Introduction
Methods
Search strategy
Inclusion/exclusion criteria
Inclusion | Exclusion | |
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Language | All papers in the English language | Non-English were excluded due to lack of translation facilities |
Type of study | Randomised controlled trials (RCTs), controlled non-randomised studies and controlled before and after studies | Qualitative research papers Mixed Method papers incorporating a qualitative/quantitative approach Feasibility, pilot, quasi-experimental studies and conference abstracts |
Type of intervention | Tele-health interventions, including any digital intervention accessed through a computer, mobile phone or hand-held device, including web-based or desktop computer programmes or applications that support self-management Comparison groups to the tele-health intervention would be usual care or no intervention | Tele-health interventions that do not support self-management |
Type of participants | Adults over the age of 18 of any gender with a diagnosis of RA | Populations incorporating inflammatory arthritis, osteo-arthritis, juvenile idiopathic arthritis, psoriatic arthritis |
Type of outcomes | Outcomes of interest include self-management-related areas such as disease activity, including objective and self-reported clinical, physiological markers of disease control. Validated measures of symptoms such as fatigue, pain, disability and quality of life. Further outcomes such as self-efficacy and medication adherence, health care utilisation will also be considered | Subjective measures or generalised outcomes such as patient satisfaction or quality of life |
Date | Studies included will be from 2014 onwards to the present date to ensure data are contemporaneous and relevant | Papers prior to 2014 were excluded as tele-health interventions were not so readily available to patients |
Quality assessment
Selection bias | Performance bias | Detection bias | Attrition bias | Reporting bias | |||
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Random sequence generation | Allocation concealment | Blinding patients/personnel | Blinding outcome assessment | Incomplete data | Selective reporting | Other biases | |
Allam et al. [18] | High risk | Low risk | High risk | Unclear | Low risk | Unclear | Unclear |
Zuidema et al. [19] | Unclear | Unclear | High risk | Unclear | Low risk | Low risk | Unclear |
Kuusalo et al. [24] | High risk | Unclear | High risk | Unclear | High risk | Unclear | Unclear |
Song et al. [21] | Unclear | Unclear | High risk | Unclear | Low risk | Unclear | High risk |
Liu et al. [22] | Low risk | Low risk | High risk | Unclear | Low risk | Low risk | High risk |
Zhao & Chen [23] | Low risk | Low risk | High risk | Unclear | Low risk | Unclear | High risk |
Salaffi et al. [20] | High risk | Low risk | High risk | Unclear | Low risk | Unclear | High risk |
Data extraction and analysis
Data synthesis
Results
Outcome of the search
Study characteristics and design
Author, date, location, design, duration | Aim | Participants | Intervention | Comparator | Outcomes & measurement times | Key findings |
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Allam et al. [18], Switzerland, RCT, 16 weeks | Examine effect of web-based intervention incorporating online information, social support features and gamification on individuals with RA | 5 arm parallel RCT: 155 patients participated (informational website: n = 30; social support: n = 29; gamification: n = 28; control: n = 40) Mean Age 57.95 years Mean duration of RA from diagnosis 11.89 years Disease Activity: Not reported | Group 1: Access to informational website with advice Group 2: Access to informational and social support features Group 3: Access to informational website advice and gaming section Group 4: Access to informational website advice social support and gaming sections | Routine care with no access to the web-based intervention | Physical Activity Exercise Behaviours Scale Health care utilisation scale Prescription medication overuse: Prescription Opioid Misuse Index RA knowledge: Patient Knowledge Questionnaire in RA Empowerment scale Measured at Baseline, 8 & 16 weeks | This study provides evidence demonstrating the potential positive effects of web-based gamification and online social support on health and behavioural self-management in patients with RA |
Zuidema et al. [19], Switzerland, Explorative RCT, 12 months | Evaluate efficacy of a web based self-management programme for patients with RA | 157 participants I/C: 78/79 Mean age-6 years Disease activity-not reported Average disease duration-not reported | Patients were given 12 months of access to a web-based self-management programme comprising nine modules and a diary to track pain and fatigue symptoms | Routine care with no access to the website | Self-Management Ability Scale (SMAS) Rheumatoid Arthritis Self-Efficacy scale RAND-36 Level of Pain & Fatigue Numerical Rating Scale The Modified Pain Coping Inventory for Fatigue (MPCI-F) The Patient Activation Measurement (PAM-13) Measured at baseline, 24, 52 weeks | No positive effects were found regarding the outcome measurements, effect sizes were low, and results show no statistically significant difference The author questions whether the structure should be modified to determine whether potential benefits could be achieved |
