N. Cuperus

Patient reported barriers and facilitators to using a self-management booklet for hip and knee osteoarthritis in primary care: results of a qualitative interview study

BackgroundTo enhance guideline-based non-surgical management of hip or knee osteoarthritis (OA), a multidisciplinary, stepped-care strategy has been implemented in primary care in a region of the Netherlands. To facilitate this implementation, the self-management booklet “Care for Osteoarthritis” was developed and introduced. The aim of the booklet was to educate patients about OA, to enhance the patient’s active role in the treatment course, and to improve the communication with health care providers. To successfully introduce the booklet on a large scale we assessed barriers and facilitators for patients to using this booklet.MethodsSeventeen primary care patients with hip or knee OA who received the self-management booklet participated in this qualitative study using semi-structured interviews. Purposive sampling was used to ensure diversity of the patients’ view about the booklet. The interviews were transcribed verbatim and analysed using a thematic analysis approach.ResultsThree core themes with patient perceived barriers and facilitators to use the booklet emerged from the interviews: 1) the role of health care providers, 2) the patient’s perceptions about OA and its manageability, and 3) the patient’s perceptions about the usefulness of the booklet and patient’s information needs. Regarding the first theme, a barrier was the lack of encouragement from health care providers to use the booklet in the treatment course of OA. Moreover, patients had doubts concerning the health care providers’ endorsement of non-surgical treatment for OA. Barriers from the second theme were: thinking that OA is not treatable or that being pro-active during the treatment course is not important. In contrast, being convinced about the importance of an active participation in the treatment course was a facilitator. Third, patients’ perceptions about the usefulness of the booklet and patients’ information needs were both identified as barriers as well as facilitators for booklet use.ConclusionsThis study contributes to the understanding of patient perceived barriers and facilitators to use a self-management booklet in the treatment course of OA. The results offer practical starting points to tailor the implementation activities of the booklet nationwide and to introduce comparable educational tools in OA primary care or in other chronic diseases.

Measurement properties of the Health Assessment Questionnaire Disability Index for generalized osteoarthritis

OBJECTIVE Generalized OA (GOA) is highly prevalent in OA. Individuals with GOA typically suffer from limitations of both upper and lower extremity function, yet we lack a validated instrument to assess their activity limitations. An appropriate instrument might be the HAQ Disability Index (HAQ-DI). Therefore the aim of this study was to evaluate the measurement properties of the HAQ-DI in GOA. METHODS Data were used from a randomized controlled trial comparing the effectiveness of two multidisciplinary treatment programmes for patients with GOA. One hundred and thirty-seven of 147 included patients completed a standardized set of questionnaires before and after treatment. Interpretability, validity, reliability and responsiveness of the HAQ-DI were assessed using the Consensus-Based Standards for the Selection of Health Status Measurement Instruments checklist (COSMIN). RESULTS Floor and ceiling effects were present. The content validity was questionable since the HAQ-DI encompasses activities that are either not relevant or too easy to perform as judged by patients and experts. Construct validity was good since 90% of the hypotheses were confirmed. Factor analysis confirmed the unidimensionality of the HAQ-DI (root mean square error of approximation = 0.057, χ(2)/df ratio = 1.48). Cronbachs α was 0.90, confirming internal consistency and the ICC was 0.81, reflecting good reliability. The minimal important change was 0.25 and the smallest detectable change was 0.60. We could not establish the responsiveness of the HAQ-DI. CONCLUSION The HAQ-DI showed good construct validity, internal consistency and reliability, whereas its content validity and responsiveness were limited. We recommend updating the items of the HAQ-DI in future research focusing on functional limitations in GOA. TRIAL REGISTRATION Dutch Trial Register NTR2137, http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2137.

Randomized trial of the effectiveness of a non-pharmacological multidisciplinary face-to-face treatment program on daily function compared to a telephone-based treatment program in patients with generalized osteoarthritis

