Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Gain Not Pain True Measure
- Kitty FitzHerbert (17 October 2006)
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Erratum - apologies for not acknowledging the contribution of the Trial Steering Committee members to this trial
- Marta J Buszewicz (27 October 2006)
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Challenges in the management of osteoarthritis
- Surya P Rajeev, Satheesh B Nair, Manchester Heart Centre. (30 October 2006)
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Dilemmas surrounding implementation of expert patient programmes.
- Suresh Kumar Chhetri (1 November 2006)
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Impact on utilisation is likely to require a more integrated approach to self management
- Anne Rogers (3 November 2006)
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Self care and quality of life in the elderly
- Angel J. Romero Cabrera, Alfredo D. Espinosa Brito (3 November 2006)
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Educational programes must be effective and benefit equally
- Rozhia Salih (6 November 2006)
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Educational programes must be effective and benefit equally
- Rozhia Salih (6 November 2006)
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Another trial on self management of arthritis in primary care
- Peter HTG Heuts, Caroline HG Bastiaenen (1 December 2006)
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Kitty FitzHerbert, Training Services Development Manager Arthritis Care, 18 Stephenson Way, London, NW1 2HD
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Arthritis Care always welcomes research into the efficacy of self- management but warns against the over-simplification of the complexities of this issue. There are many reasons why this piece of research, already criticised in the United States for lacking sufficient detail, might not reflect actual outcomes. There might, for example, be a spike in GP contacts as people who have been through the programme assume greater control of their condition; GP visits might increase because they have learned to manage better, and need less contact with secondary care; there might be no net reduction in pain because their joint mobility and feelings of well-being have improved, leading to increased exercise but potentially more pain. Nevertheless, the research has still concluded that Challenging Arthritis does reduce anxiety about living with arthritis, and increases self-efficacy, with participants being more confident about managing pain and other arthritis symptoms. The key issue, for Arthritis Care, is that the many graduates of the programme report that Challenging Arthritis has been life-changing for them. As the new NHS is intended to be patient-focused, it is imperative that planners of future care consider not just what research says but what patients themselves say. The point of the Challenging Arthritis programme was never to reduce pain, but to enable participants living with arthritis to acquire new skills, giving them greater control of their lives and greater ability to surmount the obstacles of living with this debilitating condition. The programme is based on clinical research and has a broad range of positive outcomes, including the empowerment, new confidence and self-assurance that participants report. Arguably, one of the chief measurements taken in this study – whether attendance on the programme reduced GP visits – was not an appropriate measurement since the Challenging Arthritis programme specifically aims to give participants the skills to gain more from their essential GP visits, rather than to replace them. Furthermore, this study is based on programmes that took place some years ago, and it does not appear to take into account the medical treatment that participants were receiving at the time, nor does it seem to measure important results from the programme, such as improved communication with doctors, or improved health behaviours like dietary changes or taking increased exercise, an important aspect of managing arthritis. Most significantly, it was reported by the researchers that not every participant actually attended all of the educational sessions, and therefore the purported measurement of the impact of the programme as a whole could be significantly flawed. Arthritis Care agrees with the researchers’ conclusion that there is a case for further study to identify predictive factors such as motivation levels in participants that could influence the long-term benefits of arthritis self-management. Competing interests: Arthritis Care provides the UK's self management courses |
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Marta J Buszewicz, senior lecturer in primary care Dept. of Primary Care & Pop. Sciences, Royal Free & University College Med. Schl., London N19 5LW
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Thanks to Lisa Cotterill, Gill Dorer, Jeannett Martin, Claire Newland, Gloria Randall and Tom Sensky, who were all members of the Trial Steering Committee Competing interests: I am the lead author on this paper |
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Surya P Rajeev, SHO in Diabetes and Endocrinology Prince Charles Hospital, Merthyr Tydfil, CF47 9DT., Satheesh B Nair, Manchester Heart Centre.