Kuusalo et al. [24], Finland, RCT, 12 months | Examine the influence of short messaging service (SMS) text messaging enhanced monitoring to support self-management of early RA | 166 participants I/C: 84/82 Mean age-55.5 years Mean Disease Activity Score (DAS) 28–4.60 (moderate disease activity) Mean disease duration-4 years | An SMS text message disease self-management system to enable patients to self-monitor their symptoms in early RA | Usual Care | Boolean Remission C-Reactive Protein levels Utilisation of health care resources scale SF-36 Quality of Life Measured at baseline, 12, 24, 52 weeks | The study failed the primary outcome despite a trend favouring the intervention group with remission rates higher at 6 and 12 months, statistical significance was not reached. Participants found the intervention technology difficult to use The authors concluded that despite a favourable trend in remission, text message enhanced monitoring does not significantly improve RA |
Song et al. [21], China, RCT, 12 weeks | Examine effects of a tailored tele-health intervention on medication adherence and disease activity in discharged patients with RA | 92 participants: I/C:46/46 Mean age-55.26 Mean disease duration-4.5 years Mean disease activity-DAS 28 = 4.5 (moderate disease activity) | Four tailored self-management educational sessions delivered by telephone by a nurse across a 12-week period following hospital discharge | Usual Care | Medication Adherence Compliance Rheumatology Questionnaire Disease Activity Score (DAS) 28 Measured at baseline, 12 and 24 weeks | This study demonstrated that a tailored tele-health educational intervention could significantly improve patients with RA recently discharged from hospital medication adherence Further research will be required to demonstrate longer-term effects of this intervention |
Liu et al. [22], China, RCT, 8 weeks | Examine the effects of a 4-week telephone based transitional care programme to support self-management in patients with RA | 88 participants I/C: 44/44 Mean age-49 years Mean disease duration-10 years Mean disease activity not reported | Telephone based self-management education sessions following discharge from hospital to consolidate patient’s self-management behaviours | Usual Care | RA Self Efficacy Score Health Assessment Questionnaire Disability Index (HAQ-DI.) Hospital Readmission Rates Measured at baseline, 4 & 8 weeks | This four-week self-management intervention provided evidence that telephone based self-management sessions following hospital discharge improve self-efficacy. The intervention encouraged patients reduced health care utilisation by reducing hospital readmission |
Zhao & Chen [23], China, RCT, 24 weeks | Explore the effectiveness of self-management education programme on self-efficacy in patients with RA | 92 participants I/C: 46/ 46 Mean age 55.5-years old Mean disease duration-4 years Mean DAS 28 score-5.05 (indicating high disease activity) | Health education delivered via telephone. Information included exercise, diet and medication following hospital discharge | Participants received one telephone call following | Rheumatoid Arthritis Self Efficacy (RASE) Score HAQ-DI DAS 28 Measured at baseline, 12 and 24 weeks | Self-efficacy of discharged patients with RA improved at week 12 and week 24, however, there was no statistically meaningful difference in disease activity. There was an improvement in DAS 28 scores of the intervention group at week 12 and 24 which could be meaningful |
Salaffi et al. [20], Italy, RCT, 12 months | Examine whether a tele-health intervention supports self-management to achieve remission and comprehensive disease control in early RA | 41 participants I/C:21/40 Mean age 50 years Mean disease duration 6 months Mean CDAI- 25.7 (high disease activity.) | A web-based programme enabling patients to monitor their own symptoms online and access information. This was monitored by a clinical case manager who could adjust treatment accordingly | Routine Care | CDAI RA Impact of Disease (RAID) Recent Onset of Arthritis Disability (ROAD) score CRP Radiographic evaluative of joint damage Measured at baseline, 12, 24, 36, 52 weeks | Findings support that an intensive treatment strategy utilising a web based tele-health intervention to enable patients to self-monitor their symptoms and access to relevant information promotes self-management |
Quality assessment and risk of bias
Synthesis of results
Intervention characteristics
Author/year | Brief name | Recipients | Why | What (materials & procedures) | Who (provided) | How & where | When & how much | Tailoring | Modification of intervention throughout trial | Extent of intervention fidelity |
