritis (RA).

Physical and Mental Functioning in Patients with Established Rheumatoid Arthritis over an 11-year Followup Period: The Role of Specific Comorbidities

Objective. To investigate the longterm association of a wide range of comorbidities with physical and mental functioning in patients with rheumatoid arthritis (RA). Methods. Longitudinal data over a period of 11 years were collected from 882 patients with RA. Somatic comorbidity and comorbid depression were measured at baseline, with a questionnaire including 20 chronic diseases and with the Center for Epidemiologic Depression Scale, respectively. Physical functioning was measured at 5 timepoints with a disease-specific measure [Health Assessment Questionnaire (HAQ)] and a generic measure [physical scales of the Medical Outcomes Study Short Form-36 (SF-36)]. Mental functioning was measured with the mental scales of the SF-36. To determine the association of baseline-specific comorbidities with functioning over time, we performed longitudinal analyses. Results. At baseline, 72% percent of the patients were women, mean age ± SD was 59.3 ± 14.8 years, median RA disease duration was 5.0 years, and 68% had ≥ 1 comorbid condition. The effect of comorbid conditions was more apparent when physical functioning was measured with SF-36, a disease-generic measure, compared with the HAQ, a disease-specific measure. Circulatory conditions and depression were associated (p < 0.05) with worse physical functioning according to the HAQ. Respiratory conditions, musculoskeletal conditions, cancer, and depression were associated (p < 0.05) with worse physical functioning according to the SF-36. Respiratory conditions and depression were associated with worse mental functioning. Conclusion. Patients with specific comorbid conditions have an increased risk of low functioning in the long term. Targeted attention for these specific comorbid conditions by clinicians is recommended.

Optimization of Analgesics for Greater Exercise Therapy Participation Among Patients With Knee Osteoarthritis and Severe Pain: A Feasibility Study.

Severe pain in patients with knee osteoarthritis (OA) hampers the ability to exercise. A protocol for the standardized optimization of analgesics in combination with exercise therapy was developed. The purpose of this protocol was to reduce pain, thereby allowing the patient to participate in exercise therapy. The objective of the present study was to evaluate the feasibility and outcome of the protocol.

Optimization of analgesics allows patients with knee osteoarthritis and severe pain to participate in exercise therapy – a feasibility study

Severe pain in patients with knee osteoarthritis (OA) hampers the ability to exercise. A protocol for the standardized optimization of analgesics in combination with exercise therapy was developed. The purpose of this protocol was to reduce pain, thereby allowing the patient to participate in exercise therapy. The objective of the present study was to evaluate the feasibility and outcome of the protocol.

Association of Somatic Comorbidities and Comorbid Depression With Mortality in Patients With Rheumatoid Arthritis: A 14‐Year Prospective Cohort Study

Patients with rheumatoid arthritis (RA) have a significantly increased risk of mortality compared with the general population. One of the most important predictors for mortality is somatic comorbidity. Moreover, studies have demonstrated that comorbid depression is associated with mortality. Which specific comorbidities are associated with mortality is less investigated. The purpose of this study was to investigate the association of a wide range of comorbidities with mortality in patients with RA.

Somatic comorbidities and comorbid depression are associated with mortality in patients with rheumatoid arthritis: A 14‐year prospective cohort study

Patients with rheumatoid arthritis (RA) have a significantly increased risk of mortality compared with the general population. One of the most important predictors for mortality is somatic comorbidity. Moreover, studies have demonstrated that comorbid depression is associated with mortality. Which specific comorbidities are associated with mortality is less investigated. The purpose of this study was to investigate the association of a wide range of comorbidities with mortality in patients with RA.

Association of Somatic Comorbidities and Comorbid Depression With Mortality in Patients With Rheumatoid Arthritis: A 14-Year Prospective Cohort Study: Comorbidities and Mortality in RA

Patients with rheumatoid arthritis (RA) have a significantly increased risk of mortality compared with the general population. One of the most important predictors for mortality is somatic comorbidity. Moreover, studies have demonstrated that comorbid depression is associated with mortality. Which specific comorbidities are associated with mortality is less investigated. The purpose of this study was to investigate the association of a wide range of comorbidities with mortality in patients with RA.

