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Hoeper JR, Schuch F, Steffens-Korbanka P, Gauler G, Welcker M, Wendler J, von Hinüber U, Meyer SE, Schwarting A, Zeidler J, Witte T, Meyer-Olson D, Hoeper K. [Delegation of medical duties to qualified rheumatology assistants : Effect on depression and anxiety in patients with rheumatoid arthritis]. Z Rheumatol 2024; 83:407-415. [PMID: 37648932 PMCID: PMC11147826 DOI: 10.1007/s00393-023-01403-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND At least 1 comorbidity occurs in 80% of patients with rheumatoid arthritis (RA). In addition to cardiovascular comorbidities psychological comorbid conditions are common. The prevalence of depression and anxiety is higher in patients than in the general population. Screening for comorbidities is crucial. A shortage of outpatient specialist care barely allows resources for this. The implementation of team-based care holds the potential to improve the standard of care while simultaneously working against the shortage of care. OBJECTIVE The aim of the study was to examine the effects of care on the course of depression and anxiety in patients with seropositive RA and active disease. MATERIAL AND METHODS A multicenter pragmatic randomized controlled trial was conducted over the course of 1 year with 224 patients. After baseline, five more visits followed. In the intervention group (IG), three were initially carried out by qualified rheumatological assistants. Depression, anxiety and patient satisfaction with outpatient care were looked at in detail. RESULTS In the IG the anxiety symptoms significantly improved over 12 months (p = 0.036). The proportions of patients with anxiety also significantly changed in the IG (p < 0.001), while there was no change in the control group between baseline and month 12. The values of the depression scale did not differ significantly (p = 0.866). In terms of the information dimension of the satisfaction questionnaire, patients in the IG felt significantly better informed after 6 months (p = 0.013) and 12 months (p = 0.003). CONCLUSION A positive effect of team-based care on the course of depression and anxiety in patients with seropositive RA and active disease could be shown.
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Affiliation(s)
- Juliana Rachel Hoeper
- Center for Health Economics Research Hannover (CHERH), Leibniz Universität Hannover, Hannover, Deutschland
- Klinik für Rheumatologie und Immunologie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Deutschland
| | - Florian Schuch
- Rheumatologie, Internistische Praxisgemeinschaft, Erlangen, Deutschland
| | | | - Georg Gauler
- Rheumapraxis an der Hase, Osnabrück, Deutschland
| | | | - Jörg Wendler
- Rheumatologie, Internistische Praxisgemeinschaft, Erlangen, Deutschland
| | | | - Sara Eileen Meyer
- Klinik für Rheumatologie und Immunologie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Deutschland
| | - Andreas Schwarting
- Klinik für Rheumatologie und klinische Immunologie, Universitätsmedizin Mainz, Mainz, Deutschland
- ACURA Kliniken Rheuma-Akutzentrum Rheinland-Pfalz, Bad Kreuznach, Deutschland
| | - Jan Zeidler
- Center for Health Economics Research Hannover (CHERH), Leibniz Universität Hannover, Hannover, Deutschland
| | - Torsten Witte
- Klinik für Rheumatologie und Immunologie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Deutschland
| | - Dirk Meyer-Olson
- Klinik für Rheumatologie und Immunologie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Deutschland
- Rheumatologie, m&i Fachklinik Bad Pyrmont, Bad Pyrmont, Deutschland
| | - Kirsten Hoeper
- Klinik für Rheumatologie und Immunologie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Deutschland.
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Bednarek A, Klepacz R, Bodys-Cupak IE. The Role of the Nurse in the Care and Management of Patients with Rheumatic Diseases Arising from the Current EULAR Recommendations: A Literature Review. Healthcare (Basel) 2023; 11:2434. [PMID: 37685467 PMCID: PMC10486762 DOI: 10.3390/healthcare11172434] [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: 07/20/2023] [Revised: 08/24/2023] [Accepted: 08/26/2023] [Indexed: 09/10/2023] Open
Abstract
In some countries, restructuring of the healthcare system has contributed to the introduction of a new domain in professional nursing-the Advanced Practice Nurse (APN). In order to provide the highest quality of care to patients, nurses working at the advanced level are expected to develop knowledge and to initiate services and practices carried out in collaboration with other professionals. In 2018, the European League Against Rheumatism (EULAR) updated its recommendations for the role of the nurse in the management and care of patients with rheumatic conditions. The objective of the study was a presentation of the scope of medical services provided by nurses for patients with rheumatic diseases based on current EULAR recommendations. A review of the literature on the participation of nurses, as members of a multidisciplinary team, in the education, management, psychosocial support, and promotion of self-care in patients with rheumatic diseases was presented. The expert group formulated three overarching principles and eight recommendations. The literature review and expert recommendations indicated that nurses' tasks in relation to patients with rheumatic diseases should include an initial assessment of health needs, routine follow-up care, and counseling for patients on self-care and lifestyle changes. In the EULAR recommendations, nursing care is also defined as a practice model in which nurses, in collaboration with physicians, provide support, education, and disease monitoring to patients with rheumatic conditions. The requirement for extended nursing education at the advanced practice level, aimed at acquiring diagnostic, therapeutic, caring, and educational knowledge and skills was highlighted, particularly with regard to the EULAR recommendations.
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Affiliation(s)
- Anna Bednarek
- Department of Health Promotion, Faculty of Health Sciences, Medical University of Lublin, 20-093 Lublin, Poland
| | - Robert Klepacz
- Department of Clinical Pathomorphology, Medical University of Lublin, 20-093 Lublin, Poland;
| | - Iwona Elżbieta Bodys-Cupak
- Department of Nursing Fundamentals, Institute of Nursing and Midwifery, Faculty of Health Sciences, Jagiellonian University Medical College, 31-501 Krakow, Poland;
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Cho SK, Kim H, Song YJ, Nam E, Jones B, Ndosi M, Sung YK. Validation of the Korean Leeds satisfaction questionnaire in rheumatoid arthritis with Rasch models. Int J Rheum Dis 2022; 25:1270-1278. [PMID: 35945672 DOI: 10.1111/1756-185x.14419] [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: 03/30/2022] [Revised: 07/04/2022] [Accepted: 08/01/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We conducted the cross-cultural adaptation and validation of the Leeds Satisfaction Questionnaire (LSQ) for patients with rheumatoid arthritis (RA) in Korea. METHODS The adaptation of the LSQ from English into Korean was based on guidelines for cross-cultural adaptation for self-report measures. Patients with RA were recruited from an outpatient clinic of a university hospital in South Korea. Validation of the Korean-LSQ with Rasch models was carried out using WINSTEPS. Model fit was determined by Infit and Outfit statistics (≥0.50 and ≤1.50), including the separation index (≥2.00) and reliability index (≥0.80). RESULTS The data set comprised 125 patients (82.4% female), with median (interquartile range) age 49.0 (37-57) years, and disease duration of 2.5 (1.2-3.8) years. The total and subscale scores of the Korean-LSQ demonstrated excellent or good test-retest reliability (0.88 for total, 0.71-0.82 for subscales), and items in the scale also revealed a high internal consistency (α = 0.93). The six subscales of the Korean-LSQ were found to have a good fit to the Rasch model and good reliability (Person separation index = 2.63 and reliability index = 0.87; item separation index = 37.03 and reliability index >0.99). In addition, the unidimensionality of the scale was confirmed by the principal component analysis based on the Rasch residuals. CONCLUSION Fit to the Rasch model confirmed that the construct validity, reliability, and unidimensionality of the LSQ were preserved following the adaptation into Korean. The Korean-LSQ is a valid and reliable tool for measuring satisfaction with care in Korean patients with RA.
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Affiliation(s)
- Soo-Kyung Cho
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases and Hanyang University Institute for Rheumatology, Seoul, Republic of Korea
| | - Hyoungyoung Kim
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases and Hanyang University Institute for Rheumatology, Seoul, Republic of Korea
| | - Yeo-Jin Song
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases and Hanyang University Institute for Rheumatology, Seoul, Republic of Korea
| | - Eunwoo Nam
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases and Hanyang University Institute for Rheumatology, Seoul, Republic of Korea
| | - Bethan Jones
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Mwidimi Ndosi
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases and Hanyang University Institute for Rheumatology, Seoul, Republic of Korea
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Krause* D, Mai* A, Denz R, Johow J, Reese JP, Westerhoff B, Klaaßen-Mielke R, Timmesfeld N, Rittstieg A, Saracbasi-Zender E, Günzel J, Klink C, Schmitz E, Fendler C, Raub W, Böddeker S, Dybowski F, Hübner G, Menne HJ, Lakomek HJ, Sarholz M, Trampisch U, J. Trampisch H, Braun J. The Structured Delegation of Medical Care Services for Patients With Inflammatory Rheumatic Diseases. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:157-164. [PMID: 35101166 PMCID: PMC9215273 DOI: 10.3238/arztebl.m2022.0109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/05/2021] [Accepted: 01/12/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND In some areas of Germany, there is a shortage of specialist physicians for patients with inflammatory rheumatic diseases. Delegating certain medical care services to qualified, specialized rheumatological assistants (SRAs) might be an effective way to supplement the available capacity for specialized medical care. METHODS Patients under stable treatment for rheumatoid arthritis (RA) or psoriatic arthritis (PsA) were included in this trial, which was designed to demonstrate, in a first step, the non-inferiority of a form of care involving delegation of physicians' tasks to SRAs (team-based care), in comparison to standard care, with respect to changes in disease activity at one year. "Non-inferiority," in this context, means either superiority or else an irrelevant extent of inferiority. In a second step, in case non-inferiority could be shown, the superiority of team-based care with respect to changes in patients' health-related quality of life would be tested as well. Disease activity was measured with the Disease Activity Score 28, and health-related quality of life with the EQ-5D-5L. This was a randomized, multicenter, rater-blinded trial with two treatment arms (team-based care and standard care). The statistical analysis was performed with mixed linear models (DRKS00015526). RESULTS From September 2018 to June 2019, 601 patients from 14 rheumatological practices and 3 outpatient rheumatological clinics in the German states of North Rhine-Westphalia and Lower Saxony were randomized to either team-based or standard care. Team-based care was found to be non-inferior to standard care with respect to changes in disease activity (adjusted difference = -0.19; 95% confidence interval [-0.36; -0.02]; p <0.001 for non-inferiority). Superiority with respect to health-related quality of life was not demonstrated (adjusted difference = 0.02 [-0.02; 0.05], p = 0.285). CONCLUSION Team-based care, with greater integration of SRAs, is just as good as standard care in important respects. Trained SRAs can effectively support rheumatologists in the care of stable patients with RA or PsA.
