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Team versus non-team outpatient care in rheumatoid arthritis.

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47 1
TEAM VERSUS NON-TEAM OUTPATIENT CARE IN
RHEUMATOID ARTHRITIS
A Comprehensive Outcome Evaluation Including an Overall Health Measure
MONICA AHLMEN, MARIANNE SULLIVAN, and ANDERS BJELLE
In a rheumatology department, 2 randomized
groups of female outpatients with rheumatoid arthritis
were studied prospectively for 1 year. The outcome of
multidisciplinary team care (T group, 31 patients) was
compared with that of regular outpatient clinic care (NT
group, 28 patients). Pharmacologic treatment and orthopedic specialist consultations were similar in both
groups, but use of paramedical care was higher in the T
group. Outcome measures of disease activity, specific
joint function, and self-rated physical discomfort disclosed no significant differences between the 2 groups.
Mental well-being increased in the T group. Overall
health, measured by the Sickness Impact Profile, improved significantly only in the T group. This improvement was also significant compared with the NT group.
The importance of quality of life as a measure of
disability and handicap in studies of various aspects of
health care technology has been emphasized in a
number of recent reports. Health status instruments
have been constructed for assessment of the impact of
sickness on physical, psychological, and socioecoFrom the Department of Rheumatology, Sahlgrenska University Hospital, and the Departments of Psychology and Social
Work, Gothenburg University, Gothenburg, Sweden.
Supported by grants from the Swedish Association Against
Rheumatism and the Gothenburg Medical Society.
Monica Ahlmen, MD: Department of Rheumatology, Sahlgrenska University Hospital; Marianne Sullivan, PhD: Associate
Professor, Departments of Psychology and Social Work, Gothenburg University; Anders Bjelle, MD: Professor of Rheumatology,
Sahlgrenska University Hospital.
Address reprint requests to Monica Ahlmen, MD, Department of Rheumatology, Sahlgrenska University Hospital, Gothenburg S-413 45, Sweden.
Submitted for publication April 7, 1987; accepted in revised
form October 13, 1987.
Arthritis and Rheumatism, Vol. 31, No. 4 (April 1988)
nomic function. Some were designed primarily for the
study of rheumatic diseases (1-4). Others aimed at
general applicability, e.g., the Sickness Impact Profile
(SIP) (5-8). In a trial of gold treatment in rheumatoid
arthritis (RA) patients, a health status measure was
reported to be sensitive in evaluating clinically meaningful drug-induced improvements (9).
A few earlier reports (10-12) have disclosed
favorable effects on disease activity manifestations and
on physical, psychological, and socioeconomic functions of long-term, comprehensive, multidisciplinary
outpatient care in RA. In a recent report by Spiegel et a1
(13), an overall health measure was included in the
comprehensive assessment of RA patients who initially
had been referred as inpatients to a multidisciplinary
team in a rheumatology rehabilitation unit and who
were observed prospectively for a year.
At the rheumatology department of the Sahlgrenska University Hospital in Gothenburg, an outpatient clinic with a specialized multidisciplinary team
(Figure 1) was organized in 1977. After a 5-year run-in
period, a comprehensive evaluation of the overall
effects of outpatient team treatment was requested.
The hypothesis of this prospective study of randomized ambulatory RA patients was that sickness impact
would be alleviated more by team care than by nonteam care offered by the regular outpatient clinic of the
same rheumatology unit.
PATIENTS AND METHODS
Patient selection. In 1983, female patients 38-73 years
of age, who had classic or definite RA (14) and who were due
for appointments at the regular outpatient clinic of the
university-based rheumatology department, were consecu-
AHLMEN ET AL
472
Figure 1. The design and interrelationships of the multidisciplinary team.
tively invited to participate in a 12-month study of outcome
effects of ambulatory care. Eligible patients could speak and
read Swedish, were not pregnant or lactating, and were
without current malignant, mental, or other disease, apart
from RA, that could limit their function. Patients classified in
functional class IV according to the criteria of Steinbrocker
et a1 (15) were not accepted. Patients formerly assigned to
the specialized team were excluded. The study was approved by the local ethics committee. All patients agreed to
participate.
