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Five-year followup of a cognitivebehavioral intervention for patients with recently-diagnosed rheumatoid arthritisEffects on health care utilization.

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Arthritis & Rheumatism (Arthritis Care & Research)
Vol. 59, No. 3, March 15, 2008, pp 311–316
DOI 10.1002/art.23312
© 2008, American College of Rheumatology
Five-Year Followup of a Cognitive–Behavioral
Intervention for Patients With Recently-Diagnosed
Rheumatoid Arthritis: Effects on Health Care
Objective. To investigate whether cognitive– behavioral therapy (CBT) administered early in the course of rheumatoid
arthritis (RA) has long-term effects on health care use.
Methods. We reviewed the files of 47 of the original 53 patients with early RA who volunteered for a randomized
controlled trial comparing CBT with no psychological intervention. Occasions of service provision associated with RA
were documented and health care use was compared between groups.
Results. The CBT group used fewer health care resources than the control group in the 5 years following intervention.
Significant differences were observed for the number of inpatient nights, physiotherapy referrals, injections, and for total
health care use. There was a trend that closely approached significance toward fewer episodes of surgery and orthopedic
referrals in the CBT group.
Conclusion. These results suggest that CBT administered early in the course of RA can reduce health care use for the first
5 years after treatment. This is a stringent test of the efficacy of a brief psychological intervention, and supports the fact
that brief psychological treatments can have long-term effects.
There is evidence from both meta-analysis and substantive
literature review that cognitive– behavioral therapy (CBT)
is an effective, adjuvant treatment for patients with rheumatoid arthritis (RA) (1,2). Despite this evidence, services
for patients are rarely made available as part of routine
care. Barriers to the provision of such services include the
cost and lack of long-term followup studies. In the metaanalysis by Astin et al (1), followup was available for
76% of trials, but the average length of followup was ⬍6
months. Because RA is a chronic illness with a progressive identifier: NTC001214.
Supported by a North Thames Regional Health Authority’s Research and Development grant. Dr. Sharpe’s work
was supported by a National Health and Medical Research
Council Senior Research fellowship.
L. Sharpe, PhD: The University of Sydney, Sydney, Australia; 2S. Allard, MD: West Middlesex University Hospital,
Middlesex, UK; 3T. Sensky, MD: West Middlesex University
Hospital, Middlesex, UK, and Imperial College, University
of London, London, UK.
Address correspondence to L. Sharpe, PhD, Clinical Psychology Unit A19, The University of Sydney, New South
Wales, 2006, Australia. E-mail:
Submitted for publication March 14, 2007; accepted in
revised form September 4, 2007.
and deteriorating course, it is the long-term efficacy of CBT
that is most important to service development.
Because CBT is relatively expensive, cost is also an issue
in service development. Most CBT programs involve 8
1-hour sessions administered by a clinical psychologist or
allied health professional with appropriate training and
experience. This raises the question of whether the costs of
providing the service are outweighed by the reduction in
burden of illness to patients, or are offset by a reduction in
health care use due to better long-term physical function.
Although studies have found benefits for outcomes such as
mood, joint function, pain, and disability (1), only 1 study
has reported on the effect of CBT treatments on the health
care use of patients with RA (3). In that study, Young et al
confirmed that for patients with chronic RA, CBT resulted
in reductions in the number of RA-related health care
visits and hospitalizations. However, this was based on a
sample of patients with chronic illness who were treated
in a group context, and health care use was assessed only
over an 18-month period.
Recent evidence suggests that early prognosis is particularly important to the long-term progression of RA. For
example, radiographic damage has been found to be the
most aggressive during the first 2 years of illness (4). One
study found that the majority of patients who had become
unable to work due to RA after 8 years of illness had
stopped work within the first year (5). Early functional
ability has been found not only to predict outcome after 10
years (6), but even future mortality at 15 years (7). Therefore, although the results presented by Young et al (3) are
encouraging, the greatest potential for the long-term benefit of CBT in the management of RA is in the first 2 years
of illness.
