Willingness of patients with ankylosing spondylitis to pay for inpatient treatment is influenced by the treatment environment and expectations of improvement.

OBJECTIVE: To assess the willingness to pay (WTP) for treatment in a spa resort of patients with ankylosing spondylitis (AS) and to assess if the experience of a spa influences the WTP. METHODS: 120 patients participating in a randomised trial comparing 3 weeks' treatment in a spa resort in Austria or in the Netherlands with a control group completed a WTP questionnaire before and after spa treatment. Patients indicated on a payment card the maximal co-payment they wanted to contribute for three scenarios that included (a) two levels of improvement in pain and stiffness and (b) two treatment environments: a rehabilitation hospital and a spa resort. RESULTS: At baseline, patients wanted to contribute more for the same improvement after treatment in a spa resort compared with a rehabilitation hospital (p<0.003), and were prepared to pay more when expected effects were higher (p<0.001). No differences were found between men and women, pain, or income. After the trial none of the treatment groups showed a change in their WTP. CONCLUSION: The WTP of patients with AS for inpatient treatment is influenced by the treatment environment and the expected improvement. Experiencing treatment in a spa resort does not influence the co-payment.

Assessment of disability with the World Health Organisation Disability Assessment Schedule II in patients with ankylosing spondylitis.

OBJECTIVE: To investigate in ankylosing spondylitis (AS) whether the newly developed World Health Organisation Disability Assessment Schedule II (WHODAS II) is a useful instrument for measuring disability, to assess its responsiveness in relation to other traditional disease specific instruments, and to identify factors that are associated with both short term and long term scores on the WHODAS II. METHODS: Patients with AS from a randomised controlled trial assessing the efficacy of spa treatment (n=117) and from a five year longitudinal observational study (n=97) participated. The patients completed several questionnaires, including the WHODAS II. After a three week course of spa treatment, 31 patients again completed all questionnaires to assess responsiveness. To determine to what degree the WHODAS II reflects some AS oriented measures on disease activity, functioning, and quality of life, correlation coefficients between the WHODAS II and these other questionnaires were calculated. Responsiveness was calculated by the effect size (ES) and standardised response mean (SRM). Linear regression analysis was performed to explore which factors might be associated with short term changes on the WHODAS II and to investigate (in the observational study) which factors of WHODAS II might predict disability five years later. RESULTS: Mean score on the WHODAS II was 23.9 (SD 15.5 (range 0.0-76.1)). Scores on the WHODAS II were significantly correlated with all disease specific questionnaires measured (all p<0.001). The WHODAS II showed a comparable short term responsiveness score (SRM 0.41; ES 0.39). In regression analysis these short term changes on the WHODAS II were significantly associated with changes in functioning (beta coefficient 4.25, 95% confidence interval (95% CI) 1.24 to 7.26, p=0.007). In the observational study, disease activity (beta coefficient 0.35, 95% CI 0.17 to 0.53, p<0.000) as well as functioning (beta coefficient 0.23, 95% CI 0.09 to 0.38, p=0.002) seemed to significantly predict disability (WHODAS II) after five years. CONCLUSION: The WHODAS II is a useful instrument for measuring disability in AS in that it accurately reflects disease specific instruments and that it shows similar responsiveness scores. In AS, a short term change on the WHODAS II is associated with a change in physical function. At the group level, disease activity and physical functioning may predict disability after five years.

Combined spa-exercise therapy is effective in patients with ankylosing spondylitis: a randomized controlled trial.

OBJECTIVE: To determine the efficacy of combined spa-exercise therapy in addition to standard treatment with drugs and weekly group physical therapy in patients with ankylosing spondylitis (AS). METHODS: A total of 120 Dutch outpatients with AS were randomly allocated into 3 groups of 40 patients each. Group 1 (mean age 48 +/- 10 years; male:female ratio 25:15) was treated in a spa resort in Bad Hofgastein, Austria; group 2 (mean age 49 +/- 9 years; male:female ratio 28:12) in a spa resort in Arcen, The Netherlands. The control group (mean age 48 +/- 10 years; male:female ratio 34:6) stayed at home and continued their usual drug treatment and weekly group physical therapy during the intervention weeks. Standardized spa-exercise therapy of 3 weeks duration consisted of group physical exercises, walking, correction therapy (lying supine on a bed), hydrotherapy, sports, and visits to either the Gasteiner Heilstollen (Austria) or sauna (Netherlands). After spa-exercise therapy all patients followed weekly group physical therapy for another 37 weeks. Primary outcomes were functional ability, patient's global well-being, pain, and duration of morning stiffness, aggregated in a pooled index of change (PIC). RESULTS: Analysis of variance showed a statistically significant time-effect (P < 0.001) and time-by-treatment interaction (P = 0.004), indicating that the 3 groups differed over time with respect to the course of the PIC. Four weeks after start of spa-exercise therapy, the mean difference in PIC between group 1 and controls was 0.49 (95% confidence interval [CI] 0.16-0.82, P = 0.004) and between group 2 and controls was 0.46 (95% CI 0.15-0.78, P = 0.005). At 16 weeks, the difference between group 1 and controls was 0.63 (95% CI 0.23-1.02, P = 0.002) and between group 2 and controls was 0.34 (95% CI--0.05-0.73; P = 0.086). At 28 and 40 weeks, more improvement was found for group 1 compared with controls (P = 0.012 and P = 0.062, respectively) but not for group 2 compared with controls. CONCLUSION: In patients with AS, a 3-week course of combined spa-exercise therapy, in addition to drug treatment and weekly group physical therapy alone, provides beneficial effects. These beneficial effects may last for at least 40 weeks.