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Affiliation(s)
- Dietmar Krause*
- *The authors contributed equally to this paper
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Anna Mai*
- *The authors contributed equally to this paper
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | - Robin Denz
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | - Johannes Johow
- Coordination Center for Clinical Trials of Philipps University Marburg
| | - Jens-Peter Reese
- Institute of Clinical Epidemiology and Biometry, Julius Maximilian University Würzburg
| | | | - Renate Klaaßen-Mielke
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | - Nina Timmesfeld
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | - Annette Rittstieg
- *The authors contributed equally to this paper
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | | | - Judith Günzel
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Claudia Klink
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Elmar Schmitz
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Claas Fendler
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Wolf Raub
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Stephanie Böddeker
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Friedrich Dybowski
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Georg Hübner
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Hans-Jürgen Menne
- Specialist rheumatology practices in North Rhine–Westphalia and Lower Saxony
| | - Heinz-Jürgen Lakomek
- Johannes Wesling Minden Hospital, Germany, Department of Rheumatology and Physical Medicine
| | | | - Ulrike Trampisch
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | - Hans J. Trampisch
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum
| | - Jürgen Braun
- The Ruhr District Rheumatology Center, Ruhr University Bochum
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Duncan R, Cheng L, Law MR, Shojania K, De Vera MA, Harrison M. The impact of introducing multidisciplinary care assessments on access to rheumatology care in British Columbia: an interrupted time series analysis. BMC Health Serv Res 2022; 22:327. [PMID: 35277162 PMCID: PMC8915460 DOI: 10.1186/s12913-022-07715-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 03/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background In 2011 the British Columbia (BC) Ministry of Health introduced a new fee-for-service billing code that allowed “Multidisciplinary Care Assessment” (MCA). This change has the potential to change access to and quality of care for patients. This study aimed to explore the impact on access to rheumatology services in the province. Methods Fee-for-service rheumatology billings were evaluated for each rheumatologist 2 years before and after use of the MCA code. Numbers of 1) unique patients and 2) services provided per month were used as proxy measures of access to care. A multiple-baseline interrupted time series model assessed the impact of the MCA on levels and trends of the access outcomes. Results Our analysis consisted of 82,360 patients cared for by 26 rheumatologists who billed for an MCA. In our primary analysis we observed a sustained increase in the mean number of unique patients of 4.9% (95% CI: 0.0% to 9.9%, p = 0.049) and the mean number of services of 7.1% (95% CI: 1.0% to 13.6%, (p = 0.021), per month provided by a rheumatologist, corresponding to the initial use of MCA. Conclusion The introduction of the MCA code was associated with an initial increase in the measures of access, which was maintained but did not increase over time. Our study suggests that the use of Multidisciplinary Care Assessment can contribute to expanding and/or sustaining access to care for people with complex chronic conditions, like rheumatic diseases. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07715-x.
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Apantaku G, Aguiar M, Kaal KJ, Munro S, Teo M, Harrison M. Understanding multidisciplinary care for people with rheumatic disease in British Columbia, Canada, through patients, nurses and physicians voices: a qualitative policy evaluation. BMC Health Serv Res 2021; 21:1148. [PMID: 34688296 PMCID: PMC8542329 DOI: 10.1186/s12913-021-07138-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/07/2021] [Indexed: 11/24/2022] Open
Abstract
Background In 2011, the province of British Columbia (BC) moved to allow patients with complex rheumatic disease to be seen by nurses along with their rheumatologist by introducing a ‘Multidisciplinary Care Assessments’ (MCA) billing code (G31060). Objective To describe multidisciplinary care introduced as part of MCAs across BC and investigate the perceived impact of this intervention, the addition of nurses to the care team, on patient care from the perspective of patients, nurses, and rheumatologists. Methods We conducted semi-structured interviews, informed by a qualitative evaluation approach with patients, nurses, and rheumatologists from September 2019 – August 2020. Interviews investigated 1) the experiences of all stakeholders with adopting the multidisciplinary care billing code, 2) the perceived role of the nurse in the care team, and 3) the perceived impact of multidisciplinary care on patient experience and outcomes. We purposefully sampled practices for maximum variation of geographical location (rural vs. urban), size of practice (i.e., patient caseload), and number of nurses employed. Results We interviewed 21 patients, 13 nurses, and 12 rheumatologists from across BC. Our analysis identified variation in the way rheumatologists adopted multidisciplinary care across BC. Our analysis showed some heterogeneity in the way the MCA was delivered in rheumatology practices; however, patient education was identified as the core role of nurses across practices. We identified six core themes describing the impact of this model of care, all representing improvements in the way practices functioned, from improved efficiency to access, patient experience, time management, clinician experience, and patient health outcomes. Contextual factors that influenced the presence of these themes were related to the time the nurses spent with patients and the professional roles they performed. Conclusion Our results suggest nurse care can complement physician care by extending contact time for patients and promoting the efficient use of health care professionals’ skills, time, and resources. These data may encourage future uptake of the billing code to help ensure the policy delivers maximum benefits to patients given the wide range of perceived benefits described by clinicians and patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07138-0.
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Affiliation(s)
- Glory Apantaku
- Faculty of Pharmaceutical Sciences, University of British Columbia, 2405-4625 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Magda Aguiar
- Faculty of Pharmaceutical Sciences, University of British Columbia, 2405-4625 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - K Julia Kaal
- Faculty of Pharmaceutical Sciences, University of British Columbia, 2405-4625 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Sarah Munro
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, BC, Canada.,Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Michelle Teo
- Balfour Medical Clinic, Penticton, BC, Canada.,Penticton Regional Hospital, Penticton, BC, Canada.,Clinicial Instructor, Faculty of Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mark Harrison
- Faculty of Pharmaceutical Sciences, University of British Columbia, 2405-4625 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada. .,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, BC, Canada. .,Arthritis Research Canada, Vancouver, BC, Canada.
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7
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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: 5] [Impact Index Per Article: 1.7] [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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Sezgin MG, Bektas H. The effect of nurse-led care on fatigue in patients with rheumatoid arthritis: A systematic review and meta-analysis of randomised controlled studies. J Clin Nurs 2021; 31:832-842. [PMID: 34396605 DOI: 10.1111/jocn.16003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/19/2021] [Accepted: 08/03/2021] [Indexed: 01/09/2023]
Abstract
AIMS AND OBJECTIVES This study aimed to investigate the effect of nurse-led care on fatigue in patients with rheumatoid arthritis. BACKGROUND Evaluating the effect of nurse-led care on fatigue in patients with rheumatoid arthritis will be useful in planning appropriate nursing interventions to increase the functional status and quality of life of patients. DESIGN Systematic review and meta-analysis. METHODS A comprehensive literature review was conducted on the Cochrane Library, Web of Science, PubMed, EBSCOhost/CINAHL Complete, Springer Link, ProQuest, Science Direct and Ovid databases. The selected articles were examined by two independent ratters with the PICOS criteria, and the methodological quality of the studies included in the study was evaluated with the Quality Assessment Tool for Quantitative Studies. The Comprehensive Meta-Analysis 3 software was used in the analysis of the data. The study was conducted using the checklist for PRISMA. RESULTS This meta-analysis study included six of 1,445 randomised controlled trials. These six studies consisted of a total of 994 patients and provided education and psychosocial support through 30-minute to 2-hour consultations, visits and briefings. No significant publication bias was found in the main outcomes. According to the results of the meta-analysis, the fatigue in patients with rheumatoid arthritis decreased significantly in nurse-led care groups compared with control groups (Hedge's g = -0.18; 95% CI = -0.3 to -0.06). CONCLUSIONS The findings in this systematic review and meta-analysis indicated that nurse-led care played an important role in reducing fatigue in patients with rheumatoid arthritis. RELEVANCE TO CLINICAL PRACTICE Nurse-led care is an effective and appropriate method in reducing fatigue in patients with rheumatoid arthritis. The awareness of all health professionals about the importance of nurse-led care will increase. We recommend the implementation of nurse-led education and psychosocial support interventions to reduce the fatigue of patients with rheumatoid arthritis.