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Allam et al. [18] | ONESELF Website including information, online social support and gamification | Patients > 18 with a diagnosis of RA | Web based intervention based on dual process and empowerment theory to help patient’s better cope and manage their condition by providing accurate information. Planned behaviour change theory was incorporated aiming for behaviour change by imparting the health information required to help them manage their disease Social support theory was incorporated as this is associated with self-management skills Gamification involved the application of game design to motivate by providing rewards to engage with the website | A website designed by medical staff sought to adopt a patient centred approach Sections of the website included information about RA and aimed to improve knowledge particularly in relation to physical activity & medication. Treatment options and disease management strategies An open forum and chat room was provided by clinicians This incorporated a patient blog to contribute and write to each other or ask questions Gamification was added to encourage patients to interact. Participants engagement with the materials earned points Participants received a face to face session of thirty minutes to educate them on how to use the website | Rheumatology health care professionals Social support provided by fellow patients | Delivered over the Internet Participants were given their own account for the website Patients were also sent SMS text messages notifying them about chat room sessions and inviting them to participate | Minimal engagement was requested was for one hour per week | The website was frequently updated to respond to users’ questions, and participants would receive an email outlining new information | Not described | Delivered as planned. The usage of the website was monitored by recording the number of logins to each section of the website On average participants paid a mean 53.68 (SD 93.07) visits to the various sections of ONESELF Groups who were offered the gamified experience used the website more often |
Zuidema et al. [19] | Web based self-management enhancing programme | Patients > 18 with a diagnosis of RA | Website to help individuals manage the symptoms of RA The website sought to elicit behavioural change by providing information to promote positive self-management behavioural changes. | The programme was developed in collaboration with RA patients and RA specialist healthcare professionals The Web-based self-management programme comprised 9 modules covering symptom management, diet and exercise and a diary to track patients fatigue and pain Each module comprised 2–5 sessions and assignments Participants received a written instruction manual for the programme | Rheumatology Health care Professionals | Web based Online | No set requirement Participants could engage as and when they wanted too Reminders to visit the programme were sent twice weekly via email Clinicians brought the programme to the attention of participants during consultations | Not described (authors recognised that the ability to tailor the performance objectives may improve the efficacy of the intervention.) | Not described | Intervention was delivered as planned |
Kuusalo et al. [24] | Automated Text Message-Enhanced Monitoring | Participants > 18 early stage RA | A text message monitoring system that patients can use to help self-manage their RA by monitoring their own disease activity and medication adherence and sharing that information with health care professionals Intervention is based on the treat to target approach of early RA requiring frequent monitoring and targeted treatment | Showing Any Need for Reassessment (SANDRA) software. Patients in the intervention group were given written and 30-min presentation on performing SMS monitoring Patients received text messages every N fortnight during weeks 0–24, asking patients to report on their disease activity and medication adherence The software included a cut off limit for scores, very low cut off limits were chosen in order to detect possible problems early and to improve chance of reaching early strict remission | Rheumatology Clinicians monitored the responses and gave the patient a telephone call within 48 h if problems were highlighted | SMS text messaging via mobile phone technology Participants were expected to own a mobile phone and be competent in using it | Patients received text messages every fortnight during weeks 0–24 | Each response was evaluated, and further clinic appointments triggered if required | Not described | Intervention was delivered as planned 52% found assessing their disease activity difficult |
