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Sweeney AMT, Flurey CA, McCabe CS, Robson JC, Richards P, Ndosi M. Nurse-led care for people with early rheumatoid arthritis: Interview study with thematic analysis. Musculoskeletal Care 2023; 21:1651-1661. [PMID: 37988223 DOI: 10.1002/msc.1844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/03/2023] [Accepted: 11/05/2023] [Indexed: 11/23/2023]
Abstract
AIMS To develop an understanding of what comprises nurse-led care in early rheumatoid arthritis from the perspective of rheumatology nurse specialists in England. DESIGN Qualitative study. METHODS Semi-structured telephone interviews with rheumatology nurse specialists in England were conducted in Summer 2020. Interviews were audio-recorded, transcribed verbatim and analysed using reflexive thematic analysis. Reporting follows the appropriate elements of consolidated criteria for reporting qualitative research. RESULTS Sixteen nurses were recruited and interviews lasted 30-60 min. Four themes with 14 subthemes were identified. A SPECIALIST SERVICE DELIVERED BY EXPERIENCED RHEUMATOLOGY NURSES: Specialist care is provided by experienced nurse specialists with a high degree of autonomy in the rheumatology multidisciplinary team context. ADDRESSING PATIENTS' COMPLEX CARE NEEDS Care is evidence-based and aims to start treatment, keep in treatment, educate and support. Access to psychology expertise is needed. CARE WITH COMPASSION USING PERSON-CENTRED, HOLISTIC AND EMPATHETIC APPROACHES: Nurses create patient relationships and a positive therapeutic environment. Nurse-led telephone advice lines are essential for treatment adjustment, patient support and empowerment. CONTINUED EVALUATION AND DEVELOPMENT OF THE SERVICE Consultations are reviewed, and patients are asked for feedback. The COVID-19 pandemic caused disruption, but changes streamlined procedures and improved documentation and communication. CONCLUSION Nurse-led care in early rheumatoid arthritis is a specialist service delivered with compassion, addressing complex care needs and using person-centred approaches. This study identifies key aspects of care in early disease from the nurse perspective.
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Affiliation(s)
- Anne-Marie Tetsche Sweeney
- School of Health and Social Wellbeing, College of Health, Science and Society, University of the West of England, Bristol, UK
- The Academic Rheumatology Unit, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Caroline A Flurey
- School of Social Sciences, College of Health, Science and Society, University of the West of England, Bristol, UK
| | - Candy S McCabe
- School of Health and Social Wellbeing, College of Health, Science and Society, University of the West of England, Bristol, UK
- Dorothy House Hospice Care, Bradford on Avon, UK
| | - Joanna C Robson
- School of Health and Social Wellbeing, College of Health, Science and Society, University of the West of England, Bristol, UK
- The Academic Rheumatology Unit, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Pamela Richards
- School of Health and Social Wellbeing, College of Health, Science and Society, University of the West of England, Bristol, UK
- The Academic Rheumatology Unit, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Mwidimi Ndosi
- School of Health and Social Wellbeing, College of Health, Science and Society, University of the West of England, Bristol, UK
- The Academic Rheumatology Unit, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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2
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Heyn LG, Løkkeberg ST, Ellington L, van Dulmen S, Eide H. Understanding the role of positive emotions in healthcare communication - A realist review. Nurs Open 2023; 10:3447-3459. [PMID: 36611271 PMCID: PMC10170929 DOI: 10.1002/nop2.1604] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 10/18/2022] [Accepted: 12/23/2022] [Indexed: 01/09/2023] Open
Abstract
AIM To explore how the expression of positive emotions during the interaction between patients and providers can cultivate the patient-provider relationship. DESIGN We conducted a realist review guided by the Realist and Meta-narrative Evidence Syntheses: Evolving Standards. METHODS We systematically searched CINAHL, MEDLINE, PsychINFO and Scopus from inception to March 2019. Study selection and data extraction were performed blinded in pairs. From 3146 abstracts blinded in pairs, 15 papers were included and analysed. From each included paper, we extracted contexts, mechanisms and outcomes that were relevant to answer our research questions, creating a configuration between these elements (CMO configuration). RESULTS Our findings suggest that in the contexts of person orientation and positive outlook, patient-provider relationships improve by communication conveying and eliciting positive emotions. We found six underlying mechanisms for this that form either direct or indirect pathways between the context and the outcome.
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Affiliation(s)
- Lena Günterberg Heyn
- Center for Health and Technology, University of South-Eastern Norway, Drammen, Norway
| | - Stine Torp Løkkeberg
- Faculty of Health and Welfare Studies, Østfold University College, Halden, Norway
| | - Lee Ellington
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Sandra van Dulmen
- Nivel (Netherlands Institute for Health Services Research), Utrecht, Netherlands.,Department of Primary and Community Care, Radboud University Medicalcenter, Radboud Institute for Health Sciences, Nijmegen, Netherlands.,Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Hilde Eide
- Center for Health and Technology, University of South-Eastern Norway, Drammen, Norway
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3
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Pallua J, Schirmer M. Identification of Five Quality Needs for Rheumatology (Text Analysis and Literature Review). Front Med (Lausanne) 2021; 8:757102. [PMID: 34760902 PMCID: PMC8573257 DOI: 10.3389/fmed.2021.757102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/28/2021] [Indexed: 12/14/2022] Open
Abstract
Background: While the use of the term "quality" in industry relates to the basic idea of making processes measurable and standardizing processes, medicine focuses on achieving health goals that go far beyond the mere implementation of diagnostic and therapeutic processes. However, the quality management systems used are often simple, self-created concepts that concentrate on administrative processes without considering the quality of the results, which is essential for the patient. For several rheumatic diseases, both outcome and treatment goals have been defined. This work summarizes current mainstreams of strategies with published quality efforts in rheumatology. Methods: PubMed, Cochrane Library, and Web of Science were used to search for studies, and additional manual searches were carried out. Screening and content evaluation were carried out using the PRISMA-P 2015 checklist. After duplicate search in the Endnote reference management software (version X9.1), the software Rayyan QCRI (https://rayyan.qcri.org) was applied to check for pre-defined inclusion and exclusion criteria. Abstracts and full texts were screened and rated using Voyant Tools (https://voyant-tools.org/). Key issues were identified using the collocate analysis. Results: The number of selected publications was small but specific (14 relevant correlations with coefficients >0.8). Using trend analysis, 15 publications with relative frequency of keywords >0.0125 were used for content analysis, revealing 5 quality needs. The treat to target (T2T) initiative was identified as fundamental paradigm. Outcome parameters required for T2T also allow quality assessments in routine clinical work. Quality care by multidisciplinary teams also focusing on polypharmacy and other quality aspects become essential, A global software platform to assess quality aspects is missing. Such an approach requires reporting of multiple outcome parameters according to evidence-based clinical guidelines and recommendations for the different rheumatic diseases. All health aspects defined by the WHO (physical, mental, and social health) have to be integrated into the management of rheumatic patients. Conclusion: For the future, quality projects need goals defined by T2T based initiatives in routine clinical work, secondary quality goals include multidisciplinary cooperation and reduction of polypharmacy. Quality indicators and standards in different health systems will provide new information to optimize patients' care in different health systems.
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Affiliation(s)
- Johannes Pallua
- University Hospital for Orthopedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria.,Fachhochschule Gesundheit, Health University of Applied Sciences Tyrol, Innsbruck, Austria
| | - Michael Schirmer
- Department of Internal Medicine, University Clinic II, Innsbruck Medical University, Innsbruck, Austria
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4
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Hoeper JR, Zeidler J, Meyer SE, Gauler G, Steffens-Korbanka P, Welcker M, Wendler J, Schuch F, von Hinüber U, Schwarting A, Witte T, Meyer-Olson D, Hoeper K. Effect of nurse-led care on outcomes in patients with ACPA/RF-positive rheumatoid arthritis with active disease undergoing treat-to-target: a multicentre randomised controlled trial. RMD Open 2021; 7:rmdopen-2021-001627. [PMID: 33863842 PMCID: PMC8055148 DOI: 10.1136/rmdopen-2021-001627] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/02/2021] [Accepted: 04/05/2021] [Indexed: 01/03/2023] Open
Abstract
Objective To determine the non-inferiority of nurse-led care (NLC) in patients with anticitrullinated protein antibody (ACPA)-positive and/or rheumatoid factor (RF)-positive rheumatoid arthritis (RA) with active disease who are starting disease-modifying antirheumatic drug therapy, following treat-to-target (T2T) recommendations. Methods A multicentre, pragmatic randomised controlled trial was conducted to assess clinical effectiveness, anxiety, depression and patient satisfaction following a non-inferiority design. The participants were 224 adults with ACPA/RF-positive RA who were randomly assigned to either NLC or rheumatologist-led care (RLC). The primary outcome was the Disease Activity Score in 28 Joints measured with C reactive protein (DAS28-CRP) assessed at baseline and after 3, 6, 9 and 12 months. A DAS28-CRP difference of 0.6 was set as the non-inferiority margin. Mean differences between the groups were assessed following per-protocol and intention-to-treat strategies. Results Demographic data and baseline characteristics of patients in the NLC group (n=111) were comparable to those of patients in the RLC group (n=113). The improvement in disease activity (change in DAS28-CRP, primary outcome) over the course of 12 months was significant in both groups (p<0.001). No significant differences were observed between the NLC and RLC groups (p=0.317). Non-inferiority of NLC was shown for the primary outcome and all secondary outcomes. Conclusion This study supported the non-inferiority of NLC in managing T2T and follow-up care of patients with RA with moderate to high disease activity and poor prognostic factors in addition to RLC. Trial registration number DRKS00013055.