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Affiliation(s)
- Merve Gozde Sezgin
- Department of Internal Medicine Nursing, Akdeniz University Faculty of Nursing, Antalya, Turkey
| | - Hicran Bektas
- Department of Internal Medicine Nursing, Akdeniz University Faculty of Nursing, Antalya, Turkey
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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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10
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Poulsen JH, Nørgaard LS, Dieckmann P, Clemmensen MH. Time spent by hospital personnel on drug changes: A time and motion study from an in-and outpatient hospital setting. PLoS One 2021; 16:e0247499. [PMID: 33630933 PMCID: PMC7906352 DOI: 10.1371/journal.pone.0247499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 02/08/2021] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Medicines used at Danish public hospitals are purchased through tendering. Together with drug shortage, tendering result in drug changes, known to compromise patient safety, increase medicine errors and to be resource demanding for healthcare personnel. Details on actual resources required in the clinic setting to manage drug changes are unknown. The aim of the study is to explore time spend by hospital personnel in a drug change situation when dispensing medicine to in- and outpatients in a hospital setting in the Capital Region of Denmark. METHOD A time and motion study, using direct observation combined with time-registration tools, such as eye-tracking, video recording and manual time tracking. Data were obtained from observing nurses and social and health care assistants with dispensing authority while dispensing or extraditing medicine before and after the implementation of drug changes in two clinical setting; a cardiology ward and a rheumatology outpatient clinic. RESULTS Hospital personnel at the cardiology inpatient ward spent 20.5 seconds on dispensing a drug, which was increased up to 28.4 seconds by drug changes. At the rheumatology outpatient clinic, time to extradite medicine increased from 8 minutes and 6 seconds to 15 minutes and 36 seconds by drug changes due to tender. Similarly, drug changes due to drug shortage prolonged the extradition time to 16 minutes and 54 seconds. Statistical analysis reveal that drug changes impose a significant increase in time to dispense a drug for both in- and outpatients. CONCLUSION Clinical hospital personnel spent significantly longer time on drug change situations in the dispensing of medicine to in- and outpatients in a hospitals. This study emphasizes that implementing drug changes do require extra time, thus, the hospital management should encounter this and ensure that additional time is available for the hospital personnel to ensure a safe drug dispensing process.
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Affiliation(s)
- Joo Hanne Poulsen
- Social and Clinical Pharmacy, University of Copenhagen, Copenhagen Ø, Denmark
| | - Lotte Stig Nørgaard
- Social and Clinical Pharmacy, University of Copenhagen, Copenhagen Ø, Denmark
| | - Peter Dieckmann
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources, Capital Region of Denmark, Herlev Hospital, Herlev, Denmark
- Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Hald Clemmensen
- Medicines Information Center, The Hospital Pharmacy, Capital Region of Denmark, Copenhagen NV, Denmark
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11
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Koduri GM, Gullick NJ, Hayes F, Dubey S, Mukhtyar C. Patient perceptions of co-morbidities in inflammatory arthritis. Rheumatol Adv Pract 2021; 5:rkaa076. [PMID: 33615128 PMCID: PMC7884022 DOI: 10.1093/rap/rkaa076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/19/2020] [Indexed: 11/21/2022] Open
Abstract
Objective Longer life expectancy has resulted in people living with an increasing number of co-morbidities. The average individual with inflammatory arthritis has two co-morbidities, which contribute to higher mortality, poorer functional outcomes and increased health-care utilization and cost. A number of studies have investigated the prevalence of co-morbidities, whereas this study was designed to look at patient perspectives. Methods The study comprised two parts: a patient questionnaire and an interview. Individuals with physician-verified inflammatory arthritis along with one or more Charlson co-morbidities were invited to participate. In-depth data were obtained by interviews with 12 willing participants. Results One hundred and forty-six individuals were recruited; 50 (35%) had one co-morbidity, 69 (48%) had two and 25 (17%) had more than four co-morbidities. Seventy-seven individuals (53%) reported that co-morbidities affected their health as much as their arthritis, and 82 (56%) reported dependence on others for activities of daily living. Lack of education was highlighted by 106 (73%) participants. Qualitative data provided further support for the challenges, with participants highlighting the lack of time to discuss complex or multiple problems, with no-one coordinating their care. This, in turn, led to polypharmacy and insufficient discussion around drug and disease interactions, complications and self-help measures. Conclusion This study highlights the challenges for individuals with inflammatory arthritis who suffer with multiple co-morbidities. The challenges result from limited resources or support within the current health-care environments. Individuals highlighted the poor quality of life, which is multifactorial, and the need for better educational strategies and coordination of care to improve outcomes.
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Affiliation(s)
- Gouri M Koduri
- Rheumatology Department, Southend University Hospital, Westcliff-on-Sea
| | - Nicola J Gullick
- Rheumatology Department, University Hospitals Coventry & Warwickshire NHS Trust, Coventry
| | - Fiona Hayes
- Rheumatology Department, Southend University Hospital, Westcliff-on-Sea
| | - Shirish Dubey
- Rheumatology Department, University Hospitals Coventry & Warwickshire NHS Trust, Coventry
| | - Chetan Mukhtyar
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, UK
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12
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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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13
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Carranza AN, Munoz PJ, Nash AJ. Comparing quality of care in medical specialties between nurse practitioners and physicians. J Am Assoc Nurse Pract 2020; 33:184-193. [PMID: 32384361 DOI: 10.1097/jxx.0000000000000394] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/27/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The American health care system is facing a growing health care provider shortage in primary and specialty care settings. Research has established that nurse practitioners (NPs) match or exceed their physician colleagues in providing quality care in primary care settings. OBJECTIVE This systematic review aimed to compare the quality of NP versus physician-led care in outpatient specialty care setting for clinical outcomes patient satisfaction. DATA SOURCES The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guided the literature search (CINAHL, PubMed, and Cochrane Library) and interpretation of findings. Of the 228 articles that met the inclusion/exclusion criteria, 11 were selected for further review. CONCLUSIONS Studies were conducted from 1995 to 2016 across four countries and spanned 10 distinct medical specialties. As a whole, these studies demonstrated that NPs in specialty settings perform as well as physicians terms of clinical safety and positive patient outcomes. Nurse practitioners matched or exceeded their physician counterparts in patient education and satisfaction. IMPLICATIONS FOR PRACTICE Nurse practitioners are a feasible option for addressing specialty care shortages. Further research should investigate whether NPs and physicians are equally prepared to provide equivalent care immediately following their respective postbaccalaureate programs. If not, studies should explore specific training duration and elements NPs require to provide equivalent care.
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Affiliation(s)
- Ashley N Carranza
- The University of Texas Health Science Center (UTHealth), Cizik School of Nursing (CSON), Houston, Texas
| | - Pamela J Munoz
- The University of Texas Health Science Center (UTHealth), Cizik School of Nursing (CSON), Houston, Texas
| | - Angela J Nash
- Department of Graduate Studies, UTHealth, CSON, Houston, Texas
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14
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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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15
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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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16
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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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17
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Qualitative assessment of medication adherence in patients with rheumatic diseases on biologic therapy. Clin Rheumatol 2019; 38:2699-2707. [DOI: 10.1007/s10067-019-04609-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 05/11/2019] [Accepted: 05/15/2019] [Indexed: 12/26/2022]
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18
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Doyle-Cox C, Nicholson G, Stewart T, Gin-Sing W. Current organization of specialist pulmonary hypertension clinics: results of an international survey. Pulm Circ 2019; 9:2045894019855611. [PMID: 31106660 PMCID: PMC6557030 DOI: 10.1177/2045894019855611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Optimal pulmonary hypertension (PH) management relies on a timely, accurate diagnosis and follow-up in specialized clinics by multidisciplinary teams that have clearly defined responsibilities and protocols. Internationally agreed criteria for expert center staff are lacking, particularly with respect to nurses, who often act as a central component of the team. This survey aimed to evaluate the current organization of PH clinics and the role of nurses. The survey (35 questions) was online February-December 2015 and was advertised at international PH nurse meetings and through international PH organizations to their corresponding clinics. In total, 126 healthcare professionals from 32 countries responded. According to respondents, 54% of clinics managed >200 patients, of whom 49% had a pulmonary arterial hypertension (PAH) diagnosis, on average. In terms of staff, 66% had a dedicated program administrator, 35% had one full-time nurse coordinator/practitioner/specialist, and 57% had a nurse attend outpatient clinic alongside a physician. Crucially, not all centers had a nurse in their team. The role of a nurse coordinator/practitioner/specialist varied with 51% taking patient histories/examinations and 66% managing outpatients. In 34% of clinics, nurses were involved in their own research. Protocols were available for PH therapies (81%), management of heart failure (37%) and pain (26%), and referring patients who did not have PAH/chronic thromboembolic PH back to their specialist (62%). Not all clinics are meeting all of the standards outlined in the latest guidelines with key areas of improvement being level of support from/for nurses, clear protocols, and referral pathways.
