Discussion
rheumatic and musculoskeletal diseases
RHEUMATOID ARTHRITIS, SECONDARY
This study aimed to evaluate the effectiveness of providing a multicomponent health behavior change intervention (the BRIDGE-intervention) as an adjunct to usual care in the rehabilitation of patients with rheumatic and musculoskeletal diseases. The results showed no significant treatment effects of the BRIDGE-intervention on either goal attainment, physical function, health-related quality of life, or self-assessed health. For both groups, the mean primary and secondary outcome scores remained fairly stable from discharge to 12 months follow-up, indicating small, but lasting effects of the rehabilitation provided to both groups.Our findings differ from the findings of a recent systematic review of reviews summarizing the evidence base for psychological interventions in patients with rheumatoid arthritis,One possible reason for the lack of effect in our study may be related to implementation difficulties. The BRIDGE-intervention was highly complex,This hypothesis is supported by the fidelity estimates, which showed that only 31% of the patients in the intervention group received the BRIDGE-intervention as intended, with follow-up after rehabilitation discharge as the most frequently lacking factor. Our findings thereby confirm other reports stating that care coordination across service levels still are among the weakest elements in the rehabilitation process.As the BRIDGE-intervention specifically targeted improvement of the transitions between levels of care, we expected that patients in the intervention group would receive more follow-up than the control group. However, we found that the groups received an approximately equivalent amount of follow-up, reported as a use of health- and social services after rehabilitation discharge. Variations in cluster-level delivery of the BRIDGE-intervention may potentially explain the observed variation in the primary outcome between clusters. The way institutions and individuals adopt and integrate new trial-related work into existing routines, is influenced by the degree to which the new work is perceived to be relevant and legitimate.A strength of this study is the robust research design, which may have kept the included patients blinded to group affiliation and thus protected against disappointment effects and contaminant factors during the intervention roll-out, which strengthens the internal validity of the study. Further, the pragmatic orientation enabled evaluations in real-world settings, strengthening the external validity. Other methodological strengths are the use of the rehabilitation core set of outcomes for patients with rheumatic and musculoskeletal diseases,The study has several limitations. The cluster randomized study design is prone to post-randomization selection bias,A substantial limitation is a large amount of missing data, which reduces the statistical power and the representativeness of the sample, and impacts on the validity and generalizability of the results. Another limitation is the lack of longitudinal data on patient motivation and self-managed goal-directed activity after rehabilitation discharge, which could have provided valuable information in the interpretation of the findings. Finally, the fact that missing data and attrition were highest in the experimental group compared to the control group, may also indicate that receiving in the BRIDGE-intervention was burdensome to some patients.This study demonstrates that shortcomings still exist in rehabilitation transitions between levels of care. The multicomponent BRIDGE-intervention was not shown to be more effective than usual care in terms of improving goal attainment, physical function, health-related quality of life, and self-assessed health in patients with rheumatic and musculoskeletal diseases. However, the implementation of the intervention was not optimal, as the majority of patients did not receive the required follow-up in their municipality of residence after rehabilitation discharge. This finding will be further explored in an upcoming study. Further research should focus on factors that can raise treatment fidelity among health care providers, bridge gaps across levels of care, and thus improve the quality, continuity, and long-term health effects of rehabilitation for this patient group.