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Affiliation(s)
- Juliana Rachel Hoeper
- Center for Health Economics Research Hannover (CHERH), Leibniz Universität Hannover, Hannover, Germany.,Rheumatologie and Immunologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Jan Zeidler
- Center for Health Economics Research Hannover (CHERH), Leibniz Universität Hannover, Hannover, Germany
| | - Sara Eileen Meyer
- Rheumatologie and Immunologie, Medizinische Hochschule Hannover, Hannover, Germany
| | | | | | | | - Jörg Wendler
- Internistische Praxisgemeinschaft, Rheumatologie, Erlangen, Germany
| | - Florian Schuch
- Internistische Praxisgemeinschaft, Rheumatologie, Erlangen, Germany
| | | | - Andreas Schwarting
- Division of Rheumatology and Clinical Immunology, University Hospital Mainz, Mainz, Germany.,ACURA Rheumatology Center Rhineland-Palatinate, Bad Kreuznach, Germany
| | - Torsten Witte
- Rheumatologie and Immunologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Dirk Meyer-Olson
- Rheumatologie and Immunologie, Medizinische Hochschule Hannover, Hannover, Germany.,Rheumatologie, m&i Fachklinik Bad Pyrmont, Bad Pyrmont, Germany
| | - Kirsten Hoeper
- Rheumatologie and Immunologie, Medizinische Hochschule Hannover, Hannover, Germany
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5
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Scott DL, Ibrahim F, Hill H, Tom B, Prothero L, Baggott RR, Bosworth A, Galloway JB, Georgopoulou S, Martin N, Neatrour I, Nikiphorou E, Sturt J, Wailoo A, Williams FMK, Williams R, Lempp H. Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Rheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.
Objectives
To (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.
Design
Observational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.
Setting
Observational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).
Participants
Patients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.
Interventions
Intensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.
Main outcome measures
Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR < 2.60) was the treatment target. Other outcomes included fatigue (measured on a 100-mm visual analogue scale), disability (as measured on the Health Assessment Questionnaire), harms and resource use for economic assessments.
Results
Evaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p < 0.001]. Disability (as measured on the Health Assessment Questionnaire) decreased when intensive management patients achieved remission (difference –0.40, 95% confidence interval –0.57 to –0.22) and these differences were considered clinically relevant. However, in all intensive management patients reductions in the Health Assessment Questionnaire scores were less marked (difference –0.1, 95% confidence interval –0.2 to 0.0). The numbers of serious adverse events (intensive management n = 15 vs. standard care n = 11) and other adverse events (intensive management n = 114 vs. standard care n = 151) were similar. Economic analysis showed that the base-case incremental cost-effectiveness ratio was £43,972 from NHS and Personal Social Services cost perspectives. The probability of meeting a willingness-to-pay threshold of £30,000 was 17%. The incremental cost-effectiveness ratio decreased to £29,363 after including patients’ personal costs and lost working time, corresponding to a 50% probability that intensive management is cost-effective at English willingness-to-pay thresholds. Analysing trial baseline predictors showed that remission predictors comprised baseline DAS28-ESR, disability scores and body mass index. A 6-month extension study (involving 95 intensive management patients) showed fewer remissions by 18 months, although more sustained remissions were more likley to persist. Qualitative research in trial completers showed that intensive management was acceptable and treatment support from specialist nurses was beneficial.
Limitations
The main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.
Conclusion
The benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.
Future work
Further research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.
Trial registration
Current Controlled Trials ISRCTN70160382.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David L Scott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Fowzia Ibrahim
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Harry Hill
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Brian Tom
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Louise Prothero
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Rhiannon R Baggott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | | | - James B Galloway
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Sofia Georgopoulou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Naomi Martin
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Isabel Neatrour
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Jackie Sturt
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK
| | - Allan Wailoo
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Frances MK Williams
- Twin Research and Genetic Epidemiology, School of Life Course Sciences, King’s College London, St Thomas’ Hospital, London, UK
| | - Ruth Williams
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
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Pleh DN, Rosted E, Thomsen TG. Key competences of outpatient nurses, as perceived by patients attending nurse-led clinics - An integrative review. J Clin Nurs 2020; 30:311-322. [PMID: 33169469 DOI: 10.1111/jocn.15557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/20/2020] [Accepted: 10/31/2020] [Indexed: 11/28/2022]
Abstract
AIM The aim of this review was to identify key competences of outpatient nurses, as perceived by patients attending nurse-led clinics. BACKGROUND The increased demand for nurses to manage treatment and care in hospital outpatient clinics requires a better understanding of nurses' competences important to outpatients. DESIGN An integrative review using Whittemore and Knafl's five-stage model. METHODS Relevant studies were located by systematically searching PubMed, CINAHL and Scopus. A group of three researchers assessed the studies found and the quality of the included studies using the CASP tool. Data were extracted and analysed by thematic analyses. The current study was evaluated using PRISMA checklist. RESULTS Nine studies met the inclusion criteria. Three key competences emerged: providing access, sharing knowledge and establishing relationships. The key competences were supported by ten sub-themes that were characterised by nurses' actions and qualities, derived from the included studies. CONCLUSIONS The identified key competences reflected a holistic approach that encompasses knowledge, skills and attitudes, indicating outpatient nurses being able to manage different ways of involving patients, which may lead to the consideration of outpatient consultations as a kind of negotiation, based on a respectful dialogue. RELEVANCE TO CLINICAL PRACTICE The findings are usable when optimising the performance and quality of the health workforce, including outpatient nurses, as recommended by WHO (World Health Organization, Global strategy on human resources for health: Workforce 2030, 2016). Furthermore, the identified knowledge emphasises the need for clinical skills training and academic education, specially targeted outpatient nurses, in order to enable the nurses to become experts in specific practice settings.
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Affiliation(s)
- Denise Nana Pleh
- Department of Gynecology and Obstetrics, Zealand University Hospital, Roskilde, Denmark
| | - Elizabeth Rosted
- Department of Oncology and Palliative Care, Zealand University Hospital, Roskilde, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Thora Grothe Thomsen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Otorhinolaryngology and Maxillofacial Surgery, Zealand University Hospital, Koege, Denmark
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7
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Sweeney AMT, McCabe C, Flurey CA, Robson JC, Berry A, Richards P, Ndosi M. The patient perspective of nurse-led care in early rheumatoid arthritis: A systematic review of qualitative studies with thematic analysis. J Clin Nurs 2020; 30:145-160. [PMID: 33125809 DOI: 10.1111/jocn.15531] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/01/2020] [Accepted: 10/04/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Management of rheumatoid arthritis has changed dramatically over the last decade and is characterised by early start of intensive treatment and tight monitoring of disease activity until remission. The role of nurse-led care at early stage of disease is not well understood. AIMS To develop an understanding of rheumatology nurse-led care from the perspective of patients with early rheumatoid arthritis. METHODS A systematic review of qualitative studies, reported in line with PRISMA checklist. In March 2019, the following databases were searched: MEDLINE, EMBASE, CINAHL, PsycINFO and OpenGrey. Studies were included if they: included adults with rheumatoid arthritis; were qualitative studies with data on patients' perspectives of nurse-led care; and published in peer-reviewed journals, in English, between 2010-2019. Due to few studies in early rheumatoid arthritis, inclusion was extended to adults with established rheumatoid arthritis. Two reviewers screened abstracts and full texts. Joanna Briggs Institute Critical Appraisal Tool was used for quality assessment. Thematic synthesis was conducted according to the framework of Thomas and Harden (2008). RESULTS The search identified 1034 records. After screening and assessing for eligibility, eight qualitative studies were included in the review (133 patients). Three themes were identified from the synthesis. Nurse-led care was seen to provide professional expertise in planning and delivery of care. A person-centred approach was used combined with good communication skills, thus creating a positive therapeutic environment. Nurse-led care was described as providing a sense of empowerment and psychological support. CONCLUSION Patients with rheumatoid arthritis are supportive of nurse-led care. They value its professionalism and person-centred approach which provide a sense of security and confidence. RELEVANCE TO CLINICAL PRACTICE The findings outline ingredients of nurse-led care that are important to patients. These can inform nurses' professional development plans, service improvement and the competence framework for rheumatology nursing.