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Affiliation(s)
| | | | - Traci Stewart
- 3 Heart and Vascular Center, University of Iowa, Iowa City, IA, USA
| | - Wendy Gin-Sing
- 4 Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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19
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Chou L, Ellis L, Papandony M, Seneviwickrama KLMD, Cicuttini FM, Sullivan K, Teichtahl AJ, Wang Y, Briggs AM, Wluka AE. Patients' perceived needs of osteoarthritis health information: A systematic scoping review. PLoS One 2018; 13:e0195489. [PMID: 29659609 PMCID: PMC5901923 DOI: 10.1371/journal.pone.0195489] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 03/23/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Optimal management of osteoarthritis requires active patient participation. Understanding patients' perceived health information needs is important in order to optimize health service delivery and health outcomes in osteoarthritis. We aimed to review the existing literature regarding patients' perceived health information needs for OA. METHODS A systematic scoping review was performed of publications in MEDLINE, EMBASE, CINAHL and PsycINFO (1990-2016). Descriptive data regarding study design and methodology were extracted and risk of bias assessed. Aggregates of patients' perceived needs of osteoarthritis health information were categorized. RESULTS 30 studies from 2876 were included: 16 qualitative, 11 quantitative and 3 mixed-methods studies. Three areas of perceived need emerged: (1) Need for clear communication: terms used were misunderstood or had unintended connotations. Patients wanted clear explanations. (2) Need for information from various sources: patients wanted accessible health professionals with specialist knowledge of arthritis. The Internet, whilst a source of information, was acknowledged to have dubious reliability. Print media, television, support groups, family and friends were utilised to fulfil diverse information needs. (3) Needs of information content: patients desired more information about diagnosis, prognosis, management and prevention. CONCLUSIONS Patients desire more information regarding the diagnosis of osteoarthritis, its impact on daily life and its long-term prognosis. They want more information not only about pharmacological management options, but also non-pharmacological options to help them manage their symptoms. Also, patients wanted this information to be delivered in a clear manner from multiple sources of health information. To address these gaps, more effective communication strategies are required. The use of a variety of sources and modes of delivery may enable the provision of complementary material to provide information more successfully, resulting in better patient adherence to guidelines and improved health outcomes.
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Affiliation(s)
- Louisa Chou
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lisa Ellis
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Michelle Papandony
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - K. L. Maheeka D. Seneviwickrama
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Flavia M. Cicuttini
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kaye Sullivan
- Monash University Library, Monash University, Melbourne, Victoria, Australia
| | - Andrew J. Teichtahl
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Yuanyuan Wang
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew M. Briggs
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
- Move: muscle, bone & joint health, Melbourne, Victoria, Australia
| | - Anita E. Wluka
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
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20
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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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21
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Wang J, Zou X, Cong L, Liu H. Clinical effectiveness and cost-effectiveness of nurse-led care in Chinese patients with rheumatoid arthritis: A randomized trial comparing with rheumatologist-led care. Int J Nurs Pract 2017; 24. [PMID: 29072362 DOI: 10.1111/ijn.12605] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 09/22/2017] [Accepted: 09/22/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM The concept of nurse-led care (NLC) was not familiar in China. This study was designed to evaluate the clinical effectiveness and cost-effectiveness of NLC versus rheumatologist-led care (RLC) in Chinese patients with rheumatoid arthritis (RA). METHODS Patients of either gender (aged ≥18 years) with RA were enrolled at Wenhai Central Hospital, China (January 2015 to December 2015). The participants were then randomized to NLC or RLC. Outcomes of both the groups were compared in terms of effectiveness by measuring the Disease Activity Score 28, visual analogue scores pertaining to pain and fatigue, and duration of morning stiffness. Costs associated with resource use for RA were assessed and compared between both groups. RESULTS A total of 214 RA patients in 2 groups (n = 107 in each group) were enrolled and analysed. Improvements in clinical outcomes (disease activity, pain, fatigue, and morning stiffness) over 12 months were significantly greater in the NLC group compared to RLC (P < 0.001). Overall, costs associated with resource use were higher in the RLC group compared to the NLC group (P < 0.05). CONCLUSIONS Our preliminary finding suggested that RA patients managed by NLC compared to RLC may have better clinical outcomes and more cost-effective care in China.
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Affiliation(s)
- Junru Wang
- Department of Orthopedic Surgery, Wenhai Central Hospital, Wenhai, China
| | - Xiulan Zou
- Department of Orthopedic Surgery, Wenhai Central Hospital, Wenhai, China
| | - Ling Cong
- Department of Respiratory Medicine, Wenhai Central Hospital, Wenhai, China
| | - Huina Liu
- Department of Orthopedic Surgery, Wenhai Central Hospital, Wenhai, China
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Minnock P, McKee G, Kelly A, Carter SC, Menzies V, O'Sullivan D, Richards P, Ndosi M, van Eijk Hustings Y. Nursing sensitive outcomes in patients with rheumatoid arthritis: A systematic literature review. Int J Nurs Stud 2017; 77:115-129. [PMID: 29080437 DOI: 10.1016/j.ijnurstu.2017.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 08/25/2017] [Accepted: 09/09/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although rheumatology nursing has been shown to be effective in managing patients with rheumatoid arthritis, patient outcomes sensitive to nursing interventions (nursing sensitive outcomes) have not been systematically studied. OBJECTIVES The objective of this study was to identify and delineate relevant patient outcomes measured in studies that reported nursing interventions in patients with rheumatoid arthritis. DESIGN A systematic search was conducted from 1990 to 2016. Inclusion criteria were (i) patients with rheumatoid arthritis, (ii) adult population age ≥16years, (iii) nurse as part of the care team or intervention delivery, (iv) primary research only, (v) English language, and (vi) quantitative studies with nursing sensitive outcomes. DATA SOURCES Medline, CINAHL, Ovid nursing, Cochrane library and PsycINFO databases were searched for relevant studies. REVIEW METHODS Using the predetermined inclusion/exclusion criteria, nine reviewers working in pairs assessed the eligibility of the identified studies based on titles and abstracts. Papers meeting the inclusion criteria were retrieved and full texts were further assessed. Critical Appraisal Skills Programme tools were used to assess the quality of the included studies. Data on nursing sensitive outcomes were extracted independently by two reviewers. The Outcome Measures in Rheumatology comprehensive conceptual framework for health was used to contextualise and present findings. RESULTS Of the 820 articles retrieved, 7 randomised controlled trials and 3 observational studies met the inclusion criteria. Seventeen nursing sensitive outcomes were identified (disease activity, clinical effects, pain, early morning stiffness duration, fatigue, patient safety issues, function, knowledge, patient satisfaction, confidence in care received, mental health status, self-efficacy, patient attitude/perception of ability to control arthritis, quality of life, health utility, health care resources, death). These fitted into 10 health intervention domains in keeping with the pre-specified conceptual framework for health: disease status, effectiveness, safety, function, knowledge, satisfaction, psychological status, quality of life, cost, death. A total of 59 measurement instruments were identified comprising patient reported outcome measures (n=31), and biologic measures and reports (n=28). CONCLUSIONS This review is notable in that it is the first to have identified, and reported, a set of multidimensional outcome measures that are sensitive to nursing interventions in rheumatology specifically. Further research is required to determine a core set of outcomes to be used in all rheumatology nursing intervention studies.
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Affiliation(s)
- Patricia Minnock
- Rheumatic Musculoskeletal Disease Unit, Our Lady's Hospice & Care Services, Harold's Cross, Dublin 6w, Ireland.
| | - Gabrielle McKee
- School of Nursing & Midwifery, Trinity College Dublin, Ireland
| | - Alexia Kelly
- St Vincent's Private Hospital Dublin, Ireland; St Vincent's University Hospital, Dublin, Ireland
| | - Sheree C Carter
- The University of Alabama, Capstone College of Nursing, Tuscaloosa, AL, USA
| | - Victoria Menzies
- Virginia Commonwealth University, School of Nursing, Richmond, VA, USA
| | | | - Pam Richards
- University of Bristol, Academic Rheumatology Bristol, Bristol, UK
| | - Mwidimi Ndosi
- Department of Nursing and Midwifery, University of the West of England, Bristol, UK
| | - Yvonne van Eijk Hustings
- Department of Clinical Epidemiology and Medical Technology Assessment, Department of Rheumatology, Maastricht University Medical Centre, Maastricht, The Netherlands
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Hall JJ, Katz SJ, Cor MK. Patient Satisfaction with Pharmacist-Led Collaborative Follow-Up Care in an Ambulatory Rheumatology Clinic. Musculoskeletal Care 2017; 15:186-195. [PMID: 27686752 DOI: 10.1002/msc.1160] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Patient satisfaction is known to increase with pharmacist intervention in general outpatient clinics and with nurse-led care in rheumatology clinics. The aim of the present study was to describe and compare patient satisfaction with two different types of care: a pharmacist physician collaborative model and a traditional physician model in a rheumatology clinic setting. METHODS A cross-sectional survey of inflammatory arthritis patients seen during a follow-up visit in Edmonton, Alberta, Canada, was conducted over a ten-week period. Patient satisfaction was measured using a modified version of the validated Leeds Satisfaction Questionnaire, which uses a five-point Likert scale to measure six dimensions of satisfaction, and compared between the collaborative care and traditional physician models. RESULTS A total of 62 patients completed the questionnaire (21 collaborative care and 41 traditional physician model). The average age of respondents was 52 years and the majority were female. The mean score for satisfaction across the six dimensions was 4.56 in the collaborative care group and 4.30 in the traditional physician group (p = 0.02). Patient satisfaction in the collaborative care group was consistently higher across all dimensions. No difference was noted between participants seen for the first time compared with those seen two or more times by the pharmacist. CONCLUSIONS A collaborative care model can exceed the already high expectations for care of patients with inflammatory arthritis. Our findings support the role of pharmacists using a collaborative care approach to care for patients in rheumatology clinics.
