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Keywords:

  • Rheumatoid arthritis;
  • Patient care team;
  • International Classification of Functioning, Disability and Health;
  • Prospective studies;
  • Patients' satisfaction

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A

Objective

To investigate whether the use of an International Classification of Functioning, Disability and Health (ICF)–based instrument to structure multidisciplinary care improves clinical effectiveness and satisfaction in patients with rheumatoid arthritis (RA) admitted for multidisciplinary team care.

Methods

Consecutive patients with RA admitted to an inpatient or day patient multidisciplinary team care ward were included during a 12-month period before (period I) and after (period II) the introduction of an ICF-based rehabilitation tool (Rehabilitation Activities Profile [RAP]). Patients were assessed at admission, discharge, and 6 weeks thereafter. The primary outcome measure was a patient-oriented measure of functional ability (McMaster Toronto Arthritis Patient Preference Disability Questionnaire [MACTAR]), whereas secondary outcome measures included measures of physical and mental functioning, quality of life, disease activity, and patient satisfaction. Change scores between periods were compared using analysis of covariance.

Results

A total of 80 and 85 patients were included in periods I and II, respectively. Concerning the improvement of the MACTAR score and all other secondary clinical outcome measures, there was no significant difference between the 2 periods. Patient satisfaction with care was slightly higher in period II than in period I, with the differences regarding the total score of a multidimensional satisfaction questionnaire and the domains focusing on individual problems and empathy reaching statistical significance.

Conclusion

The introduction of the RAP did not change clinical effectiveness but had a modest beneficial impact on patient satisfaction with care in patients with RA admitted for multidisciplinary team care.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A

Although medical treatment has improved markedly over the last few decades, many patients with rheumatoid arthritis (RA) find their performance of activities of daily living and participation in society to be considerably impaired. Rehabilitative management strategies, including care provided by a team of health professionals from various disciplines, are often needed to support patients in living with the consequences of the disease (1).

Despite the proven benefits of multidisciplinary team care (2), a number of weaknesses have been identified, such as the absence of common treatment goals, too little focus on daily activities and societal participation, and a lack of active participation of the patient regarding treatment priorities (3). To overcome these problems, various rehabilitation tools have been developed, such as the Canadian Occupational Performance Measure (COPM) (4), the Rehabilitation Problem-Solving Form (RPS Form) (5), the Indicators of Rehabilitation Status version 3 (IRES-3) patient questionnaire (6, 7), and the Rehabilitation Activities Profile (RAP) (8).

The RAP is based on a precursor of the International Classification of Functioning, Disability and Health (ICF) (9) (Figure 1), the International Classification of Impairments, Disabilities, and Handicaps (10). The ICF offers a globally agreed upon framework and classification to define health status in terms of 1) body functions and body structures, 2) activities and participation, and 3) contextual factors, including environmental and personal factors (11) (Figure 1). By using the ICF, the RAP aims to assist a team of health professionals in the structured and comprehensive assessment of a patient regarding activity limitations and participation restrictions, including the patient's view regarding the personal impact of these limitations and restrictions.

thumbnail image

Figure 1. The model of the International Classification of Functioning, Disability and Health (ICF) shows the relationship between the different ICF components. Each component consists of chapters and each chapter consists of categories (11). The 5 Rehabilitation Activities Profile domains can be located within the component activities and participation (broken line) and 1 domain (relationships) could also be located within the component environmental factors.

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Apart from the assessment, the RAP guides health professionals through the process of setting common treatment goals and provides the means for a systematic evaluation of outcomes for individual patients (8). This structured approach fits in well with the so-called “rehab cycle,” which was proposed by Steiner et al to be used in rheumatology (5). This cycle involves the systematic identification of the patient's problems and needs; the definition of therapy goals; the planning, implementation, and coordination of interventions; and the assessment of the effects of these interventions.

