Core Curriculum to Facilitate the Expansion of a Rheumatology Practice to Include Nurse Practitioners and Physician Assistants.

OBJECTIVE: Due to an aging population, increasing prevalence of rheumatic disease, and a growing supply and demand gap of rheumatology providers, innovative solutions are needed to meet the needs of persons with rheumatic conditions. Nurse practitioners (NPs) and physician assistants (PAs) have been identified as a group of health professionals who could help address the workforce shortage. The Executive Committee of the Association of Rheumatology Health Professionals (ARHP), a division of the American College of Rheumatology (ACR), charged a task force to facilitate the preparation of NPs/PAs to work in a rheumatology practice setting. METHODS: The task force, consisting of private practice and academic rheumatologists, and NPs and PAs, from both adult and pediatric settings, conducted a needs assessment survey of current NPs and PAs to identify mechanisms for acquiring rheumatology knowledge. Through face-to-face and webinar meetings, and incorporating stakeholder feedback, the task force designed a rheumatology curriculum outline to enrich the training of new NPs and PAs joining rheumatology practice. RESULTS: Informed by the needs assessment data and stakeholders, an NP/PA rheumatology curriculum outline was developed and endorsed by the ACR Board of Directors for use by community-based and academic rheumatology practices, whether pediatric or adult, who desire to add NPs and PAs to their practice setting. CONCLUSION: As rheumatology is facing workforce shortages, the ACR/ARHP rheumatology curriculum outline can be utilized to train NPs and PAs and create more efficient integration of NPs and PAs into rheumatology practice.

RAHelp: an online intervention for individuals with rheumatoid arthritis.

OBJECTIVE: To test an intervention for improving self-management in rheumatoid arthritis (RA) using an online, cognitive-behavioral, self-management group program (RAHelp), with weekly telephone support. METHODS: A 2-group, randomized study design was used to compare an intervention for RA versus a waiting-list control condition. The intervention used a secure web site (RAHelp.org) to provide a 10-week program with weekly educational modules for improving self-efficacy in self-management of RA, plus tools for group interaction. Weekly telephone contacts were made to encourage use of program tools and apply newly learned skills. A nationwide convenience sample of 106 adult participants (mean age 50 years, 93% women) was recruited primarily through online advertisements. Main outcome measures included the Arthritis Impact Measurement Scales 2 (affective, physical, role, social, and pain/symptom components), Arthritis Self-Efficacy Scale (ASES), Center for Epidemiologic Studies Depression Scale, Quality of Life Scale (QLS), Rapid Assessment of Disease Activity in Rheumatology, Social Provisions Scale, and University of California, Los Angeles Loneliness Scale 3. RESULTS: Group differences with large and moderate effect sizes (ES) were found immediately postintervention for self-efficacy (ASES; ES 0.92, P = 0.00001) and quality of life (QLS; ES 0.66, P = 0.003), respectively. At 9 months postintervention, differences in self-efficacy (ASES; ES 0.92, P = 0.00001) and quality of life (QLS; ES 0.71, P = 0.004) remained robust. CONCLUSION: RAHelp appears to have beneficial effects in terms of self-efficacy and quality of life among individuals with RA who are willing to use an online service format.

Online self-management in rheumatoid arthritis: a patient-centered model application.

OBJECTIVE: The aim of this study was to describe the online transformation of an empirically validated, clinic-based, self-management (SM) program for rheumatoid arthritis. MATERIALS AND METHODS: A cognitive-behavioral framework served as the theoretical basis for the intervention. As with the clinic-based approach, the psychoeducational program included educational modules, weekly homework assignments, and self-evaluation. The dynamic online environment included secure communication tools to support a virtual community for the participants to garner peer support. In addition to peer support, weekly follow-up support was provided by a trained clinician via telephone. We describe the process and structure of the online self-management (OSM) intervention. Administrative issues including clinical monitoring and management, data collection, and security safeguards are considered. Utilization and management data are provided and explored for 33 initial subjects. RESULTS: Individuals who volunteer to participate in an online modality are eager to receive this home-based programming. They readily engaged with all aspects of the OSM program and experienced few difficulties navigating the environment. CONCLUSION: An OSM site provides a convenient, effective, and securely maintained health service, once restricted to clinic settings. The OSM application can be used to extend the benefits of SM programs to broad target audiences and serves as a model for the emerging generation of Internet-based clinical management/delivery systems.

Social interactions in an online self-management program for rheumatoid arthritis.

OBJECTIVE: To evaluate social interactions among individuals with rheumatoid arthritis (RA), participating in an empirically based, cognitive-behavioural, self-management (SM), and peer-support program, delivered in an online format. METHODS: Thirty individuals with RA were recruited online. Subjects were a subset of participants in the treatment arm of a waiting-list controlled study testing the effectiveness of a 10-week, online, SM education and peer support program. Primary outcomes were process variables describing social activity in the online environment during active treatment. Qualitative review of discussion board posts was undertaken to gain insight into participants' perceptions of social interactions. RESULTS: Participants spent a large proportion of logged-in time accessing educational materials and community-level activity was vibrant, with members utilizing the discussion board and e-mail. The Chat feature was less well-used. Discussion board posts regarding RAHelp were very positive, especially in regard to perceived supportiveness and bonding among participants, and a sense of feeling uniquely understood by others who have RA. Concern arose in response to periods in which the discussion board was 'too quiet'. DISCUSSION: Our work complements the emerging literature supporting acceptance and utility of Internet-based programming as a venue for SM education and social interaction among individuals with chronic illness.

