title: Facilitating the use of COBRA combination therapy in early rheumatoid arthritis: a pilot implementation study.
abstract: OBJECTIVE
  COBRA combination therapy is well known and has uncontested efficacy in the treatment of rheumatoid arthritis (RA). However, it is infrequently applied in Dutch clinical practice. Based on qualitative research on opinions of physicians and patients towards COBRA therapy, our study describes the development and pilot testing of an implementation package to facilitate prescription and use of COBRA therapy in early RA.
  
  
  METHODS
  The implementation package was developed to address specific barriers towards prescription of COBRA therapy and comprised informational handouts (an information booklet and leaflet for patients), preprinted prescription orders, and background information on COBRA therapy for the rheumatologists. Twenty-two rheumatologists agreed to participate, including the arthritis nurse where available. Rheumatologists, nurses, and patients were asked to record their experience. All Dutch arthritis nurses were invited to an educational session on COBRA therapy.
  
  
  RESULTS
  Sixteen rheumatologists accompanied by 10 arthritis nurses used the material to prescribe COBRA therapy to a total of 27 patients. Rheumatologists and nurses both gave high marks to the supplied materials. Eighty-eight percent of rheumatologists reported that the material sped up the prescription process, and 65% indicated they would prescribe COBRA therapy more frequently if these materials were available routinely. Patients expressed great satisfaction with the information handouts, rating it 2.8 (standard deviation 0.5) on a scale of -3 (very negative) to +3 (very positive). Most patients (89%) planned to keep the information booklet as a reference and 70% used it as a tool to remember the correct intake of medication. The attitude and perceived capability of nurses towards the guidance of patients with RA receiving COBRA therapy was improved through a brief educational intervention.
  
  
  CONCLUSIONS
  Rheumatologists, patients, and arthritis nurses all highly appreciated the implementation package and indicated that its availability would increase uptake of COBRA therapy.
authors.affiliation: Department of Rheumatology, EMGO Institute, and the Department of Epidemiology and Biostatistics, VU University Medical Center, 1081 HV Amsterdam, The Netherlands. L.vanTuyl@vumc.nl
authors.forename: Lilian H D
authors.initials: LH
authors.lastname: van Tuyl
authors.forename: Anne Marie C
authors.initials: AM
authors.lastname: Plass
authors.forename: Willem F
authors.initials: WF
authors.lastname: Lems
authors.forename: Alexandre E
authors.initials: AE
authors.lastname: Voskuyl
authors.forename: Pit J S M
authors.initials: PJ
authors.lastname: Kerstens
authors.forename: Ben A C
authors.initials: BA
authors.lastname: Dijkmans
authors.forename: Maarten
authors.initials: M
authors.lastname: Boers
mesh_terms: D000328:Adult; D000368:Aged; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D004305:Dose-Response Relationship, Drug; D004359:Drug Therapy, Combination; D016568:Drugs, Generic / Q000627:therapeutic use; D005260:Female; D006284:Health Plan Implementation / Q000379:methods*; D006801:Humans; D008297:Male; D008727:Methotrexate / Q000627:therapeutic use*; D008875:Middle Aged; D010353:Patient Education as Topic; D017060:Patient Satisfaction; D010865:Pilot Projects; D011239:Prednisolone / Q000627:therapeutic use; D012460:Sulfasalazine / Q000627:therapeutic use*; D011795:Surveys and Questionnaires; D016896:Treatment Outcome
chemical_list: D018501:Antirheumatic Agents; D016568:Drugs, Generic; D012460:Sulfasalazine; D011239:Prednisolone; D008727:Methotrexate