By a sequential randomization procedure (16), 2
comparable study groups were obtained. Randomization
variables were age, duration of RA, joint involvement at
onset of RA, acute or insidious onset of RA, mode of
progression of RA, previous antiarthritic medication, duration of morning stiffness, and employment situation. The
number of patients needed in the study was estimated with
reference to the main outcome variable of overall SIP (17).
Study design. The study patients were not aware of
the differences in treatment models. Also, the 2 groups were
kept apart in separate outpatient clinics. They were intermixed with regular outpatients to minimize the possibility of
interpatient identification as study subjects. All patients
were seen at study entry (0 months) and after 6 and 12
months. Each patient was examined on all 3 occasions. At
study appointments, intervention procedures were registered and outcome measurements were applied to all patients by the same team members throughout the study. The
results of these tests were not known to the physicians who
were in charge of study patients at the regular outpatient
clinic.
Thirty-one patients were randomly allocated to mul-
tidisciplinary team outpatient care ( T group) and 29 nonteam-treated patients (NT group) to the regular outpatient
clinic. One patient in the NT group (definite RA, functional
class I) failed to complete the study because of lack of time.
inability to leave her job, and a feeling of well-being. All
patients were white women. The mean age was 58.6 years in
the T group and 58.4 in the NT group. Mean duration of RA
was 11.0 and 11.8 years, respectively. Thirty-seven percent
of the patients entered the study in late spring and 63% in the
autumn. For 26% of the patients in the T group and 29% in
the NT group, entry to the study was their first appointment
at the rheumatology department. Further characteristics of
the study patients are given in Table I .
The multidisciplinary team care. Patients from the T
group were enrolled at the outpatient team clinic for comprehensive care. The team consisted of a rheumatologist, a
nurse, a physiotherapist, an occupational therapist, and a
medical social worker (Figure 1). The physician evaluated
current disease activity (including articular indices), noted the
patient’s self-rated physical discomforts, modified and registered the drug treatment, and referred the patient to an
orthopedic surgeon if necessary. The nurse drew blood samples, administered a mood questionnaire, gave supplementary
information about medication, and answered the patient’s
questions concerning these matters. The physiotherapist reviewed joint function and muscle strength (including ambulation and walking capacity), gave advice about footwear, and
distributed walking aids or neck collars when needed. The
occupational therapist assessed specific joint function of the
hands and wrists, measured grip strength, and studied the
patient’s capacity to perform activities of daily living. Adaptive equipment and joint splints were provided if necessary.
The social worker analyzed the patient’s socioeconomic situation and psychological condition and intervened with support when necessary.
All members of the team focused on educating the
patient about the rheumatic disease, joint protection, exercise programs, self-care, energy conservation, and household and work activities, as well as recreation and social
functions. Five education sessions (2 hours each) were
arranged for groups of patients, or similar information was
Table 1. Characteristics of the tedm-treated (T) and non-teamtreated (NT) rheumatoid arthritis (RA) patient groups at study entry
T group
(n = 31)
% female
Age, mean 2 SD
% 265 years old
Duration of RA, mean ? SD
% with RA 5 4 years
% with RA 2 1 0 years
% rheumatoid factor-positive*
Functional class, mean f SDt
% in functional class I
% in functional class 11
% in functional class I11
* Red blood cell hernagglutination
t See ref. 15.
I00
58.6 2 9.4
26
11.0 F 8.1
26
39
77
2.1 2 0.5
6
74
20
titer >1:40.
N T group
(n = 28)
I00
58.4
+.
9.5
25
11.8 +- 12.2
29
36
82
2.1
2
0
89
I1
0.3
OUTPATIENT TEAM CARE IN RA
473
Table 2. Disease activity and specific joint motion function outcome measures in the team-treated (T) and non-team-treated (NT) groups
at selected timepoints*
T group (n
Disease activityt
C-reactive protein, pgiml
Ritchie Articular Index
Lansbury Articular lndex
Specific joint motion function
Keitel Index, %
Grip strength, mm Hg
=
NT group (n
31)
12 mos.
