Intervention
The impact on self-efficacy of different types of follow-up care and disease status in patients with rheumatoid arthritis—A randomized trial

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Abstract

Objective

To explore the impact from different types of outpatient care, demographic and disease related variables on self-efficacy beliefs (SE) in patients with established rheumatoid arthritis (RA) after completing an educational program.

Methods

287 adult RA outpatients with low disease activity and moderate physical disability from two Danish rheumatology clinics were randomized for follow-up care. 1: planned rheumatologist's consultations, 2: a shared care model without planned consultations, 3: planned nursing consultations. The participants’ SE were assessed by the Danish versions of the Rheumatoid Arthritis Self-Efficacy questionnaire (RASE) and the Arthritis Self-Efficacy Scale (ASES). Data were collected at baseline, 3 months and one-year follow up and were explored in random intercept models.

Results

Following an educational programme the nursing group increased or stabilized their SE during the first year compared to the medical and the shared care group. SE in the shared care group did not differ significantly from the medical group. No difference between the groups was seen in disease activity at any time.

Conclusion

Nursing consultations provide opportunities for maintenance of the patients’ SE after patient education.

Practice implications

Implementation of nursing consultations as part of follow-up care in patients with stable RA is recommended.

Introduction

Rheumatoid arthritis (RA) is a chronic autoimmune joint disease with an increased risk of joint damage and disability if disease control is not achieved and optimized from early on [1], [2]. Traditionally RA patients are managed by planned medical consultations every 3–12 months [2], [3], [4]. In Denmark we expect an increase in the incidence and prevalence of RA due to a general as well as a disease-specific longer life expectancy [5]. At the same time we expect an increased unmet demand for rheumatologists [6]. This provides a challenge to the health care system in order to organize chronic disease monitoring in the most efficient and cost-effective way, while still keeping the patient perspective in mind. British and Dutch studies have indicated that patients with RA monitored in consultations by nurse specialists [7], [8], [9], [10] or different versions of shared care [11], [12], [13], [14] are not worse off compared to outpatients managed by junior or senior hospital doctors with respect to the control of disease activity and preservation of physical function.

Based on this, the AMBRA-study (AMBulant behandling af Reumatoid Artrit – Outpatient care of established RA) was planned in a cooperation between King Christian X's Hospital for Rheumatic Diseases in Graasten, Denmark (hospital 1) and the Department of Rheumatology at Vejle Hospital, Denmark (hospital 2). The AMBRA-study was to be conducted from January 2008 through February 2011. The aim of the AMBRA-study was to compare disease control and physical disability in a traditional outpatient setting that was carried out by senior or junior rheumatologists to nursing consultations or a shared care model in a non-inferiority trial. The main data have not yet been reported. This paper describes a sub-study to the two year AMBRA-study with a focus on the participant's self-efficacy beliefs (SE) during the first year of follow-up.

There is an increasing awareness that RA is influenced by psychosocial factors such as SE [15]. Perceived SE refers to the belief in one's own capability to organize and perform the activities needed to reach a desired outcome or result [16].

Scarce evidence exist as to whether health professionals can affect the patients’ SE through individual consultations [17]. In a previous study the participants in a shared care version increased their self-efficacy beliefs in the first 21 months compared to participants in traditional medical follow up [11]. Nurses tend to focus on the patients’ self-management and coping abilities and thus an increase in the patients’ self-efficacy beliefs might be expected in the nursing group [42], whereas the rheumatologists tend to focus on disease control and the pharmacological treatment [2], [4]. We thus hypothesised that, following an educational programme, differences may occur in how the patients’ SE develop in different types of follow-up care.

The dominant measure of SE, the Arthritis Self-Efficacy Scale (ASES) [18], [19] has been found to be highly associated with disease-related variables [20], [21], [22] as improvements in disease related variables occurred at the same time as an increase in self-efficacy beliefs [19], [20], [22], [23], [24]. Still research is needed to explore how disease-related variables affect the patients’ SE beliefs [17]. A new SE scale, the Rheumatoid Arthritis Self-Efficacy questionnaire (RASE) was shown to be independent on physical disease-related variables [25].

The aim of this study was, after the completion of an educational program, to assess whether one year in nursing consultations or shared care had different impact on the participants’ SE than traditional medical follow-up. Furthermore the study aimed to explore the influence of demographic and disease-related variables on the participants’ SE.

Section snippets

Participants

Consecutive outpatients with RA were assessed during their planned medical consultations at the two participating hospitals to establish whether they met the admission criteria. Eligible patients were: aged over 18, RA diagnosis fulfilled (American College of Rheumatology's (ACR) list criteria) [26] for at least 18 months, Disease Activity Score (DAS-28-CRP)  3.2 [27], Health Assessment Questionnaire (HAQ) < 2.5 [28], no increase in steroid or DMARD in the past three months and where oral and

Descriptive statistics

In total 1080 outpatients with RA were followed at hospital 1 and 203 outpatients were enrolled (18.8%) (Fig. 1). The group of patients who did not meet the admission criteria was significantly older and the share of women was significantly higher than in the group of enrolled patients. In total 487 outpatients were followed at hospital 2 and 84 (17.2%) were enrolled in the study. Characteristics of the participants are depicted in Table 1. No information was retrieved about the reasons for

Discussion

This study adds to the very scarce evidence of whether the patients’ SE can change based on attending individual consultations [17]. In accordance with our hypothesis, differences did occur in the participants’ SE during the first year of follow-up after attending the educational program but the differences only reached significance between the nursing group and the other two groups. Apart from the ASES-subscale ‘pain’, the SE increased or stabilized in all the SE scales for participants in the

Acknowledgements

We would like to thank all the patients who patiently completed all the questionnaires in the study. Thank you to Lorna Campbell for help in fine-tuning the English language and DANBIO for hosting our data during the study. Thank you to the AMBRA support group (patient research partners, GPs and departmental managers and clinicians from the two hospitals and the Department of Quality in the Region of Southern Denmark). We also want to acknowledge the University of Southern Denmark, Sygehus

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