By using rehabilitation tools such as the RAP, it is expected that clinical effectiveness regarding the achievement of individual treatment goals on the level of activities and participation and patient satisfaction concerning aspects such as patient orientedness, autonomy, and coherence among interventions executed by various health professionals will increase. However, evidence regarding the effectiveness of the implementation of rehabilitation tools is scarce. The IRES-3 has not yet been evaluated, whereas evaluations of the RPS Form and the COPM in patients with RA concerned a single case study (5) and an observational study (4), respectively. In a recent, larger study on the clinical effectiveness of the RAP in patients with various conditions, no effect on clinical effectiveness was seen (12).

Given the lack of data on the effectiveness of the introduction of ICF-based rehabilitation tools in multidisciplinary care in rheumatology, the purpose of this study was to determine the impact of the RAP on the improvement of individual limitations on the level of activities and participation in the rheumatology setting. Moreover, the effectiveness regarding other clinical outcomes as well as patient satisfaction were studied.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A

Design.

We conducted a prospective cohort study with a pretest/posttest nonequivalent groups design (13) comparing the outcomes of multidisciplinary team care and patient satisfaction with care in a 12-month period where the rehabilitation tool was not used (January 2001 to December 2001) with the outcomes in a 12-month period after the rehabilitation tool had been implemented (January 2003 to December 2003).

Patients.

Patients were consecutively recruited at the inpatient and day patient multidisciplinary team care wards of the Rheumatology Rehabilitation Clinic of the Leiden University Medical Center. Inclusion criteria were as follows: RA as defined by the 1987 American College of Rheumatology (formerly the American Rheumatism Association) criteria (14), >18 years of age, and sufficient physical and emotional status to take part in assessments and complete questionnaires (judged by the treating rheumatologist). Exclusion criteria were admission after total joint replacement surgery or for medical complications of RA. The medical ethics committee of the Leiden University Medical Center approved the study protocol and all patients gave written informed consent.

Multidisciplinary team care.

The effectiveness and costs of multidisciplinary team care in this setting have been described in previous studies (15, 16). In both the pretest and the posttest periods, all patients were treated by a multidisciplinary team comprising a rheumatologist, an occupational therapist, a physical therapist, a social worker, and nurses in both the inpatient and day patient care wards. Day patient team care was provided between 10:00 AM and 4:00 PM. Inpatients and day patients followed prescribed treatment programs tailored to individual needs.

The Rehabilitation Activities Profile and its implementation.

Before the introduction of the RAP, all team members contributed to weekly initial and followup team conferences of every patient in a fixed order (rheumatologist, nurse, physical therapist, occupational therapist, and social worker). General treatment goals were set at the end of the initial team conferences, but were neither systematically discussed with the patient nor evaluated during followup team conferences. During the initial team conferences team members used their own records, whereas for the followup team conferences minutes of the previous team conference were also available. The RAP was introduced in January 2002 and was fully implemented in January 2003. The RAP consists of 5 domains: communication (ICF component 2, chapter 3), mobility (ICF component 2, chapter 4), personal care (ICF component 2, chapter 5), occupation (ICF component 2, chapters 6, 8, and 9), and relationships (ICF component 2, chapter 7 and ICF component 3, chapter 3) (8). These domains are divided into 21 items, which comprise 71 subitems (Appendix A). For every (sub)item, 2 aspects are determined: the health professionals' judgment regarding the extent of an activity limitation or participation restriction and the patient's perceived problem with that limitation or restriction (8). For the present study, each item and its corresponding subitems were allocated to 2 health professionals from different disciplines according to their specific expertise. Other team members were encouraged to make a contribution to any (sub)item if this would provide additional information. A yes/no format was used for both the activity limitation and participation restriction scores and the patient's perceived problem scores.

For the present study, an electronic RAP report form was developed. In this form, the observations of ≥2 team members were recorded for every (sub)item and were delivered on paper to all team members before the team conference. During the initial team conference of a newly admitted patient, the RAP report form directed the team members towards the definition of shared goals. These goals were discussed with the patient by the rheumatologist afterwards and were adjusted if needed. During the weekly followup team conferences, progress regarding the achievement of the shared goals was discussed and recorded by means of structured followup electronic report forms. All team members and administrative assistants were trained (1.5 days) regarding the background of the RAP, the formulation of common treatment goals, and the use of the RAP report forms.