OBJECTIVE To compare the effectiveness of a non-pharmacological multidisciplinary face-to-face self-management treatment program with a telephone-based program on daily function in patients with generalized osteoarthritis (GOA). DESIGN A pragmatic single-blind randomized clinical superiority trial involving 147 patients clinically diagnosed with GOA, randomly allocated to either a 6 week non-pharmacological multidisciplinary face-to-face treatment program comprising seven group sessions or a 6 week telephone-based treatment program comprising two group sessions combined with four telephone contacts. Both programs aimed to improve daily function and to enhance self-management to control the disease. The programs critically differed in mode of delivery and intensity. Daily function (primary outcome) and secondary outcomes were assessed at baseline, 6, 26 and 52 weeks. Data were analyzed using linear or logistic multilevel regression models corrected for baseline, sex and group-wise treatment. RESULTS No differences in effectiveness between both treatment programs were observed on the primary outcome (group difference (95% CI): -0.03 (-0.14, 0.07)) or on secondary outcome measures, except for a larger improvement in pain in the face-to-face treatment group (group difference (95% CI): 1.61 (0.01, 3.21)). Within groups, significant improvements were observed on several domains, especially in the face-to-face group. However, these benefits are relatively small and unlikely to be of clinical importance. CONCLUSIONS We found no differences in treatment effect between patients with GOA who followed a non-pharmacological multidisciplinary face-to-face self-management program and those who received a telephone-delivered program. Besides, our findings demonstrated limited benefits of a self-management program for individuals with GOA. Dutch Trial Register trial number: NTR2137.

Are people with rheumatoid arthritis who undertake activity pacing at risk of being too physically inactive

Objective: To gain insight into the relationship between activity pacing and physical inactivity. Design: A cross-sectional study. Setting: Outpatient clinic of a rheumatology department. Subjects: Men and women diagnosed with rheumatoid arthritis Main measures: Physical activity was assessed using self-reported measures and an accelerometer-based activity monitor. An occupational therapist and specialized nurse analysed the self-reported physical activity data and classified on the basis of consensus the pacing of activities of all patients as ‘adequate’ or ‘not adequate’. Results: Thirty rheumatoid arthritis patients participated in this study of whom nine were categorized as adequate activity pacers. None of these nine undertook sufficient exercise whereas 6 of the 20 people who did not pace activity appropriately did. Physical activity levels assessed by self-reported measures were significantly higher than when assessed by an accelerometer-based activity monitor. Conclusions: Activity pacing was associated with lower levels of physical activity. Since patients with rheumatoid arthritis are already at risk for inactivity, further inactivation by activity pacing might potentially be harmful.

Responsiveness of four patient-reported outcome measures to assess physical function in patients with knee osteoarthritis

Objectives: The aim of this study was to evaluate the responsiveness of four patient-reported outcome measures (PROMs) to measure change in physical function simultaneously in patients with knee osteoarthritis (OA) following currently recommended COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) standards. Method: Patients with knee OA receiving conservative treatment following a stepped care approach were invited to complete a set of questionnaires at baseline and 3 months. Questionnaires included four widely used measures of physical function: the Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), the Lequesne algofunctional index (LAI), the Lower Extremity Functional Scale (LEFS), and the Western Ontario and McMaster University Osteoarthritis Index Physical Function subscale (WOMAC-PF). Responsiveness of physical function was investigated according to the COSMIN standards by testing 15 a priori defined hypotheses. Responsiveness was considered positive if > 75% of the hypotheses could be confirmed. Results: A total of 161 patients participated [61% female, mean (sd) age 59 (9) years and body mass index 29.7 (5.0) kg/m2]. Baseline values of the four PROMs were, mean (sd): KOOS-PS 53.6 (16.8), LAI 11.0 (4.0), LEFS 40.6 (14.1), and WOMAC-PF 51.8 (19.4). We could confirm 12 out of 15 predefined hypotheses (80%) about expected correlations for the WOMAC-PF whereas for the KOOS-PS, LAI, and LEFS < 75% hypotheses could be confirmed (73, 67, and 73%. respectively). Conclusions: Our results suggest that the WOMAC-PF is able to detect changes over time in physical function and therefore should be the measure of first choice in clinical trials evaluating the effectiveness of an intervention on physical function in knee OA patients.

Characterizing the concept of activity pacing as a non-pharmacological intervention in rheumatology care: Results of an international Delphi survey

Objective: To develop a consensual list of the most important aspects of activity pacing (AP) as an intervention within the context of non-pharmacological rheumatology care. Method: An international, multidisciplinary expert panel comprising 60 clinicians and/or healthcare providers experienced in AP across 12 different countries participated in a Delphi survey. Over four Delphi rounds, the panel identified and ranked the most important goals of AP, behaviours of AP (the actions people take to meet the goal of AP), strategies to change behaviour in AP, and contextual factors that should be acknowledged when instructing AP. Additionally, topics for future research on AP were formulated and prioritized. Results: The Delphi panel prioritized 9 goals, 11 behaviours, 9 strategies to change behaviour, and 10 contextual factors of AP. These items were integrated into a consensual list containing the most important aspects of AP interventions in non-pharmacological rheumatology care. Nine topics for future research on AP with the highest ranking were included in a research agenda highlighting that future research should focus on the effectiveness of AP interventions and on appropriate outcome measures to assess its effectiveness, as selected by 64% and 82% of the panellists, respectively. Conclusions: The diversity and number of items included in the consensual list developed in the current study reflect the heterogeneity of the concept of AP. This study is an important first step in achieving more transparency and homogeneity in the concept of AP in both rheumatology daily clinical practice and research.