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Affiliation(s)
- Anne-Marie Tetsche Sweeney
- Department of Nursing and Midwifery, Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.,The Academic Rheumatology Unit, Bristol Royal Infirmary, University Hospitals Bristol NHS Trust, Bristol, UK
| | - Candy McCabe
- Department of Nursing and Midwifery, Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.,Dorothy House Hospice Care, Winsley, UK.,Florence Nightingale Foundation, London, UK
| | - Caroline A Flurey
- Department of Health and Social Sciences, Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Joanna C Robson
- Department of Nursing and Midwifery, Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.,The Academic Rheumatology Unit, Bristol Royal Infirmary, University Hospitals Bristol NHS Trust, Bristol, UK
| | - Alice Berry
- Department of Nursing and Midwifery, Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.,The Academic Rheumatology Unit, Bristol Royal Infirmary, University Hospitals Bristol NHS Trust, Bristol, UK
| | - Pamela Richards
- Department of Nursing and Midwifery, Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.,The Academic Rheumatology Unit, Bristol Royal Infirmary, University Hospitals Bristol NHS Trust, Bristol, UK
| | - Mwidimi Ndosi
- Department of Nursing and Midwifery, Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.,The Academic Rheumatology Unit, Bristol Royal Infirmary, University Hospitals Bristol NHS Trust, Bristol, UK
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8
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Nurse-led care for the management of rheumatoid arthritis: a review of the global literature and proposed strategies for implementation in Africa and the Middle East. Rheumatol Int 2020; 41:529-542. [PMID: 32851423 PMCID: PMC7867556 DOI: 10.1007/s00296-020-04682-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/09/2020] [Indexed: 11/29/2022]
Abstract
Globally, increasing demand for rheumatology services has led to a greater reliance on non-physician healthcare professionals (HCPs), such as rheumatology nurse specialists, to deliver care as part of a multidisciplinary team. Across Africa and the Middle East (AfME), there remains a shortage of rheumatology HCPs, including rheumatology nurses, which presents a major challenge to the delivery of rheumatology services, and subsequently the treatment and management of conditions such as rheumatoid arthritis (RA). To further explore the importance of nurse-led care (NLC) for patients with RA and create a set of proposed strategies for the implementation of NLC in the AfME region, we used a modified Delphi technique. A review of the global literature was conducted using the PubMed search engine, with the most relevant publications selected. The findings were summarized and presented to the author group, which was composed of representatives from different countries and HCP disciplines. The authors also drew on their knowledge of the wider literature to provide context. Overall, results suggest that NLC is associated with improved patient perceptions of RA care, and equivalent or superior clinical and cost outcomes versus physician-led care in RA disease management. Expert commentary provided by the authors gives insights into the challenges of implementing nurse-led RA care. We further report practical proposed strategies for the development and implementation of NLC for patients with RA, specifically in the AfME region. These proposed strategies aim to act as a foundation for the introduction and development of NLC programs across the AfME region.
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9
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Bech B, Lykkegaard JJ, Lundbak T, Schrøder HM, Birkeland LM, Schlyter ML, Hansen LH, Dalsgaard L, Esbensen BA. Patient-Initiated Follow-Up (PIFU) as reorganized support for increased patient involvement - focus group discussions among patients' with inflammatory arthritis. BMC Rheumatol 2020; 4:44. [PMID: 32613158 PMCID: PMC7325086 DOI: 10.1186/s41927-020-00143-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 06/01/2020] [Indexed: 01/08/2023] Open
Abstract
Background Inflammatory Arthritis is characterized by lifelong medical treatment and an unpredictable trajectory because of the fluctuating nature of the diseases. Proactive disease management is recommended, which includes close monitoring of disease activity that traditionally has been ensured by outpatient visits to rheumatologists at various fixed intervals. Internationally, there is a growing interest in how healthcare systems can be more flexible, individual-oriented and increasingly involve patients with lifelong diseases in their own treatment and care. We aimed to explore how patients with Inflammatory Arthritis with low disease activity or remission (DAS-CRP < 2.9) experience patient involvement in a reorganized follow-up care based on flexibility and patient-initiated contact. Methods We conducted a qualitative study based on four mixed group discussions focused on patients with inflammatory arthritis (rheumatoid arthritis [n = 21], axial spondyloarthritis [n = 3] and psoriatic arthritis [n = 1]) participating in a reorganized follow-up care. Changes in follow-up included access to a nurse and patient-initiated follow-up (PIFU). The analysis was based on content analysis. The reporting adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ). Results In total, 25 patients (20 females (80%), mean age 61.8 [range 28–79]) participated. We identified three categories. 1) Patient-Initiated Follow-Up do not affect patients’ perceived support in disease control; this refers to patients’ experience of more time available through better resource utilization, as well as trust that access to professional support would be available whenever needed. The category 2) Information is valued by patients to delineate responsibilities in a new patient role reflects patients’ uncertainty in the transition to PIFU, combined with confusion about the distribution of responsibilities. 3) Patients need both extended perspectives of their arthritis and focused dialogue is about expanding patients’ understanding of their arthritis by interaction over time with both a rheumatologist and a rheumatology nurse in a focused dialogue to involve the patient. Conclusions Patients participating in PIFU welcome the flexibility and involvement. However, patients need relevant information to act adequately within a new patient role. Interaction with both rheumatologists and nurses, combined with sufficient time for dialogue, broaden patients’ perspective, make opportunities for action visible, and contribute to patients’ ability to participate in follow-up care.
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Affiliation(s)
- Bianca Bech
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Valdemar Hansens Vej 17, Indgang 5, stuen, 2600 Glostrup, Denmark.,Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
| | - Jens Jørgen Lykkegaard
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Valdemar Hansens Vej 17, Indgang 5, stuen, 2600 Glostrup, Denmark
| | - Tine Lundbak
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Valdemar Hansens Vej 17, Indgang 5, stuen, 2600 Glostrup, Denmark
| | - Heidi Morsø Schrøder
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Valdemar Hansens Vej 17, Indgang 5, stuen, 2600 Glostrup, Denmark
| | - Line Mette Birkeland
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Valdemar Hansens Vej 17, Indgang 5, stuen, 2600 Glostrup, Denmark
| | - Mette Lund Schlyter
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Valdemar Hansens Vej 17, Indgang 5, stuen, 2600 Glostrup, Denmark
| | - Lotte Hanne Hansen
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Valdemar Hansens Vej 17, Indgang 5, stuen, 2600 Glostrup, Denmark
| | | | - Bente Appel Esbensen
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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10
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Lempp H, Baggott R, Scott DL, Parker L, Bosworth A, Georgopoulou S, Firth J. The value, impact and role of nurses in rheumatology outpatient care: Critical review of the literature. Musculoskeletal Care 2020; 18:245-255. [PMID: 32222059 DOI: 10.1002/msc.1467] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/16/2020] [Accepted: 03/20/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND As rheumatology nurses make substantial contributions to intensive management programmes following 'treat to target' principles of people with rheumatoid arthritis (RA), there is a need to understand the impacts of their involvement. A structured literature review was undertaken of qualitative studies, clinical trials and observational studies to assess the impacts of rheumatology nurses on clinical outcomes and the experiences of patients with RA and to examine the skills and training of the nurses involved. METHOD A structured literature review was conducted to examine the value, impact and professional role of nurses in RA management. RESULTS The literature search identified 657 publications, and 20 of them were included comprising: seven qualitative studies (242 patients), nine trials (a total of 2,440 patients) and four observational studies (1,234 patients). In clinical trials, nurses achieved similar patient clinical outcomes to doctors, and nurses also enhanced patients' satisfaction of received care and self-efficacy. In the qualitative studies reviewed, the nurses increased patients' knowledge and promoted their self-management. The observational studies studied examined found that nursing care led to improved patients' global functioning. The nurses in the various studies had a wide range of titles, experiences and training. DISCUSSION Our structured literature review provides strong evidence that rheumatology nurses are effective in delivering care for RA patients. However, their titles, experience and training were highly variable. CONCLUSION There is a convincing case to maintain and extend the role of nurses in managing RA, but further work is needed on standardisation of their titles and training.
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Affiliation(s)
- Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, King's College London, London, UK
| | - Rhiannon Baggott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, King's College London, London, UK
| | - David L Scott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, King's College London, London, UK
| | - Louise Parker
- Rheumatology Department, Royal Free London NHSFT, London, UK
| | - Ailsa Bosworth
- National Patient Champion, National Rheumatoid Arthritis Society, Maidenhead, UK
| | - Sofia Georgopoulou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, King's College London, London, UK.,Applied Health Services Research Group, The Royal Marsden Hospital, London, UK
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11
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Ferreira RJO, Santos EJF, de Wit M, Marques A, Barbieri-Figueiredo MDC, Marques A, Ventura F, da Silva JAP, Ndosi M. Shared decision-making in people with chronic disease: Integrating the biological, social and lived experiences is a key responsibility of nurses. Musculoskeletal Care 2020; 18:84-91. [PMID: 31837252 DOI: 10.1002/msc.1443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Ricardo J O Ferreira
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
| | - Eduardo J F Santos
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
- Abel Salazar Institute of Biomedical Sciences, University of Porto, Porto, Portugal
| | - Maarten de Wit
- Patient research partner, EULAR Standing Committee of People with Arthritis/Rheumatism in Europe, Zurich, Switzerland
- Department of Medical Humanities, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Andréa Marques
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
- Nursing School of Coimbra, Coimbra, Portugal
| | - Maria do Céu Barbieri-Figueiredo
- Abel Salazar Institute of Biomedical Sciences, University of Porto, Porto, Portugal
- Nursing School of Porto, Porto, Portugal
- CINTESIS - Center for Health Technology and Services Research, University of Porto, Porto, Portugal
| | - António Marques
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
- AGI médica I, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
| | - Filipa Ventura
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
| | - José A P da Silva
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR) - Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Mwidimi Ndosi
- Department of Nursing and Midwifery, University of the West of England, Bristol, UK
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12
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Feddersen H, Kristiansen TM, Andersen PT, Hørslev-Petersen K, Primdahl J. Interactions between women with rheumatoid arthritis and nurses during outpatient consultations: A qualitative study. Musculoskeletal Care 2019; 17:363-371. [PMID: 31777181 DOI: 10.1002/msc.1435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/19/2019] [Accepted: 09/22/2019] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is a chronic inflammatory disease, and patients with RA receive services in various settings-for example, in nurse-led follow-up consultations. The present study aimed to investigate how the management of RA in everyday life is expressed in interactions between nurses and women with RA during nursing consultations. METHODS The study was conducted in accordance with constructivist grounded theory, with data based on participant observations and subsequent interviews with 10 women with RA. RESULTS A core category was developed, "Collaboration through mutual acknowledgement", which documented how the women and nurses confirmed their shared understanding of the content and the structure of the consultation. Three subcategories were identified: (i) "On safe ground", which illustrated that biomedical factors, such as blood test results and pharmacological treatment, structured the basis of the dialogue; (ii) "Venturing forward", which documented how both parties were aware of each other's reactions when the dialogue dealt with women's perspectives of illness in their everyday lives; and (iii) "Gentle steering", which showed that the nurses gently steered the dialogue if the women strayed from the planned content. CONCLUSIONS Both parties agreed that a disease perspective consistent with biomedical factors formed the basis for further dialogue. Subsequently, the women's perspectives on illness were included, and the women felt acknowledged. Therefore, the recommendation is that the consultations start by all parties agreeing on a shared agenda to facilitate the inclusion of the women's perspectives on illness.