Assessments.

Clinical assessments were performed at admission (baseline), discharge, and 6 weeks thereafter during both 12-month periods. Patient satisfaction was measured within 2 weeks after discharge. All clinical assessments were executed by 1 trained investigator who was not involved in the treatment (JV).

Sociodemographic and disease characteristics.

Sociodemographic and disease characteristics recorded at baseline were age, disease duration, sex, rheumatoid factor, presence of erosions, current medication, status of living (i.e., living alone), education level (low: up to and including lower technical and vocational training; medium: up to and including secondary technical and vocational training; and high: up to and including higher technical and vocational training and university), employment status, and previous admission to a rehabilitation clinic.

Medical treatment.

Data on the number of treatment days and the use of nonsteroidal antiinflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), oral corticosteroids (prednisone), and intraarticular or intramuscular injections with corticosteroids (yes/no) were gathered from the medical records.

Primary outcome measure.

To measure improvements in individual activity limitations, the McMaster Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR) (17) was administered. The MACTAR is a semistructured interview consisting of status questions and transitional questions to record and evaluate activity limitations relevant to the individual patient (17, 18). These activities were obtained from and ranked by the patient at each assessment. The baseline weighted MACTAR score ranges between 39 and 59 and the weighted followup score ranges between 21 and 77, whereas changes from baseline of the weighted score could range from −38 (maximal deterioration) to 38 (maximal improvement).

Secondary outcome measures.

Functional ability.

Functional ability was measured by means of the Health Assessment Questionnaire (19), comprising 20 questions regarding 8 domains of activities of daily living, with a total score ranging from 0 (no functional limitations) to 3 (serious functional limitations).

Quality of life and psychological functioning.

Quality of life was measured with the Rheumatoid Arthritis Quality of Life (RAQoL) questionnaire (20). This questionnaire consists of 30 yes/no questions and ranges from 0 to 30, with a lower score indicating higher quality of life. Psychological functioning was measured with the psychological health scale of the Dutch Arthritis Impact Measurement Scales (21). The scale score ranges from 0 to 10, with a higher score indicating a poorer psychological health status (22).

Disease activity.

Disease activity was measured with the Disease Activity Score in 28 joints (DAS28), a composite index including the number of swollen and tender joints, a visual analog scale (VAS) for the patients' global assessment of disease activity, and erythrocyte sedimentation rate (ESR). The DAS28 score was calculated according to the following formula: 0.56(√number of tender joints) + 0.28(√number of swollen joints) + 0.70 ln(ESR) + 0.014(VAS patients' global assessment of disease activity) (23). DAS28 end point scores <3.2 are considered to represent low disease activity, 3.2–5.1 represent moderate disease activity, and >5.1 represent high disease activity (24).

Patient satisfaction.

Patient satisfaction was measured with a multidimensional questionnaire based on a previously validated 28-item questionnaire to evaluate RA patients' satisfaction with multidisciplinary care (25). For the present study, the original domains knowledge, empathy, and continuity were used (6 items). In addition, 24 extra items were added to the original domains autonomy, information, coordination among health professionals, patient-centered care (formerly: efficiency), and effectiveness (34 items), resulting in a final questionnaire comprising 40 statements that was scored on a 5-point Likert scale (where 0 = totally disagree and 4 = totally agree). For every domain, the scores of the items were added and divided by the total number of items in that domain, yielding a score ranging from 0 (totally unsatisfied) to 4 (completely satisfied) for every domain. Adding the scores of all 40 items and dividing the sum by 1.6 transformed the total score to a score ranging from 0 (totally unsatisfied) to 100 (completely satisfied).

Statistical analysis.

The study was designed using the MACTAR score as the primary outcome measure, with an estimated mean ± SD difference in weighted MACTAR change score of 3 ± 6 between the 2 periods, a difference that is considered to be clinically relevant (26). According to this estimation, with a power of 0.80 and a P value less than 0.05 (2-tailed test), 63 patients per period would be required. Taking into account a 10% dropout rate, a minimum of 70 patients per period were to be recruited.

