Validation of the Danish versions of the Bristol Rheumatoid Arthritis Fatigue Multi-Dimensional Questionnaires (BRAFs).

Objective: This study aimed to validate the Danish versions of the Bristol Rheumatoid Arthritis Fatigue Multi-Dimensional Questionnaire (BRAF-MDQ) and BRAF Numerical Rating Scale version 2 (NRSv2).Method: We tested face and content validity, internal consistency, criterion validity, construct validity, and reproducibility for the BRAF-MDQ, and face and criterion validity and reproducibility for the BRAF-NRS.Results: In all, 224/236 patients (95%) completed the questionnaires [70% female, mean ± sd age 59 ± 13.04 years, disease duration 11.2 ± 9.49 years, Health Assessment Questionnaire (HAQ) 0.724 ± 0.70, and 28-joint Disease Activity Score-C-reactive protein 2.55 ± 1.24]. The unidimensionality for the physical and cognitive fatigue subscales was confirmed, whereas the living with fatigue and emotional fatigue subscales were not unidimensional. Cronbach's α was 0.94 for the BRAF-MDQ total and 0.78-0.92 for the four subscales. The correlations between BRAF-MDQ and various measures were: 36-item Short Form Health Survey (SF-36) vitality subscale, 0.75; Hospital Anxiety and Depression Scale (HADS) anxiety subscale, 0.65; HADS depression subscale, 0.62; visual analogue scale (VAS) pain, 0.62; VAS global, 0.73; and HAQ, 0.62. The intraclass correlation coefficient for agreement was 0.995. A Bland-Altman plot showed a mean ± sd difference of -1.9 ± 3.62 for BRAF-MDQ. Correlation coefficients between the BRAF-NRSv2 subscales and other subscales were: BRAF-MDQ subscales, 0.57-0.93; SF-36 vitality subscale, 0.54-0.68; and VAS fatigue, 0.66-0.82.Conclusions: The Danish BRAFs are considered valid and reliable for use among Danish patients with rheumatoid arthritis, despite the subscales living with fatigue and emotional fatigue not being unidimensional, as they are in the original version.

Mortality and its predictors in patients with rheumatoid arthritis: a Danish population-based inception cohort study.

OBJECTIVES: To investigate mortality and its predictors in a retrospectively defined population-based rheumatoid arthritis (RA) inception cohort Method: We included patients ascertained with incident RA from a region in the southern part of Denmark from 1995 to 2002. All patients fulfilled the 1987 American College of Rheumatology criteria for RA. The patients were followed from RA classification until death, emigration, or end of follow-up on 31 December 2013. We used personal record linkage with national public registers to obtain information on education, employment, cohabitation, comorbidity, and vital status. RESULTS: The cohort comprised 509 patients, of whom 200 (39%) died during 6079 person-years. The most frequent underlying causes of death were cardiovascular disease (34%), neoplasms (26%), and respiratory disease (12%). In rheumatoid factor (RF)-positive males, the standardized mortality ratio (95% confidence interval) from all causes was 1.47 (1.15-1.88), from cardiovascular disease 1.63 (1.09-2.46), from respiratory disease 2.03 (1.06-3.90), and from neoplasms 2.26 (1.02-5.03) in the age group < 70 years, and 2.45 (1.23-4.90) in the age group > 79 years. On applying Cox models after multiple imputations by chained equations, we found that RF modified the effect of age. Employment status, comorbidity, and gender were independent baseline predictors of subsequent mortality. CONCLUSION: In this cohort, significant excess mortality was confined to RF-positive males. The effect of age was modified by RF, and employment status and comorbidity were independent predictors of mortality.

Impact of patient-reported flares on radiographic progression and functional impairment in patients with rheumatoid arthritis: a cohort study based on the AMBRA trial.

OBJECTIVE: To investigate the impact of patient-reported flares on radiographic damage and disability in rheumatoid arthritis (RA). METHOD: Patients with low-active (Disease Activity Score based on 28-joint count with C-reactive protein < 3.2) RA were followed for 2 years. Based on annual questionnaires about incidence of flares, three 'flare phenotypes' were distinguished: no flares (NF), transient flares (TF), and a mixed category reporting persistent joint complaints (PJC) in at least one year. Baseline and 2 year radiographs of hands and feet were evaluated according to the Sharp/van der Heijde method. Major outcomes were change from baseline in Total Sharp Score (ΔTSS) and functional impairment, expressed by the Health Assessment Questionnaire (ΔHAQ). Their association with flare phenotype was analysed by logistic regression. RESULTS: The study included 268 RA patients (70% female; 73% immunoglobulin M rheumatoid factor positive), with a median age (interquartile range) of 63 (55-70) years, and 7 (4-13) years' disease duration. Flares were recalled as NF (n = 77), TF (n = 141), and PJC (n = 50). ΔTSS > 0 was observed in 35%, 37%, and 46%, respectively (p = 0.42), but statistically significantly (p = 0.01) more patients progressed in the TF (10%) and PJC (14%) compared to NF (0%), based on the smallest detectable change (> 4.4 ΔTSS unit). ΔHAQ above the minimal clinically important difference (> 0.22) was seen in 13% (NF), 21% (TF), and 40% (PJC) (p = 0.0015), with PJC being associated with statistically significant impairment in function (odds ratio 4.47, 95% confidence interval 1.87-10.69) compared to NF. CONCLUSION: In RA patients with low disease activity, the incidence of radiographic progression and functional impairment was higher in patients with flares and persistent complaints, compared to those without flares.

EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update.

Patients with rheumatoid arthritis (RA) and other inflammatory joint disorders (IJD) have increased cardiovascular disease (CVD) risk compared with the general population. In 2009, the European League Against Rheumatism (EULAR) taskforce recommended screening, identification of CVD risk factors and CVD risk management largely based on expert opinion. In view of substantial new evidence, an update was conducted with the aim of producing CVD risk management recommendations for patients with IJD that now incorporates an increasing evidence base. A multidisciplinary steering committee (representing 13 European countries) comprised 26 members including patient representatives, rheumatologists, cardiologists, internists, epidemiologists, a health professional and fellows. Systematic literature searches were performed and evidence was categorised according to standard guidelines. The evidence was discussed and summarised by the experts in the course of a consensus finding and voting process. Three overarching principles were defined. First, there is a higher risk for CVD in patients with RA, and this may also apply to ankylosing spondylitis and psoriatic arthritis. Second, the rheumatologist is responsible for CVD risk management in patients with IJD. Third, the use of non-steroidal anti-inflammatory drugs and corticosteroids should be in accordance with treatment-specific recommendations from EULAR and Assessment of Spondyloarthritis International Society. Ten recommendations were defined, of which one is new and six were changed compared with the 2009 recommendations. Each designated an appropriate evidence support level. The present update extends on the evidence that CVD risk in the whole spectrum of IJD is increased. This underscores the need for CVD risk management in these patients. These recommendations are defined to provide assistance in CVD risk management in IJD, based on expert opinion and scientific evidence.

Shared care or nurse consultations as an alternative to rheumatologist follow-up for rheumatoid arthritis (RA) outpatients with stable low disease-activity RA: cost-effectiveness based on a 2-year randomized trial.

OBJECTIVES: To compare the cost-effectiveness of three types of follow-up for outpatients with stable low-activity rheumatoid arthritis (RA). METHOD: In total, 287 patients were randomized to either planned rheumatologist consultations, shared care without planned consultations, or planned nurse consultations. Effectiveness measures included disease activity (Disease Activity Score based on 28 joint counts and C-reactive protein, DAS28-CRP), functional status (Health Assessment Questionnaire, HAQ), and health-related quality of life (EuroQol EQ-5D). Cost measures included activities in outpatient clinics and general practice, prescription and non-prescription medicine, dietary supplements, other health-care resources, and complementary and alternative care. Measures of effectiveness and costs were collected by self-reported questionnaires at inclusion and after 12 and 24 months. Incremental cost-effectiveness rates (ICERs) were estimated in comparison with rheumatologist consultations. RESULTS: Changes in disease activity, functional status, and health-related quality of life were not statistically significantly different for the three groups, although the mean scores were better for the shared care and nurse care groups compared with the rheumatologist group. Shared care and nurse care were non-significantly less costly than rheumatologist care. As both shared care and nurse care were associated with slightly better EQ-5D improvements and lower costs, they dominated rheumatologist care. At EUR 10,000 per quality-adjusted life year (QALY) threshold, shared care and nurse care were cost-effective with more than 90% probability. Nurse care was cost-effective in comparison with shared care with 75% probability. CONCLUSIONS: Shared care and nurse care seem to cost less but provide broadly similar health outcomes compared with rheumatologist outpatient care. However, it is still uncertain whether nurse care and shared care are cost-effective in comparison with rheumatologist outpatient care.

It means everything: continuing normality of everyday life for people with rheumatoid arthritis in early remission.

OBJECTIVE: The aim of this follow-up study was twofold: firstly, to explore how people who were clinically regarded to be in a state of remission experienced their everyday lives with rheumatoid arthritis (RA); secondly, to explore the experiences of people in early remission with healthcare provision and their perceived support needs. METHODS: Two focus group interviews were conducted with 11 participants in total. Interview data were analysed using content analysis methods. RESULTS: All participants felt that they were able to continue their normal everyday activities at home, at leisure and at work. They were also able to maintain their normal roles. Continuing the normality of everyday life seemed to be the most important defining variable for experiencing being in remission. Support needs were directly related to the participants' positive experiences of actual support from the healthcare providers and were related to the continuity of the care provider, coherence, being taken care of, having a personal and trusting relationship with the health professionals and being properly informed about RA and how to manage it. CONCLUSION: The participants wanted to concentrate on wellness and tended to avoid thinking of possible side effects, being chronic ill and the development of RA in the future.