0 mos.
6 mos.
17.5 t 23.1
11.1 t 7.4
71.1 k 43.7
14.7 2 19.5
10.8 i 7.0
57.4 2 37.7t
15.5
10.6
51.0
40.9 2 23.0
121 +- 75
39.2 i 20.6
118 i 64
37.2 ? 19.3
116 t 61
?
?
2
22.4
8.4
43.3
=
28)
0 mos.
6 mos.
12 mos.
18.4 i 25.5
12.1 ? 8.2
64.4 f 37.8
15.9 2 18.8
10.3 t 7.2
54.1 i 33.7$
12.5 -+ 16.9
11.1 2 7.5
50.0 -f 34.9i
37.0 t 17.9
118 t 67
35.3 t 15.8
124 i 67
37.7 t 17.0
I16 t- 62
* Values are the mean i SD.
t For all measures except grip strength, a higher numerical value implies a higher degree of disease activity or dysfunction.
i P < 0.05 versus 0 mos.
given individually to patients at the regular appointments
with team members.
Patients were examined separately by each team
member, and treatment needs were assessed, explained, and
discussed with the patient. A team conference followed.
This was attended by all members of the team, but not the
patient, and the accumulated information on the patient’s
overall condition was discussed and analyzed. An individualized therapeutic and education program was drawn up,
treatment goals were formulated, and time limits set. To
carry out the planned interventions, appointments were
given to the patients by telephone or by letters from each
member of the team.
The team’s capacity was 5 patients per day, 2 to 3
days per week. Patient education and all treatment were given
by the team members and their assistants at the team clinic.
The regular outpatient clinic. The patients in the NT
group were seen by physicians in charge of the regular
outpatient clinic of the rheumatology department. Eighteen
of the NT patients were seen by qualified specialists in
rheumatology at all followup visits throughout the 12-month
study period. Six additional patients were seen by a specialist twice, and 4 patients once.
Nurses and a medical social worker attended the
outpatient clinic; their services to patients were initiated by
the doctor. Physiotherapists and occupational therapists
trained in rheumatology were available within the hospital
for patient treatment upon referrals from the physicians.
Patient education on rheumatic disease, treatment, and joint
Table 3.
protection was organized through the Department of Occupational Therapy at the hospital, on referral from a physician. Treatment decisions were made exclusively by the
outpatient clinic staff. Those patients who reported dysfunctions at the study examinations by team members were
asked to discuss these matters with their doctors. Besides
the study followup appointments, the frequency of medical
consultations at the outpatient clinic for the NT patients was
decided by each physician. The average time for visits to the
outpatient clinic was 60 minutes for first appointments and
30 minutes for followup visits.
Outcome measures. Disease activity was measured
by routine analysis of C-reactive protein (CRP; normal 5 5
pg/ml) (18) and assessment ofjoint tenderness by the physician according to the Ritchie Articular Index (RAI; maximum score 78) (19) and the Lansbury Articular Index (LAI)
(20), in which joints painful on pressure or motion are scored
in relation to their size (maximum score 242) (Table 2).
Specific joint function of isolated joints and joint
groups, including walking time and stair tests, was scored
according to the method of Keitel et al (21), as described by
Eberl et al ( 2 2 ) . The worst possible function index was 96
points (loo%), with knee bend performance excluded because it was potentially detrimental to the patients. Grip
strength was measured using an aneroid manometer attached
to a special rubber cuff (Boots, Nottingham, UK) inflated to
20 mm Hg. The best of 3 readings for the right hand was
registered to the nearest 5 rnm Hg (Table 2 ) .
Self-rated physical discomforts were recorded using
Mood Adjective Check List (MACL) scores in the team-treated (T) and non-team-treated (NT) groups at selected timepoints*
T group (n = 3 1)
0 mos.
6 mos.
NT group (n = 28)
0 mos.
12 mos.
6 mos.
12 mos.
