Abstract
The existing medical model for managing rheumatoid arthritis (RA) focuses on minimising joint inflammation using suppressive treatments. However, patients have broader concerns spanning other symptoms like fatigue and pain and the way their health care is delivered. This thesis used qualitative and quantitative research methods to address three inter-related aspects of clinical care. Firstly, identifying critical challenges for providing patient-centred care. Secondly, defining outcomes important to patients like fatigue and pain and concomitant fibromyalgia. Finally, examining temporal changes in the RA management and evaluating aspects of clinical decision making.Firstly the thesis shows current care is not optimal. Key limitations include: being insufficiently patient-centred, failing to integrate management across the primary/secondary divide, over-emphasising drug treatment and overlooking "whole-person" care.
Secondly, care overlooks several crucially important areas to RA patients. Many patients had high levels of fatigue, associated with pain, disability and psychological factors. Their fatigue spanned several domains. Current fatigue questionnaires are heavily weighted towards psychological aspects, and a more balanced assessment is needed. Pain, a dominant RA symptom, is often not directly addressed. The research showed central sensitisation causes persistent pain in many RA patients; it may require different management approaches. The research also characterised patients with the fibromyalgic rheumatoid clinical phenotypes; their higher disease activity scores may not fully reflect disease activity. Despite changes in treatment over the years their disease activity scores have not improved significantly, unlike RA patients in general. Different treatment strategies are needed to improve their outcomes.
Finally although patients with high disease activity usually have their treatment changed when reviewed in rheumatology clinics, patients with moderate disease activity often have insufficient treatment changes; patients' age has a significant influence on treatment decisions. Strategies are needed to better target moderate disease activity and overcome the limiting effect of age on treatment decisions.
| Date of Award | 1 Jun 2013 |
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| Original language | English |
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| Supervisor | David Scott (Supervisor), Gabrielle Kingsley (Supervisor) & Ernest Choy (Supervisor) |