Mwidimi Ndosi

Patients and nursing staff views of using the education needs assessment tool in rheumatology clinics: a qualitative study

AIMS AND OBJECTIVESnTo evaluate the usability of the educational needs assessment tool in clinical practice, from a practitioner and patient perspective and to establish whether patients perceive that they are getting an equally good or equally inadequate education service for their needs.nnnBACKGROUNDnThe educational needs assessment tool was developed to enable patients with Rheumatoid Arthritis to assess their education needs prior to a consultation with a health professional. The educational needs assessment tool has been translated into nine languages and measurement properties have been established, however, its usability in clinical practice has not been studied.nnnDESIGNnA qualitative study embedded into a multicentre RCT in which patients had been randomised into either educational needs assessment tool-focused education (Experimental Group) or usual care (control group).nnnMETHODSnBoth groups were seen by a clinical nurse specialist. Sixteen patients and four clinical nurse specialists were recruited from the Rheumatology Outpatient Departments of three Acute Hospitals within the U K. Data were collected by interviews with patients and clinical nurse specialist. Analysis followed the Framework approach.nnnRESULTSnPatients and clinical nurse specialist found completion of the educational needs assessment tool straightforward, comprehensive and easy to use. Completing the educational needs assessment tool helped patients to focus on what they needed to know from the clinical nurse specialist. Patients in both the control group and the experimental group felt supported and reassured by their clinical nurse specialist and perceived that they received a good and adequate education provision.nnnCONCLUSIONnThis study provides useful insights into the ability of the educational needs assessment tool to assess the educational needs of patients with rheumatoid arthritis in routine clinical practice.nnnRELEVANCE TO CLINICAL PRACTICEnThe educational needs assessment tool would be useful as a structured guide for nurses when assessing and meeting individual patient educational needs. This has the potential to improve patient-centred care, involve patients more actively in their care and enhance the long-term effects of patient education provision.

Prognosis of the infected diabetic foot ulcer: a 12-month prospective observational study

To determine clinical outcomes and explore prognostic factors related to ulcer healing in people with a clinically infected diabetic foot ulcer.

National variation in the composition of rheumatology multidisciplinary teams: a cross-sectional study

The objective of this study is to describe the composition of multidisciplinary teams (MDT) working within rheumatology departments across the UK. All rheumatology departments in the United Kingdom (UK) were invited to participate in a national electronic survey between February 2014 and April 2015 as a part of a national audit for the management of rheumatoid and early inflammatory arthritis commissioned by Healthcare Quality Improvement Partnership. Rheumatology departments were asked to report their MDT composition; defined as a rheumatologist (consultant or specialist trainee), specialist nurse, occupational therapist physiotherapist, and podiatrist. The data were collected as Whole Time Equivalent (WTE) of each professional group at each department adjusted to 100,000 population. The data were grouped according to British Society for Rheumatology regions to study regional variations. The survey was completed by 164/167 departments (98% response rate). All departments reported an MDT comprising a rheumatologist (consultant or specialist trainee) and almost all included a specialist nurse but only 28 (17%) of the departments had MDTs comprising all the professional groups. There was a high degree of regional variation in the provision of Allied Health Professionals (physiotherapists, occupational therapists, and podiatrists) in the UK. MDT care is recommended for the management of inflammatory arthritis, but few UK rheumatology departments have a full complement of healthcare professionals within their MDT. There is a high degree of regional variation in the composition and staffing levels of the rheumatology MDT across the UK; the impact of which warrants further investigation.

The Portuguese Rheumatoid Arthritis Impact of Disease (RAID) score and its measurement equivalence in three countries: validation study using Rasch Models