~
Pleasantnessiunpleasantness
Activation/deactivation
Calmnessitension
Extraversionlintroversion
Positivehegative social orientation
Confidence/lack of confidence
Overall MACL
3.33
3.29
3.18
3.07
3.71
3.09
3.28
t 0.43
t 0.47
2
5
t
t
t
0.71
0.46
0.33
0.49
0.33
3.35
3.11
3.18
3.04
3.61
3.08
3.22
0.36
2 0.501
i 0.67
2 0.49
t 0.36
2 0.52
i 0.31
2
3.33
3.17
3.20
3.20
3.62
3.22
3.29
0.45
i 0.53
i 0.62
2 0.42t
t 0.38
i 0.46
i 0.31
?
* A higher MACL score implies a more positive emotional state; values are the mean
t P < 0.05 versus 0 mos.
?
3.26
3.21
2.86
3.12
3.72
2.78
3.16
SD.
t 0.65
i
2
t
t
t
t
0.53
0.95
0.46
0.32
0.73
0.46
3.25
3.11
2.92
3.13
3.72
3.00
3.17
t 0.60
I
0.54
i 0.87
2
0.53
i 0.19
t 0.74
t 0.45
3.26 2 0.56
3.04 2 0.60
3.00 2 0.80
3.06 2 0.47
3.67 ? 0.27
2.89 2 0.69
3.15 ? 0.44
474
AHLMEN ET AL
Table 4. Group mean scores of indices and subscales of the Sickness Impact Profile (SIP) in the team-treated (T) and non-team-treated
(NT) groups at 0 months and mean score differences at the 12-month observation*
T group (n = 3 1)
Score, 0
mos.
Overall SIP Index
Physical Index
Ambulation
Mobility
Body Care and Movement
Psychosocial Index
Social Interaction
Communication
Alertness Behavior
Emotional Behavior
Independent subscales
Sleep and Rest
Eating
Work
Home Management
Recreation and Pastimes
* Values are the mean -C SD. N S
t P < 0.01 versus 0 mos.
t P < 0.05 versus 0 mos.
=
NT group (n = 28)
Difference, 12
mos.
Score, 0
mos .
22.1
22.7
27.7
21.0
19.2
11.1
13.3
9.7
7.5
13.7
t 11.8
f 15.8
f 18.1
f 22.3
f 11.3
f 7.8
t 9.5
f 8.2
f 14.0
t 13.7
-3.6
-4.6
-5.4
-4.8
-3.6
-3.3
-3.4
-3.1
- 1.1
-5.7
?
t 9.3t
t 14.9
f 8.53:
f 7.1$
7.w
2 8.33:
f 14.6
t 13.7t
19.8
19.8
23.9
19.0
16.6
11.2
10.5
6.9
9.8
17.6
25.9
4.1
45.2
44.9
33.3
t 20.1
f 4.7
t 32.3
f 26.2
-2 8
-0.8
-5.8
-4.0
-2.3
t 17.2
f 6.2
t 32.5
4 15.6
i 15.5
26.5
4.2
36.0
37.4
29.3
f
18.8
6.2t
5 7.7t
Difference, 12
mos.
f 11.0
-0.1
f 13.1
k 12.7
t 22.3
? 9.1
f 11.6
t 9.9
f 8.6
f 18.2
t 21.5
0.3
1.7
-0.3
-0.6
-0.7
0.5
-0.6
2.1
-4.7
f 17.3
2 5.6
1.3 t 14.9
0.2 t 6.8
1.0 f 25.1
-3.9 t 11.5
1.7 t 17.8
t 33.4
26.4
-c 18.5
?
?
?
f
t
t
t
f
f
5.3
5.5
8.6
9.1
6.8
6.7
8.8
10.2
f 11.2
Tt 10.7f
P
<0.05
<0.01
<0.01
NS
NS
NS
<0.10
NS
NS
NS
NS
NS
NS
NS
NS
not significant.
the Body Symptom Scale (BSS) questionnaire (23), to which
12 rheumatic complaint items were added. The patients
checked items of discomfort experienced during the preceding week on a scale of 1-4, where a higher score implied less
discomfort. From a factor analysis of BSS records of 99
women with RA (Sullivan M, Ahlmen M, Bjelle A: unpublished observations), 3 groups of items relevant to arthritis
emerged, as follows: 1) Joint pain during the day, at night, or
on motion; muscle pain, joint tenderness, and sleep disturbances. 2) Diminished interest in sex, headache, fatigue, and
perspiration. 3) Joint stiffness on motion, joint swelling, and
morning stiffness. Only items with factor loadings >0.50
were included. The mean scores of each of these symptom
groups were used as composite variables for outcome assessment in this study.
