Involvement of the multidisciplinary team and outcomes in inpatient rehabilitation among patients with inflammatory rheumatic disease

Musculoskeletal diseases are among the most regular complaints in the general population [1]. Recommmendatations highlight a multidisciplinary team care approach for the best management in musculoskeletal conditions [2], but there is limited evidence for effects. Effective management of RA requires a range of nonpharmacological interventions [3], which are delivered by members of the multidisciplinary team. Applicable approaches are for example a combination of physical exercise and cognitive behavioural therapy [4] or a combination of physical exercise, surgery and diet [5], and often consist of broad education programmes [6‐8]. The multidisciplinary team may consist of rheumatologists, rehabilitation specialists, occupational therapists, physical therapists, social workers, nurses, manual therapists, podiatrists, dieticians, psychologists, vocational counsellors and orthopaedic surgeons.

Inpatient multidisciplinary care over a short time has demonstrated effect in active patients with rheumatoid arthritis (RA) [9] and ankylosing spondylitis [10] as well as in patients with inflammatory and non-inflammatory musculoskeletal diseases [11]. A systematic review found inpatient multidisciplinary care more effective compared to regular outpatient care [12], while some studies found equivalent clinical effects between inpatient and day-care [13, 14] or outpatient [15] team care programmes.

Care in the field of rheumatology has in the last decades moved towards more physically active rehabilitation programs provided as out-patients, a development which could provide access to a larger multidisciplinary team. Another development during recent years has been that patients referred to multidisciplinary rehabilitation present with lower levels of physical disability than previously, but still benefit from multidisciplinary rehabilitation for their inflammatory joint diseases in an era where effective pharmacological therapies are widely available [16]. Thus, given the effectiveness of inpatient rehabilitation, we hypothesized that rehabilitation also is effective when provided in rheumatology departments, and also that the extent to which the multidisciplinary team is involved would be reflected in rehabilitation outcomes among patients with specific inflammatory rheumatic diseases.

The objective of this study was thus to examine 6-month outcomes of patients with different inflammatory rheumatic diseases who were admitted to departments of rheumatology with a need for multidisciplinary rehabilitation. We especially examined whether the extent of using the multidisciplinary team of health care professionals (HCP) or of single health professions, before or during rehabilitation, was related to levels and changes in health outcomes.

The demographic and clinical baseline characteristics of all 373 included patients and those 317 (85.0 %) completing the 6 months follow-up are displayed in Table 1. Completers were older, more often female, married or cohabiting, and had a shorter hospital stay than non-completers. There were no statistically significant differences in baseline PROs between completers and non-completers.

In this study we examined the effects of consultations with HCP on clinical outcomes in patients with inflammatory rheumatic diseases admitted to departments of rheumatology. For all patient groups, independent of diagnosis and extent of HCP use, improvements for PRO were mainly temporary and had largely levelled off already at 3 months of the 6 months follow-up after the rehabilitation stay. More importantly, involving a high number of HCP or any specific HCP was not associated with better health, measured as any of the PROs, neither immediately after the rehabilitation stay nor delayed during the next 3-6 months. Changes in health outcomes were generally small. Almost all numeric and all statistically significant findings pointed towards better baseline function and larger improvements during the stay in the group with less involvement of HCP.

These findings are counterintuitive, as all efforts by HCP are directed to alleviating disease burden and enhance coping with the disease. Most likely unmeasured, and maybe unmeasurable factors contribute to involving HPC in patients with perceived problems. The patients will then not necessarily demonstrate better PRO in follow-up assessments. Thus, our findings contribute to a hypothesis that high use of the multidisciplinary team is a marker of disability and of specific rehabilitation needs, indicating more complicated disease where one may not expect major improvement of health status. We find it important to clearly state this conundrum, so health care workers who spend much time with highly disabled patients with inflammatory rheumatic disease will not go discouraged when their rehabilitation efforts do not show as improvements demonstrated by means of standardized PROs.

Future research mandates to quantify study elements of efforts made by the individual HCP. Only a randomized controlled trial which compares high and low levels of multidisciplinary rehabilitation, could study whether the broad multidisciplinary team provides better health outcomes. This should also include proper goal setting process and coordinated multidisciplinary team-care in many of these patients, which is now recommended [23].

Rehabilitation in inflammatory joint diseases has also in other studies shown at least short lived improvements. A three-week multidisciplinary day-care program has early shown to be beneficial in patients with RA [24], and a number of studies has shown at least temporary improvement after multidisciplinary team care in mixed populations [25, 26], especially in patients with rheumatoid arthritis [13, 14, 16, 24, 27‐29] and ankylosing spondylitis [10]. As a typical finding scores in patients with inflammatory rheumatic disease after 6 months again have reached baseline [30], suggesting supportive follow-up interventions to possibly maintain outcome improvement [31]. Disappointing in the results of our study was also the observed lack of lasting improvement of self-efficacy, which could be expected to improve after involvement of the multidisciplinary team. Our findings indicate that self-management issues were not effectively addressed even in patients with high use of HCP in departments of rheumatology.

Multidisciplinary team care has developed during the last years with increasing focus on evidence-based evaluation [32]. Due to the questionable responsiveness of multidisciplinary team care [15], evaluation should be function specific and overall physical disability [33]. We therefore applied a wide range of outcome measures, including physical function, pain, fatigue, health related quality of life, but also self-efficacy and a utility measure which could be applied for health economy. An improvement in SF-36 derived utility of about 0.025 would – if maintained for one year - correspond to a gain of 2.5 quality adjusted life years in 100 patients.

While our study did not examine the specific content and intensity of rehabilitation, it investigated the involvement of HCP, constituting the multidisciplinary team. Strengths of this study are the relative large sample size from four departments of rheumatology, inclusion of a typical spectre of inflammatory rheumatic diseases, and broad outcome assessments which also included disease activity, self-efficacy and utility.

A number of limitations apply to our study. First, included patients reported on use of HCP, but not further on the contents of these consultations or rehabilitation interventions. Further, rehabilitation in our study was most likely given individualised to patients’ needs parallel to other treatment modalities for the rheumatic disease at regular hospital departments, which is again part of multidisciplinary treatment in itself, i.e. we did not evaluate pharmaceutical modalities. Also, more tailored rehabilitation interventions could have led to greater outcome effects. We gave patients in the questionnaires the opportunity to state events which during the rehabilitation stay could have affected outcomes, e.g. initiation of biological medication, surgical procedures, or infections. Only a minority of patients made such statements, and we did not systematically register all other medication, for example analgetics, preventing us from specifically accounting for these factors in our analyses. Another limitation is the observational design of the study which prevents causal conclusions. Finally, our results are restricted to patients with inflammatory arthropathies, where some need for rehabilitation was seen during regular admissions at departments of rheumatology. This clinical setting does represent predefined major rehabilitation needs, and our findings can thus not be generalized to rehabilitation effects.

More focus on goals and other aspects of rehabilitation could have led to better health outcomes than seen in our study. In fact, we know that the different departments of rheumatology do not have a unified practice of rehabilitation, and we do not know which specific rehabilitation modalities were applied in our patients.

This study addressed rehabilitation outcomes until 6 months in inpatients with inflammatory rheumatic diseases, finding small and mainly short-term improvements in a wide range of PRO. High use as compared to low use of HCP in a multidisciplinary team did not enhance or preserve rehabilitation outcomes. High use of HCP was, however, associated to poorer PRO at baseline, and these findings illustrate that in clinical practice resources are used according to clinical need. Research using randomized controlled trials is warranted to study how effective multidisciplinary teams are in the rehabilitation of inflammatory rheumatic diseases.