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We have the following concerns regarding the study on the `self management of arthritis in primary care'. 1.One of the important factor determining the outcome in osteoarthritis is the stage of the disease. It is not mentioned whether patients are at an early stage with mild symptoms or at an advanced stage ,awaiting surgery and the results of the study might be different in both cases. 2.Osteoarthritis being a chronic disease, whether the quality of life which was the primary outcome of the study(1), can be assessed by follow up in four months and maximum of twelve months raises doubt. Longer periods of follow up might lead to variation in results. 3.The finding that self management did not reduce the number of consultations with general practitioners can be due to the greater awareness created in this group. The possibility of a proportion of these consultations for other comorbidities cannot be ruled out especially because study group was graeter than fifty years in whom significant comorbidities are not rare. As much as life style interventions play an important part in delaying the onset of diabetes(2),the improvement in mental health and reduction in anxiety in the management of osteoarthritis carries great significance. References: 1. BMJ 2006,333:879,doi10.1136/bmj.38965.37571880 2. BMJ 2006,333:764-765,doi:10.1136/bmj.38996.709340.BE Competing interests: None declared |
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Suresh Kumar Chhetri, Clinical Observer, Department of Rheumatology. Pontefract General Infirmary, WF8 1PL
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The findings of this study are contrary to the consistent evidence from other studies, but it is interesting to note that a similar study done in the primary care setting in United States also did not demonstrate significant clinical benefits(1). Although this study was well designed, there are few issues that might have had a bearing on the outcome. Out of the 2891 patients approached, only 812 patients entered into the study. The patients who declined to participate in the study might have grounds that could have influenced the outcome. Although the patients were randomised by stratifying certain baseline characteristics, they have not been randomised for other important confounding factors like associated co-morbidities including obesity, alternative therapies, duration and stage of illness. This might have significantly skewed the result. This may also explain the observed lack of significant difference in the number of subsequent consultations with the general practitioners. It might also have been of interest to consider the relative efficiencies of the “challenging arthritis” intervention programs in the study groups. The sample size recruited for the study is around 20% less than the power calculation done by the authors at the start of the study. This could have resulted in a type II error where the study might not have been able to portray the difference between the groups. This study definitely raises questions on the efficacies of such self management programmes but does not imply that they should not be instituted. A further research and economic analysis is needed to ensure that the government plans of implementing expert patient programmes are evidence based. It might also be of interest to look into the factors that have brought the discrepancies in the outcome of the various studies. 1. Solomon DH, Warsi A, Brown-Stevenson T, Farrell M, Gauthier S, Mikels D, Lee TH .Does self-management education benefit all populations with arthritis? A randomized controlled trial in a primary care physician network. J Rheumatol. 2002 Feb; 29(2):362-8. Competing interests: None declared |
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Anne Rogers, Professor of the Sociology of Health Care Division of Primary Care, Univeristy of Manchester M13 9PL
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The lack of impact on utilisation shown in the Buszewicz et al trial of self management of arthritis in primary care is perhaps not surprising. Whilst patients were recruited to this trial from General Practice the delivery of the self-management training took place outside of mainstream general practice. Since demand for NHS services is to a large extent ‘supply’ led it seems logical to assume that self –management skills training or other interventions that are not designed to actively engage the existing professional and organizational systems and activities for managing long term conditions will not have much of an impact on subsequent utilization (1). Seemingly, more significant reductions in health utilization (without evidence of an adverse effect on patient outcomes ) are evident in Randomised Controlled Trials of self- management using a more integrated approach (see for example Kennedy et al 2004). Approaches which include a focus on engaging patients and clinicians in a shared approach to self-management within a health service organisational environment which is able to support a partnership approach may be a more fruitful avenue to pursue than self-care skills training delivered at a distance from main stream primary care and other health provision. (see:http://www.npcrdc.ac.uk/WISEApproachSelf-management.cfm) 1. Rogers A, Entwistle V, and Pencheon D Managing demand: A patient led NHS: managing demand at the interface between lay and primary care BMJ, Jun 1998; 316: 1816 - 1819 2. Kennedy A Nelson E, Reeves D et al A randomised controlled trial to assess the effectiveness and cost of a patient orientated self management approach to chronic inflammatory bowel disease. Gut. 2004 Nov;53(11):1639-45. Competing interests: I am involved in undertaking research into self- management at the National Primary Care Research & Development Centre |
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Angel J. Romero Cabrera, Associate Professor Gustavo Aldereguía Hospital, Cienfuegos, Cuba, Alfredo D. Espinosa Brito