The Mood Adjective Check List (MACL) (24) was
used to measure emotional state and mental well-being. This
self-administered test contains 71 mood adjectives. Patients
check items, according to their current emotional state on a
scale of 1-4. A higher MACL score implies a more positive
emotional state. The MACL is reduced into 6 bipolar dimensions (Table 3). In this study, these were also aggregated into
an overall MACL dimension for further analysis. A detailed
description of the MACL has been given elsewhere (25).
Overall health was assessed using the SIP (8). This
measure has been found to be valuable for clinical use in RA
(26), especially for discrimination between groups of patients
(27). Validity of the SIP has been reported to be maintained
with repeated administrations (28). The SIP is a standardized
questionnaire with I36 items describing behavior or activities within 12 categories of life function. Respondents check
only those items that describe current dysfunction due to
their illness. Each item has been given a weight figure based
on estimates of the severity of each dysfunction. Individual
patient scores calculated are expressed as a percent of
maximum dysfunctional score. SIP subscales (Table 4) are
aggregated into a Physical Index covering Ambufation, Mobility, and Body Care and Movement; a Psychosocial Index
covering Social Interaction, Communication, Alertness Behavior, and Emotional Behavior; and into an Overall SIP
Index including Physical Index, Psychosocial Index, and the
independent subscales Sleep and Rest, Eating, Work, Home
Management, and Recreation and Pastimes. Prior to this
study, a Swedish version of the SIP had been tested and
found reliable, valid, and sensitive in a population study of
women with rheumatic disorders (29). In both studies, the
interviewer administration form was used.
Statistical methods. Fisher’s nonparametric permutation test was used for the main analysis: the significance
testing of differences between groups (30). Findings were
considered significant, positive or negative, at the 5% level
(2-tailed test) if the exact P value was >1-0.05/2 or <0.05/2,
respectively. To correct for differences between groups at
the start of the study, an extension of Mantel’s technique of
pooling (31) was applied to Fisher’s permutation test. To test
differences between groups concerning therapeutic interventions, contingency tables with a chi-square method were
used. To study intragroup changes over time, Fisher’s
nonparametric permutation test for paired observations was
used (30).
Of every 20 test results found to be significant at the
5% level, 1 falsely significant value may be expected; therefore, the analytic procedure was fixed in advance, with the
number of variables minimized. Three disease activity variables, 2 function tests, 3 symptom variables, 3 health indices and their 12 basic subscales, and 1 mood index with
OUTPATIENT TEAM CARE IN RA
its 6 dimensions were chosen as main outcome variables
(Tables 1-4).
475
Joint pain days and nights, joint pain on motion,
muscle pain, joint tenderness, sleep disturbances.
Score
RESULTS
Study entry data. No significant differences
were found between the 2 patient groups regarding
mean age o r age distribution, disease duration, rheumatoid factor, or functional class (Table 1). Long-term
drug treatment was also similar: 65% of the patients
were treated with nonsteroidal antiinflammatory
drugs, 30% with disease-modifying antirheumatic
drugs, and 25% with low-dose oral corticosteroids.
Previous contacts with physiotherapists, occupational
therapists, and medical social workers were equivalent. The mean values of CRP, RAI, and LA1 disclosed a moderate degree of disease activity in both
patient groups, the Keitel Index was reduced by 40%
compared with normal function, and grip strength was
approximately one-third of normal (Table 2).