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Affiliation(s)
- Jill J Hall
- Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Steven J Katz
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - M Ken Cor
- Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
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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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25
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Cock K, Kent B. Patient satisfaction with clinicians in colorectal 2-week wait clinics. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2017; 26:319-323. [PMID: 28345973 DOI: 10.12968/bjon.2017.26.6.319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM To determine if patient satisfaction is affected by the clinician (nurse or doctor), conducting the colorectal 2-week wait (2ww) clinics. METHODS A prospective non-randomised comparative cohort study of 339 consecutive patients (divided by blind allocation into nurse-led (n=216) and doctor-led (n=123) cohorts) conducted over a 3-month period. Patient satisfaction in both cohorts was assessed by an adapted version of the Grogan et al validated patient satisfaction questionnaire. The questionnaire was piloted first and was found to have high internal reliability (Cronbach's alpha=0.91). RESULTS The study had a response rate of 78% (n=258/331) and overall satisfaction scores showed 85% (n=149/175) of patients in the nurse-led cohort and 65% (n=54/83) of patients in the doctor-led cohort strongly agreed that they were satisfied with the care they received. Mean overall satisfaction scores in the two cohorts revealed that the nurse-led cohort achieved significantly more 'strongly agree' responses than the doctor-led cohort (p<0.001, CI: 95%). Further analysis of the responses to each question demonstrated statistical significance when comparing the two cohorts. CONCLUSIONS The study offered patients the opportunity to reflect on service delivery enabling a more responsive approach to health care within the colorectal 2ww service. It found that patient satisfaction was affected by the clinician conducting the 2ww clinic, in that the nurse-led cohort displayed significantly higher patient satisfaction. However, there are areas that merit further research.
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Affiliation(s)
- Karen Cock
- Lead Colorectal Specialist Nurse, Royal Cornwall Hospital NHS Trust, Treliske, Cornwall
| | - Bridie Kent
- Professor in Leadership in Nursing, Plymouth University/Director of Truro Clinical School (Hon Associate Director of Nursing), Royal Cornwall Hospital NHS Trust
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26
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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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Muñoz-Fernández S, Aguilar MD, Almodóvar R, Cano-García L, Fortea S, Alcañiz-Escandell CP, Rodríguez JR, Cebrián L, Lázaro P. SCORE study: quality indicators for rheumatology nursing clinics. Rheumatol Int 2017; 37:353-361. [PMID: 28108765 DOI: 10.1007/s00296-016-3644-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 12/21/2016] [Indexed: 12/19/2022]
Abstract
Nursing clinics in rheumatology (NCR) are organizational care models that provide care centred within the scope of nurses abilities. To analyse patients differences in the knowledge of the disease, adherence to the treatment, quality indicators of the Rheumatology Departments included quality perceived by the patients with and without NCR. National multicenter observational prospective cohort study 1 year follow-up, comparing patients attending rheumatology services with and without NCR. NCR was defined by the presence of: (1) office itself; (2) at least one dedicated nurse; (3) its own appointment schedule, and (4) phone. Variables included were (baseline and 12 months) Batalla, Haynes-Sackett, Morisky-Green and quality perceived tests. In addition, another specific questionnaire was drawn up to collect the healthcare, teaching and research activities of each Rheumatology Department. A total of 393 patients were included; 181 NCR and 212 not NCR, corresponding to 39 units, 21 with NCR and 18 without NCR (age 53 ± 11.8 vs 56 ± 13.5 years). Significant differences in favour of the NCR group were found in Haynes-Sackett (p = 0.033) and Morisky-Green (p = 0.03) tests in the basal visit. Significant differences were found in questions about "the courtesy and/or kindness received by the nurse", being "good or very good" in greater proportion in the NCR group. The publications from the last 5 years were significantly higher in the NCR group in both, national (p = 0.04) and international (p = 0.03) journals. A higher research activity and quality perceived by the patients are observed in the Rheumatology Departments with NCR.
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Affiliation(s)
- Santiago Muñoz-Fernández
- Department of Rheumatology, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes (Madrid), Universidad Europea, Paseo de Europa 34, San Sebastián de los Reyes, 28702, Madrid, Spain.
| | - Ma Dolores Aguilar
- Independent researcher in the field of Health Services Research, Madrid, Spain
| | - Raquel Almodóvar
- Rheumatology Unit, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Laura Cano-García
- Rheumatology Clinical Management Unit, Institute for Biomedical Research in Malaga (Instituto de Investigación biomédica de Málaga, IBIMA), Hospital Regional de Málaga, Universidad de Málaga, Málaga, Spain
| | - Sandra Fortea
- Rheumatology Section, Hospital de Sagunto, Valencia, Spain
| | | | | | - Laura Cebrián
- Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Pablo Lázaro
- Independent researcher in the field of Health Services Research, Madrid, Spain
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28
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Watts RA, Mooney J, Barton G, MacGregor AJ, Shepstone L, Irvine L, Scott DGI. The outcome and cost-effectiveness of nurse-led care in the community for people with rheumatoid arthritis: a non-randomised pragmatic study. BMJ Open 2015; 5:e007696. [PMID: 26307614 PMCID: PMC4550717 DOI: 10.1136/bmjopen-2015-007696] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To determine the outcome and cost-effectiveness of nurse-led care in the community for people with rheumatoid arthritis (RA). DESIGN Non-randomised pragmatic study. SETTING Primary (7 primary care practices) and secondary care (single centre) in the UK. METHODS In a single area, pragmatic non-randomised study, we assessed the outcome, cost-effectiveness of community-based nurse-led care (NLC) compared with rheumatologist-led outpatient care (RLC). Participants were 349 adults (70% female) with stable RA assessed at baseline, 6 and 12 months. In the community NLC arm there were 192 participants. Outcome was assessed using Stanford Health Assessment Questionnaire (HAQ). The economic evaluation (healthcare perspective) estimated cost relative to change in HAQ and quality-adjusted life years (QALY) derived from EQ-5D-3L. We report complete case and multiple imputation results from regression analyses. RESULTS The demographics and baseline characteristics of patients in the community group were comparable to those under hospital care apart from use of biological disease-modifying antirheumatic drugs (DMARDS), which were adjusted for in the analysis. The mean incremental cost was estimated to be £224 less for RLC compared to the community NLC, with wide CIs (CI -£213 to £701, p=0.296). Levels of functional disability were not clinically significantly higher in the community NLC group: HAQ 0.096 (95% CI -0.026 to 0.206; p=0.169) and QALY 0.023 (95% CI -0.059 to 0.012; p=0.194). CONCLUSIONS The results suggest that community care may be associated with non-significant higher costs with no significant differences in clinical outcomes, and this suggests a low probability that it is cost-effective.
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Affiliation(s)
- Richard A Watts
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Janice Mooney
- School of Nursing Sciences University of East Anglia, Norwich, UK
| | - Garry Barton
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Lee Shepstone
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Lisa Irvine
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - David G I Scott
- Norwich Medical School, University of East Anglia, Norwich, UK
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Tsiachristas A, Wallenburg I, Bond CM, Elliot RF, Busse R, van Exel J, Rutten-van Mölken MP, de Bont A. Costs and effects of new professional roles: Evidence from a literature review. Health Policy 2015; 119:1176-87. [PMID: 25899880 DOI: 10.1016/j.healthpol.2015.04.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Revised: 03/30/2015] [Accepted: 04/01/2015] [Indexed: 10/23/2022]
Abstract
One way in which governments are seeking to improve the efficiency of the health care sector is by redesigning health services to contain labour costs. The aim of this study was to investigate the impact of new professional roles on a wide range of health service outcomes and costs. A systematic literature review was performed by searching in different databases for evaluation papers of new professional roles (published 1985-2013). The PRISMA checklist was used to conduct and report the systematic literature review and the EPHPP-Quality Assessment Tool to assess the quality of the studies. Forty-one studies of specialist nurses (SNs) and advanced nurse practitioners (ANPs) were selected for data extraction and analysis. The 25 SN studies evaluated most often quality of life (10 studies), clinical outcomes (8), and costs (8). Significant advantages were seen most frequently regarding health care utilization (in 3 of 3 studies), patient information (5 of 6), and patient satisfaction (4 of 6). The 16 ANP studies evaluated most often patient satisfaction (8), clinical outcomes (5), and costs (5). Significant advantages were seen most frequently regarding clinical outcomes (5 of 5), patient information (3 of 4), and patient satisfaction (5 of 8). Promoting new professional roles may help improve health care delivery and possibly contain costs. Exploring the optimal skill-mix deserves further attention from health care professionals, researchers and policy makers.
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Affiliation(s)
- A Tsiachristas
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK.
| | - I Wallenburg
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - C M Bond
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
| | - R F Elliot
- Health Economics Research Unit, University of Aberdeen, Aberdeen, Scotland, UK
| | - R Busse
- Department of Healthcare Management, Technische Universität Berlin, Berlin, Germany
| | - J van Exel
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - M P Rutten-van Mölken
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - A de Bont
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Sørensen J, Primdahl J, Horn HC, Hørslev-Petersen K. Shared care or nurse consultations as an alternative to rheumatologist follow-up for rheumatoid arthritis (RA) outpatients with stable low disease-activity RA: cost-effectiveness based on a 2-year randomized trial. Scand J Rheumatol 2014; 44:13-21. [PMID: 25380077 DOI: 10.3109/03009742.2014.928945] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To compare the cost-effectiveness of three types of follow-up for outpatients with stable low-activity rheumatoid arthritis (RA). METHOD In total, 287 patients were randomized to either planned rheumatologist consultations, shared care without planned consultations, or planned nurse consultations. Effectiveness measures included disease activity (Disease Activity Score based on 28 joint counts and C-reactive protein, DAS28-CRP), functional status (Health Assessment Questionnaire, HAQ), and health-related quality of life (EuroQol EQ-5D). Cost measures included activities in outpatient clinics and general practice, prescription and non-prescription medicine, dietary supplements, other health-care resources, and complementary and alternative care. Measures of effectiveness and costs were collected by self-reported questionnaires at inclusion and after 12 and 24 months. Incremental cost-effectiveness rates (ICERs) were estimated in comparison with rheumatologist consultations. RESULTS Changes in disease activity, functional status, and health-related quality of life were not statistically significantly different for the three groups, although the mean scores were better for the shared care and nurse care groups compared with the rheumatologist group. Shared care and nurse care were non-significantly less costly than rheumatologist care. As both shared care and nurse care were associated with slightly better EQ-5D improvements and lower costs, they dominated rheumatologist care. At EUR 10,000 per quality-adjusted life year (QALY) threshold, shared care and nurse care were cost-effective with more than 90% probability. Nurse care was cost-effective in comparison with shared care with 75% probability. CONCLUSIONS Shared care and nurse care seem to cost less but provide broadly similar health outcomes compared with rheumatologist outpatient care. However, it is still uncertain whether nurse care and shared care are cost-effective in comparison with rheumatologist outpatient care.
