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While there is strong evidence supporting a multidisciplinary team approach in arthritis management, access and use are hindered by limited human and financial resources. To safeguard the provision of comprehensive care throughout the disease trajectory, alternative care models are being developed. Three promising arthritis care models include the use of information technology and telemedicine, patient initiated care, and extended roles of health professionals. Future research projects should focus on: (1) the cost-effectiveness of information technology for exchange of patient-based data and education and management support; (2) the characteristics and needs of patients who can versus those who cannot self-manage; (3) strategies to improve access to care for patients with early arthritis, such as extending roles of health professionals to include triage; and (4) further structuring and standardizing rheumatology training of nursing and allied health professionals.

Multidisciplinary team care, defined as care provided by a group of health professionals from various disciplines, has been widely used in arthritis management since the 1950s. Its effectiveness in comparison with regular outpatient care has mainly been established in patients with rheumatoid arthritis (RA). Recent studies have shown that similar outcomes can be achieved in patients with RA at lower costs using care provided by a clinical nurse specialist. These latter findings suggest that the active components of the multidisciplinary team care model may not be related to the number or professional backgrounds of the health professionals involved, nor with their physical proximity, but rather to the provider's skills in rheumatology and the coordination of services. Because many patients with arthritis have healthcare needs that are not met through treatment by the rheumatologist alone and since traditional multidisciplinary team care in many countries is unavailable or may be undesirable in specific situations, the development and evaluation of alternative, comprehensive models of care delivery is recommended.

Objective: To analyze whether sex differences in referral exist in patients with rheumatoid arthritis (RA)., Methods: At the Department of Rheumatology of the Leiden University Medical Center, a special early arthritis clinic (EAC) was established. General practitioners (GPs) were encouraged to refer patients with joint complaints to the EAC. Subsequently, the diagnosis RA was made by a rheumatologist., Results: In this report, 142 women and 82 men were included. The delays in patient's first encounter with a GP for both sexes were comparable. However, a significant difference in the GP's delay in referring female patients with RA to the EAC in comparison with male patients was observed (median of 93 days vs 58 days; p = 0.008)., Conclusion: This report determined GP referral delay of female patients to a rheumatologist. GPs should be made aware that early detection and early referral of patients with RA are crucial for early treatment.

Objective: To evaluate the effect of high dose chemotherapy (HDC) followed by autologous hematopoietic stem cell transplantation (ASCT) in comparison to conventional pharmacological therapy in the treatment of patients with refractory, progressively erosive rheumatoid arthritis (RA)., Methods: Decision analysis using a Markov model with a 5.5 year time horizon. Probabilities of transition towards 5 different health states, ranging from 70% improvement to death, were derived from published case reports, patient series, and expert panels. Quality of life (QOL) estimates were obtained from 2 RA clinical trials. Patients were hypothetical cohorts of 50-year-old female patients with progressively erosive, active RA, who failed treatment with methotrexate, combination therapy, and tumor necrosis factor blocking agents. Interventions were HDC + ASCT versus conventional pharmacological treatment with a (combination) therapy of disease modifying antirheumatic drugs. As main outcome measures, we included the number of quality adjusted life years (QALY) after HDC + ASCT compared to conventional therapy. Sensitivity analysis was performed to investigate the influence of treatment related mortality (TRM) and the influence of QOL during HDC + ASCT, and to assess the minimal desired effectiveness of HDC + ASCT for a given TRM of 1% and 10%., Results: HDC + ASCT and conventional pharmacological treatment were equally effective in the base-case analysis (3.48 vs 3.46 QALY). A TRM of less than 3.3% favored HDC + ASCT as the preferred treatment. The analysis showed that when TRM was set at 1%, a relatively short period of efficacy was sufficient to remain the preferred strategy, whereas a TRM of 10% would require a sustained response for several years., Conclusion: This model predicted equally favorable effects of HDC + ASCT and conventional therapy in the treatment of refractory RA in the base-case. The minor differences in terms of QALY seem to indicate that clinical decision making should be guided by patient preferences. However, better clinical efficacy might be achieved by adaptation of the treatment regimen of HDC + ASCT and patient selection. The model supports the need for randomized clinical trials and may contribute to an optimal study design.