All measures were expressed as medians and ranges, or means and standard deviations where appropriate. Differences between patients' characteristics and the use of medical treatment at baseline and during admission between the 2 periods were analyzed using the chi-square test, Fisher's exact test, or the Mann-Whitney U test where appropriate. Cronbach's alpha was used to estimate the internal consistency of the 8 domains of the patient satisfaction questionnaire and the total internal consistency of all 40 items.

For all clinical outcome measures, changes between baseline and discharge and between baseline and 6 weeks after discharge were computed and presented as the crude mean difference in change between both periods with a 95% confidence interval. Change scores of the clinical outcome measures and the patient satisfaction scores were compared between the 2 periods using analysis of covariance. Baseline variables that were statistically significantly different between the periods were entered as covariates. To account for possible confounding due to unknown differences between the inpatient and day patient team care settings, the setting was also entered as a covariate. For the analysis of every variable, all covariates were entered into the model first. Covariates were removed from the model if their effects were not statistically significant; otherwise, adjusted P values were used.

All analyses were based on the intent-to-treat principle. In case of patients lost to followup, all available data were used. All statistical analyses were performed using SPSS software, version 11.5 (SPSS, Chicago, IL) with P values less than or equal to 0.05 considered to be statistically significant.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A

In total, 88 patients (period I) and 98 patients (period II) were eligible for screening. Eight (9%) and 13 (13%) patients declined participation in periods I and II, respectively, resulting in 80 and 85 patients who were finally included.

Twenty-six patients, equally distributed over periods I and II, did not complete the study. In period I, 14 patients (18%) were lost to followup at discharge (n = 5) or at 6 weeks after discharge (n = 9) for the following reasons: logistics problem (n = 4), referral to other department (n = 2), refusal of further participation (n = 6), deceased (n = 1), and surgery (n = 1). In period II, 12 patients (14%) were lost to followup at discharge (n = 6) or at 6 weeks after discharge (n = 6) for the following reasons: referral to other department (n = 1), refusal of further participation (n = 5), worsened health status (n = 3), cardiac disease (n = 1), moved (n = 1), surgery (n = 1), and unknown reason (n = 1).

The baseline clinical and sociodemographic characteristics and previous admissions for multidisciplinary team care of the patients admitted in periods I and II are shown in Table 1. Apart from the greater proportion of women in period II compared with period I, no statistically significant differences between the periods were found. Twenty-two patients in period I and 16 patients in period II were not taking DMARDs at admission. In period I, 10 patients had recently been diagnosed with RA, and 12 patients who had been taking DMARDs stopped recently because of ineffectiveness and/or side effects. In period II, there were 5 patients newly diagnosed with RA and 11 patients who had taken DMARDs but had recently stopped.

Table 1. Baseline clinical and sociodemographic characteristics of patients with RA admitted for multidisciplinary team care in a period before (I) and a period after (II) the introduction of the Rehabilitation Activities Profile*
CharacteristicPeriod I (n = 80)Period II (n = 85)P
  • *

    Values are the number (percentage) unless otherwise indicated. RA = rheumatoid arthritis; NSAID = nonsteroidal antiinflammatory drug; DMARD = disease-modifying antirheumatic drug.

  • Chi-square or Mann-Whitney U test, where appropriate.

  • Statistical significance with a significance level of P ≤ 0.05.

  • §

    Low = up to and including lower technical and vocational training; medium = up to and including secondary technical and vocational training; high = up to and including higher technical and vocational training and university.