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Affiliation(s)
- J Sørensen
- Centre for Applied Health Services Research, University of Southern Denmark , Odense , Denmark
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31
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Vliet Vlieland TPM. New models of care for patients with rheumatoid arthritis. Expert Rev Pharmacoecon Outcomes Res 2014; 6:159-69. [DOI: 10.1586/14737167.6.2.159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Cottrell JED, Jonas M, Bergsten U, Blaas E, de la Torre Aboki J, Howse C, Korandova J, Löfman P, Logtenberg C, Lupton T, Mallon C, Oliver S, Pickles D, Bulinckx L. The nurse's role in addressing unmet treatment and management needs of patients with rheumatoid arthritis: Delphi-based recommendations. Int J Nurs Knowl 2013; 24:66-76. [PMID: 23750901 DOI: 10.1111/j.2047-3095.2013.01231.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Evaluate nurse's role in management of patients with rheumatoid arthritis (RA). METHODS Modified Delphi with two rounds of questionnaires, followed by in-person meeting. International group of 12 nurses experienced with RA patients receiving biologic therapy. FINDINGS Nurses often spend more time with patients than doctors do. Nurse is in unique position to explore patient needs; educate about treatment, administration, product storage, and self-injection technique; determine readiness for and understanding of treatment; monitor safety and progress; and coordinate care within multidisciplinary setting. CONCLUSIONS Nurse's role is complex and vitally important to optimal RA patient care. Additional nurse involvement may address unmet needs. IMPLICATIONS FOR NURSING PRACTICE Rheumatology nurses can address unmet patient needs by expanding current roles and by adopting additional functions.
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Affiliation(s)
- Jane E D Cottrell
- Rebecca MacDonald Centre for Arthritis & Autoimmunity, Toronto, Ontario, Canada
| | | | - Ulrika Bergsten
- Spenshult Hospital for Rheumatic Diseases, Oskarström, Sweden
| | | | | | - Catriona Howse
- South London Healthcare NHS Trust-Queen Mary's, Sidcup, Kent, United Kingdom
| | | | - Päivi Löfman
- Saimaa University of Applied Sciences, Lappeenranta, Finland
| | | | - Terri Lupton
- University of Calgary Medical Clinics, Calgary, Alberta, Canada
| | - Catherine Mallon
- University of Alberta, RAPPORT Centre, Edmonton, Alberta, Canada
| | | | | | - Leeanna Bulinckx
- PerCuro Clinical Research Ltd., Victoria, British Columbia, Canada
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Li J, Westbrook J, Callen J, Georgiou A, Braithwaite J. The impact of nurse practitioners on care delivery in the emergency department: a multiple perspectives qualitative study. BMC Health Serv Res 2013; 13:356. [PMID: 24053508 PMCID: PMC3848906 DOI: 10.1186/1472-6963-13-356] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 09/17/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Despite well-articulated benefits, the introduction of Nurse Practitioners (NPs) in Australia has been slow. Poorly defined nomenclature relating to advanced practice roles in nursing and variations in such roles both across Australia and worldwide have resulted in confusion and uncertainty regarding the functions and roles of NPs. Qualitative studies focussing on the perceived impact on the care settings into which NPs are introduced are scarce, but are valuable in providing a complete contextual account of NPs in care delivery settings. This study aimed to investigate the perceived impact of the NP on the delivery of care in the ED by senior doctors, nurses, and NPs. Results will facilitate adoption and best use of this human resource innovation. METHODS A cross-sectional qualitative study was undertaken in the Emergency Departments (EDs) of two large Australian metropolitan public teaching hospitals. Semi-structured, in-depth interviews were conducted with five nurse practitioners, four senior doctors (staff specialists and ED directors) and five senior nurses. Transcribed interviews were analysed using a grounded theory approach to develop themes in relation to the conceptualisation of the impact of the NP role on the ED. Member checking of results was conducted by revisiting the sites to clarify findings with participants and further explore emergent themes. RESULTS The impact of the NP role was perceived differently by different groups of participants. Whilst NPs were observed to deliver few quantitative improvements to ED functioning from the perspective of ED directors, NPs believed that they assisted doctors in managing the increasing subacute presentations to the contemporary ED. NPs also believed they embraced a preventative paradigm of care which addressed the long term priorities of chronic disease prevention and cost containment in the broader healthcare environment. The ambiguous position of the NP role, which crosses the gap between nursing and medicine, emerged and resulted in a duality of NP governance. CONCLUSIONS Interpretation of the NPs' role occurred through different frames of reference. This has implications for the development of the NP role in the ED. Collaboration and dialogue between various stakeholders, such as ED doctors and senior nursing management is required.
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Affiliation(s)
- Julie Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Kensington, NSW 2052, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Kensington, NSW 2052, Australia
| | - Joanne Callen
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Kensington, NSW 2052, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Kensington, NSW 2052, Australia
| | - Jeffrey Braithwaite
- Centre for Clinical Governance Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Kensington, NSW 2052, Australia
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Ndosi M, Lewis M, Hale C, Quinn H, Ryan S, Emery P, Bird H, Hill J. The outcome and cost-effectiveness of nurse-led care in people with rheumatoid arthritis: a multicentre randomised controlled trial. Ann Rheum Dis 2013; 73:1975-82. [PMID: 23982436 PMCID: PMC4215359 DOI: 10.1136/annrheumdis-2013-203403] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the clinical effectiveness and cost-effectiveness of nurse-led care (NLC) for people with rheumatoid arthritis (RA). METHODS In a multicentre pragmatic randomised controlled trial, the assessment of clinical effects followed a non-inferiority design, while patient satisfaction and cost assessments followed a superiority design. Participants were 181 adults with RA randomly assigned to either NLC or rheumatologist-led care (RLC), both arms carrying out their normal practice. The primary outcome was the disease activity score (DAS28) assessed at baseline, weeks 13, 26, 39 and 52; the non-inferiority margin being DAS28 change of 0.6. Mean differences between the groups were estimated controlling for covariates following per-protocol (PP) and intention-to-treat (ITT) strategies. The economic evaluation (NHS and healthcare perspectives) estimated cost relative to change in DAS28 and quality-adjusted life-years (QALY) derived from EQ5D. RESULTS Demographics and baseline characteristics of patients under NLC (n=91) were comparable to those under RLC (n=90). Overall baseline-adjusted difference in DAS28 mean change (95% CI) for RLC minus NLC was -0.31 (-0.63 to 0.02) for PP and -0.15 (-0.45 to 0.14) for ITT analyses. Mean difference in healthcare cost (RLC minus NLC) was £710 (-£352, £1773) and -£128 (-£1263, £1006) for PP and ITT analyses, respectively. NLC was more cost-effective with respect to cost and DAS28, but not in relation to QALY utility scores. In all secondary outcomes, significance was met for non-inferiority of NLC. NLC had higher 'general satisfaction' scores than RLC in week 26. CONCLUSIONS The results provide robust evidence to support non-inferiority of NLC in the management of RA. TRIAL REGISTRATION ISRCTN29803766.