Self-rated physical discomforts (Figure 2)
mainly concerned the composite symptom variable
“joint stiffness and swelling, morning stiffness.” Considerable discomfort was also noted for the symptom
group “joint pain days and nights, joint pain on
motion, muscle pain, joint tenderness, sleep disturbances.” The mean scores did not differ significantly
between the T and NT groups. The mood dimension
scores (Table 3 ) in the T and NT groups deviated only
slightly from MACL scores reported earlier in a population group of nonarthritic women in Gothenburg
(25). The mean scores for confidenceilack of confidence were higher ( P < 0.10) in the T group.
The overall SIP score indicated dysfunction levels -20% of the maximum dysfunction level in both
patient groups (Figure 3 ) . No significant differences
between group means were found. SIP categories contributing most to the overall sickness impact were
Work, Home Management, Recreation and Pastimes,
Ambulation, Sleep and Rest, and Mobility (Table 4). In
7 corresponding SIP subscales (Sleep and Rest, Emotional Behavior, Home Management, Mobility, Alertness Behavior, Work, and Recreation and Pastimes) in
each patient group, a maximum dysfunction score
>60% was noted (Table 4). The influence on overall
health from the SIP Psychosocial Index was less pronounced than that from the SIP Physical Index.
Followup data. A similar increase in drug treatment was noticed in both patient groups, and no
significant differences were found between the T and
NT patients, either at the 6-month or at the 12-month
followup. At the 12-month followup, approximately
80% of the patients were taking nonsteroidal antiin-
Team group
Mild
Non-team group
4
1
Severe
I
0
6
12
0
6
12 Months
Diminished interest in sexual life, headache,
fatigue, perspiration.
1
Score
Mild
4
Team group
- r T T
,
-
7
0
6
12 Months
Non-team group
*I
Severe
0
6
12
Joint stiffness and swelling, morning stiffness.
Score
Mild
Team group
Non-team group
4
3-1
0
6
12
0
6
12 Months
Figure 2. Self-rated physical discomforts in the team-treated group
(n = 31) and non-team-treated group (n = 28) at study entry (0
months) and at the 6- and 12-month followups. Values are the means
5 SD. * = P < 0.05,6- and 12-month scores versus scores at study
entry; t = P < 0.01, 12-month score versus score at study entry.
flammatory drugs, and 50% were receiving diseasemodifying antirheumatic drugs. The percentage of
patients receiving low-dose oral corticosteroid medication was unchanged compared with the percentage
at study entry. No significant differences were found
between the groups concerning intraarticular corticosteroid injections given during the study period. Orthopedic specialist consultations were equally common in both study groups, as was the number of
patients referred for inpatient rheumatologic care.
Correcting for outpatient visits for gold injections only, the number of appointments with physi-
AHLMEN ET AL
476
Team group
Non-team group
Score
means
%
Score
means
%
Overall SIP
index
Physical
Index
Overall SIP
Index
TT
Physical
Index
T
20
20
Psychosocial
Index
10
10
0612
0612
0612
Months
0 6 12
0 6 12
0 6 12
Months
Figure 3. Sickness Impact Profile (SIP) scores in the team-treated (n = 31) and non-team-treated (n =
28) groups at study entry (0 months) and at the 6- and 12-month observations. Higher SIP score implies
SEM. * = P < 0.01. 6- and 12-month scores versus
greater dysfunction; values are the means
scores at study entry; t = P < 0.05, 6- and 12-month scores versus scores at study entry.
*
cians during the study period was similar for the T and
NT groups (mean 4.0 and 3.7, respectively). The
number of physiotherapist contacts (mean 16.2) among
T patients significantly (P < 0.01) exceeded that of NT
patients (mean 5.6); thus, the majority of T patients
had joined groups for their physiotherapy training. At
the 6-month followup visit, 18 T and 9 NT patients had
received physiotherapy training, and after 12 months
another T patient and 2 NT patients had been treated.
Furthermore, 29 of the 31 patients in the T group, but
only 1 patient in the NT group, received instructions
for home exercises at the start of the study. Interventions by the occupational therapist in the T group
(mean number of visits 6.9) also significantly ( P <
0.01) outnumbered those in the NT group (mean
number of visits 2.1). Hand exercise training and joint
protection instructions, combined with assessment of
the need for technical aids or devices, had been given
to 23 T patients and to 7 NT patients at the 6-month
observation, and an additional 7 T patients and 8 NT
patients had received such treatment at 12 months. A
significantly (P < 0.01) higher frequency of contacts
with the medical social worker was registered in the T
group, where all patients, by definition, visited this
team member at the regular study appointments, and 4
patients needed additional attendance during the I2
months of observation. In the NT group, 8 patients in
all were referred to a medical social worker.