Internet use and e-mail communications between patients and providers: a survey of rheumatology outpatients.

BACKGROUND: As health care costs rise in the United States and elsewhere, adopting health information technology is being advocated to reduce costs and improve efficiency. PATIENT: Physician e-mail communication is a frequently proposed tool in this strategy. OBJECTIVES: We examined the interest of rheumatology outpatients in using E-mail for communication with their rheumatologist. We sought to identify their privacy and cost concerns on this issue, and examine the patients' demographics, internet usage, and preferences. METHODS: An anonymous survey was given to 150 consecutive patients. Patients responded to questions on demographics, rheumatic diseases, comorbidities, computer/internet access, E-mail use, privacy concerns, payment issues, and preferences regarding communication with their rheumatologist. Statistical analyses on the relationships between demographics and patient preferences on communications with their rheumatologist were conducted. RESULTS: There were 145 respondents; the mean age was 52.3 years, mean education level was 13.6 years. The sample tended to be women (74%), retired/disabled (46%) or employed full time (35%). Most had internet access (74.5%). Differences were found based on gender, age, education, and income levels. Younger adults were more likely to desire E-mail communication with their rheumatologists, especially if paid by insurance. More men than women had concerns about privacy; persons with higher income levels were more willing to self-pay for E-mail. CONCLUSION: As a significant number of patients with rheumatic diseases express interest in E-mail communication with their providers, rheumatologists need to be cognizant of patients' preferences. To deliver patient-centered care, rheumatology practices might consider incorporating E-mail communication into their practices.

Relationship of psychiatric history to pain reports in rheumatoid arthritis.

OBJECTIVE: The purpose was to examine the relationship of pre-existing psychiatric history to pain reports in a cohort of persons with RA and concomitant major depression who were receiving a trial of antidepressant medication. METHOD: RA patients (n = 41) with a current episode of major depression were divided into two subgroups comprised of those with a previous psychiatric history (PSY+) (n = 20) and those without a previous psychiatric history (PSY-) (n = 21). The groups were compared with regard to their responsiveness to a regimen of antidepressive medication on measures of depression, pain, coping, and life stress over a period of 15 months. RESULTS: Although depression scores for both the PSY+ and the PSY- groups decreased significantly from baseline to 15-month follow-up, the composite pain score was found to be significantly decreased only for the PSY- group. CONCLUSION: Psychiatric history appears to predispose persons with concomitant RA and major depression to report less pain reduction following antidepressive treatment than those persons without a psychiatric history.

Analyzing reliability of change in depression among persons with rheumatoid arthritis.

OBJECTIVE: To examine several methods of determining reliability of change constructs in depressive symptoms in patients with rheumatoid arthritis (RA) and to demonstrate the strengths, weaknesses, and uses of each method. METHODS: Data were analyzed from a cohort of 54 persons with RA who participated in a combined behavioral/pharmacologic intervention of 15 months duration. These longitudinal data were used to examine 3 methodologies for assessing the reliability of change for various measures of depression. The specific methodologies involved the calculations of reliable change, sensitivity to change, and reliability of the change score. RESULTS: The analyses demonstrated differences in reliability of change performance across the various depression measures, which suggest that no single measure of depression for persons with RA should be considered superior in all contexts. CONCLUSION: The findings highlight the value of utilizing reliability of change constructs when examining changes in depressive symptoms over time.

Health status, cognitive coping, and depressive symptoms: testing for a mediator effect.

OBJECTIVE: Research has established a link between health status and symptoms of depression in persons with rheumatoid arthritis (RA), but the effects of "cognitive coping" variables have not been extensively studied. We examined the mediator effect of a cognitive coping variable (Pain Control and Rational Thinking factor score from the Coping Strategies Questionnaire) over the course of a pharmacological intervention. METHOD: Data were analyzed from 54 persons with RA, all of whom met diagnostic criteria for major depression. Measures of depression, health status, and cognitive coping were collected at 4 different stages of a pharmacological (antidepressant) study as follows: (1) at baseline, (2) postintervention, (3) 6 month followup, and (4) 15 month followup. RESULTS: Results indicated that a direct relationship existed between health status and depression at all 4 time periods. However, this relationship was mediated by cognitive coping only at the postintervention and the 6 month followup. CONCLUSION: A cognitive coping variable was found to mediate the relationship between health status and depression, but only at moderate levels of depression.

Anxiety in rheumatoid arthritis.