Age, median (range) years65 (23–86)61 (22–83)0.76
Duration of RA, median (range) years8 (0.3–47)6 (0.1–43)0.20
Female sex49 (61)65 (77)0.05
Positive rheumatoid factor57 (71)58 (73)0.99
With erosions59 (74)49 (61)0.11
Current use of medication   
 NSAID59 (74)55 (66)0.33
 DMARD58 (73)69 (81)0.26
 Prednisone21 (26)15 (18)0.25
Living alone24 (30)21 (25)0.56
Education level§   
 Low63 (79)62 (73)0.49
 Medium8 (10)11 (13)0.73
 High9 (11)12 (14)0.75
With paid employment18 (23)17 (20)0.84
With previous admission to rehabilitation clinic33 (41)38 (45)0.77

Medical treatment during admission in both periods is shown in Table 2. Overall, the duration of treatment; the distribution of patients over the inpatient and day patient wards; and the proportions of patients in whom treatment with NSAIDs, DMARDs, or oral corticosteroids was instituted or changed or in whom injections with corticosteroids were administered were similar in both periods. Of the 22 and 16 patients in periods I and II who were not receiving a DMARD at baseline, 22 and 11 patients started with ≥1 DMARDs during admission, respectively. For the 5 patients in period II who were not receiving a DMARD at baseline and did not start during admission, treatment with DMARDs was planned but postponed because of medical reasons. In 3 of these 5 patients, oral prednisone was started during admission.

Table 2. Number of treatment days, unit of admission, and use of medication in patients with RA admitted for multidisciplinary team care in a period before (I) and a period after (II) the introduction of the Rehabilitation Activities Profile*
 Period I (n = 80)Period II (n = 85)P
  • *

    Values are the number (percentage) unless otherwise indicated. See Table 1 for definitions.

  • Chi-square test, Fisher's exact test, or Mann-Whitney U test, where appropriate; significance level P ≤ 0.05.

Median number of treatment days (range)10 (3–40)10 (1–31)0.41
Unit of admission   
 Day patient care52 (65)56 (66)0.99
 Inpatient care28 (35)29 (34) 
Medical treatment   
 NSAIDs   
  Stable34 (61)40 (75) 
  Dose or application change4 (7)2 (4)0.30
  Start new NSAIDs18 (32)11 (21) 
 DMARDs   
  Stable26 (33)28 (36) 
  Dose or application change21 (27)28 (36)0.23
  Start new DMARDs32 (40)22 (28) 
 Prednisone   
  Stable6 (23)10 (45) 
  Dose or application change14 (54)5 (23)0.08
  Start prednisone6 (23)7 (32) 
Intramuscular or intraarticular corticosteroid injections27 (34)21 (25)0.27

The baseline clinical outcome data and changes from baseline at discharge and 6 weeks thereafter in the 2 periods are shown in Table 3. Patients improved significantly between admission and discharge and 6 weeks thereafter according to all outcome measures in both periods, except for the RAQoL in period I. Concerning the primary outcome measure, the MACTAR, there were no statistically significant differences in improvement between the 2 periods. With respect to the secondary clinical outcome measures, the magnitude of improvement was also in the same range in the 2 periods, with no statistically significant differences.

Table 3. Clinical outcome data at baseline and crude mean change scores at discharge and 6 weeks after discharge in patients with RA admitted for multidisciplinary team care in a period before (period I; n = 80) and after (period II; n = 85) the introduction of the Rehabilitation Activities Profile*
 Baseline, Mean ± SDChange score at discharge, mean (95% CI)P value, difference between periods I and II§Change score 6 weeks after discharge, mean (95% CI)P value, difference between periods I and II§
  • *

    RA = rheumatoid arthritis; 95% CI = 95% confidence interval; MACTAR = McMaster Toronto Arthritis Patient Preference Disability Questionnaire; HAQ = Health Assessment Questionnaire; RAQoL = Rheumatoid Arthritis Quality of Life; D-AIMS2 = Dutch Arthritis Impact Measurement Scales-2.

  • All P values regarding differences between absolute baseline values >0.05 (unpaired Student's t-test).

  • All P values <0.05, except for RAQoL, period I (paired sample t-test).

  • §

    P values refer to analysis of covariance with the following covariates: sex, baseline value, and clinical setting and its interaction with period.