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Affiliation(s)
- Helle Feddersen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Institute of Health Studies, University College of Southern Denmark, Sønderborg, Denmark.,King Christian Xth Hospital for Rheumatic Diseases, Graaasten, Denmark
| | | | | | - Kim Hørslev-Petersen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,King Christian Xth Hospital for Rheumatic Diseases, Graaasten, Denmark
| | - Jette Primdahl
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,King Christian Xth Hospital for Rheumatic Diseases, Graaasten, Denmark.,Hospital of Southern Denmark, Aabenraa, Denmark
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13
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Bech B, Primdahl J, van Tubergen A, Voshaar M, Zangi HA, Barbosa L, Boström C, Boteva B, Carubbi F, Fayet F, Ferreira RJO, Hoeper K, Kocher A, Kukkurainen ML, Lion V, Minnock P, Moretti A, Ndosi M, Pavic Nikolic M, Schirmer M, Smucrova H, de la Torre-Aboki J, Waite-Jones J, van Eijk-Hustings Y. 2018 update of the EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis. Ann Rheum Dis 2019; 79:61-68. [DOI: 10.1136/annrheumdis-2019-215458] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 06/08/2019] [Accepted: 06/23/2019] [Indexed: 12/14/2022]
Abstract
To update the European League Against Rheumatism (EULAR) recommendations for the role of the nurse in the management of chronic inflammatory arthritis (CIA) using the most up to date evidence. The EULAR standardised operating procedures were followed. A task force of rheumatologists, health professionals and patients, representing 17 European countries updated the recommendations, based on a systematic literature review and expert consensus. Higher level of evidence and new insights into nursing care for patients with CIA were added to the recommendation. Level of agreement was obtained by email voting. The search identified 2609 records, of which 51 (41 papers, 10 abstracts), mostly on rheumatoid arthritis, were included. Based on consensus, the task force formulated three overarching principles and eight recommendations. One recommendation remained unchanged, six were reworded, two were merged and one was reformulated as an overarching principle. Two additional overarching principles were formulated. The overarching principles emphasise the nurse’s role as part of a healthcare team, describe the importance of providing evidence-based care and endorse shared decision-making in the nursing consultation with the patient. The recommendations cover the contribution of rheumatology nursing in needs-based patient education, satisfaction with care, timely access to care, disease management, efficiency of care, psychosocial support and the promotion of self-management. The level of agreement among task force members was high (mean 9.7, range 9.6-10.0). The updated recommendations encompass three overarching principles and eight evidence-based and expert opinion-based recommendations for the role of the nurse in the management of CIA.
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14
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Bergsten U, Almehed K, Baigi A, Jacobsson LTH. A randomized study comparing regular care with a nurse-led clinic based on tight disease activity control and person-centred care in patients with rheumatoid arthritis with moderate/high disease activity: A 6-month evaluation. Musculoskeletal Care 2019; 17:215-225. [PMID: 31219668 PMCID: PMC6852576 DOI: 10.1002/msc.1403] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 11/20/2022]
Abstract
Introduction A recent survey showed that 27% of rheumatoid arthritis (RA) patients had inadequately controlled disease activity. Hence, there is a need for new strategies aiming at improving patient outcomes. The aim of the present study was to evaluate the effect of a nurse‐led clinic with frequent visits, treat‐to‐target and person‐centred care of patients with established RA and moderate‐to‐high disease activity compared with patients receiving regular care. Methods The study was a randomized, controlled trial over 26 weeks, with a nonrandomized extension to week 50. Patients were randomized to an intervention group (IG; nurse‐led clinic) based on person‐centred care, frequent visits and “treat to target”, or to a control group (CG) which visited the clinic according to care as usual. The primary outcome was the difference in the DAS28 change between the IG and the CG groups. Results A total of 332 patients were screened for eligibility, of which 70 were randomly assigned to either the IG (n = 36) or the CG (n = 34) group. The primary outcome was not met, although patients in the IG group tended to improve more than those in the CG group (difference: 0.43 (95% confidence interval [CI] –0.27, 1.13). In both the IG and CG groups, delta‐DAS28 improved significantly. The European League Against Rheumatology moderate or good response was achieved by 76% (95% CI 58, 89) in the IG and 49% (95% CI 32, 65) in the CG group. Conclusions Disease activity tended to improve more with the nurse‐led intervention compared with regular care, although the difference was not significant, probably partly due to the lack of statistical power.
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Affiliation(s)
- Ulrika Bergsten
- Research and Development Department at Region of Halland, Halmstad, Sweden
| | - Katarina Almehed
- Rheumatology Department, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Amir Baigi
- Research and Development Department at Region of Halland, Halmstad, Sweden
| | - Lennart T H Jacobsson
- Department of Rheumatology and Inflammation Research, University of Gothenburg, Goteborg, Sweden
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15
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Karimi‐Shahanjarini A, Shakibazadeh E, Rashidian A, Hajimiri K, Glenton C, Noyes J, Lewin S, Laurant M, Colvin CJ. Barriers and facilitators to the implementation of doctor-nurse substitution strategies in primary care: a qualitative evidence synthesis. Cochrane Database Syst Rev 2019; 4:CD010412. [PMID: 30982950 PMCID: PMC6462850 DOI: 10.1002/14651858.cd010412.pub2] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Having nurses take on tasks that are typically conducted by doctors (doctor-nurse substitution, a form of 'task-shifting') may help to address doctor shortages and reduce doctors' workload and human resource costs. A Cochrane Review of effectiveness studies suggested that nurse-led care probably leads to similar healthcare outcomes as care delivered by doctors. This finding highlights the need to explore the factors that affect the implementation of strategies to substitute doctors with nurses in primary care. In our qualitative evidence synthesis (QES), we focused on studies of nurses taking on tasks that are typically conducted by doctors working in primary care, including substituting doctors with nurses or expanding nurses' roles. OBJECTIVES (1) To identify factors influencing implementation of interventions to substitute doctors with nurses in primary care. (2) To explore how our synthesis findings related to, and helped to explain, the findings of the Cochrane intervention review of the effectiveness of substituting doctors with nurses. (3) To identify hypotheses for subgroup analyses for future updates of the Cochrane intervention review. SEARCH METHODS We searched CINAHL and PubMed, contacted experts in the field, scanned the reference lists of relevant studies and conducted forward citation searches for key articles in the Social Science Citation Index and Science Citation Index databases, and 'related article' searches in PubMed. SELECTION CRITERIA We constructed a maximum variation sample (exploring variables such as country level of development, aspects of care covered and the types of participants) from studies that had collected and analysed qualitative data related to the factors influencing implementation of doctor-nurse substitution and the expansion of nurses' tasks in community or primary care worldwide. We included perspectives of doctors, nurses, patients and their families/carers, policymakers, programme managers, other health workers and any others directly involved in or affected by the substitution. We excluded studies that collected data using qualitative methods but did not analyse the data qualitatively. DATA COLLECTION AND ANALYSIS We identified factors influencing implementation of doctor-nurse substitution strategies using a framework thematic synthesis approach. Two review authors independently assessed the methodological strengths and limitations of included studies using a modified Critical Appraisal Skills Programme (CASP) tool. We assessed confidence in the evidence for the QES findings using the GRADE-CERQual approach. We integrated our findings with the evidence from the effectiveness review of doctor-nurse substitution using a matrix model. Finally, we identified hypotheses for subgroup analyses for updates of the review of effectiveness. MAIN RESULTS We included 66 studies (69 papers), 11 from low- or middle-income countries and 55 from high-income countries. These studies found several factors that appeared to influence the implementation of doctor-nurse substitution strategies. The following factors were based on findings that we assessed as moderate or high confidence.Patients in many studies knew little about nurses' roles and the difference between nurse-led and doctor-led care. They also had mixed views about the type of tasks that nurses should deliver. They preferred doctors when the tasks were more 'medical' but accepted nurses for preventive care and follow-ups. Doctors in most studies also preferred that nurses performed only 'non-medical' tasks. Nurses were comfortable with, and believed they were competent to deliver a wide range of tasks, but particularly emphasised tasks that were more health promotive/preventive in nature.Patients in most studies thought that nurses were more easily accessible than doctors. Doctors and nurses also saw nurse-doctor substitution and collaboration as a way of increasing people's access to care, and improving the quality and continuity of care.Nurses thought that close doctor-nurse relationships and doctor's trust in and acceptance of nurses was important for shaping their roles. But nurses working alone sometimes found it difficult to communicate with doctors.Nurses felt they had gained new skills when taking on new tasks. But nurses wanted more and better training. They thought this would increase their skills, job satisfaction and motivation, and would make them more independent.Nurses taking on doctors' tasks saw this as an opportunity to develop personally, to gain more respect and to improve the quality of care they could offer to patients. Better working conditions and financial incentives also motivated nurses to take on new tasks. Doctors valued collaborating with nurses when this reduced their own workload.Doctors and nurses pointed to the importance of having access to resources, such as enough staff, equipment and supplies; good referral systems; experienced leaders; clear roles; and adequate training and supervision. But they often had problems with these issues. They also pointed to the huge number of documents they needed to complete when tasks were moved from doctors to nurses. AUTHORS' CONCLUSIONS Patients, doctors and nurses may accept the use of nurses to deliver services that are usually delivered by doctors. But this is likely to depend on the type of services. Nurses taking on extra tasks want respect and collaboration from doctors; as well as proper resources; good referral systems; experienced leaders; clear roles; and adequate incentives, training and supervision. However, these needs are not always met.