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Dear Sir: We have read with pleasure the article from Buszewicz et al (1) published in the Journal, because osteoarthritis, as a chronic disease in the elderly, is the first cause of disability (2) affecting greatly their functional status, independence and neccesity from long-term care. Osteoarthritis can be considered, hence, a tracer condition of chronic diseases, and can serve as a model to evaluate effective actions in its management in primary care. Self care is an important approach to manage these elderly conditions in community settings. It has defined as the assistance given to ourself to maintain a suitable health status, well-being and quality of life (3). Quality of life is centered in objectives biological pointings as health, life´material conditions, etc.,but also in a subjective judgment which produces a satisfaction feeling and a possitive state of mind (4). The results of the trial from Buszewicz et al (1) agree with these concepts, showing a reduction of anxiety and improving the subjective well -being in a self management programme for patients with osteoarthritis. Such programms have the difficulties that spend doctors´time in the patient education and to elaborate, edit and print the educational booklet. They need to be understandable and easy to read, specially to older persons. In fact, this is not easy work. In the trial no differences were seen in number of general practitioner visits between the groups, but we must remind that statistical significance is different to clinical significance, in which symptoms improvement and patient well-being are priorities aspects, mainly in the elderly. Every efforts with similar purpose to this trial are encouraging because they bring the possibility to arrive at latest life stage in better conditions as possible and, what is the same, to reach a successfull aging. Sincerely, Associate Professor Angel J. Romero-Cabrera, MD and Professor Alfredo D. Espinosa-Brito, MD, PhD. Department of Internal Medicine Teaching Hospital "Dr. Gustavo Aldereguia
Lima", Ave 5 de Septiembre and Calle 51A, Cienfuegos, 55100, CUBA
Competing interests: None declared References: 1. Buszewicz M, Ralt G, Griffin M, Nazareth I, Patel A, Atkinson A, et al. Self management of arthritis in primary care: randomized controlled trial. BMJ 2006; 333:879. 2. Adams PF, Marano MA. Current stimates from the National Health Interview Survey 1994. Vital Health Statistics 1995; 10(193):83-84. 3. Romero Cabrera AJ. Temas de autocuidado para el adulto mayor. Anuario Universidad "Carlos Rafael Rodríguez", Cienfuegos, 2003. URL: http://www.ucf.edu.cu. 4. Flórez Lozano JA. Las crisis del envejecer. JANO 2005; 65(1):20-34. Competing interests: None declared |
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Rozhia Salih, Foundation Year 2 Doctor Halton and St Helens PCT WA7 1tW
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I read with great interest the article by Buszewicz et al describing an educational programme inline with current government plans to implement an expert patient programme. As others have commented the trial would benefit from longer follow up period, larger sample size and in considering the effect of co founders such as obesity, co morbidity, alternative therapies etc. It was surprising that despite the large numbers that did not attend the thearpeutic dose of four sessions (44% of intervention participants) a significant statistical difference was still shown in reducing anxiety and improved self efficacy in the intention to treat analysis. There is a definite place for interventions such as this but they must be shown to be cost effective and I look forward to the report of the economic evaluation. I would also like to raise the point that participants who are motivated enough and flexible enough to attend these programmes may not neccessarily be the ones who would benefit from them the most; this study excluded those who could not speak english and indeed there was a slight predominance of white participants; the point I am trying to make is that services should not exist that increase inequality; those most likely to attend these programmes are not neccessarily those in the most need. Competing interests: None declared |
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Rozhia Salih, Foundation Year 2 Doctor in Public Health Halton and St Helens PCT WA7 1tW
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I read with great interest the article by Buszewicz et al describing an educational programme inline with current government plans to implement an expert patient programme. As others have commented the trial would benefit from longer follow up period, larger sample size and in considering the effect of co founders such as obesity, co morbidity, alternative therapies etc. It was surprising that despite the large numbers that did not attend the thearpeutic dose of four sessions (44% of intervention participants) a significant statistical difference was still shown in reducing anxiety and improved self efficacy in the intention to treat analysis. There is a definite place for interventions such as this but they must be shown to be cost effective and I look forward to the report of the economic evaluation. I would also like to raise the point that participants who are motivated enough and flexible enough to attend these programmes may not neccessarily be the ones who would benefit from them the most; this study excluded those who could not speak english and indeed there was a slight predominance of white participants; the point I am trying to make is that services should not exist that increase inequality; those most likely to attend these programmes are not neccessarily those in the most need. Competing interests: None declared |
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Peter HTG Heuts, MD, PhD Hoensbroek Rehabilitation Centre, Developmental Centre for Painrehabilitation Hoensbroek, PO BOX 88,, Caroline HG Bastiaenen