To our knowledge, there is 1 prior study examining the
efficacy of CBT in the treatment of RA during this crucial
early period. Sharpe and colleagues (8) found that CBT
was effective in improving mood and joint function at
6-month followup. Their 18-month followup indicated
that over time, further improvements of physical and psychological morbidity became evident only in the CBT
group (9). The aim of the present study was to follow up
with these patients after 5 years and compare health care
utilization among those who received CBT with those who
did not. The earlier results showed that there were benefits
to patients in the CBT group in terms of physical outcomes
(joint function) at 6 months (8), and in disability as measured by the Health Assessment Questionnaire (10), which
has been found to predict long-term outcomes (6,7), at 18
months (9). We hypothesized that there would be significantly less health care usage among those who had received CBT 5 years previously than those who had not.
Participants. The original cohort was recruited at 3 hospitals in or near London, UK, between July 1994 and July
1996. The cohorts consisted of consecutive patients attending the rheumatology departments who had been diagnosed with RA in the past 2 years and who were seropositive for rheumatoid factor. Of the patients approached,
89% agreed to take part in the study. The mean ⫾ SD age
of the sample at recruitment was 55.06 ⫾ 14.07 years, and
the mean ⫾ SD illness duration was 12.63 ⫾ 8.22 months.
The majority of the sample were of Anglo-Saxon descent,
with only 3 Asian participants. Nearly two-thirds of the
sample was married or cohabiting. Despite the recent onset of RA, only 22% were working full-time, with a further
12% working part-time. The remainder of the sample was
either retired (10%) or not working outside the home
(55%). Only 14% were university-educated, 24% had
completed school (i.e., 12 years), and the remainder had
⬍10 years of education (63%). Ninety-six percent of the
sample was taking medication, with 10% taking diseasemodifying medication only, 6% taking nonsteroidal antiinflammatories only, 13% taking steroids only, and the
remainder taking combination medications. The groups
were relatively well-matched on most variables at baseline (8). The only difference between groups at pretreatment was in C-reactive protein (CRP) level, where the
control groups had lower levels of inflammation. Groups
did not differ on any other variables, including age, sex,
medications taken, duration of illness, disability, joint
function, erythrocyte sedimentation rate, or psychosocial
functioning (8).
Participants were randomly allocated to receive either
standard clinical care alone (n ⫽ 27) or standard clinical
Sharpe et al
care plus CBT (n ⫽ 26). Four patients dropped out of both
the treatment and control groups prior to the end of treatment, leaving 22 and 23 completers, respectively. Files
were available for 24 participants in the CBT group and 23
participants in the control group (89% of the original
At the 5-year followup, 9 participants had been discharged from rheumatology services; therefore, data were
available for those patients only until their point of discharge. For 5 patients (4 in the CBT group and 1 in the
control group), this was due to improvements in clinical
presentation. For all of the patients discharged due to
improvements, the discharge occurred after the third year
of treatment. Because all patients were recruited within
the National Health Service, which refers patients to receive services at the local hospital in the area in which
they reside, we are confident that had these patients been
re-referred to a specialist for treatment of their RA, it
would have been to the same services and we would have
had access to the data. Therefore, we assumed that patients
who were discharged due to clinical improvement did not
receive any further rheumatology-related services. For the
4 participants who were not discharged due to improvement, the patients had moved away in each case. These
participants were split across the groups (2 in CBT and 2 in
control), and all moved after the third year of treatment;
therefore, it is very unlikely that these low levels of attrition would affect our results. Further, because many of the
more expensive medical procedures (e.g., surgery) were
rare occurrences (i.e., if they occurred, they occurred only
once in the 5-year period), there was not a reliable way in
which to estimate health care usage for the participants
who moved. Therefore, we used their data until the point
at which they moved.
Treatment. Detailed descriptions of the CBT program
used in the current study are available elsewhere (8,9,11).