Cost-Utility and Cost-Effectiveness Analyses of Face-to-Face Versus Telephone-Based Nonpharmacologic Multidisciplinary Treatments for Patients With Generalized Osteoarthritis

To evaluate, from a societal perspective, the cost utility and cost effectiveness of a nonpharmacologic face‐to‐face treatment program compared with a telephone‐based treatment program for patients with generalized osteoarthritis (GOA).

AB0851 Assessment and Comparison of Responsiveness of Four Patient Reported Outcome Measures to Assess Physical Function in Knee OA: Womac-PF Subscale Responds Best

Background Although physical function is one of the core outcome domains in knee OA, the ability of a measurement instrument to detect changes over time in the construct (physical function) being measured, i.e. the responsiveness, has never been tested as currently recommended by the Consensus-based Standards for the selection of health status Measurement Instruments (COSMIN)1. Objectives The aim of the current study was to compare the responsiveness of four disease-specific patient related outcome measures (PROMs) of physical function for patients with knee osteoarthritis receiving conservative treatment. Methods Consecutive patients fulfilling the clinical ACR criteria for knee OA visiting our specialized knee OA outpatient clinic were invited to complete questionnaires at baseline and 3 month follow-up. Physical function was measured with four PROMs: the Lequesne Algofunctional index (LAI), Lower Extremity Functional Scale (LEFS), Knee Injury and Osteoarthritis Outcome Function Short Form (KOOS-PS) and Western Ontario and McMaster University Osteoarthritis Index Physical Function subscale (WOMAC-PF). Responsiveness was investigated by testing a priori defined hypotheses formulated by an expert group in analogy to construct validity1. These a priori defined hypotheses addressed expected correlations between changes in physical function with changes in other (un)related measures (pain, fatigue, self-efficacy, coping, anxiety, depression and mental health) or expected differences in correlation in changes between groups. The expert group reached consensus on 15 a priori defined hypotheses and responsiveness was considered positive if >75% of the hypotheses were confirmed. Results Of the 161 included patients, 61% was female with a mean age of 59.0 years (SD 9.3) and BMI of 29.7 kg/m2 (SD 5.0). The majority (n=129, 80.6%) remained stable and 14 patients (8.8%) indicated (very) much worsening in their physical function assessed by the transition question after 3 months. The 17 patients (10.6%) who indicated (very) much improvement, showed significant mean improvement in physical function after 3 months in all four disease-specific PROMs compared with baseline (p<0.05). We could confirm 12 out of 15 of the a priori defined hypotheses (80%) using the physical function subscale of the WOMAC. For the LAI, LEFS and KOOS-PS, respectively 10 (67%), 11 (73%) and 11 (73%) hypotheses were confirmed respectively. Conclusions This is the first study that comprehensively assessed and compared the responsiveness of physical function measured with LAI, LEFS, KOOS-PS and WOMAC-PF according to the latest standards1. Our results suggest that the WOMAC-PF is potentially better able to detect changes over time in physical function than the LAI, LEFS and KOOS-PS in a population of patients with knee OA receiving conservative treatment. We therefore recommend that clinicians and researchers should prefer the WOMAC-PF subscale in future clinical trials to evaluate the effectiveness of (conservative) treatment. References Mokkink LB, Terwee CB, Knol DL, Stratford PW, Alonso J, Patrick DL et al. The COSMIN checklist for evaluating the methodological quality of studies on measurement properties: a clarification of its content. BMC Med Res Methodol 2010; 10: 22 Disclosure of Interest None declared

SAT0594-HPR Measurement Properties of the Health Assessment Questionnaire Disability Index in Patients with Generalized Osteoarthritis (GOA)

