OVERVIEW OF THE SELECTED STUDIES
Ahlmen et al. (1988) conducted a controlled trial to assess the effectiveness of a multidisciplinary team approach in treating patients with rheumatoid arthritis (RA). Sixty female patients were sequentially randomized to either a multidisciplinary treatment team or a regular outpatient clinic team. The intervention consisted of 5, 2-hour individualized patient training sessions led by a multidisciplinary team of providers. A rheumatologist, a nurse, a physiotherapist, an occupational therapist, and a medical social worker conducted the sessions. Regular outpatient clinic team patients received only usual care.
Results of this study showed that patients treated in the multidisciplinary team had statistically significant improvement in the Sickness Impact Profile Physical Index score when compared with the regular outpatient team (effect size [ES] 0.60; 95% confidence interval [CI] 0.07, 1.12). Other clinical outcomes measured include the Ritchie Articular Index (RAI), the Keitel Index for specific joint function, the Body Symptom Scale questionnaire for self-assessed physical problems, and the Mood Adjective Check List. No significant differences were observed for these tests.
A controlled before and after trial performed by Anderson (1988) evaluated the effects of short periods of hospitalization to treat active RA on long-term outcomes. Patients were given the option of admission into the rheumatic disease unit (intervention group) or continuation of regular outpatient care (comparison group). Sixteen patients enrolled in the intervention group and 10 patients continued with outpatient care. A multidisciplinary team of physicians, nurses, physical and occupational therapists, social workers, nutritionists, and chaplain treated the hospitalized intervention group patients. Upon discharge, each patient continued to receive care from the same rheumatologist they interacted with while hospitalized. The comparison group maintained their regular outpatient medical program. Clinical outcomes measured were serum rheumatoid factor, erythrocyte sedimentation rate (ESR), morning stiffness, visual analog scale (VAS), grip strength, number of inflamed joints, and a self-reported global assessment. The intervention group had statistically significant improvements in morning stiffness, pain, and joint score at all time points throughout the 2-year followup. The comparison group saw significant improvement only at the end of the 2 years. The results indicated that outcomes improved much quicker in the hospitalized patients and that these improvements were maintained over time. Authors concluded that short hospitalization and multidisciplinary treatment of patients with active RA would lead to a more rapid improvement in clinical outcomes compared to regular outpatient therapy.
Katz (1968) measured the effectiveness of extending the efforts of a multidisciplinary team into the home environment. Forty hospitalized patients were randomized evenly into treatment and control groups. Treatment patients received care from a multidisciplinary team at the arthritis clinic. The multidisciplinary team consisted of rheumatologists, internists, orthopedists, resident physicians, nurses, physical and occupational therapists, a podiatrist, a social worker, and various support staff. In addition, the treatment group received home care service from a public health nurse. The control group only received care from the multidisciplinary team at the arthritis clinic. The Lansbury's Index was used to measure disease activity and functional status. A 5-grade walking scale measured patients' walking ability and the index of independence in activities of daily living assessed functional performance in day-to-day activities. House confinement and socioeconomic function were also recorded. Results showed that the decrease in deterioration of activities of daily living was statistically significant for the treatment group (ES 1.08; 95% CI 0.05, 2.11). The treatment group also had more numerous improvements on the other outcomes, but these did not reach statistical significance. The authors agreed that patients with severe RA would benefit from a multidisciplinary team approach extending into coordinated home care.
In their controlled trial, Taal et al (1993) evaluated the effects of group education on health status, behavior, self-efficacy and outcomes expectations, and disease knowledge of patients with RA. Thirty-eight patients were randomized to the group education program and 37 patients to the comparison group not receiving the education program. The intervention was comprised of a 1-hour educational seminar meeting for 5 consecutive weeks. Nurses specializing in rheumatic diseases, physiotherapists, or social workers led the group sessions. A program book and an audiotape with relaxation exercises were also distributed. A Dutch version of the modified Health Assessment Questionnaire (mHAQ) was used to measure functional disability 6 weeks after the start of the intervention. A statistical improvement was seen for patients in the group education program (ES 0.63; 95% CI 0.10, 1.17). This positive effect was still present at the 14-month followup.
Schned (1995) examined how effective a multidisciplinary team intervention approach would be if provided early in the course of chronic inflammatory arthritis. Employing a pairwise randomization scheme, 57 patients were enrolled into the experimental group and 50 to the control group. The experimental group participated in a Comprehensive Care Program, consisting of a baseline assessment interview, normal primary care services, and a half-day self-management and education seminar within 4 months of enrollment. In addition, members of the multidisciplinary team (a rheumatologist, a mental health specialist, a social worker, a podiatrist, a nurse, a dietitian, a physical therapist, and an occupational therapist) reviewed the status of all experimental group patients on a monthly basis. The control group received traditional care from rheumatologists and primary care physicians. Various clinical outcomes were assessed: mHAQ for functional disability, VAS for overall health, Arthritis Impact Measurement Scale (AIMS) for health status, Acquired Helplessness Index for arthritis control, Beck Depression Inventory (BDI) for psychological depression. No statistically significant differences were observed between the experimental and control groups. However, the control group did show a slight improvement on the mHAQ compared to the experimental group (ES −0.30; 95% CI −0.75, 0.14). Authors concluded that a different team care approach might improve outcomes.