Self-efficacy as an outcome measure and its association with physical disease-related variables in persons with rheumatoid arthritis: a literature review.

BACKGROUND: Studies have demonstrated a positive impact of patient education on self-efficacy in persons with rheumatoid arthritis (RA). However, the relationship between self-efficacy, physical disease-related variables and educational interventions has not yet been reviewed. AIM: The aims of this study, in relation to persons with RA, were: 1) to provide an overview of the existing research into the association between self-efficacy and physical disease-related variables and, with this knowledge, 2) to provide an overview of the existing research on the effect of different types of educational interventions on self-efficacy. METHOD: A systematic literature search was performed using eight databases, based on the terms 'rheumatoid arthritis' AND 'self-efficacy'. In total, 74 studies reporting associations between self-efficacy and physical disease-related variables and using self-efficacy as an outcome measure in educational interventions were included. RESULTS: The scores obtained by the most commonly used questionnaire, the Arthritis Self-Efficacy Scale (ASES), was highly associated with physical disability, pain, fatigue and disease duration. If educational activities had a positive impact on self-efficacy, disease-related variables usually improved as well. Evidence is scarce as to whether disease-related variables affect patients' self-efficacy or vice versa and whether individual consultations can affect patients' self-efficacy. CONCLUSION: The scores attained by the ASES is highly associated with physical disease-related variables. This relationship requires further research using a specific study design to restrict bias when evaluating the impact of interventions on self-efficacy in persons with RA. Research is needed on whether individual consultations can affect patients' self-efficacy. Disease-related variables do not affect the Rheumatoid Arthritis Self-Efficacy (RASE) questionnaire but this needs further exploration.

Self-efficacy in rheumatoid arthritis: translation and test of validity, reliability and sensitivity of the Danish version of the Rheumatoid Arthritis Self-Efficacy Questionnaire (RASE).

OBJECTIVES: To describe the translation and test of the Danish version of the original British 'Rheumatoid Arthritis Self-Efficacy Questionnaire' (RASE). METHODS: The questionnaire was forward and back translated by individuals with Danish and English as their respective primary languages. The questionnaire was tested by five lay-people and in the field by 10 + five persons with rheumatoid arthritis (RA). A test-retest was performed on 62 outpatients with RA. The sensitivity of the adapted Danish version of RASE (RASE-DK) was finally tested on 106 outpatients with RA - before, immediately after and three months after they had participated in a short self-management course performed by a multidisciplinary team. RESULTS: RASE-DK showed good face validity, but 'relaxation' was interpreted in various ways. Internal consistency evaluated by Cronbach's alpha was 0.91. Reliability evaluated by the intra-class correlation coefficient (ICC) was 0.88. A Bland-Altman plot showed good agreement. RASE-DK, like the original English version of RASE, was not associated with disease activity (Disease Activity Score, DAS-28) or disability (Health Assessment Questionnaire, HAQ), and correlated significantly with the Arthritis Self-Efficacy Scale (ASES) subscales 'other' and 'pain', and total ASES. RASE-DK showed a highly significant change, from baseline to immediately after participation in the short course (p < 0.001). The effect faded during the following three months. CONCLUSION: RASE-DK met the appropriate standards for validity, reliability and sensitivity, and is appropriate for use in Denmark. However, the concept of self-efficacy may be too abstract for a few individuals, and relaxation is interpreted in various ways by the Danish patients.

Environmental effects of agri-environmental schemes in Western Europe.

Agri-environmental schemes (AES) have been introduced as part of European Union's (EU) Common Agricultural Policy and are now an important part of this. A methodological approach to analyse the policy effects of AES is outlined, in which we distinguish between performance effects (on agricultural practices) and outcome effects (environmental impact). The performance effects are further approached including measurement of improvement and protection effects based on 12 indicators on changes/maintenance of land use and agricultural management. Data from personal interviews of participating and non-participating farmers in AES measures in nine EU Member States and Switzerland were used to analyse policy effects, including single indicator effects on agricultural practices as well as combined effects at the agreement level. Significant effects were found for mineral N-fertiliser use, stocking density reduction, maintenance of a minimum livestock density and pesticides. For AES agreements regulating grassland management, fertiliser use and pesticides, clear indications of combined improvement and protection effects were found. In addition clear improvement effects of agreements regulating fertiliser and pesticides use on mainly arable lands were revealed. It is concluded that the approach presented including the 12 selected indicators has proven to be operational.