OBJECTIVE: To examine the level of anxiety experienced by individuals with rheumatoid arthritis (RA). METHODS: Data from 2 previous studies were used to compare the level of anxiety (measured by the State-Trait Anxiety Inventory) in the following 4 subgroups: a general RA sample, a general osteoarthritis sample, a sample with both RA and major depression, and a normative sample of age-equivalent, working adults. Canonical correlations were used to examine associations between measures of anxiety and measures of both stress and depression. The relationship between anxiety and duration of RA was also explored. RESULTS: The general RA sample had state anxiety levels that were comparable to the normative sample, although trait anxiety levels were significantly higher (P < 0.001). In addition, individuals with RA who also met criteria for depression exhibited significantly higher levels of both state anxiety (P < 0.0001) and trait anxiety (P < 0.0001) than was observed in the normative sample. Canonical correlations revealed that measures of anxiety were correlated with both measures of depression (r = 0.83) and measures of stress (r = 0.50). Anxiety was not found to be significantly related to RA disease duration. CONCLUSION: These findings demonstrated that individuals with RA, especially if concomitantly depressed, tend to exhibit levels of anxiety that are generally higher than a normative group of age-equivalent, working adults. The substantial canonical correlations between anxiety and both depression and stress revealed that anxiety shares variance with these more frequently studied variables in RA. However, anxiety was not found to be related to RA disease duration.

Management of depression in rheumatoid arthritis: a combined pharmacologic and cognitive-behavioral approach.

OBJECTIVE: To examine the effectiveness of cognitive-behavioral and pharmacologic treatment of depression in rheumatoid arthritis (RA). METHODS: Subjects (n = 54) with confirmed diagnoses of both major depression and RA were randomly assigned to 1 of 3 groups: 1) cognitive-behavioral/pharmacologic group (CB-PHARM), 2) attention-control/pharmacologic group, or 3) pharmacologic control group. Measures of depression, psychosocial status, health status, pain, and disease activity were collected at baseline, posttreatment (10 weeks), 6-month followup, and 15-month followup. Data were analyzed to compare the treatment effectiveness of the groups; data also were aggregated to examine the effects of antidepressive medication over time. Lastly, a no-treatment control group was defined from a cohort of persons who declined participation. RESULTS: Baseline comparisons on demographic and dependent measures revealed a need to assess covariates on age and education; baseline scores on dependent measures also were entered as covariates. Analyses of covariance revealed no statistically significant group differences at postintervention, 6-month followup, or 15-month followup, except higher state and trait anxiety scores for the CB-PHARM group at the 15-month followup. In the longitudinal analyses of the effects of antidepressive medication, significant improvement in psychological status and health status were found at posttreatment, 6-month followup, and 15-month followup, but no significant improvements were shown for pain or disease activity. In addition, the comparison of the aggregated pharmacologic group with a no-treatment group revealed a statistically significant benefit for the 3 groups that received the antidepressive medication. CONCLUSION: In persons with RA, cognitive-behavioral approaches to the management of depression were not found to be additive to antidepressant medication alone, but antidepressant intervention was superior to no treatment.

Assessment of depression in rheumatoid arthritis: a modified version of the center for epidemiologic studies depression scale.

OBJECTIVE: The Center for Epidemiologic Studies Depression Scale (CES-D) is an instrument commonly used to assess depressive symptoms. Although the psychometric properties of the instrument are well established, the instrument's ability to identify confirmed cases of major depression has been unclear. The purpose of this study was to evaluate the ability of cutoff scores from both a full scale and a modified CES-D to detect major depression in people with rheumatoid arthritis (RA). METHOD: Data were analyzed from 457 persons with RA, including 91 who met criteria for major depression. RESULTS: Results indicated that, in general, a full scale cutoff score of 19 was the most efficient in identifying cases of major depression; the cutoff score of 19 outperformed a variety of other cutoff scores from the modified scale. Even the most efficient cutoff scores, however, demonstrated problems in accurately identifying people with depression. CONCLUSION: The CES-D, while potentially useful as a screening tool, should not be used to identify cases of major depression.

Clinical outcomes following a trial of sertraline in rheumatoid arthritis.

We report an open-label trial of sertraline in the treatment of major depression in 54 consecutive rheumatoid arthritis (RA) patients meeting DSM-IV criteria for major depressive disorder. We initially surveyed 628 RA outpatients with the Center for Epidemiologic Studies Depression Scale (CES-D) and invited those with depression to be evaluated further and treated. Eighty-four RA patients reporting depressive symptoms agreed to participate in person, and 56 met the criteria for major depressive disorder. Of these 56 patients, 54 agreed to medication treatment and were enrolled in the study. Patients were also randomized to one of three psychological treatment conditions, but for this study, conditions were collapsed because previous research on this sample indicated no significant between-group differences in depression after treatment. Patients were assessed with the CES-D and the Hamilton Rating Scale for Depression after the intervention, at 6-month follow-up, and at 15-month follow-up. At the last follow-up, 41 patients remained for assessment. In this study, sertraline was found to be a safe and efficacious treatment of depression complicating RA.