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Affiliation(s)
- Akram Karimi‐Shahanjarini
- Hamadan University of Medical SciencesDepartment of Public HealthMahdeieh Ave. Hamadan, IranHamadanHamadanIran
- Hamadan University of Medical SciencesSocial Determinants of Health Research CenterHamadanIran
| | - Elham Shakibazadeh
- Tehran University of Medical SciencesDepartment of Health Education and Health PromotionTehranTehranIran
| | - Arash Rashidian
- Tehran University of Medical SciencesDepartment of Health Management and Economics, School of Public HealthPoursina AveTehranIran1417613191
| | - Khadijeh Hajimiri
- School of Public Health, Zanjan University of Medical SciencesDepartment of Health Education and Health PromotionZanjanIran
| | - Claire Glenton
- Norwegian Institute of Public HealthPO Box 7004 St Olavs plassOsloNorwayN‐0130
| | - Jane Noyes
- Bangor UniversityCentre for Health‐Related Research, Fron HeulogBangorWalesUKLL57 2EF
| | - Simon Lewin
- Norwegian Institute of Public HealthPO Box 7004 St Olavs plassOsloNorwayN‐0130
- South African Medical Research CouncilHealth Systems Research UnitPO Box 19070TygerbergSouth Africa7505
| | - Miranda Laurant
- Radboud Institute for Health Sciences, IQ healthcareRadboud University Medical CenterPO Box 9101NijmegenNetherlands6500 HB
- Institute of Nursing StudiesHAN University of Applied SciencesNijmegenNetherlands
| | - Christopher J Colvin
- School of Public Health and Family Medicine, University of Cape TownDivision of Social and Behavioural SciencesCape TownSouth Africa
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16
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Nurses' roles in the management of chronic inflammatory arthritis: a systematic review. Rheumatol Int 2018; 38:2027-2036. [PMID: 30128732 PMCID: PMC6208652 DOI: 10.1007/s00296-018-4135-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/14/2018] [Indexed: 01/10/2023]
Abstract
In 2011 EULAR first published recommendations for the potential role of nurses in the management of patients with rheumatic diseases. To perform a literature update for the role of nurses in the management of chronic inflammatory arthritis (CIA) from 2010 to 2018. A systematic literature review (SLR) was performed according to the PRISMA guidelines, in accordance with the search strategies and eligibility criteria of the EULAR taskforce. The eligibility criteria were “inflammatory arthritis”, “interventions undertaken by nurses” and “relevant outcomes to answer the research questions”. Exclusion criteria were in itself contradictory outcomes, insufficient data, consideration if they did not clearly distinguish between nurses and health professionals or focused on chronic other than rheumatic diseases. Systematic reviews were classified as descriptive and excluded. Quality of selected trials was determined according to Oxford—levels of evidence 2009. A total of 48 articles and 10 abstracts were identified fulfilling the eligibility and exclusion criteria. Recommendation 1 has been well established in Europe so far. New evidence strengthens the recommendation 3, and—at least in part—recommendation 6. High evidence strengthens recommendation 4, especially for outpatients with low and stable disease activity. Some new evidence also exists for recommendations 7 and 8. This SLR reveals new evidence for the role of nurses in managing CIA patients since 2010, especially for RA-patients with low disease activity or in remission.
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17
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Sjö AS, Bergsten U. Patients' experiences of frequent encounters with a rheumatology nurse-A tight control study including patients with rheumatoid arthritis. Musculoskeletal Care 2018; 16:305-312. [PMID: 29808592 DOI: 10.1002/msc.1348] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 04/04/2018] [Accepted: 04/06/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Rheumatoid arthritis (RA) is a chronic inflammatory disease that is treated with both pharmacological and nonpharmacological methods. The treatment works well for patients who are knowledgeable about their disease and situation. However, this may be different for others as, among other things, it depends on how well informed the patients are in relation to their condition. Available research primarily focuses on patients in remission. One way of supporting and strengthening the group who experience a lack of well-being due to their disease and providing them with increased knowledge about their situation can be to give them access to a nurse-led clinic based on person-centred care. AIM The aim of the study was to describe the experience of patients with RA attending person-centred, nurse-led clinics over a 12-month period. METHODS A qualitative method was employed to deepen the understanding of the phenomenon. Fifteen participants were interviewed, and the text of the interviews was analysed using the phenomenographic method. RESULTS The analysis resulted in three categories that described participants' experiences of their encounters with a nurse. The three categories describe a process with interrelated concepts: first, Encountering competence, followed by Experiencing a sustainable relationship and, finally, Making a personal journey. CONCLUSION Patients with RA who had frequent meetings with a nurse experienced being strengthened on several levels and having gained increased knowledge about their disease. The person-centred approach made them feel that they had been met on their own level, in accordance with their needs and level of knowledge.
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Affiliation(s)
- Ann-Sofi Sjö
- Rheumatology Department, Sahlgrenska Hospital, Gothenburg, Sweden
| | - Ulrika Bergsten
- Research and Development Department at Region Halland, Halmstad, Sweden
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18
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Bala SV, Forslind K, Fridlund B, Samuelson K, Svensson B, Hagell P. Person-centred care in nurse-led outpatient rheumatology clinics: Conceptualization and initial development of a measurement instrument. Musculoskeletal Care 2018; 16:287-295. [PMID: 29417713 DOI: 10.1002/msc.1233] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 12/13/2017] [Accepted: 12/15/2017] [Indexed: 06/08/2023]
Abstract
BACKGROUND Person-centred care (PCC) is considered a key component of effective illness management and high-quality care. However, the PCC concept is underdeveloped in outpatient care. In rheumatology, PCC is considered an unmet need and its further development and evaluation is of high priority. The aim of the present study was to conceptualize and operationalize PCC, in order to develop an instrument for measuring patient-perceived PCC in nurse-led outpatient rheumatology clinics. METHODS A conceptual outpatient PCC framework was developed, based on the experiences of people with rheumatoid arthritis (RA), person-centredness principles and existing PCC frameworks. The resulting framework was operationalized into the PCC instrument for outpatient care in rheumatology (PCCoc/rheum), which was tested for acceptability and content validity among 50 individuals with RA attending a nurse-led outpatient clinic. RESULTS The conceptual framework focuses on the meeting between the person with RA and the nurse, and comprises five interrelated domains: social environment, personalization, shared decision-making, empowerment and communication. Operationalization of the domains into a pool of items generated a preliminary PCCoc/rheum version, which was completed in a mean (standard deviation) of 5.3 (2.5) min. Respondents found items easy to understand (77%) and relevant (93%). The Content Validity Index of the PCCoc/rheum was 0.94 (item level range, 0.87-1.0). About 80% of respondents considered some items redundant. Based on these results, the PCCoc/rheum was revised into a 24-item questionnaire. CONCLUSIONS A conceptual outpatient PCC framework and a 24-item questionnaire intended to measure PCC in nurse-led outpatient rheumatology clinics were developed. The extent to which the questionnaire represents a measurement instrument remains to be tested.