The program was a broad-based approach that included
psychoeducation, behavioral strategies, and cognitive
strategies. Behavioral strategies aimed to help patients develop a balance between rest and exercise through the use
of goal setting and pacing. We also included relaxation and
imagery strategies. The cognitive strategies targeted the
illness perceptions of the patients and aimed to facilitate a
realistic yet optimistic approach to their illness. Strategies
to help people communicate more effectively about their
illness were also included. The session-by-session plan is
presented in Table 1.
Procedure. The first author (LS) reviewed the files of
patients for the 5 consecutive years following their recruitment into the trial. The file review took place in June and
July of 2001. All rheumatology-related occasions of care
or referrals to other services that took place in the 5 calendar years after recruitment were recorded (see Measures
for details). Occasions of care that were associated with
other medical conditions were excluded. The trial was
approved by the ethics committees of the relevant health
Cognitive–Behavioral Intervention for RA Patients
Table 1. Session-by-session content of
cognitive– behavioral treatment
Session #
Education, treatment rationale
Goal setting, relaxation training
Relaxation, problem-solving skills
Brief relaxation, attention diversion techniques,
imaginal pain transformation
Cognitive therapy: automatic thoughts, time
Challenging cognitions, identifying problematic
attitudes, assertion skills
Challenging pain beliefs, coping self-talk
Summary, relapse prevention
Measures. The 3 main sources of medical care provision in rheumatology are medication, physician (or other
health professional) visits, and hospitalizations and surgery (12). Unfortunately, the files were not sufficiently
detailed to determine the precise medications that patients
were taking at 1 of the sites. However, data in our previous
work demonstrated that patients were well-matched on
medication at baseline (8) and that no differences in medications prescribed were noted over the first 18 months of
the trial (9). The variables recorded were rheumatology
consultations; inpatient nights; surgery; physiotherapy, orthopedic, and psychiatric referrals; pain management referrals and injections; magnetic resonance imaging (MRI)
scans; discharges; and total occasions of care.
The number of rheumatology consultations was recorded for each of the 5 years from the point at which each
participant was recruited; therefore, the number of consultations is available for each consecutive year. The number
of nights that each participant had been admitted due to a
rheumatology-related problem was calculated and recorded as inpatient nights. Two types of surgery had been
performed on participants: hip replacement operations
(n ⫽ 4) and knee reconstructions (n ⫽ 2). Whether or not
the participant had surgery was recorded. The number of
physiotherapy, orthopedic, and psychiatric referrals made
was calculated. We included psychiatry referrals because a
large proportion of patients in the trial had clinically significant levels of depression and anxiety, which improved
with CBT but worsened over time without psychological
intervention (8,9). A number of patients were referred to
the pain management physician for cortisone injections,
and those referrals were recorded for each patient. All
patients in the sample had routine radiographs taken to
assess radiographic progression. We recorded the number
of those who were referred for more extensive investigations (i.e., MRIs). A number of patients were discharged
from their rheumatology services. For some, this was due
to practical issues (e.g., moving away). However, several
patients were discharged due to improvement. The number of patients discharged as improved was recorded.
We were interested in the total number of occasions of
care that were saved by adding psychological intervention
to routine care. Therefore, we derived a number for the
total occasions of care from the data collected. The total
number of occasions of care was determined by develop-
ing a weighting system based on the relative costs of each
type of service. Relative costs were assessed using the
Australian Medicare Benefits Schedules (13), which list
the costs for different medical procedures and have been
used previously in health economics research in RA (14).
Each variable was multiplied by the relative cost of that
procedure, and the weighted scores were added together to
give a weighted total of occasions of care.