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Letter to the editor, We are delighted by the trial of Buszewizc et al.(1) on Self Management of Arthritis in Primary Care, because it is well-designed and offering opportunities for discussions and further study for the benefit of the enormous population of people suffering osteoarthritis. We would like to commend on several points. We think it might be helpful to compare the available trials on self management of arthritis in primary care, looking for differences, overlap, and remaining questions. First, this is actually the third RCT (not the second as the authors stated) to evaluate self management of arthritis in primary care (2,3). Our trial was designed in order to assess the efficacy of a self- management programme in a primary health care setting in middle-aged patients with osteoarthritis. This also was a two-group randomized controlled trial. The experimental intervention was compared with care-as- usual. Duration of follow-up was 21 months after start of the intervention. Recruitment of participants, treatments and follow-up measurement all were performed in a general health care setting and was done by GPs and via advertisements. Self-management was instructed by physiotherapists. Primary outcome measures were pain severity in hip(s) and/or knee(s) (VAS) and functional limitations (WOMAC). Second outcome measures were SF36 and the TSK (tapping into fear-avoidance). We found that the self-management programme positively influenced knee pain and self-reported functional level in this sample of osteoarthritis patients. Interestingly, the differences between the groups increased during follow-up in favour of the intervention group(3. There is overlap as well as there are some interesting differences (1 -3: The self management interventions in all three trials are based on the work of Kate Lorig. The format seems rather the same: 6 sessions guided by two instructors. In our trial self management was offered by physiotherapists, especially trained for this purpose. Buszewizc et al claim that strength of their study is -in contrast with previous studies- the application of validated questionnaires. However, the same holds for our study as there is considerable overlap in the measurements used (SF36, WOMAC). The presentation of outcomes differs somewhat between the studies: Buszewizc et al have chosen quality of life (SF36) as primary outcome. In our trial pain (VAS) and self-reported functioning (WOMAC) were primary outcomes. Quality of life (SF36) was a secondary outcome in our trial. Buszewizc et al did not find effects on pain and physical functioning, while our study demonstrated some beneficial effects in this regard. This might be due to the different characteristics of the outcome measurements. It is likely that the SF36 is less responsive than the VAS-pain and WOMAC with regard to changes in pain and physical functioning. Nevertheless, there is considerable overlap in the use of standardized measurement scales between the studies which makes comparison possible and worthwhile. Duration of follow up differed in the three studies: 4 months(2), 12 months(1) and 21 months (3). This is important because the long term results appear to be better in the self management group than in the control group(1,3). In sum, in our trial the effects of the current self-management interventions administered in a primary health care setting showed improvement in pain and self-reported daily functioning, while the control group deteriorated. At long term follow up (3) the differences between the groups increased during follow-up in favour of the self-management group. This seems to be an important finding since arthritis is a chronic condition. Buszewizc reported the trend of improvement over time, though not statistically significant. Probably this is due to the shorter period of follow up. In the discussion paragraph Buszewizc and colleagues argue that participants in their study had been diagnosed with osteoarthritis and included by their general practitioner rather than applying formal assessment criteria. In our study participants were included in 2 ways. First, like in Buscewizc’ trial by the general practitioner and additionally we recruited via advertisements. In both groups the diagnosis was checked with formal criteria: in the GP-group we used the ICPPH-2, in the advertisement group both ICPPH-2 and the ACR-criteria. All participants matched these criteria-sets. We also looked for possible differences between the participants recruited via general practitioners and via advertisement. We found one relevant finding, namely differences on a scale measuring “readiness-to- change”(4,5). We did not find differences in outcome effects between the population recruited via GPs or via advertisement. The claim by Buszewizc that larger effects of the self management programme are likely in volunteers with high levels of motivation and morbidity is interesting but warrants further research. The question remains whether participants not recruited via GPs but via advertisements might benefit more from self management. We thank Buszewizc c.s. for their interesting work. Peter HTG Heuts, MD, PhD. Caroline HG Bastiaenen, PhD, PT. References: 1. Buszewizc M, Rait G, Griffin M, Nazareth I, Patel A, Atkinson A, et al. Self management of arthritis in primary care: randomised controlled trial. BMJ 2006;333:879-882. 2. Solomon DH, Warsi A, Brown-Stevenson T, Farrell M, Gauthier S, Mikels D, et al. Does self-management education benefit all populations with arthritis? A randomized controlled trial in primary care physician network. J Rheumatol 2002;29:362-8. 3. Heuts PH, Bie de RA, Drietelaar M, Aretz K, Hopman-Rock M, Bastiaenen CH, et al. Self-Management in Osteoarthritis of Hip or Knee: A Randomized Clinical Trial in a Primary Healthcare Setting. J Rheumatol 2005;32:543- 49. 4. Heuts PH, Bie de RA, Dijkstra A, Aretz K, Vlaeyen JW, Schouten HJ, et al. Assessment of readiness to change in patients with osteoarthritis. Development and application of a new questionnaire. Clin Rehabil 2005;19(3):290-99. 5. Kerns R, Rosenberg R, Jamison R, Caudill M, Haythornthwaite J. Readiness to adopt a self-management approach to chronic pain: The Pain Stages of Change Questionnaire (PSOCQ). Pain 1997;72:227-234. Competing interests: None declared |
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