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Affiliation(s)
- Sidona-Valentina Bala
- Department of Health Sciences, Lund University, Lund, Sweden
- Section of Rheumatology, Department of Medicine, Helsingborg Central Hospital, Sweden
| | - Kristina Forslind
- Section of Rheumatology, Department of Medicine, Helsingborg Central Hospital, Sweden
- Department of Clinical Science, Section of Rheumatology, Faculty of Medicine Lund University, Lund, Sweden
| | - Bengt Fridlund
- School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Karin Samuelson
- Department of Health Sciences, Lund University, Lund, Sweden
| | - Björn Svensson
- Department of Clinical Science, Section of Rheumatology, Faculty of Medicine Lund University, Lund, Sweden
| | - Peter Hagell
- The PRO-CARE Group, School of Health & Society, Kristianstad University, Kristianstad, Sweden
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Rizzello F, Olivieri I, Armuzzi A, Ayala F, Bettoli V, Bianchi L, Cimino L, Costanzo A, Cristaudo A, D'Angelo S, Daperno M, Fostini AC, Galeazzi M, Gilio M, Gionchetti P, Gisondi P, Lubrano E, Marchesoni A, Offidani A, Orlando A, Pugliese D, Salvarani C, Scarpa R, Vecchi M, Girolomoni G. Multidisciplinary Management of Spondyloarthritis-Related Immune-Mediated Inflammatory Disease. Adv Ther 2018. [PMID: 29516409 PMCID: PMC5910456 DOI: 10.1007/s12325-018-0672-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction Immune-mediated inflammatory diseases (IMIDs) are chronic autoimmune conditions that share common pathophysiologic mechanisms. The optimal management of patients with IMIDs remains challenging because the coexistence of different conditions requires the intervention of several specialists. The aim of this study was to develop a series of statements defining overarching principles that guide the implementation of a multidisciplinary approach for the management of spondyloarthritis (SpA)-related IMIDs including SpA, psoriasis, psoriatic arthritis, Crohn’s disease, ulcerative colitis and uveitis. Methods A Delphi consensus-based approach was used to identify a core set of statements. The process included development of initial questions by a steering committee, an exhaustive search of the literature using complementary approaches to identify potential statements and two Delphi voting rounds for finalization of the statements. Results Consensus was achieved on the related nature of IMIDs, the existence of a high prevalence of multiple IMIDs in a single patient and the fact that a multidisciplinary approach can result in a more extensive evaluation and comprehensive approach to treatment. The goals of a multidisciplinary team should be to increase diagnosis of concomitant IMIDs, improve the decision-making process, and increase patient satisfaction and adherence. Early referral and diagnosis, early recognition of concomitant IMIDs and optimizing treatment to improve patient quality of life are some of the advantages of using multidisciplinary teams. To be effective, a multidisciplinary team should be equipped with the appropriate tools for diagnosis and follow-up, and at a minimum the multidisciplinary team should include a dermatologist, gastroenterologist and rheumatologist; providing psychologic support via a psychologist and involving an ophthalmologist, general practitioners and nurses in multidisciplinary care is also important. Conclusion The present Delphi consensus identified a set of overarching principles that may be useful for implementation of a multidisciplinary approach for the management of SpA-related IMIDs. Funding Aristea and Hippocrates.
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Affiliation(s)
- Fernando Rizzello
- IBD Unit, DIMEC, University of Bologna, S Orsola-Malpighi Hospital Bologna, Bologna, Italy
| | - Ignazio Olivieri
- Istituto Reumatologico Lucano (IReL), Potenza, Italy
- Dipartimento di Reumatologia della Regione Basilicata, Ospedale Madonna delle Grazie di Matera, Potenza, Italy
- Dipartimento di Reumatologia della Regione Basilicata, Ospedale San Carlo di Potenza, Potenza, Italy
- Fondazione BRB (Basilicata Ricerca Biomedica), Potenza, Italy
| | - Alessandro Armuzzi
- UOC di Medicina Interna e Malattie dell'Apparato Digerente, Presidio Columbus Fondazione Policlinico Gemelli Universita' Cattolica, Rome, Italy
| | - Fabio Ayala
- UOC di Dermatologia, Dipartimento di Medicina Clinica e Chirurgia, Università di Napoli Federico II, Naples, Italy
| | - Vincenzo Bettoli
- Department of Clinical and Experimental Dermatology, O.U. of Dermatology, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Luca Bianchi
- U.O.C. Dermatologia, Fondazione Policlinico Tor Vergata, Tor Vergata University of Rome, Rome, Italy
| | - Luca Cimino
- SSD di Immunologia Oculare, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Antonio Costanzo
- Unità Dermatologia Dipartimento di Scienze Biomediche Humanitas University, Rozzano, Milan, Italy
- UOC Dermatologia IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy
| | - Antonio Cristaudo
- UO Dermatologia, MST, Ambientale e Tropicale San Gallicano Dermatological Institute-IRCCS, Rome, Italy
| | - Salvatore D'Angelo
- Istituto Reumatologico Lucano (IReL), Potenza, Italy.
- Dipartimento di Reumatologia della Regione Basilicata, Ospedale Madonna delle Grazie di Matera, Potenza, Italy.
- Dipartimento di Reumatologia della Regione Basilicata, Ospedale San Carlo di Potenza, Potenza, Italy.
- Fondazione BRB (Basilicata Ricerca Biomedica), Potenza, Italy.
| | - Marco Daperno
- Gastroenterology Unit, Mauriziano Hospital, Turin, Italy
| | - Anna Chiara Fostini
- Section of Dermatology and Venereology, Department of Medicine, University of Verona, Verona, Italy
| | - Mauro Galeazzi
- Dipartimento di Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Siena, Italy
| | - Michele Gilio
- Istituto Reumatologico Lucano (IReL), Potenza, Italy
- Dipartimento di Reumatologia della Regione Basilicata, Ospedale Madonna delle Grazie di Matera, Potenza, Italy
- Dipartimento di Reumatologia della Regione Basilicata, Ospedale San Carlo di Potenza, Potenza, Italy
- Department of Health Science, University "Magna Grecia", Catanzaro, Italy
| | - Paolo Gionchetti
- IBD Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Paolo Gisondi
- Section of Dermatology and Venereology, Department of Medicine, University of Verona, Verona, Italy
| | - Ennio Lubrano
- Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio", Università degli Studi del Molise, Campobasso, Italy
| | - Antonio Marchesoni
- U.O.C. Day Hospital di Reumatologia, ASST Gaetano Pini-CTO, Milan, Italy
| | | | - Ambrogio Orlando
- UOSD MICI-A.O. Ospedali Riuniti "Villa Sofia-Cervello" Palermo, Palermo, Italy
| | - Daniela Pugliese
- UOC di Medicina Interna e Malattie dell'Apparato Digerente, Presidio Columbus Fondazione Policlinico Gemelli Universita' Cattolica, Rome, Italy
| | - Carlo Salvarani
- Azienda USL-IRCCS e Università di Modena e Reggio Emilia, Reggio Emilia, Italy
| | | | - Maurizio Vecchi
- Department of Biomedical Science for the Health, University of Milan, Milan, Italy
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giampiero Girolomoni
- Section of Dermatology and Venereology, Department of Medicine, University of Verona, Verona, Italy
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Hall J, Julia Kaal K, Lee J, Duncan R, Tsao N, Harrison M. Patient Satisfaction and Costs of Multidisciplinary Models of Care in Rheumatology: a Review of the Recent Literature. Curr Rheumatol Rep 2018; 20:19. [DOI: 10.1007/s11926-018-0727-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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de Thurah A, Esbensen BA, Roelsgaard IK, Frandsen TF, Primdahl J. Efficacy of embedded nurse-led versus conventional physician-led follow-up in rheumatoid arthritis: a systematic review and meta-analysis. RMD Open 2017; 3:e000481. [PMID: 28879053 PMCID: PMC5574437 DOI: 10.1136/rmdopen-2017-000481] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 06/28/2017] [Accepted: 07/04/2017] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To compare the efficacy of embedded nurse-led versus conventional physician-led follow-up on disease activity in patients with rheumatoid arthritis (RA). METHODS In a systematic literature search, we identified randomised controlled trials (RCTs) reporting on the efficacy of nurse-led follow-up on disease control in patients with RA compared with physician-led follow-up. Primary outcome was disease activity indicated by Disease Activity Score (DAS)-28. Secondary outcomes were: patient satisfaction, physical disability, fatigue, self-efficacy and quality of life. Outcomes were assessed after 1-year and 2 year follow-ups. RESULTS Seven studies representing five RCTs, including a total of 723 participants, were included. All but one study included stable patients in low disease activity or remission at baseline. No difference in DAS-28 was found after 1 year (mean difference (MD) -0.07 (95% CI -0.23 to 0.09)). After 2 years, a statistically significant difference was seen in favour of nurse-led follow-up (MD -0.28 (95% CI -0.53 to -0.04)). However, the difference did not reach a clinically relevant level. No difference was found in patient satisfaction after 1 year (standard mean difference (SMD) -0.17 (95 % CI -1.0 to 0.67), whereas a statistical significant difference in favour of nurse-led follow-up was seen after 2 years (SMD: 0.6 (95% CI -0.00 to 1.20)). CONCLUSION After 1 year no difference in disease activity, indicated by DAS-28, were found between embedded nurse-led follow-up compared with conventional physician-led follow-up, in RA patients with low disease activity or remission.