Primary outcome measure     
 MACTAR (weighted)     
  Period I48.16 ± 3.7712.03 (10.08, 13.98)0.899.89 (7.12, 12.65)0.58
  Period II47.27 ± 3.5713.23 (11.60, 14.86) 12.11 (9.63, 14.58) 
Secondary outcomes measures     
 HAQ (0–3)     
  Period I1.40 ± 0.74−0.17 (−0.28, −0.05)0.85−0.18 (−0.3, −0.02)0.93
  Period II1.39 ± 0.66−0.15 (−0.24, −0.07) −0.18 (−0.3, −0.07) 
 RAQoL questionnaire (0–30)     
  Period I16.13 ± 6.51−0.70 (−1.90, 0.49)0.56−0.63 (−2.25, 1.00)0.59
  Period II17.43 ± 5.87−1.38 (−2.11, −0.65) −1.79 (−3.08, −0.50) 
 D-AIMS2, psychological scale   (0–10)     
  Period I4.31 ± 1.70−0.63 (−0.91, −0.35)0.64−0.58 (−1.01, −0.15)0.96
  Period II4.47 ± 1.70−0.57 (−0.87, −0.26) −0.61 (−0.94, −0.28) 
 Disease Activity Score in 28 joints     
  Period I5.49 ± 1.39−0.88 (−1.16, −0.60)0.09−0.68 (−0.99, −0.36)0.69
  Period II5.45 ± 1.43−0.58 (−0.80, −0.36) −0.73 (−1.02, −0.44) 

The results regarding patient satisfaction with care are presented in Table 4. Sixty-three patients in period I (79%) and 74 patients in period II (87%) completed the satisfaction questionnaire. Reliability analysis demonstrated that Cronbach's alpha was 0.95 for the total questionnaire and 0.54, 0.57, and 0.67 for the original domains continuity, empathy, and knowledge, respectively. Regarding the extended domains, Cronbach's alpha was 0.85 for autonomy, 0.84 for information, 0.86 for coordination among health professionals, 0.85 for patient-centered care, and 0.82 for effectiveness.

Table 4. Rheumatoid arthritis patients' satisfaction with multidisciplinary team in a period before (I) and after (II) the introduction of the Rehabilitation Activities Profile*
Domains (score range)No. of itemsPeriod I (n = 63)Period II (n = 74)P
  • *

    Values are the mean ± SD unless otherwise indicated.

  • P values refer to analysis of covariance with the following covariates: sex and clinical setting and its interaction with period.

  • Statistical significance with a significance level of P ≤ 0.05.

Patient-centered care (0–4)83.0 ± 0.73.3 ± 0.60.037
Autonomy (0–4)102.9 ± 0.63.1 ± 0.60.235
Information (0–4)63.0 ± 0.83.2 ± 0.60.385
Knowledge (0–4)23.3 ± 0.83.5 ± 0.60.104
Empathy (0–4)23.0 ± 0.83.3 ± 0.70.036
Coordination (0–4)43.2 ± 0.73.3 ± 0.60.351
Effectiveness (0–4)62.8 ± 0.82.8 ± 0.80.691
Continuity (0–4)22.6 ± 1.02.9 ± 1.00.146
Total score (0–100)4074.2 ± 13.978.9 ± 13.30.046

Except for the effectiveness domain, where similar results were achieved in the 2 periods, patient satisfaction was slightly higher in period II than in period I for all domains. For the domains patient-centered care and empathy, as well as the total satisfaction score, the differences between the 2 periods reached statistical significance.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A

This prospective cohort study demonstrated that the introduction of an ICF-based rehabilitation tool did not change improvement of individual limitations on the level of activity and participation in patients with RA admitted for multidisciplinary team care. The same result was obtained for all other secondary measures of clinical effectiveness; however, the rehabilitation tool appeared to slightly improve various aspects of patient satisfaction with care.