Statistical analyses. With the exception of the number
of rheumatology consultations, data were not normally
distributed and the majority of analyses were conducted
using nonparametric statistics. However, because there
was a significant difference between the groups at baseline
in CRP, we performed a series of correlations (Pearson’s
product-moment for the rheumatology consultations and
Spearman’s rank correlations for the other variables) to
determine whether the differences in CRP were associated
with long-term health care use. A 2 (treatment: CBT versus
no psychological intervention) ⫻ 5 (years) mixed-model
analysis of variance was conducted for the number of
rheumatology consultations. Mann-Whitney U tests for independent samples were conducted to compare the number of referrals for physiotherapy, orthopedic surgeons,
and psychiatric services; number of injections; number of
inpatient nights; number of MRIs; and total occasions of
care for the CBT and control groups. For dichotomous
variables, chi-square analyses were performed for whether
the patient had surgery or not and whether the patient was
discharged as improved or not. Finally, in order to ensure
that the baseline differences in CRP could not account for
the differences in overall health care use, which we define
as the primary outcome measure, we also performed an
analysis of covariance (ANCOVA) with total occasions of
care, controlling for CRP.
Correlations with CRP level. CRP level was only significantly correlated with 1 of the 15 variables, the number of
physiotherapy referrals (r ⫽ 0.296, P ⫽ 0.048). That is,
those with higher levels of baseline CRP were more likely
to have a referral to physiotherapy services at baseline
than those with lower levels of baseline CRP. However,
there were also 2 trends in the analysis, such that those
who had higher levels of CRP at baseline also tended to be
referred for MRIs more often (r ⫽ 0.273, P ⫽ 0.07) and to
have more rheumatology appointments in the first year
(r ⫽ 0.266, P ⫽ 0.08). None of the other correlations approached significance (r ⬍ 0.22, P ⬎ 0.16). As a result, we
decided to include CRP as a covariate in all parametric
Health care utilization. As seen in Figure 1, there was a
main effect of year on the number of rheumatology consultations, with both groups having fewer consultations as
the years progressed (F[1,42] ⫽ 7.838, P ⫽ 0.008). However, there was no effect of treatment group (F[1,42] ⫽
0.187, P ⫽ 0.668) and no interaction effect (F[1,42] ⫽
0.104, P ⫽ 0.981).
Sharpe et al
health care utilization among those participants who had
received CBT 5 years previously. Specifically, significant
reductions in health care use were seen in the number of
inpatient nights, physiotherapy referrals, and injections.
Moreover, trends were identified that suggested that the
CBT group tended to be referred to orthopedic surgeons or
to have surgery less often. Even when controlling for acute
inflammation at baseline, there were significant differences for total health care use, which reflected an average
Figure 1. Number of rheumatology consultations by year. CBT ⫽
cognitive– behavioral therapy.
Significant differences emerged using Mann-Whitney U
tests between the groups for the number of inpatient nights
(t ⫽ ⫺1.768, P ⫽ 0.039), number of physiotherapy referrals
(t ⫽ ⫺1.895, P ⫽ 0.029), number of injections (t ⫽ ⫺2.507,
P ⫽ 0.007), and total occasions of care (t ⫽ ⫺2.144, P ⫽
0.032). In each instance, the CBT group used fewer health
care resources (see Figure 2). No differences were evident
in the number of psychiatric referrals (t ⫽ ⫺1.177, P ⫽
0.115) or the number of patients discharged as improved
(␹2 ⫽ 1.607, P ⫽ 0.217). However, a trend was evident for
fewer orthopedic referrals (t ⫽ ⫺1.567, P ⫽ 0.059) and
surgeries (␹2 ⫽ 3.740, P ⫽ 0.067) in the CBT group.
In order to ensure that the effect of CBT on total
weighted health care use could not be attributed to baseline differences in CRP, we excluded physiotherapy referrals from the total health care use variable because 1) it
was correlated significantly with CRP, and 2) there were
significant differences between the groups, favoring CBT.
Although the correlations with CRP and the number of
rheumatology consultations and MRI scans approached
significance, because neither reached significance and
neither were different between the groups we decided to
retain them in the weighted total health care use variable.