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Affiliation(s)
- Annette de Thurah
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Bente Appel Esbensen
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ida Kristiane Roelsgaard
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Copenhagen, Denmark
| | - Tove Faber Frandsen
- Department of Design and Communication, University of Southern Denmark, Kolding, Denmark
| | - Jette Primdahl
- King Christian X's Hospital for Rheumatic Diseases, Graasten, Denmark.,Hospital of Southern Jutland, Aabenraa, Denmark.,Institute for Regional Health Research, University of Southern Denmark, Odense, Denmark
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LARSSON INGRID. Nurse-led Care and Patients as Partners Are Essential Aspects of the Future of Rheumatology Care. J Rheumatol 2017; 44:720-722. [DOI: 10.3899/jrheum.170215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Garner S, Lopatina E, Rankin JA, Marshall DA. Nurse-led Care for Patients with Rheumatoid Arthritis: A Systematic Review of the Effect on Quality of Care. J Rheumatol 2017; 44:757-765. [DOI: 10.3899/jrheum.160535] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2016] [Indexed: 10/20/2022]
Abstract
Objective.In the nurse-led care (NLC) model, nurses take on the primary responsibility for patient management. We systematically assessed the effect of NLC for patients with rheumatoid arthritis (RA) on multiple dimensions of quality of care from the Alberta Quality of Care Matrix for Health.Methods.We searched MEDLINE, EMBASE, and CINAHL from 1950 to January 2015. English-language studies were included if they reported on NLC for patients with RA and assessed 1 or more dimensions of quality (effectiveness, acceptability, efficiency, accessibility, appropriateness, and safety). Data were synthesized using narrative analysis.Results.We included 10 studies. The NLC models varied in terms of nurses’ professional designation (clinical nurse specialists or nurse practitioners); however, their role in the clinic was fairly consistent. Disease activity was the most common measure of effectiveness, with NLC being equal (n = 2) or superior (n = 3) to the comparator. NLC was equal (n = 1) or superior (n = 5) versus the comparator in terms of patient satisfaction (i.e., acceptability of care). NLC was equally safe as other models (n = 2). Regarding efficiency, results varied across studies (n = 6) and did not allow for conclusions about models’ cost-effectiveness. In qualitative studies, patients found NLC to be superior in terms of accessibility [i.e., continuity of care (n = 3) and appropriateness measured with education and support (n = 4)]; however, no quantitative measures were found.Conclusion.NLC for patients with RA is effective, acceptable, and safe as compared with other models. However, current evidence is insufficient to draw conclusions about its efficiency, accessibility, and appropriateness.
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Larsson I, Fridlund B, Arvidsson B, Teleman A, Svedberg P, Bergman S. A nurse-led rheumatology clinic versus rheumatologist-led clinic in monitoring of patients with chronic inflammatory arthritis undergoing biological therapy: a cost comparison study in a randomised controlled trial. BMC Musculoskelet Disord 2015; 16:354. [PMID: 26573936 PMCID: PMC4647492 DOI: 10.1186/s12891-015-0817-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 11/13/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Recommendations for rheumatology nursing management of chronic inflammatory arthritis (CIA) from European League Against Rheumatism (EULAR) states that nurses should take part in the monitoring patients' disease and therapy in order to achieve cost savings. The aim of the study was to compare the costs of rheumatology care between a nurse-led rheumatology clinic (NLC), based on person-centred care (PCC), versus a rheumatologist-led clinic (RLC), in monitoring of patients with CIA undergoing biological therapy. METHODS Patients with CIA undergoing biological therapy (n = 107) and a Disease Activity Score of 28 ≤ 3.2 were randomised to follow-up by either NLC or RLC. All patients met the rheumatologist at inclusion and after 12 months. In the intervention one of two annual monitoring visits in an RLC was replaced by a visit to an NLC. The primary outcome was total annual cost of rheumatology care. RESULTS A total of 97 patients completed the RCT at the 12 month follow-up. Replacing one of the two annual rheumatologist monitoring visits by a nurse-led monitoring visit, resulted in no additional contacts to the rheumatology clinic, but rather a decrease in the use of resources and a reduction of costs. The total annual rheumatology care costs including fixed monitoring, variable monitoring, rehabilitation, specialist consultations, radiography, and pharmacological therapy, generated € 14107.7 per patient in the NLC compared with € 16274.9 in the RCL (p = 0.004), giving a € 2167.2 (13 %) lower annual cost for the NLC. CONCLUSIONS Patients with CIA and low disease activity or in remission undergoing biological therapy can be monitored with a reduced resource use and at a lower annual cost by an NLC, based on PCC with no difference in clinical outcomes. This could free resources for more intensive monitoring of patients early in the disease or patients with high disease activity. TRIAL REGISTRATION The trial is registered as a clinical trial at the ClinicalTrials.gov (NCT01071447). Registration date: October 8, 2009.
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Affiliation(s)
- Ingrid Larsson
- School of Health and Welfare, Halmstad University, Box 823, S-30118, Halmstad, Sweden.
- Spenshult Research and Development Centre, Halmstad, Sweden.
| | - Bengt Fridlund
- School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Barbro Arvidsson
- School of Health and Welfare, Halmstad University, Box 823, S-30118, Halmstad, Sweden
| | | | - Petra Svedberg
- School of Health and Welfare, Halmstad University, Box 823, S-30118, Halmstad, Sweden
| | - Stefan Bergman
- School of Health and Welfare, Halmstad University, Box 823, S-30118, Halmstad, Sweden
- Spenshult Research and Development Centre, Halmstad, Sweden
- Primary Health Care Unit, Department of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
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Ndosi M, Johnson D, Young T, Hardware B, Hill J, Hale C, Maxwell J, Roussou E, Adebajo A. Effects of needs-based patient education on self-efficacy and health outcomes in people with rheumatoid arthritis: a multicentre, single blind, randomised controlled trial. Ann Rheum Dis 2015; 75:1126-32. [PMID: 26162769 PMCID: PMC4893097 DOI: 10.1136/annrheumdis-2014-207171] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 06/09/2015] [Indexed: 12/22/2022]
Abstract
Objectives The Educational Needs Assessment Tool (ENAT) is a self-completed questionnaire, which allows patients with arthritis to prioritise their educational needs. The aim of this study was to evaluate the effects of needs-based patient education on self-efficacy, health outcomes and patient knowledge in people with rheumatoid arthritis (RA). Methods Patients with RA were enrolled into this multicentre, single-blind, parallel-group, pragmatic randomised controlled trial. Patients were randomised to either the intervention group (IG) where patients completed ENAT, responses of which were used by the clinical nurse specialist to guide patient education; or control group (CG) in which they received patient education without the use of ENAT. Patients were seen at weeks 0, 16 and 32. The primary outcome was self-efficacy (Arthritis Self Efficacy Scale (ASES)-Pain and ASES-Other symptoms). Secondary outcomes were health status (short form of Arthritis Impact Measurement Scale 2, AIMS2-SF) and patient knowledge questionnaire-RA. We investigated between-group differences using analysis of covariance, adjusting for baseline variables. Results A total of 132 patients were recruited (IG=70 and CG=62). Their mean (SD) age was 54 (12.3) years, 56 (13.3) years and disease duration 5.2 (4.9) years, 6.7 (8.9) years for IG and CG, respectively. There were significant between-group differences, in favour of IG at week 32 in the primary outcomes, ASES-Pain, mean difference (95% CI) −4.36 (1.17 to 7.55), t=−2.72, p=0.008 and ASES-Other symptoms, mean difference (95% CI) −5.84 (2.07 to 9.62), t=−3.07, p=0.003. In secondary outcomes, the between-group differences favoured IG in AIMS2-SF Symptoms and AIMS2-SF Affect. There were no between-group differences in other secondary outcomes. Conclusions The results suggest that needs-based education helps improve patients’ self-efficacy and some aspects of health status. Trial registration number ISRCTN51523281.
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Affiliation(s)
- M Ndosi
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK School of Healthcare, University of Leeds, Leeds, UK
| | - D Johnson
- Department of Rheumatology, Barnsley Hospital NHS Foundation Trust, Barnsley, UK Research & Development Department, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - T Young
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - B Hardware
- Department of Rheumatology, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - J Hill
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - C Hale
- School of Healthcare, University of Leeds, Leeds, UK
| | - J Maxwell
- Department of Rheumatology, Rotherham Hospital NHS Foundation Trust, Rotherham, UK
| | - E Roussou
- Department of Rheumatology, King George Hospital, Barking Havering and Redbridge University Hospitals NHS Trust, Ilford, UK
| | - A Adebajo
- Department of Rheumatology, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
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Dures E, Almeida C, Caesley J, Peterson A, Ambler N, Morris M, Pollock J, Hewlett S. Patient preferences for psychological support in inflammatory arthritis: a multicentre survey. Ann Rheum Dis 2014; 75:142-7. [PMID: 25261572 DOI: 10.1136/annrheumdis-2014-205636] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 09/13/2014] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Inflammatory arthritis (IA) can lead to anxiety, depression, pain and fatigue. Psychological support can improve quality of life and self-management; and European and American guidelines recommend support be offered. This study examined patient views on psychological support for their IA. METHODS A questionnaire designed by researchers, patient partners and clinicians was administered to 2280 patients with IA. RESULTS 1210 patients responded (53%): 74% women; mean age 59 years (SD 12.7); patient global 5 (2.3); disease duration <5 years (41%), 5-10 (20%), >10 (39%). Only 23% reported routinely being asked about social and emotional issues by a rheumatology professional, but 46% would like the opportunity to discuss psychological impact. If offered, 66% of patients reported they would use a self-management/coping clinic (63% pain management, 60% occupational therapy, 48% peer support groups, 46% patient education, 46% psychology/counselling). Patients want support with managing the impact of pain and fatigue (82%), managing emotions (57%), work and leisure (52%), relationships (37%) and depression (34%). Preferences are for support to be delivered by the rheumatology team (nurse 74%, doctor 55%) and general practitioners (GPs) (51%). Only 6% of patients stated that social and emotional issues were not relevant. CONCLUSIONS Demand for psychological support is high; however, less than a quarter of patients reported being asked about social and emotional issues, suggesting a gap between needs and provision. The preference is for delivery from rheumatology clinicians and GPs, and research should establish whether they have the skills and resources to meet patients' needs.