Objective: To examine the reliability, validity, and responsiveness of a continuous ambulatory activity monitor in patients with rheumatoid arthritis (RA)., Methods: Forty-one patients with RA, participating in a randomized controlled trial examining the effect of an intensive exercise program, were assessed by means of the Dynaport ADL (activities of daily living) monitor (AM). The time spent on activities (locomotion, standing, and active sitting) during 24 hours and the intensity of trunk movement during these activities were recorded. To determine test-retest reliability 20 patients were reassessed with the AM one week after the first assessment. Construct validity of the AM was determined by comparing the AM results with physical fitness measures (muscle strength, endurance, joint mobility), disease activity, and functional status. As well, 37 patients were assessed 18 months after the first assessment to determine responsiveness., Results: All AM measurements showed satisfactory test-retest reliability (ICC 0.63-0.76). AM measures were significantly associated with physical fitness, functional status, and disease activity, indicating construct validity of the AM. The AM could discriminate between patients with improvement and deterioration in physical fitness, indicating sufficient responsiveness of AM variables., Conclusion: This study shows the value of an ambulatory activity monitor to quantify both the amount and intensity of physical activity of patients with RA during a day in their own environment. The ambulatory activity monitor seems to be a promising instrument for research into rehabilitation of patients with RA.

Objective: To investigate which clinical variables contribute to the function of the hand in activities of daily living (ADL) in patients with rheumatoid arthritis (RA)., Methods: In 50 patients with RA hand function in ADL was assessed by (1) the dexterity items of the Arthritis Impact Measurement Scales (AIMS), (2) direct observation of the same items by an occupational therapist, and (3) the Jebsen hand function test. A combined hand function factor was constructed by principal component analysis of the 3 hand function measures. Further assessments included measurements of muscle strength, deformity and destruction, range of motion, and local arthritis activity. After bivariate analyses, variables that correlated significantly with the measures of hand function were entered into stepwise multiple regression analyses., Results: The variables having a significant correlation with most of the hand function measures were: pinch and grip strength, patient's assessment of pain and stiffness of the hands, flexion of the thumb and fingers, range of motion of the wrist, alignment of the metacarpophalangeal (MCP) joints, swan neck and Z deformities, and the Larsen erosion score. 78% of the variance of the combined hand function factor could be explained by pinch strength, stiffness of the hands, and the presence of Z deformity and ulnar deviation., Conclusion: Pinch and grip strength should be carefully considered in setting goals for conservative or surgical treatment of the rheumatoid hand. In addition, reported stiffness of the hands, malalignment of the MCP joints, and flexion and deformity of the thumb were the most consistent indicators of impaired hand function.

Objective: Evaluation of joint range of motion (ROM) is important in the therapeutic approach to patients with rheumatoid arthritis (RA). The reliability, construct validity and sensitivity to change of the Escola Paulista de Medicina (EPM)--range of motion scale that measures 10 distinct movements of small and large joints were examined., Methods: Fifty patients with active RA who were participating in an inpatient multidisciplinary treatment program were examined by 2 investigators. Twenty-five of the patients were examined both at admission and at discharge from the hospital., Results: The mean EPM-ROM score at study entry was 11.52 (SD +/- 3.80). The intra and inter-observer reliability of the EPM-ROM scale was high, with correlations of r = 0.91 and r = 0.85, respectively. There was a good correlation between the EPM-ROM scale and measures of functional ability. Correlations with measures of disease activity were poor. After a mean duration of the treatment program of 4.2 weeks, patients generally improved in variables of functional status and disease activity. The improvement of the EPM-ROM score (mean difference 1.58, 95% CI 0.84-2.32) was generally larger than improvement in other variables of functional status., Conclusion: The EPM-ROM scale is a reliable instrument, and according to its correlation with measures of functional status, relevant to the performance of activities of daily living. It showed a good response to improvement of functional status and disease activity and was more sensitive to changes than other variables of functional status.