We then analyzed the data parametrically, controlling for
CRP at baseline. We performed a log-linear transformation of the weighted average score, which resulted in normal distribution of the data. We then conducted the
ANCOVA, which confirmed that there were significant
differences in total weighted health care use between the
groups (F[1,42] ⫽ 5.745, P ⫽ 0.02). These results showed
that the patients receiving CBT used fewer health care
resources overall. The mean ⫾ SD per person cost of the
health care resources monitored in this study was
$1,454.58 ⫾ $1,357.58 for the CBT group compared with
$3,156.00 ⫾ $3,038.11 for the control group. This represents a savings of $1,701.42 per patient. In this small
sample, this represents a total savings of $40,834.08.
Given that we had found both psychological and physical
benefits of CBT at posttreatment, 6-month followup, and
18-month followup (8,9), we hypothesized that CBT administered early in the course of RA would result in longterm benefits in terms of reduced health care usage. These
hypotheses were largely supported. Overall, there was less
Figure 2. Number of occasions of care for the cognitive– behavioral therapy group (striped bars) and the control group (solid bars)
over 5 years, recorded by category. A, Drs appt ⫽ appointments with
the treating rheumatologist; In-pt ⫽ number of nights inpatient admissions; MRI ⫽ number of magnetic resonance imaging scans;
Orthopod ⫽ number of referrals to orthopedic surgeons, and B,
Physio ⫽ percent of patients referred to physiotherapy services;
Psychol ⫽ percent of referrals to psychological or psychiatric services; Disch-Imp ⫽ percent patients who were discharged as improved. For both A and B, ⴱⴱ ⫽ P ⬍ 0.01; ⴱ ⫽ P ⬍ 0.05; # ⫽ P ⬍ 0.07.
Cognitive–Behavioral Intervention for RA Patients
savings on the indices measured of approximately $1,700
per patient. These results strongly support the use of CBT
for patients who are diagnosed with RA.
Although these findings are very encouraging, there are
several limitations that need to be considered in interpreting them. First, the sample size was small and therefore
a number of findings, such as those requiring surgery or
referral to orthopedic surgeons, approached but failed to
reach significance. The participants were still relatively
early in the trajectory of their illness and only small proportions needed such interventions; this study is likely
to be underpowered in detecting these differences. As a
result, it is important to interpret the data cautiously.
Further, we did not adopt a stringent health economics
model, and we assessed only selected health care outcomes. Nonetheless, the fact that significant differences
were observed in a number of variables indicates that
large effect sizes were evident between the groups, supporting the clinical significance of the present findings. We
did not include general health care utilization measures
because in an aging population such as this, we expected
that there would be other illnesses and medical issues that
one would not expect to be affected by psychological therapy specifically targeting RA.
Second, the file reviews for the present study were conducted by the first author (LS). Although she was not
aware of the group to which all participants were allocated, because she provided treatment to some of the participants (n ⫽ 11) 5 years earlier, she was not entirely blind
to condition. Nonetheless, some of the reported indices
are clearly objective, such as the number of operations,
inpatient nights, and referrals to orthopedic surgeons,
physiotherapists, and injections. Differences were found
on a number of these variables and it is difficult to imagine
that these could be influenced by judgment bias.
Third, we were unable to collect accurate information
on medication from the files in this study. Clearly, this is
a major limitation. However, we assessed for differences in
medication usage in our earlier publications (8,9) and
none were evident up until the 18-month point. It is therefore unlikely that differences in medication can account
for these findings.
Finally, although the groups were relatively wellmatched on most of the outcome indices, there was a
difference at baseline in CRP levels. In our previous work,
however, we were able to show that this did not affect
outcome at posttreatment, 6-month followup (8), or 18month followup (9). Nonetheless, in order to ensure that
the effects could not be accounted for by CRP level differences, we excluded physiotherapy referrals from the total
health care use variable and included it as a covariate in
all parametric analyses. The results remained significant,
making it very unlikely that they are attributable to this
difference in a group that was otherwise very wellmatched at pretreatment.