PurposeThe Rheumatoid Arthritis Impact of Disease (RAID) score assesses seven impact domains of interest for people with RA. This study aimed to test patients’ understanding of the Portuguese RAID and evaluate its cross-cultural validity for use in Portugal.MethodsThis was a mixed methods study comprising two phases: (i) cognitive debriefing to determine patient’s comprehension of the Portuguese RAID and (ii) cross-cultural validation using Rasch analysis. Construct validity was determined by fit to the model, invariance culture (compared with France and UK datasets) and evidence of convergent and divergent validity.ResultsPatients’ input (nu2009=u200938) led to minor changes in the phrasing of two items to ensure conceptual equivalence between the Portuguese and the original RAID. In Rasch analysis (nu2009=u2009288), two items ‘Sleep’ and ‘Physical well-being’ in the Portuguese dataset did not adequately fit the model specifications, suggesting multidimensionality (sleep—not necessarily associated with RA) and redundancy (physical well-being overlapping with functional disability). Despite the imperfections, the scale had high internal consistency, evidence of convergent and divergent validity and invariance to culture (compared to France nu2009=u2009195 and UK nu2009=u2009205 datasets). The scale was well targeted for patients with different levels of disease impact.ConclusionsThe RAID has been successfully adapted into Portuguese and it can be used with confidence in clinical practice. Further research will be required to ensure it captures the full range of sleep problems in RA. Meanwhile, data across the three countries (Portugal, France and the UK) are comparable except for the two items (sleep and physical well-being).

The controversy of using PGA to define remission in RA

We read with interest the commentary by van Tuyl and Boers (van Tuyl, L. H. D. & Boers, M. Remission — keeping the patient experi‐ ence front and centre. Nat. Rev. Rheumatol. 13, 573–574 (2017))1 referring to our paper on the role of patient global assessment (PGA) in the definition of remission in rheumatoid arthritis (RA)2. However, we cannot agree with their interpretation that by suggesting to remove the PGA from the ACR/EULAR remission definition we are “calling for a para‐ digm change that limits the responsibility of the rheumatologist to prescribing immuno‐ suppressive therapy,” or that our proposal is “taking away the incentive to improve RA care by removing the patient’s perspective from the remission criteria.”1 Nothing could be further from the inter‐ pretation we made of our own data and from our proposals. What we actually proposed is that the management of RA should be guided by two separate targets: a measure of inflam‐ matory activity (physician’s perspective) and a measure of disease impact (patient’s perspective). We advocate that 3v‐remission (defined as swollen and tender 28‐joint counts and C‐reactive protein in mg/dl all ≤1) is the most appropriate target for immunosuppressive therapy given that PGA has been shown to have no more than a weak correlation with disease activity, and is at least as much linked to personality and emotional aspects, which are not amenable to change by immunosuppres‐ sive therapy. Achieving 3v‐remission is a decisive step towards achieving good patient outcomes but does not guarantee the total abrogation of dis‐ ease impact. In fact, the percentage of patients with RA who are missing remission solely because of a high PGA score is greater than the percentage who achieve full remission2,3. To further assist such patients, physicians ought to consider adjuvant interventions instead of reinforced immunosuppression. For these reasons, a measure of disease impact should be part of the recommended treatment targets in RA management. This measure should be examined separately from inflammatory activity and include more ana‐ lytical measures than PGA, in order to guide efforts to alleviate impact beyond what is achieved through control of inflammation. We suggest that the Rheumatoid Arthritis Impact of Disease (RAID) score, using its seven domains as separate items, is ideally suited for this purpose. The RAID score was developed in close cooperation with patients from various countries4. Our views were summarized in the abstract: “PGA mainly reflects fatigue, pain, function, and psychological domains, which are inadequate to define the target for immuno suppressive therapy. This considera‐ tion suggests that clinical practice should be guided by two separate remission targets: inflammation (3v‐remission) and disease impact.”2 In summary, we do not propose to “limit the responsibility of the rheuma‐ tologist to prescribing immunosuppressive therapy”1, but rather we want to highlight the rheumatologist ́s and multidisciplinary team’s responsibility to assess and manage disease impact. The appropriateness of these proposals will be further scrutinized by clari‐ fying whether high PGA in patients otherwise in remission is associated with subclinical inflammation and whether full remission is a better predictor than 3v‐remission (with‐ out PGA) of a long‐term good radiological outcome5. Both investigations are underway. Ricardo J. O. Ferreira1,2*, Cátia Duarte1,3, Mwidimi Ndosi4, Maarten de Wit5,6, Laure Gossec7,8 and J. A. P. da Silva1,3

Nursing sensitive outcomes in patients with rheumatoid arthritis: A systematic literature review

