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Group cognitive–behavioural programme to reduce the impact of rheumatoid arthritis fatigue: The RAFT RCT with economic and qualitative evaluations

Hewlett, Sarah; Almeida, Celia; Ambler, Nicholas; Blair, Peter S; Choy, Ernest; Dures, Emma; Hammond, Alison; Hollingworth, William; Kadir, Bryar; Kirwan, John; Plummer, Zoe; Rooke, Clive; Thorn, Joanna; Turner, Nicholas; Pollock, Jonathan


Nicholas Ambler

Peter S Blair

Ernest Choy

Emma Dures
Associate Professor in Rheumatology and Self-management

Alison Hammond

William Hollingworth

Bryar Kadir

John Kirwan

Zoe Plummer

Clive Rooke

Joanna Thorn

Nicholas Turner

Jon Pollock
Associate Professor in Epidemiology


BACKGROUND: Fatigue is a major problem in rheumatoid arthritis (RA). There is evidence for the clinical effectiveness of cognitive-behavioural therapy (CBT) delivered by clinical psychologists, but few rheumatology units have psychologists. OBJECTIVES: To compare the clinical effectiveness and cost-effectiveness of a group CBT programme for RA fatigue [named RAFT, i.e. Reducing Arthritis Fatigue by clinical Teams using cognitive-behavioural (CB) approaches], delivered by the rheumatology team in addition to usual care (intervention), with usual care alone (control); and to evaluate tutors' experiences of the RAFT programme. DESIGN: A randomised controlled trial. Central trials unit computerised randomisation in four consecutive cohorts within each of the seven centres. A nested qualitative evaluation was undertaken. SETTING: Seven hospital rheumatology units in England and Wales. PARTICIPANTS: Adults with RA and fatigue severity of ≥ 6 [out of 10, as measured by the Bristol Rheumatoid Arthritis Fatigue Numerical Rating Scale (BRAF-NRS)] who had no recent changes in major RA medication/glucocorticoids. INTERVENTIONS: RAFT - group CBT programme delivered by rheumatology tutor pairs (nurses/occupational therapists). Usual care - brief discussion of a RA fatigue self-management booklet with the research nurse. MAIN OUTCOME MEASURES: Primary - fatigue impact (as measured by the BRAF-NRS) at 26 weeks. Secondary - fatigue severity/coping (as measured by the BRAF-NRS); broader fatigue impact [as measured by the Bristol Rheumatoid Arthritis Fatigue Multidimensional Questionnaire (BRAF-MDQ)]; self-reported clinical status; quality of life; mood; self-efficacy; and satisfaction. All data were collected at weeks 0, 6, 26, 52, 78 and 104. In addition, fatigue data were collected at weeks 10 and 18. The intention-to-treat analysis conducted was blind to treatment allocation, and adjusted for baseline scores and centre. Cost-effectiveness was explored through the intervention and RA-related health and social care costs, allowing the calculation of quality-adjusted life-years (QALYs) with the EuroQol-5 Dimensions, five-level version (EQ-5D-5L). Tutor and focus group interviews were analysed using inductive thematic analysis. RESULTS: A total of 308 out of 333 patients completed 26 weeks (RAFT, n/N = 156/175; control, n/N = 152/158). At 26 weeks, the mean BRAF-NRS impact was reduced for the RAFT programme (-1.36 units; p 


Hewlett, S., Almeida, C., Ambler, N., Blair, P. S., Choy, E., Dures, E., …Pollock, J. (2019). Group cognitive–behavioural programme to reduce the impact of rheumatoid arthritis fatigue: The RAFT RCT with economic and qualitative evaluations. Health Technology Assessment, 23(57),

Journal Article Type Article
Acceptance Date Jan 1, 2019
Online Publication Date Oct 1, 2019
Publication Date Oct 1, 2019
Deposit Date Oct 16, 2019
Publicly Available Date Oct 17, 2019
Print ISSN 1366-5278
Electronic ISSN 2046-4924
Publisher NIHR Journals Library
Volume 23
Issue 57
Keywords Health Policy
Public URL
Additional Information Contractual start date: 11-2013; Editorial review begun: 6-2018; Accepted for publication: 1-2019


Group cognitive–behavioural programme to reduce the impact of rheumatoid arthritis fatigue: the RAFT RCT with economic and qualitative evaluations (1.1 Mb)

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