Despite these limitations, our findings are important and
mark the first long-term demonstration of the reduction in
health care use among RA patients treated with CBT in the
crucial first 2 years of illness. However, in terms of service
planning, these reductions in health care use need to be
weighed against the cost of service provision. The treat-
ment in this study was administered by 2 psychologists: an
experienced clinical psychologist and a psychology graduate. The cost of this service per patient, using the same
medical benefits costs (12) as we used to weight health
care costs, is $1,000 ($125 per session ⫻ 8 sessions per
patient). Therefore, these data suggest that, on the limited
range of variables that we were able to assess, the cost of
the service is offset by the savings in health care use within
the first 5 years following diagnosis.
There are a number of strengths of the present study that
should be highlighted. The randomized controlled trial
was methodologically rigorous. We recruited consecutive
patients and the study benefited from high recruitment
rates and low attrition rates. Treatment was manualized
and could be replicated in clinical practice relatively easily. To our knowledge, our followup over 5 years is the
longest followup of a psychological intervention for RA.
This study was also the first to investigate the effect of
CBT administered in the crucial first 2 years after diagnosis of RA on health care usage. Investigating the effect of
CBT on long-term health care use is a particularly stringent test of a psychological invention administered over
a brief, 2-month period without any followup psychological care. The results support the long-term efficacy of
CBT administered early in the course of RA. If these results are extrapolated from the small sample reported here,
the savings to the health service industry are likely to be
While it is possible that not all of the differences we
found are directly attributable to CBT, there are a number
of reasons to believe that CBT contributed substantially to
our results. First, the earlier trial results found treatmentrelated differences in physical parameters, including CRP
level, joint function (8), and disability (9) that one might
expect to affect health care use. Second, the treatment was
administered within the first 2 years of illness, which is
known to be important to the long-term prognosis (4 –
7,15). The groups were relatively well-matched at baseline
(8). Further, other authors have reported changes in physical parameters of illness following CBT (16 –18). Although some other studies have failed to find physical
effects of CBT, these have typically involved patients with
severe and chronic RA (19,20). Therefore, our finding of
long-term health benefits of CBT use could be predicted on
the basis of the literature, including the only other study to
investigate health care use (3). The net savings in terms of
health care use are large for a small sample with earlystage disease. The net savings included 1 knee reconstruction and 3 hip replacement operations, 20 inpatient nights,
3 courses of physiotherapy, 3 referrals to orthopedic surgeons, 3 psychiatric referrals, 5 cortisone injections, and
1.45 rheumatology consultations per patient (37.7 total for
this sample). When the costs were used to weight the data,
the net savings from each patient to the health service
industry was $1,700 (over $40,000 total). The cost of 8
sessions of CBT ($1,000) is offset by these savings. These
results provide further support for recent arguments that
providing evidence-based treatments for RA is likely to be
cost-effective (14).
In summary, the present study indicates that CBT not
only produces improvements in psychological and physi-
Sharpe et al
cal morbidity (8,9), but also produces long-term reductions
in health care usage over 5 years. This provides further
strong support for the efficacy of CBT for patients with RA,
particularly when administered early in the course of the
illness. Importantly, in addition to reducing the emotional
burden to patients, these results suggest that CBT is likely
to be cost-effective. Over as short a period as 5 years, CBT
was found in this small sample to reduce the economic
burden of RA to patients and health care systems alike.
These results suggest that CBT within the first or second
year of the illness has long-term benefits, and that health
service systems should be encouraged to provide such
services to patients.
We would like to thank Dr. Natalie Timberlake and Mrs.
Bridget Ryan for their work on the project. We would also
like to thank all the participants who took part in the
Dr. Sharpe had full access to all of the data in the study and
takes responsibility for the integrity of the data and the accuracy
of the data analysis.
Study design. Sharpe, Allard, Sensky.
Acquisition of data. Sharpe.
Analysis and interpretation of data. Sharpe, Sensky.
Manuscript preparation. Sharpe, Sensky.
Statistical analysis. Sharpe.
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