Economic evaluation of a brief education, self-management and upper limb exercise training in people with rheumatoid arthritis (EXTRA) programme: a trial-based analysis.

OBJECTIVE: The aim of this study was to conduct a cost-utility analysis of the Education, Self-management and Upper Limb Exercise Training in People with RA (EXTRA) programme compared with usual care. METHODS: A within-trial incremental cost-utility analysis was conducted with 108 participants randomized to either the EXTRA programme (n = 52) or usual care (n = 56). A health care perspective was assumed for the primary analysis with a 36 week follow-up. Resource use information was collected on interventions, medication, primary and secondary care contacts, private health care and social care costs. Quality-adjusted life years (QALYs) were calculated from the EuroQol five-dimension three-level (EQ-5D-3L) questionnaire responses at baseline, 12 and 36 weeks. RESULTS: Compared with usual care, total QALYs gained were higher in the EXTRA programme, leading to an increase of 0.0296 QALYs. The mean National Health Service (NHS) costs per participant were slightly higher in the EXTRA programme (by £82), resulting in an incremental cost-effectiveness ratio of £2770 per additional QALY gained. Thus the EXTRA programme was cost effective from an NHS perspective when assessed against the threshold of £20 000-£30 000/QALY gained. Overall, costs were lower in the EXTRA programme compared with usual care, suggesting it was the dominant treatment option from a societal perspective. At a willingness-to-pay of £20 000/QALY gained, there was a 65% probability that the EXTRA programme was the most cost-effective option. These results were robust to sensitivity analyses accounting for missing data, changing the cost perspective and removing cost outliers. CONCLUSION: The physiotherapist-led EXTRA programme represents a cost-effective use of resources compared with usual care and leads to lower health care costs and work absence. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number Register; http://www.controlled-trials.com/isrctn/ (ISRCTN14268051).

Are patients meeting the updated physical activity guidelines? Physical activity participation, recommendation, and preferences among inner-city adults with rheumatic diseases.

BACKGROUND: Physical activity (PA) improves the health of people with rheumatic diseases. Revised guidelines (published in the United States in 2008 and in the United Kingdom in 2011) recommend that adults complete 150 or more minutes of moderate-intensity PA or 75 or more minutes of vigorous-intensity PA (or equivalent) in bouts of 10 or minutes per week, yet whether people with rheumatic diseases meet these guidelines is unknown. OBJECTIVES: This study evaluates the PA levels of adults with rheumatic diseases attending an inner-city hospital against the updated PA guidelines. It assesses respondents' PA preferences and the proportion who report ever receiving PA advice from a healthcare professional (HCP). METHODS: Five hundred and eight patients (46% response rate) attending the general rheumatology clinics of an inner-city UK hospital completed the self-report International Physical Activity Questionnaire and 3 additional questions: "Has a doctor or other HCP ever suggested PA or exercise to help your arthritis or joint symptoms?" "Would you like help from your doctor or health service to become more physically active?" and "Which physical activities do you enjoy?" RESULTS: Overall, 61% of respondents met the updated PA guidelines, and 39% did not meet the guidelines. Forty-three percent of respondents reported ever receiving PA advice from an HCP, and 50% reported that they would "like help" to become more physically active. Walking was the most preferred PA (65%). CONCLUSIONS: Almost two-thirds of our respondents met the updated PA guidelines; however, many were entirely inactive. Recommending regular PA should be integral to rheumatic disease management, and walking offers a potentially accessible, inexpensive, and acceptable PA intervention.

Participants' experiences of an Education, self-management and upper extremity eXercise Training for people with Rheumatoid Arthritis programme (EXTRA).

BACKGROUND: The Education, self-management and upper extremity eXercise Training for people with Rheumatoid Arthritis programme (EXTRA) is an individualized, upper limb, home exercise regimen supplemented by four supervised, group sessions, a handbook and exercise dairy which improves upper extremity disability and self-efficacy. OBJECTIVE AND STUDY DESIGN: This qualitative interview study explored participants' experience of EXTRA to inform development and implementation of EXTRA into practice. PARTICIPANTS: Adults with Rheumatoid Arthritis who completed EXTRA were purposively sampled to include a range of ages, upper extremity disabilities, self-efficacy for arthritis self-management and attendance at EXTRA sessions. METHODS: Individual, semi-structured interviews were conducted with a single researcher until data saturation of themes was reached. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. RESULTS: Twelve participants (10 females; 32 to 87 years) were interviewed. Four overarching themes were identified: (i) empowering self-management; (ii) influence of others and (iii) the challenge of sustaining exercise, which resonate with the Social Cognition Theory, and (iv) refining EXTRA: consistent and personalised. CONCLUSIONS: EXTRA enhanced participants' confidence to manage their arthritis independently and was adaptable so it could be integrated with other life commitments. Whilst healthcare professionals, peers and family and friends influenced exercise uptake, sustaining exercise was challenging. Participants desired consistent and continuing contact with a familiar physiotherapist (e.g. via follow-up appointments, digital health technologies) which accommodated individual needs (e.g. different venues, session frequency). Implementation of EXTRA needs to appreciate and address these considerations to facilitate success.

Education, self-management, and upper extremity exercise training in people with rheumatoid arthritis: a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of a brief supervised education, self-management, and global upper extremity exercise training program, supplementing a home exercise regimen, for people with rheumatoid arthritis (RA; the Education, Self-Management, and Upper Extremity Exercise Training in People with Rheumatoid Arthritis [EXTRA] program). METHODS: Adults with RA of ≤5 years' duration were randomized to receive either usual care or the EXTRA program comprising 4 (1-hour) group education, self-management, and global upper extremity exercise training sessions supplementing the first 2 weeks of a 12-week individualized, functional home exercise regimen in addition to usual care. Outcome measures were assessed at baseline, 12 weeks (primary end point), and 36 weeks and included the Disabilities of the Arm, Shoulder, and Hand questionnaire (primary outcome measure), the Grip Ability Test, handgrip strength (N), the Arthritis Self-Efficacy Scale (pain, function, and symptoms subscales), and the 28-joint Disease Activity Score. RESULTS: One hundred eight participants (26 men, mean ± SD age 55 ± 15 years, mean ± SD disease duration 20 ± 19 months) were randomized to receive either usual care (n = 56) or the EXTRA program (n = 52). At 12 weeks, there was a significant between-group difference in the mean change in disability (-6.8 [95% confidence interval (95% CI) -12.6, -1.0]; P = 0.022), function (-3.0 [95% CI -5.0, -0.5]; P = 0.011), nondominant handgrip strength (31.3N [95% CI 9.8, 52.8]; P = 0.009), self-efficacy (10.5 [95% CI 1.6, 19.5]; P = 0.021 for pain and 9.3 [95% CI 0.5, 18.2]; P = 0.039 for symptoms), and disease activity (-0.7 [95% CI -1.4, 0.0]; P = 0.047), all favoring the EXTRA program. CONCLUSION: The EXTRA program improves upper extremity disability, function, handgrip strength, and self-efficacy in people with RA, with no adverse effects on disease activity.