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Affiliation(s)
- Mwidimi Ndosi
- Academic and Clinical Unit for Musculoskeletal Nursing, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Martyn Lewis
- Arthritis Research UK Primary Care Centre, Keele University, Staffordshire, UK
| | - Claire Hale
- Academic and Clinical Unit for Musculoskeletal Nursing, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK School of Healthcare, University of Leeds, Leeds, UK
| | - Helen Quinn
- School of Healthcare, University of Leeds, Leeds, UK
| | | | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Howard Bird
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Jackie Hill
- Academic and Clinical Unit for Musculoskeletal Nursing, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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Chew LC, Yee SL. The Rheumatology Monitoring Clinic in Singapore — A Novel Advanced Practice Nurse-/Pharmacist-Led Clinic. PROCEEDINGS OF SINGAPORE HEALTHCARE 2013. [DOI: 10.1177/201010581302200108] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Li-Ching Chew
- Department of Rheumatology and Immunology, Singapore General Hospital
- Duke-NUS Graduate Medical School, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore
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Primdahl J, Sørensen J, Horn HC, Petersen R, Hørslev-Petersen K. Shared care or nursing consultations as an alternative to rheumatologist follow-up for rheumatoid arthritis outpatients with low disease activity--patient outcomes from a 2-year, randomised controlled trial. Ann Rheum Dis 2013; 73:357-64. [PMID: 23385306 DOI: 10.1136/annrheumdis-2012-202695] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To compare patient outcomes of three regimes of follow-up care for rheumatoid arthritis (RA) outpatients with low disease activity. METHODS RA outpatients (n=287) with Disease Activity Score (DAS28-CRP)<3.2 and Health Assessment Questionnaire<2.5 from two Danish rheumatology clinics were randomised to 2-year follow-up by either: (1) planned rheumatologist consultations, (2) shared care without planned consultations or (3) planned nursing consultations. The primary outcome was change in disease activity. DAS28-CRP, Health Assessment Questionnaire, visual analogue scale (VAS)-pain, fatigue, global health, confidence and satisfaction, quality-of-life by the Short Form 12 and self-efficacy measured by the RA Self-Efficacy questionnaire and the Arthritis Self-Efficacy Scale, were recorded annually and safety measures were recorded. x-Rays of hands and feet were taken at baseline and at 2-year follow-up. Mixed effect models were used to explore differences between the three groups over time. RESULTS At 2-year follow-up, the group allocated to nursing consultations had lower disease activity than the group that underwent rheumatologist consultations (DAS28-CRP -0.3, p=0.049). The nursing group increased their self-efficacy (Arthritis Self-Efficacy Scale 18.8, p=0.001), confidence (10.7, p=0.001) and satisfaction (10.8, p<0.001) compared with the rheumatologist group. The shared care group reported a transient lower satisfaction compared with the rheumatologist group after 1 year (-8.8, p=0.004). No statistically significant differences were seen in other outcome variables. CONCLUSIONS It is safe to implement shared care and nursing consultations as alternatives to rheumatologist consultations for RA outpatients with low disease activity without deterioration in disease control. Nursing consultations can enhance patients' self-efficacy, confidence and satisfaction.
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Affiliation(s)
- Jette Primdahl
- Institute for Regional Health Research, University of Southern Denmark, , Odense Denmark
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Bala SV, Samuelson K, Hagell P, Svensson B, Fridlund B, Hesselgard K. The experience of care at nurse-led rheumatology clinics. Musculoskeletal Care 2012; 10:202-211. [PMID: 22745012 DOI: 10.1002/msc.1021] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To describe how people with rheumatoid arthritis (RA) experience the care provided by Swedish nurse-led rheumatology outpatient clinics. METHODS Eighteen adult people with a diagnosis of RA who had had at least three documented contact sessions with a nurse-led clinic were interviewed. The interviews were analysed with qualitative content analysis. RESULTS Care was expressed in three categories: social environment, professional approach and value-adding measures. A social environment including a warm encounter, a familial atmosphere and pleasant premises was desired and contributed to a positive experience of care. The nurses' professional approach was experienced as empathy, knowledge and skill, as well as support. The care was described as person centred and competent, as it was based on the individual's unique experience of his/her disease and needs. The nurses' specialist knowledge of rheumatology and rheumatology care was highly valued. The offered care represented added value for the participants, instilling security, trust, hope and confidence. It was perceived as facilitating daily life and creating positive emotions. The nurse-led clinics were reported to be easily accessible and provided continuity of the care. These features were presented as fundamental guarantees for health care safety. CONCLUSION The experiences emphasized the need for a holistic approach to care. In this process, the organization of care and the role and skills of the nurse should be focused on the individual's needs and perspectives. The social environment, professional approach and value-adding measures are particularly relevant for optimal care at nurse-led rheumatology outpatient clinics.
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Cottrell JED, Jonas M, Bergsten U, Blaas E, de la Torre Aboki J, Howse C, Korandova J, Löfman P, Logtenberg C, Lupton T, Mallon C, Oliver S, Pickles D, Bulinckx L. The Nurse's Role in Addressing Unmet Treatment and Management Needs of Patients With Rheumatoid Arthritis: Delphi-Based Recommendations. Int J Nurs Knowl 2012:n/a-n/a. [PMID: 23206315 DOI: 10.1111/j.2047-3095.2012.01231.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Evaluate nurse's role in management of patients with rheumatoid arthritis (RA). METHODS Modified Delphi with two rounds of questionnaires, followed by in-person meeting. International group of 12 nurses experienced with RA patients receiving biologic therapy. FINDINGS Nurses often spend more time with patients than doctors do. Nurse is in unique position to explore patient needs; educate about treatment, administration, product storage, and self-injection technique; determine readiness for and understanding of treatment; monitor safety and progress; and coordinate care within multidisciplinary setting. CONCLUSIONS Nurse's role is complex and vitally important to optimal RA patient care. Additional nurse involvement may address unmet needs. IMPLICATIONS FOR NURSING PRACTICE Rheumatology nurses can address unmet patient needs by expanding current roles and by adopting additional functions.
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Affiliation(s)
- Jane E D Cottrell
- Rebecca MacDonald Centre for Arthritis & Autoimmunity, Toronto, Ontario, Canada
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Primdahl J, Wagner L, Holst R, Hørslev-Petersen K. The impact on self-efficacy of different types of follow-up care and disease status in patients with rheumatoid arthritis--a randomized trial. PATIENT EDUCATION AND COUNSELING 2012; 88:121-128. [PMID: 22386009 DOI: 10.1016/j.pec.2012.01.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 01/27/2012] [Accepted: 01/28/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To explore the impact from different types of outpatient care, demographic and disease related variables on self-efficacy beliefs (SE) in patients with established rheumatoid arthritis (RA) after completing an educational program. METHODS 287 adult RA outpatients with low disease activity and moderate physical disability from two Danish rheumatology clinics were randomized for follow-up care. (1) planned rheumatologist's consultations, (2) a shared care model without planned consultations, (3) planned nursing consultations. The participants' SE were assessed by the Danish versions of the rheumatoid arthritis self-efficacy questionnaire (RASE) and the arthritis self-efficacy scale (ASES). Data were collected at baseline, 3 months and one-year follow up and were explored in random intercept models. RESULTS Following an educational programme the nursing group increased or stabilized their SE during the first year compared to the medical and the shared care group. SE in the shared care group did not differ significantly from the medical group. No difference between the groups was seen in disease activity at any time. CONCLUSION Nursing consultations provide opportunities for maintenance of the patients' SE after patient education. PRACTICE IMPLICATIONS Implementation of nursing consultations as part of follow-up care in patients with stable RA is recommended.
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Affiliation(s)
- Jette Primdahl
- Institute for Regional Health Research, University of Southern Denmark, Odense C, Denmark.
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Abdelhamid AS, Mooney J, Walker AA, Barton G, MacGregor AJ, Scott DGI, Watts RA. An evaluation of rheumatology practitioner outreach clinics: a qualitative study. BMC Health Serv Res 2012; 12:119. [PMID: 22607063 PMCID: PMC3457863 DOI: 10.1186/1472-6963-12-119] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 05/07/2012] [Indexed: 11/16/2022] Open
Abstract
Background Services for Rheumatoid Arthritis (RA) have evolved with the development of
independently led outreach Rheumatology Practitioner (RP) clinics in Primary Care
(PC). Their clinical and cost effectiveness, compared with Secondary Care (SC)
services, has not been assessed. The RECIPROCATE study aims to evaluate their
clinical and cost effectiveness. This part of the study aimed to explore health
professionals’ opinions of rheumatology outreach service. Methods Using a qualitative design, semi-structured interviews were conducted with GPs,
practice nurses, hospital doctors and RPs, from one hospital and seven PC
practices in Norfolk, to elicit their opinions of the service. The interviews were
analysed using thematic analysis. Results All participants agreed the service was supportive and valuable providing high
quality personalised care, disease management, social, and educational support.
Advantages identified included convenience, continuity of care and proximity of
services to home. RPs helped bridge the communication gap between PC and SC. Some
participants suggested having a doctor alongside RPs. The service was considered
to be cost effective for patients but there was uncertainty about cost
effectiveness for service providers. Few disadvantages were identified the most
recurring being the lack of other onsite services when needed. It was noted that
more services could be provided by RPs such as prescribing and joint injections as
well as playing a more active role in knowledge transfer to PC. Conclusions Professionals involved in the care of RA patients recognised the valuable role of
the RP outreach clinics. This service can be further developed in rheumatology and
the example can be replicated for other chronic conditions.
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Affiliation(s)
- Asmaa S Abdelhamid
- Norwich Medical School, University of East Anglia, NR4 7TJ, Norwich, Norfolk, UK.
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Li J, Westbrook J, Callen J, Georgiou A. The role of ICT in supporting disruptive innovation: a multi-site qualitative study of nurse practitioners in emergency departments. BMC Med Inform Decis Mak 2012; 12:27. [PMID: 22462409 PMCID: PMC3359193 DOI: 10.1186/1472-6947-12-27] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 04/02/2012] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The disruptive potential of the Nurse Practitioner (NP) is evident in their ability to offer services traditionally provided by primary care practitioners and their provision of a health promotion model of care in response to changing health trends. No study has qualitatively investigated the role of the Emergency NP in Australia, nor the impact of Information and Communication Technology (ICT) on this disruptive workforce innovation. This study aimed to investigate ways in which Nurse Practitioners (NP) have incorporated the use of ICT as a mechanism to support their new clinical role within Emergency Departments. METHODS A cross-sectional qualitative study was undertaken in the Emergency Departments (EDs) of two large Australian metropolitan public teaching hospitals. Semi-structured, in-depth interviews were conducted with five nurse practitioners, four senior physicians and five senior nurses. Transcribed interviews were analysed using a grounded theory approach to develop themes in relation to the conceptualisation of the ED nurse practitioner role and the influences of ICT upon the role. Member checking of results was achieved by revisiting the sites to clarify findings with participants and further explore emergent themes. RESULTS The role of the ENP was distinguished from those of Emergency nurses and physicians by two elements: advanced practice and holistic care, respectively. ICT supported the advanced practice dimension of the NP role in two ways: availability and completeness of electronic patient information enhanced timeliness and quality of diagnostic and therapeutic decision-making, expediting patient access to appropriate care. The ubiquity of patient data sourced from a central database supported and improved quality of communication between health professionals within and across sites, with wider diffusion of the Electronic Medical Record holding the potential to further facilitate team-based, holistic care. CONCLUSIONS ICT is a facilitator through which the disruptive impact of NPs can be extended. However, integration of ICT into work practices without detracting from provider-patient interaction is crucial to ensure utilisation of such interventions and realisation of potential benefits.