BACKGROUNDnAlthough rheumatology nursing has been shown to be effective in managing patients with rheumatoid arthritis, patient outcomes sensitive to nursing interventions (nursing sensitive outcomes) have not been systematically studied.nnnOBJECTIVESnThe objective of this study was to identify and delineate relevant patient outcomes measured in studies that reported nursing interventions in patients with rheumatoid arthritis.nnnDESIGNnA systematic search was conducted from 1990 to 2016. Inclusion criteria were (i) patients with rheumatoid arthritis, (ii) adult population age ≥16years, (iii) nurse as part of the care team or intervention delivery, (iv) primary research only, (v) English language, and (vi) quantitative studies with nursing sensitive outcomes.nnnDATA SOURCESnMedline, CINAHL, Ovid nursing, Cochrane library and PsycINFO databases were searched for relevant studies.nnnREVIEW METHODSnUsing the predetermined inclusion/exclusion criteria, nine reviewers working in pairs assessed the eligibility of the identified studies based on titles and abstracts. Papers meeting the inclusion criteria were retrieved and full texts were further assessed. Critical Appraisal Skills Programme tools were used to assess the quality of the included studies. Data on nursing sensitive outcomes were extracted independently by two reviewers. The Outcome Measures in Rheumatology comprehensive conceptual framework for health was used to contextualise and present findings.nnnRESULTSnOf the 820 articles retrieved, 7 randomised controlled trials and 3 observational studies met the inclusion criteria. Seventeen nursing sensitive outcomes were identified (disease activity, clinical effects, pain, early morning stiffness duration, fatigue, patient safety issues, function, knowledge, patient satisfaction, confidence in care received, mental health status, self-efficacy, patient attitude/perception of ability to control arthritis, quality of life, health utility, health care resources, death). These fitted into 10 health intervention domains in keeping with the pre-specified conceptual framework for health: disease status, effectiveness, safety, function, knowledge, satisfaction, psychological status, quality of life, cost, death. A total of 59 measurement instruments were identified comprising patient reported outcome measures (n=31), and biologic measures and reports (n=28).nnnCONCLUSIONSnThis review is notable in that it is the first to have identified, and reported, a set of multidimensional outcome measures that are sensitive to nursing interventions in rheumatology specifically. Further research is required to determine a core set of outcomes to be used in all rheumatology nursing intervention studies.

Dual target strategy: A proposal to mitigate the risk of overtreatment and enhance patient satisfaction in rheumatoid arthritis

With great interest we read the viewpoint from Professor Landewe,1 calling for more caution, research and debate regarding the risks of overdiagnosis and overtreatment in rheumatology. Strongly agreeing with the overall message, especially that ‘(…) overtreatment is hardly discussed but likely present’, we would like to contribute to this discussion by raising an issue that touches base on two paradigms listed by Professor Landewe: remission and evidence-based rheumatology.nnThere is now ample evidence that a substantial proportion (12%–38%) of patients with rheumatoid arthritis (RA) do not achieve the status of remission according to disease activity indices, solely because of a patient global assessment (PGA) scorexa0>1 (0–10 scale, 10=worst).2 3 If the elevated score on PGA does not reflect disease activity, additional immunosuppressive agents cannot improve the status of these patients, as inflammation is already essentially abrogated. Elevated PGA, therefore, may induce the risk of overtreatment when applying disease indices or Boolean-based criteria to define the treatment aim, which is remission or at least low disease activity (LDA) according to current treatment recommendations.4 5 Naturally, patients who still report relevant disease symptoms despite the absence of significant inflammation need …

Pain, fatigue and functional disability are associated with higher educational needs in systemic sclerosis: a cross-sectional study

