Team rehabilitation and health care utilization in chronic inflammatory arthritis patients

Sammanfattning: The aim of this thesis was to study outcome and evaluation of rheumatological multidisciplinary team rehabilitation programmes in patients with chronic inflammatory arthritis (CIA); rheumatoid arthritis (RA), ankylosing spondylitis, psoriatic arthritis and other spondyloarthritides, and to analyse health care utilization over the last decade in patients with RA. In Study I the outcome of an 18 days outpatient multidisciplinary team rehabilitation programme in 174 patients with CIA was analysed. The patients were evaluated pre- and post the rehabilitation programme and 4 and 12 months thereafter. Health related quality of life (HRQoL), general health and aerobic capacity was significantly improved at the end of the rehabilitation programme and after 12 months. In Study II 731 patients with CIA participated in different team rehabilitation programmes in four European countries and were evaluated pre- and post rehabilitation. Through analysis of covariance we studied which patients improved the most by team rehabilitation. Females experiencing more pain, fatigue and lower psychosocial wellbeing improved most in HRQoL. HRQoL for half of the patients improved according to analysis of Minimal Important Difference. In Study III we analysed the validity and responsiveness of 15 standardized outcome measures used to evaluate outcomes from multidisciplinary team rehabilitation in 216 patients with CIA. According to our linking of the outcome measures to the International Classification of Functioning, Disability and Health (ICF) most ICF components were reasonably well covered except environmental aspects.Further, out of three outcome measures used to evaluate HRQoL, the Euroqol-5Dimensions (EQ-5D) performed as well as the more extensive short form 36 health survey (SF-36) and Nottingham health profile (NHP). Aerobic capacity did not correlate to other measures of observed physical functioning . It was highly responsive to change. In Study IV we wanted to study health care utilization in patients with RA over time. By using the Skåne Health Care Register we identified 3977 persons who had been diagnosed with RA when consulting health care during 1998-2001. Two referents from the general population per RA patient were matched for age, sex, and area of residence. The annual mean number of hospitalizations and outpatient clinic visits 2001-2010 and the annual ratio (RA cohort/referents) were analysed. The overall inpatient and outpatient health care utilization was found to decrease in RA patients as compared to the general population. To conclude, multidisciplinary team rehabilitation is beneficial for patients with CIA with regards to HRQoL, general health and aerobic capacity, both short and long term. Further, patients with more severe disease consequences benefit most from rheumatological team rehabilitation. When evaluating HRQoL in rheumatological team rehabilitation the commonly used questionnaires EQ-5D, NHP and SF-36, showed important differences in construct validity and responsiveness and are thus not interchangeable. Improving aerobic capacity is an important aspect of team rehabilitation not covered by other outcome measures on physical function and thus important to evaluate. Patients with RA have utilized less health care during the last decade which might be an effect of changing treatment strategies.