Of the disease activity outcome measures (Table
2), LA1 had improved significantly (P < 0.05) in both
the T and NT groups at 6 months. N o additional
improvement was noted at the 12-month observation.
No significant difference between the T and NT groups
was found, however, regarding LA1 improvement at
the 6-month or 12-month observation. CRP values and
RAI scores remained essentially unchanged in both
patient groups during the study period. The specific
joint motion function score failed to disclose significant
intra- or intergroup differences (Table 2), and the mean
functional class rating remained unchanged (data not
shown). BSS scores improved in both study groups
during the 12-month observation period (Figure 2);
however, no significant differences were found between
the T and NT patients. Improvements in mood dimensions were registered within the T group for activation
(P< 0.05) at 6 months and for extraversion (P < 0.05)
at 12 months (Table 3). lntragroup MACL scores in NT
patients were essentially unchanged. Intergroup testing
of mean score differences indicated a significant improvement regarding confidence (P < 0.05) in the T
OUTPATIENT TEAM CARE IN RA
group at I2 months. After correction for individual
differences at study entry, however, this significance
could not be confirmed.
At study entry, a positive correlation (r =
0.472, P < 0.01) was found between SIP Physical
Index and SIP Psychosocial Index scores, while a
negative correlation ( r = -0.24, P < 0.05) was noted
for SIP Psychosocial Index scores and duration of RA.
Comparisons of overall health changes between the 2
patient groups at the conclusion of the study revealed
significant improvements in the T group for SIP Physical Index ( P < 0.01) and for overall SIP (P < 0.05),
while the SIP Psychosocial Index failed to disclose
significant intergroup differences (Table 4). An intragroup improvement of mean scores for all 3 SIP indices
was noted at 12 months in the T group, but no significant changes were found within the NT group (Figure
3). Intragroup analyses of SIP score differences at 12
months (Table 4) indicated improvement in all subscales in the T group. The small differences, in both
directions, found for SIP subscale scores in the NT
group indicated both improvement and deterioration,
and the 3 SIP indices remained essentially unchanged.
DISCUSSION
This prospective randomized study of female
RA outpatients confirmed the assumption that overall
health, as registered by a multidimensional measure,
the SIP, would improve more with multidisciplinary
team care than with regular rheumatology outpatient
clinic care. The enhancement was most pronounced
for physical aspects of life activity, especially ambulation; the laboratory measure of disease activity, the
arthritis indices used, and the judgments of function by
assessors failed to disclose differences between the
study groups, as did the patients’ self-rating of physical discomforts and emotional feelings.
The study patients were not aware of the treatment models being compared. All expressed expectations of coming into contact with a physician at a
rheumatology clinic and receiving a suitable treatment
program for their RA. For NT patients, the assessment
of outcome measures by the team members at study
visits may have led to increased focus on functional
impairments that they readily discussed with their
physicians. This, in turn, might have led the physicians to increase the measures taken at the regular
outpatient clinic to treat the dysfunctions observed.
To diminish the bias due to lack of “blinded” observers for assessment of outcome measures, team members had been trained in objectivity in an earlier
477
investigation. Also, all calculations were made when
the study was completed. Results of outcome measures from previous study appointments were not
made available to the assessors at later visits.
Therapeutic interventions that generally are
looked upon as initiated by a physician (e.g., drug
treatment, orthopedic specialist consultations, and referral to inpatient care) were equally common in both
patient groups. Equal changes were found in both
groups concerning disease activity, and LA1 had already improved significantly in both study groups at 6
months of observation. Also, no significant differences
were registered between the 2 patient groups concerning specific joint motion function or grip strength.