THU0627-HPR Exercise Therapy in Patients with Knee Osteoarthritis and Severe Pain is Enabled by Optimization of Analgesics – a Feasibility Study

Background Severe pain in patients with knee OA hampers the ability to exercise. A protocol for the optimization of analgesics in combination with exercise therapy was developed. The purpose of this protocol is to reduce pain and thereby allowing the patient to participate in exercise therapy. Objectives The objective of the present study was to evaluate the feasibility and outcome of the protocol. Methods Forty-nine patients with knee OA and severe knee pain (NRS-pain≥7, range 0-10) were included in this study. Analgesics were prescribed following an incremental protocol. The incremental steps were (1) acetaminophen, (2) NSAIDs, (3) weak opioids and (4) intra-articular steroid injections. After six weeks of analgesic use a supervised exercise therapy program for 12 weeks was added, consisting of muscle strengthening exercises and training of daily activities. Knee pain was assessed with NRS-pain and activity limitations were assessed with WOMAC-PF. Data were collected at baseline, after six weeks, and after 18 weeks. Results In intention-to-treat analyses statistically significant improvements in pain and activity limitations were found after six weeks of analgesic use and after the complete intervention. Mean improvements from baseline were 30% (p<0.001) for pain and 16% (p<0.001) for activity limitations after the complete intervention. Eighty-two percent of the patients were able to exercise according to the protocol. In these patients exercise therapy following on six weeks of analgesic use resulted in a further improvement of activity limitations of 10% (p=0.004). Conclusions The combined intervention of analgesics and exercise therapy allows most patients with knee osteoarthritis and severe pain to participate in exercise therapy, leading to reduction of pain and activity limitations. These promising results need to be confirmed in a randomized controlled trial. Disclosure of Interest None declared

AB0857 Standardized Optimization of Analgesics in Patients with Knee Osteoarthritis and Severe Pain – a Feasibility Study

Background Prescription of analgesics is complex in patients with knee OA and severe pain. We developed a protocol for the standardized prescription of analgesics based on the World Health Organization analgesic ladder (1) and the Beating osteoARTritis (BART) strategy for stepped care in hip and knee OA (2). Objectives The aim of this study was to evaluate the feasibility and outcome of the analgesic protocol. Methods Forty-nine patients with knee OA and severe knee pain (NRS≥7; range 0-10) were included. Analgesics were prescribed following an incremental protocol (Figure 1) for a period of six weeks. Pain intensity was evaluated every two weeks. When there was insufficient pain reduction (NRS-pain>5), a consultation at the rheumatologist was planned to offer an analgesic of the next step. Analgesics of the next step were added to analgesics of the previous step(s). Analgesic use was recorded. Knee pain (NRS-pain) and activity limitations (WOMAC-PF) were measured. Data were collected at baseline and after six weeks. Subsequently, patients started with exercise therapy. Results At baseline 84% of the patients used analgesics. Of all patients, 77% used acetaminophen, 36% used NSAIDs and 16% used weak opioids. At baseline, analgesics were used irregularly and at an suboptimal dose. Analgesic use after six weeks is described in Figure 1. The maximal daily dosage was used in 93% of the patients that used acetaminophen, in 66% of the patients that used NSAIDs, and in 44% of the patients that used weak opioids. Combinations of analgesics were common. No serious adverse events occurred. In 39% of the patients NRS-pain was ≤5 after six weeks. Despite NRS-pain>5, a further step in the analgesic protocol was not accepted by the patient (n=14) or not prescribed by the rheumatologist (n=13), the latter mostly due to contra-indications or side effects. Statistically significant and clinically relevant mean improvements from baseline were 19% (p<0.001) for pain and 12% (p=0.002) for activity limitations after six weeks.Figure 1. Flow-chart for the prescription of analgesics. NRS-pain: numeric rating scale for pain (0–10); NSAIDs: non-steroidal anti-inflammatory drugs; IA-injection: intra-articular steroid injection. Dosage of analgesics: number of tablets per day x dosage of tablet in milligram. Percentages denote the group of patients that used analgeics of that step after six weeks. Conclusions After six weeks, patients used analgesics regularly and often at a preferential dose. Prescription of analgesics following an incremental protocol reduces pain and activity limitations in patients with knee OA and severe pain. References World Health Organization. Cancer pain relief: with a guide to opioid availability. Available at: http://whqlibdoc.who.int/publications/9241544821.pdf (accessed 14 January 2014). Smink AJ, et al. Clin Rheumatol 2011;30:1623-9. Disclosure of Interest None declared