Scholten (1999) conducted a prospective, randomized, controlled trial to study the effects of multidisciplinary training and education. The study enrolled 38 patients in the experimental group and 30 patients in the control group. Experimental group patients attended training programs that met 9 times over a 2-week period. Multidisciplinary team members, consisting of rheumatologists, orthopedists, physiotherapists, psychologists, and social workers led the training programs. Patients also received Lorig's Arthritis Helpbook, which covered the contents of the training programs. Control group patients received no training. The following tests were used: Stanford HAQ to measure disability, the Freiburg Questionnaire of Coping with Illness to evaluate coping with illness, and the BDI to measure depression. Results at one year showed that the experimental group had statistically significant improvement in these clinical tests compared to baseline. No statistical differences were noted in the control group when compared to baseline. In terms of functional disability between the 2 groups, the experimental group displayed a very small improvement compared to the control group. However, this was not significant (ES 0.16, 95% CI −0.32, 0.64).
Vliet Vlieland et al (1997) evaluated whether treatment conducted by a multidisciplinary team produced significant change in disease-modifying antirheumatic drugs. Thirty-nine patients with active RA were randomized to the experimental inpatient group receiving treatment from a multidisciplinary team followed by routine outpatient care. The multidisciplinary team consisted of primary medical and nursing care, a physical therapist, an occupational therapist, and a social worker. The intervention period lasted for 11 days. Forty-one active RA patients were randomized to the control group, receiving only routine outpatient care. A VAS, the modified RAI, ESR, C-reactive protein, and number of swollen joints assessed disease activity. The Dutch version of the HAQ and AIMS assessed functional and emotional status respectively. At the 2-year followup, the experimental group displayed greater improvement in all outcomes, but these differences did not reach statistical significance. However, patients in the control group showed a slight improvement in HAQ score compared to the experimental group patients at follow-up (ES −0.14; 95% CI −0.59, 0.30). The authors concluded that treatment effects from the 11-day intervention period decreased over time with no statistical differences observed at 2 years.
Spiegel (1986) compared the outcomes of RA patients admitted to a rehabilitation unit with those of RA patients treated by rheumatologists on an outpatient basis. Using a controlled before-and-after study design, 49 consecutive non-surgical patients were enrolled into the rehabilitation group, while 43 RA outpatients comprised the comparison group. A questionnaire based on the AIMS and the Rand Corporation's Health Insurance Experiment was used to evaluate outcomes. Outcomes include morning stiffness, grip strength, ESR, swollen joint count, social activity, manual dexterity, activities of daily living, knowledge of arthritis, depression, and anxiety. The rehabilitation group received treatment from a multidisciplinary team, consisting of rheumatologists, physical and occupational therapists, a nurse educator, and a social worker. Orthopedic surgeons were available for consultation. Those in the comparison group received usual care. Results at the 1-year followup showed that the rehabilitation group significantly improved in all questionnaire outcomes, except for physical activity and anxiety, when compared with the comparison group. In addition, more comparison patients required hospitalization for an arthritis problem, but more rehabilitation patients required orthopedic surgery. The authors suggested that this discrepancy is due to the fact that those in the rehabilitation group were clinically worse than those in the comparison group at the beginning of the study. Nonetheless, the authors concluded that the rehab group showed continued and significant improvement in their functional ability, mental health, and disease activity when compared with the comparison group.
Lindroth et al (1995) carried out a controlled before-and-after trial to examine the effects of a patient education program at the 5-year followup. One hundred consecutively referred outpatients were enrolled into the intervention group and 100 consecutive patients at a rheumatology clinic were enrolled into the control group. Those in the intervention group attended six educational sessions, each 2.5 hours in duration. A multidisciplinary team of rheumatologists, nurses, physiotherapists, occupational therapists, and social workers directed the sessions. Those in the control group received basic and usual care from a rheumatology clinic. Clinical outcomes measured include a VAS for pain intensity, a modified HAQ for disability, and a true/false quiz for patient knowledge. Ninety-two patients (53 intervention and 39 control) responded to the questionnaire mailed out at the 5-year followup. The results showed that only knowledge about the pathophysiology of arthritis was statistically better in the intervention group. Interestingly, stratified results for RA patients in the intervention group demonstrated a statistically significant reduction in disability compared with RA patients in the control group (ES 0.71; 95% CI 0.21, 1.21.
Parker et al (1984) published a RCT of 18 men hospitalized at a Veterans Administration hospital. Patients were randomized into an educational group or a control group. Both groups received inpatient care from a multidisciplinary treatment team. But only those in the educational group received the formal education program, a 7-hour educational seminar given by rheumatology educators. Outcomes measured included RA knowledge by the Arthritis Knowledge Inventory, functional status by AIMS, and emotional status by BDI. At the end of the 3-month followup, the additional patient education did not affect the majority of AIMS subscales or the BDI. However, the educational group did report significantly more impaired physical activity and increased pain intensity on the AIMS Physical Activity Scale and AIMS Pain Scale respectively, compared to the control group. The authors suggested that the patient education program did not offer additional benefits and, in some cases, resulted in a worse clinical condition.
In their RCT, Lindroth et al (1997) developed an RA school to increase patients' behaviors in practicing exercise and work simplification. The goal was to examine whether this educational intervention would improve pain and disability outcomes. Forty-nine patients were enrolled into the intervention group to receive the educational sessions. Sessions were run by a multidisiciplinary group to receive the educational sessions. Sessions were run by a multidisciplinary team, which included a physician, nurse, physiotherapist, occupational therapist, social worker, and dietitian. Sessions lasted for 8 weeks and were 2.5 hours in length. Forty-seven patients enrolled into the control group and received only usual care. The Stanford HAQ measured disability, a VAS-recorded pain scores, and a multiple choice quiz assessed patient knowledge. At 1 year of followup, results showed significant improvements in the intervention group when compared to the control group. Significantly fewer intervention patients reported lack of knowledge on disease, diet, and physical therapy. Joint protection and capacity to relieve pain also significantly improved. The authors concluded that this patient education program improves knowledge, health behaviors, and some disease-related problems and should be incorporated into RA management.