These results deviated from those of earlier studies
(10,12), where disease activity measures and grip
strength were reported to be significantly improved in
patients treated by a multidisciplinary RA outpatient
team for I year. One possible explanation for these
divergent results is differences in disease activity at
entry to the study. Also, regular home visits by a nurse
were included in the program in the previous studies.
Thus, control of medication and joint protection may
have been better than in our model of comprehensive
team care.
In the T group, the use of instruction and
training by the physiotherapist and occupational therapist services exceeded that in the NT group. The
skills of these allied health professionals were actively
exploited in the assessment of T patients’ needs. This
may partly explain the more pronounced improvement
of ambulation and body care and movement observed
among T patients. Accordingly, significant improvement of activities of daily living was reported in earlier
studies of comprehensive outpatient care in RA
(10,12). Also, in the recent report by Spiegel et al (13),
team-treated RA patients improved significantly more
in physical function measures than did non-teamtreated patients.
The services of the medical social worker were
readily accessible to T patients. Interventions concerning psychosocial and economic impacts of illness
were substantial, with a minimum of delay in problemsolving. A common goal for the members of the
specialized team was patient education about the
rheumatic disease, various treatment modalities, and
self-care. Besides formal education courses, information was given continuously during training sessions,
which were noted to be more frequent among T
patients, and at other appointments with the team
members. Similar therapeutic interventions have been
shown by others (32) to increase not only factual
AHLMEN ET AL
478
knowledge about the disease, but also the self-concept
in patients with RA, with no increase in depression
level reported. Another factor contributing to the
psychosocial improvement in the T group might have
been the spontaneous interpatient counseling about
illness problems that arose through these group contacts. Communication between patients, and with and
between team members, was made easier by our
model of comprehensive multidisciplinary care. These
factors are also likely to improve the psychosocial
well-being of team-treated patients. Similar effects and
causes have been suggested in other studies (10-13).
Describing dysfunctional behavior, rather than
observed or self-assessed symptoms, the SIP does not
include a separate pain subscale. Pain has been reported to be important in health status measurement in
RA (33). Also, joint pain has been shown to contribute
to morbidity in experimentally induced arthritis (34).
In a study of patients with rheumatic disease ( 3 3 ,
current pain was found to be associated with subsequent physical disability. In a study of arthritis patients (80% osteoarthritis, 20% RA), however, the SIP
was reported to efficiently describe dysfunctional
changes in mobility and social and global assessments,
even in comparison with health status instruments that
include pain scales (36). No significant differences
were found between our randomized study groups
concerning self-rated physical discomforts (BSS), including pain. Nevertheless, the T group patients
showed more improvement in their overall health than
NT patients, especially in physical ability.
In our patient samples, the mean age was 58
years and the mean duration of RA was 1 1 years. An
earlier observation (37) that disability in RA increases
most rapidly in the first 10-12 years of disease perhaps
explains the rather low numerical values of change in
this study.
The SIP Physical and Psychosocial dimension
scores in RA have been reported to correlate positively with each other (i.e., at a given time point,
poorer physical function is accompanied by poorer
psychosocial status) (26). The finding was confirmed in
our female RA group. We also confirmed that SIP
Psychosocial dimension scores were negatively correlated with RA duration, which suggests improved
psychosocial function in patients with longstanding
disease (26). These postulates, and the finding in this
study that overall health improved more with team
care, suggest that RA patients with medium disease
duration and high disease activity would be the most
suitable group for comprehensive team care. RA patients with longstanding disease, who face the threat of
imminent physical deterioration, should also benefit
from multidisciplinary team treatment in an outpatient
setting. A forthcoming report will scrutinize predictive
factors for improvement from team care, and address
the issue of economic outcome of team care versus
non-team care.
ACKNOWLEDGMENTS
The authors acknowledge the contributions of the
members of the team: nurse Helene Pettersson, physiotherapist Ingela Nordwall, occupational therapist Birgitha Archenholtz, and medical social worker Gunnel Svensson, as
well as secretaries Ulla Nydeglrd, Wanda Lagerkvist, and
Ava Andersson. Nils-Gunnar Pehrson, PhD, was the statistical advisor.
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