An evaluation of a biopsychosocial framework for health-related quality of life and disability in rheumatoid arthritis
Introduction
Rheumatoid arthritis (RA) is a chronic, inflammatory disease that can lead to disability and significantly interfere with functional adaptation [1], [2]. Symptoms such as joint pain, swelling, and fatigue are disease-specific stressors that tax the adaptive resources of patients and heighten the risk for patient reported declines in function (i.e., difficulties in carrying out activities of daily living) as well as reports of emotional disturbance [3] which together create enormous psychological and financial loss for those afflicted [4].
Given the salience of such subjective reports of declines in patients' physical, social, and psychological functioning, there is growing interest in using patient-reported outcomes (PROs) to assess treatment effectiveness [5]. PROs represent a patient's evaluation of his/her unique health status distinct from the evaluations of physicians and laboratory findings, and have a long history of use in the measurement of outcomes such as psychological distress, pain, and depression in patients with RA. Increasingly, PROs are being adopted as a mechanism for evaluating clinical efficacy in randomized clinical trials [6], [7] to allow for an analysis of whether treatments that are designed to reduce disease activity, for example, will also improve clinical functioning from the patient's perspective.
An important measure of PROs is health-related quality of life (HRQOL). While various definitions have been proposed, HRQOL generally refers to the ways in which a given health condition affects a patient's physical ability and capacity to function in a variety of social and emotional roles. HRQOL, which may be generic or disease-specific, is generally divided into measures of physical functioning and emotional well-being [8]. In contrast to disability measures, which assess how health limits a patient's ability to perform specific tasks, HRQOL is a more global construct that indicates how well a patient is doing given the totality of his/her medical condition. Hence, the determinants of disability and HRQOL are likely to differ, as they are distinct constructs tapping different facets of functioning.
A key issue in HRQOL research in RA concerns the identification of variables, along with disease activity, that play prominent roles in explaining physical and mental health functioning. A common observation among rheumatologists is that significant variability in health functioning exists among RA patients who have similar levels of disease activity and joint damage [1], [9], raising the question of what factors are responsible for these functional differences. In fact, research has demonstrated that disease activity and inflammation in RA correlate only modestly with HRQOL and other psychosocial measures [10], [11]. The same pattern has been found in other rheumatic diseases such as systemic lupus erythematosus [12].
At this juncture, research has not adequately addressed the variables contributing to HRQOL in RA. Indeed, while studies have demonstrated that variables such as illness beliefs, coping, and social support are correlated with pain and psychosocial adjustment in RA patients [13], [14], [15], the contribution of such factors to HRQOL has not been adequately determined. This research adopted a biopsychosocial framework [16] to evaluate the role of psychosocial and biomedical factors, in understanding patient variability in functional outcomes. Previous research has not explicitly adopted this approach in conceptualizing the variables affecting HRQOL in RA. This study evaluated this framework for HRQOL and disability in a sample of patients with RA in the greater metropolitan Los Angeles area.
Section snippets
Patient recruitment
Patients were recruited through advertisements in local newspapers and flyers posted in clinic offices in the Departments of Rheumatology at UCLA and Cedars Sinai Medical Center (CSMC), Los Angeles to participate in a treatment outcome study that would help them manage their RA. Recruitment for the study started in spring 2004 and ended in winter 2008. After a brief telephone screening conducted by the project coordinator at UCLA, patients were referred to CSMC to determine medical eligibility.
Sample characteristics
There were 106 predominantly female (83%) participants with an average age of 56.2 years and an average of 16.0 years of education. The majority of participants (52.8%) were Caucasian, with 10.4% African-American, 14.1% Hispanic, and 22.6% of “other” ethnic descent. Average disease duration was 12.00 years (sd=11.4). DAS-28 scores indicated moderate disease activity (m=4.3, sd=.1), and SF-36 summary scores indicated substantial difficulty with physical functioning (m=33.2, sd=7.9). Means for
Discussion
Despite significant improvements in the medical management, treatment, and prognosis of RA, it is common for patients to experience deficits in physical and mental health functioning. This research adopted an integrated, biopsychosocial framework [16] to evaluate the relative contribution of disease activity and psychosocial factors to physical and mental health functioning outcomes in a sample of RA patients living in greater metropolitan Los Angeles. Based on this conceptual framework,
Acknowledgments
This research was supported by grant AR R01-049840 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institute of Health to Perry M. Nicassio, Ph.D. The authors have no financial gain related to the outcome of this research, and there are no potential conflicts of interest. This work was also supported in part by grants T32-MH19925, HL 079955, AG034588, AG 026364, CA119159, DA 027558, RR00827, P30-AG028748, General Clinical Research Centers Program,
References (35)
- et al.
Patient questionnaires in rheumatoid arthritis: advantages and limitations as a quantitative standardized scientific medical history
Rheum Dis Clin North Am
(2009) - et al.
Psychosocial factors, disease status, and quality of life in patients with rheumatoid arthritis
J Psychosom Res
(2009) - et al.
Development of a questionnaire for assessing active and passive pain coping strategies in chronic pain patients
Pain
(1987) - et al.
The role of pain coping strategies in prognosis after whiplash injury: passive coping predicts slowed recovery
Pain
(2006) - et al.
The disablement process in rheumatoid arthritis
Arthritis Rheum
(2002) - et al.
Profile of arthritis disability: II
Arthritis Rheum
(2006) Arthritis and psychiatric disorders: disentangling the relationship
J Psychosom Res
(2009)- et al.
The economic burden of disease: comparison between rheumatoid arthritis and ankylosing spondylitis
Clin Exp Rheumatol
(2009) - et al.
Association between health-related quality of life and clinical efficacy endpoints in rheumatoid arthritis patients after four weeks treatment with anti-inflammatory agents
Int J Clin Pharmacol Ther
(2005) - et al.
Clinical improvement as reflected in measures of function and health-related quality of life following treatment with leflunomide compared with methotrexate in patients with rheumatoid arthritis: sensitivity and relative efficiency to detect a treatment effect in a twelve-month, placebo-controlled trial
Arthritis Rheum
(2000)
36-item short-form health survey (SF-36). I. Conceptual framework and item selection
Med Care
Focusing interventions for disability among patients with rheumatoid arthritis
Arthritis Rheum
Disability and health-related quality of life among patients with rheumatoid arthritis: association with radiographic joint damage, disease activity, pain, and depressive symptoms
Scand J Rheumatol
Psychosocial research on systemic lupus erythematosus: a literature review
Lupus
Problematic social support, family functioning, and subjective well-being in women with rheumatoid arthritis
Women Health
The measurement of helplessness in rheumatoid arthritis: the development of the Arthritis Helplessness Index
J Rheumatol
The clinical application of the biopsychosocial model
Am J Psychiatry
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