Over recent years, a number of tools have been developed to support rehabilitation health professionals providing multidisciplinary care, examples of which are the COPM (4), RPS Form (5), IRES-3 (6, 7), and RAP (8). The overall aims of these tools are to structure the multidisciplinary team care process by providing methods for a systematic assessment and for the setting and evaluation of shared treatment goals. These tools explicitly include those aspects of health status that are relevant for the functioning of individual patients. Therefore, all of the tools have the ICF component activities and participation as their main focus. Moreover, the working methods connected with these tools do generally enhance the active participation of the patient in the goal setting and treatment process.

So far, evidence regarding the effectiveness of rehabilitation tools is scanty. The only available evaluation of substantial size was, similar to the present study, concerned with the RAP (12). That study compared the outcomes of 3 groups of patients with miscellaneous disorders in 8 rehabilitation centers who were treated by multidisciplinary teams that were either using the RAP, partially using the RAP, or not using the RAP. Overall, no effect of the use of the RAP on improvement of functional status, perceived health, and total length of stay was observed. According to the authors, the lack of effectiveness could probably be ascribed to an insufficient level of implementation of the RAP. Insufficient implementation does not seem to apply to the present study, because the RAP was fully implemented in both settings before the second assessment period started. The most important explanation for the absence of effectiveness of the introduction of the RAP could be the lack of contrast between the 2 periods regarding the primary focus of the study: the improvement of individual limitations on the level of activities and participation. Overall, the improvements of functional status between admission and discharge in the period before the introduction of the RAP were similar to those obtained in previous studies of multidisciplinary team care (15, 27). However, with respect to improvement of MACTAR score, the results in period I were considerably better than those previously obtained in the same setting (15). This latter finding could imply that with respect to the focus of care on patients' priorities regarding their personal activity limitations, advances had already been made over time, leaving relatively little room for improvement. Another explanation for the lack of effectiveness could be the relatively short period of followup (6 weeks after discharge) in the present study. It is conceivable that improvements on the level of individual limitations concerning activities and participation can only be seen after a period of sufficient length. For some patients and some activities, a period of 6 weeks may be too short to fully profit from gains in bodily functions or from acquired skills.

In the present study, we found a modest positive effect of the introduction of the RAP on patient satisfaction. Given the favorable satisfaction scores before the RAP had been introduced, a further improvement could have been hard to achieve. Because patient satisfaction has not been included in studies on the effectiveness of rehabilitation tools, comparisons with other studies are difficult. In addition, instruments that measure patient satisfaction with multidisciplinary care are scarce (2). An existing questionnaire that was specifically developed for measuring satisfaction with multidisciplinary care in patients with RA (25) lacked statements about dealing with patients' specific problems, patient-centered care, and individual expectations, elements that were relevant for the present study and indeed showed a modest effect of the intervention. This finding could indicate that for some research questions, the methodology of previously developed satisfaction instruments can be used, but that the development of specific items, tailored to the study population and the intervention, is needed. It remains undisputable that the psychometric properties of any new or adjusted questionnaire should be examined. In our study, the psychometric properties of the adjusted questionnaire were similar to or slightly better than those of the questionnaire on which it was based (25).

This study has a number of limitations. Because neither a parallel groups design nor a randomization procedure was used, unknown differences between the patient populations or changes in the multidisciplinary care process other than those attributed to the introduction of the RAP cannot be totally ruled out. In addition, data for the medical treatment were gathered retrospectively from the medical records. Therefore, incomplete documentation could have resulted in missing information. However, it is unlikely that this may have affected the group comparisons, because data collection was performed in both groups in the same manner. Concerning the generalizability of our study results, it must be kept in mind that regarding the provision of multidisciplinary care in rheumatology, team composition may vary among institutions. For example, the absence of a psychologist in the team could have resulted in an underestimation of limitations of mental functions.

In conclusion, although the introduction of an ICF-based rehabilitation tool did not change improvement of individual limitations on the level of activities or participation nor of any other clinical outcome measures, it did, to a limited extent, improve various aspects of patient satisfaction with multidisciplinary care in patients with RA. For future research it is important that the contrast between settings where rehabilitation tools are used or not used is sufficiently large. Moreover, a considerable followup period is recommended, because the impact on the level of activities and participation may only be visible after a period of sufficient length. In addition, the effect of the introduction of an ICF-based tool on satisfaction of the health professionals as well as the economic consequences need to be further investigated.