In the process of the planned and systematic education of patients/families, it is extremely important to identify patients’ health problems as well as their needs and expectations. The objective of this study was to determine the relationship between functional disability, health problems and perceived educational needs in people with systemic sclerosis (SSc). This was a cross-sectional analytic study conducted in six rheumatology centers in Poland. Functional disability was measured using HAQ-DI, and the magnitude of other health problems (pain, fatigue, intestinal problems, breathing problems, Raynaud’s phenomenon, finger ulcerations) was measured using 0–100xa0mm visual analogue scales. The educational needs were measured using the Polish version of the Educational Needs Assessment Tool (Pol-ENAT). Spearman’s correlation coefficient (rs) was used to report associations. The sample comprised 140 patients, 125 (89.28%) were women. They had a mean (SD) age of 54 (14.23) and disease duration of 11 (10.27) years. The median (IQR) HAQ-DI was 1.12 (0.62–1.62) and mean ENAT score was 71.54 (SD 27.72). Patients needed to know more about the disease process, self-help measures and managing pain. All health problems had significant correlations with the overall educational needs, pain, functional disability and fatigue having the highest rsxa0=xa00.359, pu2009<u20090.0001; rsxa0=xa00.314, pu2009<u20090.001 and rsxa0=xa00.270, pu2009=u20090.001, respectively. Health problems in people with SSc are associated with considerable educational needs; therefore, health professionals should take this into account when planning patient education. Group interventions should consider providing patient education related to disease process as a minimum.

Cross-cultural validation of the educational needs assessment tool into Chinese for use in severe knee osteoarthritis

Background Patient education is an integral part of the management of osteoarthritis. The educational needs assessment tool (ENAT) was developed in the UK to help direct needs-based patient education in rheumatic diseases. Aim The aim of the study was to adapt and validate the ENAT into Chinese, for use in severe knee osteoarthritis (KOA). Methods This cross-cultural validation study took two phases: 1) adaptation of the ENAT into Chinese (CENAT) and 2) validation of the CENAT. The Construct validity was determined using factor analysis and criterion-related validity by comparing data from CENAT with data from different self-efficacy scales: patient–physician interactions scale (PEPPI-10), self-efficacy for rehabilitation outcome scale (SER), and the self-efficacy for exercise scale (SEE). Results The sample comprised 196 patients, with mean age 63.6±8.7 years, disease duration was11.5 years, and 57.1% were female. The CENAT was found to have high internal consistency. The CENAT had weak correlations with the Chinese versions of PEPPI r=0.40, SER r=0.40, and SEE r=0.39. There were no correlations with age r=−0.03 or disease duration r=−0.11. Conclusion The ENAT translated well into Chinese and has evidence of validity in KOA. Future studies will further inform its usefulness in clinics, community, and online settings.

The educational needs of patients with undifferentiated spondyloarthritis: Validation of the ENAT questionnaire and needs assessment

OBJECTIVESnThe aim of the present study was to validate the Swedish version of the educational needs assessment tool (SwENAT) in undifferentiated spondyloarthritis (USpA) and use it to study the educational needs of patients with USpA.nnnMETHODSnThis was a cross-sectional study, recruiting a random sample of patients with USpA from a hospital register in Sweden. Educational needs data were collected, together with disease activity and function indices (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI] and Bath Ankylosing Spondylitis Functional Index [BASFI]). Rasch analysis was utilized to evaluate the construct validity, internal consistency and unidimensionality of the SwENAT before studying differences in educational needs between patient subgroups (gender, age and disease severity).nnnRESULTSnComplete responses were obtained from 77 patients (48 women), with a mean age (standard deviation [SD]) of 50 (12) years, a disease duration of 16 (11) years, a BASDAI score of 4.9 (1.9) and a BASFI score of 3.1 (2.3). The SwENAT satisfied the requirements of the Rasch model (χ2 = 11.488; p = 0.119), including strict unidimensionality. Overall, the mean (SD) SwENAT score was 86 (32). Women reported higher needs than men in the domains of pain (mean [SD] 13.1 [6.8] versus 10.1 [6.0]; p = 0.05); movement (mean [SD] 13.0 [5.5] versus 9.9 [5.7]; p = 0.02) and self-help (mean [SD] 17.0 [5.8] versus 14.1 [5.0]; p = 0.03). Higher disease activity (BASDAI >4) was associated with higher educational needs (mean [SD] 92.6 [31.9] versus 73.7 [29.4]; p = 0.02).nnnCONCLUSIONSnThese data suggest that the SwENAT is valid in USpA. Women and patients with higher disease activity are more likely to have high levels of educational needs, so special attention and strategies to target patient education are warranted.