Song et al. [21] | Telephone delivered self-management education | Patients > 18 with RA recently discharged from hospital (following admission for RA related reasons) | This intervention focussed on helping patients perceive the consequences of RA, educating them on medication management skills and empowering them with the knowledge to self-manage their condition | Educational sessions delivered by telephone Core content of the intervention included: psychological support, knowledge about RA, treatment goals and medication adherence Based on initial assessments the nurses provided knowledge about RA and prescribed medication, reviewed progress towards achieving treatment goal emphasising the importance of self-managing the condition through medication concordance During the next 3 sessions conducted at the 4th, 8th and 12th week after hospital discharge, the nurses evaluated the adherence to their medication regimen | Rheumatology clinicians | Four individual telephone calls to the participant | Delivered over a period of 12 weeks Initially four weekly one to one sessions lasting 20–40 min The following 3 sessions were conducted at the 4th, 8th and 12th week following patient discharge | Education was tailored to patients’ specific needs identified through assessment | Not described | Intervention was delivered as planned |
Liu et al. [22] | Transitional Care Programme | Patients with RA > 18 being discharged from hospital for RA related reasons | A telephone intervention The aim was to increase self-efficacy of RA patients by delivering education to empower them to manage disease activity, pain and, fatigue Patient centred assessment and goal setting to improve individual’s self-management of the disease | The intervention was divided into increasing knowledge on how to self-manage RA following hospital discharge through goalsetting, monitoring & treatment & procedures On discharge patients were telephoned within 72 h after which the nurse would provide 1–3 phone calls every week depending on the patient’s condition until 4 weeks after discharge Following the initial assessment of the patient’s health condition, the nurse focussed on the existing problems, assessing disease progression, providing advice, consolidating the patient’s self-management behaviours and health goals and encouraging patients to implement positive changes | Rheumatology specialists delivered the intervention following training in supporting self-management through telephone follow up intervention procedures | Telephone calls Participants were based in their own homes | 1–3 telephone calls every week until 4 weeks after discharge With no specific restrictions on the duration of each call | Intervention was tailored according to the patients need and goals providing more phone calls as required | Not described | Intervention was delivered as planned |
Zhao & Chen [23] | Self-management health education by telephone | Patients > 18 with a diagnosis of RA | Telephone health education to improve patients with RA recently discharged from hospital self-efficacy and enhance their disease management Based on the concept that effective health education can improve knowledge and influence behaviours. | Intervention was guided by a checklist which was completed to identify the patient’s educational needs regarding RA health education including information about medication, diet and exercise Clinicians delivered structured education sessions to patients over the telephone exploring patients’ beliefs and needs for health education based on their reason for hospital admission to assist them to improve self-management strategies Patients were given leaflets and verbal information about the intervention prior to discharge | Clinicians delivered the telephone educational sessions | Tele- Phone Clinicians were based at the hospital and patients in their own homes | Intervention was delivered 4 times in 12 weeks. Each call time ranged from 20–40 min | Education could be tailored to patients’ specific needs and questions | Not described | Intervention was delivered as planned |
Salaffi et al. [20] | Remote TElemonitoring for MAngaing Rheumatologic Condition & HEalthcare programmes (RETE-MARCHE) | Newly diagnosed patients with RA | A telemonitoring system for patients with RA focussed on an intensive self-management strategy utilising a web-based monitoring system to achieve remission and tight disease control Based on the treat to target (T2T) strategy which promotes tight control of disease activity and aims for low disease activity or remission | RETE-MARCHE is a specialised website platform The patient completes an online RA Impact of Disease (RAID) score which measures seven domains each with a numeric rating score (NRS) Each domain has the following: weight, pain, functional disability, fatigue, sleep problems, emotional well-being, physical well-being and coping. The score has a range from 0–10 (10 worst health). The computer system generates warnings to both the patient and their clinical case manager whenever it detected based on the patients report that their condition was deteriorating. Patients were given face to face training sessions prior to using the website | Clinical case manager trained in web-based interventions | Web-based platform Participants were based in their own homes | The intervention was engaged with once a month over a period of 12 months, however patients could utilise it at any time if they felt their RA symptoms were worsening and they wanted to assess their score | Participants could utilise the platform between scheduled times if they felt their symptoms were worsening, thereby triggering follow up from the clinical case manager | Not described | Intervention was delivered as planned |