title: Implementation of a physical activity intervention for people with rheumatoid arthritis: a case study.
abstract: OBJECTIVE
  To investigate the potential facilitators and barriers regarding the implementation on a larger scale of an internet-based physical activity intervention which had previously proved to be effective in a randomized, controlled trial concerning sedentary patients with rheumatoid arthritis (RA).
  
  
  METHODS
  Assuming a central delivery of the intervention by two trained physical therapists in four regions in the Netherlands, the following activities were employed: the recruitment of potential participants (RA patients), the acquisition of cooperation from referring rheumatologists and the acquisition of reimbursement from regional health insurance companies. Evaluation was done by means of the Reach, Evaluation, Adoption, Implementation and Maintenance framework, of which the following three dimensions were considered relevant: Reach (the number of potential participants), Adoption (readiness for adopting the programme in real life among rheumatologists) and Implementation (the extent to which the intervention could be delivered as intended). Evaluation measures comprised a postal survey among 927 patients with RA in two regions, a telephone survey among rheumatology centres in four regions and consultations with five regional health insurance companies.
  
  
  RESULTS
  Seventy-six out of 461 responding RA patients (20%) met the original study inclusion criteria (being sedentary and having access to the internet) and were interested in participation. However, the potential costs of the purchase of a bicycle ergometer and the interference with patients' current physical therapy were obstacles for eligible patients actually to participate. Rheumatologists in four out of five rheumatology centres were willing to participate. All five health insurance companies were willing to reimburse the guidance and feedback by the physical therapist, and the costs of the internet site (estimated costs 271 euro [203 pound] per patient per year), but not the bicycle ergometer (estimated costs 350 euro [262 pound]), provided that current physical therapy would be discontinued.
  
  
  CONCLUSIONS
  Facilitators for the implementation of an internet-based physical activity intervention were: (i) a considerable proportion of RA patients were eligible and interested in the programme; (ii) the majority of rheumatologists were willing to refer patients; and (iii) health insurance companies were willing partially to reimburse the intervention. Barriers were the additional costs for patients and their unwillingness to discontinue current physical therapy. These findings underscore the need for additional research into barriers to participation in physical activity interventions among patients with RA, and in reimbursement strategies in particular.
authors.affiliation: Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands. mh.vandenberg@vumc.nl
authors.forename: M H
authors.initials: MH
authors.lastname: van den Berg
authors.forename: F J
authors.initials: FJ
authors.lastname: van der Giesen
authors.forename: D
authors.initials: D
authors.lastname: van Zeben
authors.forename: J H L M
authors.initials: JH
authors.lastname: van Groenendael
authors.forename: P E H
authors.initials: PE
authors.lastname: Seys
authors.forename: T P M
authors.initials: TP
authors.lastname: Vliet Vlieland
mesh_terms: D001172:Arthritis, Rheumatoid / Q000523:psychology / Q000534:rehabilitation*; D001642:Bicycling / Q000191:economics; D015444:Exercise; D017048:Health Care Costs; D019538:Health Care Surveys; D006297:Health Services Accessibility; D006801:Humans; D020407:Internet; D010342:Patient Acceptance of Health Care; D015397:Program Evaluation; D012959:Socioeconomic Factors