Background Individuals with GOA typically suffer from limitations of both upper and lower extremity function. However, current OA specific instruments for activity limitations are usually site specific and do not involve activities of both upper and lower extremities. We hypothesized that the Health Assessment Questionnaire Disability Index (HAQ-DI), originally developed for patients with inflammatory arthritis, might be appropriate to measure functional limitations in GOA. Objectives To evaluate the measurement properties (content validity, construct validity and reliability) of the HAQ-DI in patients with GOA. Methods Data were used from a randomized clinical trial evaluating the effectiveness of a 6-week multidisciplinary treatment program for patients with GOA. 137 patients completed a standardized set of questionnaires before and directly after treatment. The measurement properties of the HAQ-DI were assessed according the Consensus Based Standards for the Selection of health Status Measurement Instruments Checklist1. Floor and ceiling effects for each HAQ-DI category at baseline were considered present if >15% of patients scored the worst or best possible score. For content validity, 17 health professionals were asked to judge the relevance of each HAQ-DI item. Construct validity was assessed by computing associations (Pearson r) between HAQ-DI scores and scores on other clinical (un)related measures. Reliability was assessed by confirmatory factor analysis (CFA), Cronbachs alpha and intra-class correlation coefficient (ICC). The minimal important change (MIC) score was calculated using an anchor based method. Results Of 137 patients (mean age 60 (SD 8) years; (85%) female), 93% reported to have complaints in both the upper and lower extremities. The mean (SD) HAQ-DI score was 1.27 (0.5) at baseline and 1.20 (0.5) at follow-up. 20% - 30% of patients reported the best possible score on the HAQ-DI categories eating, dressing and gripping; 16% reported the worst possible score on the category hygiene. The content validity was questionable since according to the health professionals the HAQ-DI encompasses 9 (out of 20) activities that are not relevant or too easy to perform for GOA patients. Construct validity was rated positive given the moderate to strong associations with related constructs and weak associations with unrelated constructs. The CFA confirmed the unidimensionality of the HAQ-DI (Root Mean Square Error of Approximation =0.057, χ2/df ratio =1.48). Cronbachs alpha was 0.90, confirming internal consistency and the ICC was 0.81, reflecting good reliability. The MIC was 0.25 points and the smallest detectable change was 0.60 indicating that important changes cannot be distinguished from measurement error in individuals. Conclusions The HAQ-DI showed good construct validity and reliability to measure functional limitations in GOA. Yet, the content validity was unsatisfactory and we cannot support the use of the HAQ-DI to monitor individuals with GOA in daily clinical practice. Considering the unsatisfactory content validity, we recommend to update the items of the HAQ-DI when using the HAQ-DI in future research focusing on functional limitations in GOA. The latter might also be relevant for other arthritic populations. References Mokkink et al. (2010). Qual Life Res 19:539-549. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3483

SAT0590-HPR Functional Limitations in Patients with Generalized Osteoarthritis

Background Physical functioning is one of the core outcomes in clinical practice and research in osteoarthritis (OA). Although individuals with generalized osteoarthritis (GOA) represent a relatively large subgroup of patients, the clinical burden in terms of limitations in physical functioning in this patient group is largely unknown. Objectives To describe the nature and severity of functional limitations in patients with GOA according to the International Classification of Functioning, Disability and Health (ICF) component Activities and Participation (d-codes). Methods Baseline data from a randomised controlled trial comparing two non-pharmacological treatment programmes in 128 patients (86% female; mean age (SD) 60 (7.7) years) with GOA were used. GOA was defined as having complaints in three or more joint groups, having at least two objective signs that indicate OA in at least two joints and being limited in daily functioning. The number of painful joint groups was assessed by patient self-report using a paper manikin including eight joint groups. Functional limitations were assessed by the Health Assessment Questionnaire (HAQ), the SF36 subscale physical functioning and the patient specific functional scale (PSFS). In the latter, every patient was asked to report the three most important activities difficult to perform due to GOA and to rate their severity on a 10 cm VAS. Subsequently, these activities were linked to the most precise ICF component (3rd or 4th level) by using established ICF linking rules1. This was done independently by three researchers. The resulting ICF codes were then compared and disagreements were discussed until consensus was achieved. Results The median number of painful joint groups was 5 (interquartile range 4-6). Joint groups most often affected were the hands (108, 84%) and knees (105, 82%). Mean (SD) HAQ score and SF-36 physical functioning score were 1.27 (0.50) and 43 (18), respectively. One patient reported two activities difficult to perform, whereas all the other patients were able to identify three functional limitations. The 383 activities obtained with the PSFS were linked to 405 ICF codes within the Activities and Participation component. Of these 405 codes, 270 (67%) pertained to the chapter mobility (d4), 79 (20%) to domestic life (d6), 24 (6%) to community, social and civic life (d9) and 18 (4%) to self-care. The most frequently identified ICF codes and corresponding mean severity scores are presented in hierarchical order in the table. Conclusions The results indicate that in patients with GOA who have limitations in physical functioning, limitations in activities concerning mobility and domestic life appear to be most frequent and severe. Insight into the severity and spectrum of activity limitations in GOA can be used to develop tailored treatment for this subgroup of patients. References Cieza et al. (2002). J Rehabil Med;34:205-1 Disclosure of Interest None Declared