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Affiliation(s)
- Emma Dures
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Celia Almeida
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Judy Caesley
- Academic Rheumatology, University Hospitals Bristol, Bristol, UK
| | - Alice Peterson
- Academic Rheumatology, University Hospitals Bristol, Bristol, UK
| | - Nicholas Ambler
- Pain Management Centre, North Bristol NHS Trust, Bristol, UK
| | - Marianne Morris
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Jon Pollock
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Sarah Hewlett
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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Neher M, Ståhl C, Ellström PE, Nilsen P. Knowledge sources for evidence-based practice in rheumatology nursing. Clin Nurs Res 2014; 24:661-79. [PMID: 25059719 DOI: 10.1177/1054773814543355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
As rheumatology nursing develops and extends, knowledge about current use of knowledge in rheumatology nursing practice may guide discussions about future knowledge needs. To explore what perceptions rheumatology nurses have about their knowledge sources and about what knowledge they use in their practice, 12 nurses working in specialist rheumatology were interviewed using a semi-structured interview guide. The data were analyzed using conventional qualitative content analysis. The analysis yielded four types of knowledge sources in clinical practice: interaction with others in the workplace, contacts outside the workplace, written materials, and previous knowledge and experience. Colleagues, and physicians in particular, were important for informal learning in daily rheumatology practice. Evidence from the medical arena was accessed through medical specialists, while nursing research was used less. Facilitating informal learning and continuing formal education is proposed as a way toward a more evidence-based practice in extended roles.
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Al Chalabi H, O'Riordan JM, Richardson A, Flannery D, O'Connor K, Stuart C, Larkin J, McCormick P, Mehigan B. Six-year experience of a nurse-led colorectal cancer follow-up clinic. Surg Res Pract 2014; 2014:368060. [PMID: 25374950 PMCID: PMC4208456 DOI: 10.1155/2014/368060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 05/09/2014] [Indexed: 01/17/2023] Open
Abstract
Aims and Objectives. To review the experience of a nurse-led colorectal cancer follow-up clinic in a tertiary referral colorectal cancer centre. Methodology. Data from the nurse-led colorectal cancer follow-up clinic in our unit was prospectively maintained in a colorectal cancer database. Data was analysed from January 1, 2006 until the December 31, 2011. Results. 1125 patients were diagnosed with colorectal cancer, and referred to our unit as a tertiary centre for specialised colorectal cancer. Nine hundred and four patients had surgical resection of their colorectal cancer. Four hundred and seven patients were referred to the nurse-led colorectal cancer clinic for surveillance. The mean age of the patient cohort was 67 years (range 32-88) and 56% of patients were male. One hundred and seventeen patients were discharged to their general practitioner having been disease free after 5 years of followup. Fifty-four patients were diagnosed with either local or distant recurrence. Conclusion. A nurse-led colorectal cancer follow-up clinic is running according to strict follow-up protocols. This type of clinic significantly reduces the number of routine follow-up patients that have to be seen by the colorectal surgical consultant.
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Affiliation(s)
- Hasan Al Chalabi
- Department of Colorectal Surgery, GEMS Directorate, Saint James' Hospital, Dublin 8, Ireland
| | - James M. O'Riordan
- Department of Colorectal Surgery, GEMS Directorate, Saint James' Hospital, Dublin 8, Ireland
| | - Alex Richardson
- Department of Colorectal Surgery, GEMS Directorate, Saint James' Hospital, Dublin 8, Ireland
| | - Delia Flannery
- Department of Colorectal Surgery, GEMS Directorate, Saint James' Hospital, Dublin 8, Ireland
| | - Katrina O'Connor
- Department of Colorectal Surgery, GEMS Directorate, Saint James' Hospital, Dublin 8, Ireland
| | - Charlotte Stuart
- Department of Colorectal Surgery, GEMS Directorate, Saint James' Hospital, Dublin 8, Ireland
| | - John Larkin
- Department of Colorectal Surgery, GEMS Directorate, Saint James' Hospital, Dublin 8, Ireland
| | - Paul McCormick
- Department of Colorectal Surgery, GEMS Directorate, Saint James' Hospital, Dublin 8, Ireland
| | - Brian Mehigan
- Department of Colorectal Surgery, GEMS Directorate, Saint James' Hospital, Dublin 8, Ireland
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Barton C, Merrilees J, Ketelle R, Wilkins S, Miller B. Implementation of advanced practice nurse clinic for management of behavioral symptoms in dementia: A dyadic intervention (innovative practice). DEMENTIA 2014; 13:686-96. [DOI: 10.1177/1471301213519895] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Behavioral symptoms are common in all types of dementia and often result in significant caregiver stress and illness, institutionalization of the patient, and reduced quality of life for the patient and caregiver. Health care practitioners often lack the expertise or time to adequately assess behavioral symptoms or counsel caregivers about interventions. Our goal was to implement a specialty clinic managed by advanced practice nurses to assess and manage behavioral symptoms associated with dementia. The clinic evaluations consisted of an assessment of the patient by the Nurse Practitioner during the time that the family caregiver(s) was interviewed by the Clinical Nurse Specialist and focused on an assessment of the cognitive and functional abilities of the patient, identification of triggers for the problematic behaviors, and assessment of caregiver coping. We evaluated 66 dyads since implementation in February 2010. The patients were primarily female, Caucasian, 74.3 years of age with Alzheimer’s disease. The majority of caregivers were spouses ( n = 44) followed by adult children ( n = 20) and then siblings ( n = 2). Targeted interventions were developed and caregiver counseling, support, and education were an integral part of the consultation and included written information, video instruction, and internet resources. Evaluations indicated caregivers and referring providers found the appointment helpful in managing behavioral symptoms and caregiver stress.
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Affiliation(s)
- Cynthia Barton
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, CA, USA; School of Nursing, University of California, San Francisco, CA, USA
| | - Jennifer Merrilees
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, CA, USA; School of Nursing, University of California, San Francisco, CA, USA
| | - Robin Ketelle
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, CA, USA; School of Nursing, University of California, San Francisco, CA, USA
| | - Sarah Wilkins
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, CA, USA
| | - Bruce Miller
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, CA, USA
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Waldheim E, Elkan AC, Pettersson S, Vollenhoven RV, Bergman S, Frostegård J, Henriksson EW. Health-related quality of life, fatigue and mood in patients with SLE and high levels of pain compared to controls and patients with low levels of pain. Lupus 2013; 22:1118-27. [DOI: 10.1177/0961203313502109] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective The objective of this paper is to investigate health-related quality of life (HRQoL), fatigue, anxiety and depression in patients with systemic lupus erythematosus (SLE) and higher levels of pain and to compare them to patients with lower levels of pain and controls. Method Patients were dichotomized into two groups based on SLE-related pain score on the visual analog scale (VAS): low-pain group (76%, n = 64, VAS 0–39 mm) and high-pain group (24%, n = 20, VAS 40–100 mm) . Sex- and age-matched controls were randomly selected from the general population. Participants were asked to complete questionnaires regarding self-reported pain, HRQoL, fatigue, anxiety and depression. Medical assessments also were recorded. Result Fatigue score in the high-pain group (median, 36.5; interquartile range (IQR), 32.5–39.7) was significantly higher ( p < 0.001) compared to the low-pain group (median, 23; IQR, 14.6–34.1), as well as scores for anxiety (median, 9; IQR, 6.5–11.5) and depression (median, 7.5; IQR, 5.5–9) ( p < 0.001). The high-pain group had significantly lower scores compared to the low-pain group in all dimensions in the SF-36 ( p ≤ 0.001–0.007). No statistical differences were detected between the low-pain group and controls in any measurement except for the dimensions physical function, general health, vitality and social function in SF-36. Conclusion Patients with SLE scoring higher degrees of pain were burdened with more fatigue, anxiety and depression and lower levels of HRQoL compared to patients with lower levels of pain who did not differ significantly from the general population in most dimensions. These results elucidate the importance of identifying patients with higher degrees of pain who are probably in need of more extensive multidimensional interventions to decrease symptom burden.
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Affiliation(s)
- E Waldheim
- Unit of Rheumatology, Karolinska University Hospital, Sweden; Division of Nursing, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Sweden
| | - A-C Elkan
- Innovation and Development SRQ (Swedish Rheumatology Quality Register) Dept. of Rheumatology, Karolinska University Hospital, Sweden; Institute of Environmental Medicine, Karolinska Institutet, Sweden
| | - S Pettersson
- Unit of Rheumatology, Karolinska University Hospital, Sweden; Division of Nursing, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Sweden
| | - R van Vollenhoven
- Unit of Rheumatology, Karolinska University Hospital, Sweden; Department of Medicine, Solna, Karolinska Institutet, Sweden
| | - S Bergman
- Research and Development Centre, Spenshult Hospital, Sweden; Department of Rheumatology, Clinical Sciences, Lund University, Sweden
| | - J Frostegård
- Institute of Environmental Medicine, Unit of Immunology and Chronic Disease, Karolinska Institutet, Sweden
| | - E Welin Henriksson
- Unit of Rheumatology, Karolinska University Hospital, Sweden; Division of Nursing, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Sweden
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