AUTHOR CONTRIBUTIONS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A

Mr. Verhoef 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. Verhoef, Toussaint, Zwetsloot-Schonk, Breedveld, Putter, Vliet Vlieland.

Acquisition of data. Verhoef.

Analysis and interpretation of data. Verhoef, Putter, Vliet Vlieland.

Manuscript preparation. Verhoef, Toussaint, Zwetsloot-Schonk, Breedveld, Putter, Vliet Vlieland.

Statistical analysis. Verhoef, Putter, Vliet Vlieland.

Acknowledgements

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A

The authors would like to thank all the participating patients and health professionals of the inpatient and day patient care wards at the Rheumatology Rehabilitation Clinic of the Leiden University Medical Center (LUMC); H. W. Hoogvliet, Central Information Processing Department, LUMC; W. Otten, Department of Medical Decision Making, LUMC; J. W. Schoones, Walaeus Library, LUMC; and A. de Vries, Rehabilitation Center of the University Medical Center Groningen, Beatrixoord for sharing their expertise in the practical use of the RAP. The authors also thank Tanja Stamm, Vienna Medical University, Vienna, Austria for her comments on the use of the ICF terminology and appendix.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A
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APPENDIX A

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A
Table  . Overview of the linking of the 21 Rehabilitation Activities Profile (RAP) items to the ICF component “Activities and Participation,” including the presence of the 21 RAP items in the comprehensive ICF core set for rheumatoid arthritis
RAP domains with the titles of the 21 itemsICF chapters (cursive) and categories 2nd level of the ICF component “Activities and Participation” (d110-d999)ICF category codes 2nd levelICF comprehensive core set RA
  • *

    In the ICF, the RAP item “sleeping” is represented by code b1349 from the ICF component “body functions,” which is “sleep functions, unspecified.” In the ICF chapter “self-care,” sleeping is not specified.

  • The RAP domain “occupation” is not represented in one ICF chapter. The ICF component “activities and participation” represents 3 RAP items (15, 16, and 18) by the ICF chapters 6, 8, and 9. The RAP item “professional activities” (17) is represented by the ICF chapter “major life areas” (chapter 8).

CommunicationCommunication (Chapter 3)d310–d399
 1. ExpressingCommunicating-producingd330–d349
 2. ComprehendingCommunicating-receivingd310–d329
MobilityMobility (Chapter 4)d410–d499+
 3. Maintaining postureMaintaining a body positiond415+
 4. Changing postureChanging basic body positiond410+
 5. WalkingWalkingd450+
 6. Using wheelchairMoving around using equipmentd465+
 7. Climbing stairsMoving aroundd455+
 8. Using transportUsing transportationd470+
Personal careSelf-care (Chapter 5)d510–d599+
 9. SleepingSelf-care, other specified*d598+
 10. Eating and drinkingEating/drinkingd550/d560+
 11. Washing and groomingWashing oneselfd510+
 12. DressingDressingd540+
 13. UndressingDressingd540+
 14. Maintaining continenceToiletingd530+
OccupationDomestic life (Chapter 6), Major life areas (Chapter 8), Community, social and civic life (Chapter 9)d610–d699, d810–d899, d910–d999+
 15. Providing for mealsPreparing meals/doing houseworkd630
 16. Household activitiesDoing houseworkd640
 17. Professional activitiesMajor life areas (Chapter 8)d810–d899+
 18. Leisure activitiesRecreation and leisured920+
RelationshipsInterpersonal interactions and relationships (Chapter 7) and Support and relationships (Chapter 3 from ICF component “Environmental Factors”)d710–d799 and e310–325+
 19. PartnerIntimate relationships; immediate familyd770 and e310+
 20. Child(ren)Family relationships; immediate familyd760 and e310+
 21. Friends/acquaintancesInformal social relationships; friends/acquaintances, peers, colleagues, neighbors, and community membersd750 and e320/e325