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Affiliation(s)
- Julie Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, NSW 2052, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, NSW 2052, Australia
| | - Joanne Callen
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, NSW 2052, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, NSW 2052, Australia
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Hibbert D, Al-Sanea NA, Balens JA. Perspectives on specialist nursing in Saudi Arabia: a national model for success. Ann Saudi Med 2012; 32:78-85. [PMID: 22156643 PMCID: PMC6087647 DOI: 10.5144/0256-4947.2012.78] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In many parts of the world, vulnerable patient populations may be cared for by a clinical nurse specialist (CNS). Nurses desiring to develop themselves professionally in the clinical arena, within the specialty of their choice, have the opportunity to obtain the knowledge, skills, experience and qualifications necessary to attain advanced practice positions such as CNS or nurse consultant (NC). Although studies have demonstrated the benefits of such roles and while the World Health Organization (WHO) recommends it, advanced nursing practice is not yet integrated into the health care culture in Saudi Arabia. The reasons for this are multiple, but the most important is the poor image of clinical nursing throughout the country. This article aims to share a perspective on CNS practice, while casting light on some of the obstacles encountered within Saudi Arabia. A model is proposed representing specialist nurse-physician collaborative practice for implementation nationally. The model has been implemented in the care of the colorectal and stoma patient populations while taking into consideration patient population needs and local health care culture. This model is based on the concepts of holistic "patient-centered care", specialist nurse-physician collaborative practice, and the four practice domains for NCs (expert practice, leadership, research and education) as indicated by the Department of Health in the United Kingdom. We suggest this model will enable the introduction of advanced specialist nursing and collaborative partnerships in Saudi Arabia with benefits for patients, physicians, health care organizations and the nursing profession as a whole.
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Affiliation(s)
- Denise Hibbert
- Department of Nursing, Colorectal Therapy and Department of Surgery, Colorectal Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
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Abstracts of the 34th Scandinavian Congress of Rheumatology, Copenhagen, Denmark, September 2nd – 5th, 2012. Scand J Rheumatol Suppl 2012; 126:1-68. [DOI: 10.3109/03009742.2012.725576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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de la Torre Aboki J. [Contribution of nurse-led clinics in the management of the patient with rheumatoid arthritis]. ACTA ACUST UNITED AC 2011; 6S3:S16-9. [PMID: 21794766 DOI: 10.1016/j.reuma.2010.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Accepted: 11/06/2010] [Indexed: 11/16/2022]
Abstract
The goal of a nurse-led clinic in the management of rheumatoid arthritis patients is to promote patient independence. Patient education and empowerment are efficacious tools for achieving this. The main nursing care roles are vigilance of physical symptoms, drug toxicity and co-morbidities; management of physical and psychological symptoms; to provide continuity of care. There is evidence supporting the effectiveness of nurse-led clinics and the economic benefits related to it.
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Affiliation(s)
- Jenny de la Torre Aboki
- Enfermería, Sección de Reumatología, Hospital General Universitario de Alicante, Alicante, España. delatorre
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Ndosi M, Vinall K, Hale C, Bird H, Hill J. The effectiveness of nurse-led care in people with rheumatoid arthritis: a systematic review. Int J Nurs Stud 2011; 48:642-54. [PMID: 21392764 DOI: 10.1016/j.ijnurstu.2011.02.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2010] [Revised: 01/18/2011] [Accepted: 02/06/2011] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The objective of this systematic review was to determine the effectiveness of nurse-led care in rheumatoid arthritis. DESIGN Systematic review of effectiveness. DATA SOURCES Electronic databases (AMED, CENTRAL, CINAHL, EMBASE, HMIC, HTA, MEDLINE, NHEED, Ovid Nursing and PsycINFO) were searched from 1988 to January 2010 with no language restrictions. Inclusion criteria were: randomised controlled trials, nurse-led care being part of the intervention and including patients with RA. REVIEW METHODS Data were extracted by one reviewer and checked by a second reviewer. Quality assessment was conducted independently by two reviewers using the Cochrane Collaboration's Risk of Bias Tool. For each outcome measure, the effect size was assessed using risk ratio or ratio of means (RoM) with corresponding 95% confidence intervals (CI) as appropriate. Where possible, data from similar outcomes were pooled in a meta-analysis. RESULTS Seven records representing 4 RCTs with an overall low risk of bias (good quality) were included in the review. They included 431 patients and the interventions (nurse-led care vs usual care) lasted for 1-2years. Most effect sizes of disease activity measures were inconclusive (DAS28 RoM=0.96, 95%CI [0.90-1.02], P=0.16; plasma viscosity RoM=1 95%CI [0.8-1.26], p=0.99) except the Ritchie Articular Index (RoM=0.89, 95%CI [0.84-0.95], P<0.001) which favoured nurse-led care. Results from some secondary outcomes (functional status, stiffness and coping with arthritis) were also inconclusive. Other outcomes (satisfaction and pain) displayed mixed results when assessed using different tools making them also inconclusive. Significant effects of nurse-led care were seen in quality of life (RAQoL RoM=0.83, 95%CI [0.75-0.92], P<0.001), patient knowledge (PKQ RoM=4.39, 95%CI [3.35-5.72], P<0.001) and fatigue (median difference=-330, P=0.02). CONCLUSIONS The estimates of the primary outcome and most secondary outcomes showed no significant difference between nurse-led care and the usual care. While few outcomes favoured nurse-led care, there is insufficient evidence to conclude whether this is the case. More good quality RCTs of nurse-led care effectiveness in rheumatoid arthritis are required.
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Affiliation(s)
- Mwidimi Ndosi
- Academic and Clinical Unit for Musculoskeletal Nursing, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK.
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Lesko M, Young M, Higham R. Managing inflammatory arthritides: Role of the nurse practitioner and physician assistant. ACTA ACUST UNITED AC 2011; 22:382-92. [PMID: 20590962 DOI: 10.1111/j.1745-7599.2010.00525.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE To review the current management of the inflammatory arthritides, including rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis. This review examines the role of the nurse practitioner (NP) and physician assistant (PA) in the management of these chronic diseases. DATA SOURCES A review of the scientific literature and current guidelines regarding the management of inflammatory arthritides. CONCLUSIONS NPs and PAs play important roles in the interdisciplinary team involved in the treatment of patients with chronic inflammatory arthritic conditions. The management of inflammatory arthritides has evolved with the development of new treatment strategies and is focused on early intervention and minimizing progressive joint damage. NPs and PAs are ideally positioned to educate patients regarding treatment options and other important aspects of the disease process and to monitor disease activity using a number of validated instruments. IMPLICATIONS FOR PRACTICE Through active disease management, NPs and PAs can influence their patients to make better, more informed choices regarding treatment, which may optimize patient outcomes.
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Affiliation(s)
- Mary Lesko
- University Hospitals Case Medical Center, Beachwood, Ohio, USA
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Ndosi M, Lewis M, Hale C, Quinn H, Ryan S, Emery P, Bird H, Hill J. A randomised, controlled study of outcome and cost effectiveness for RA patients attending nurse-led rheumatology clinics: study protocol of an ongoing nationwide multi-centre study. Int J Nurs Stud 2011; 48:995-1001. [PMID: 21334623 PMCID: PMC3629570 DOI: 10.1016/j.ijnurstu.2011.01.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 01/11/2011] [Accepted: 01/16/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND The rise in the number of patients with arthritis coupled with understaffing of medical services has seen the deployment of Clinical Nurse Specialists in running nurse-led clinics alongside the rheumatologist clinics. There are no systematic reviews of nurse-led care effectiveness in rheumatoid arthritis. Few published RCTs exist and they have shown positive results for nurse-led care but they have several limitations and there has been no economic assessment of rheumatology nurse-led care in the UK. OBJECTIVE This paper outlines the study protocol and methodology currently being used to evaluate the outcomes and cost effectiveness for patients attending rheumatology nurse-led clinics. DESIGN AND METHODS A multi-centred, pragmatic randomised controlled trial with a non-inferiority design; the null hypothesis being that of 'inferiority' of nurse-led clinics compared to physician-led clinics. The primary outcome is rheumatoid arthritis disease activity (measured by DAS28 score) and secondary outcomes are quality of life, self-efficacy, disability, psychological well-being, satisfaction, pain, fatigue and stiffness. Cost effectiveness will be measured using the EQ-5D, DAS28 and cost profile for each centre. POWER CALCULATIONS In this trial, a DAS28 change of 0.6 is considered to be the threshold for clinical distinction of 'inferiority'. A sample size of 180 participants (90 per treatment arm) is needed to reject the null hypothesis of 'inferiority', given 90% power. Primary analysis will focus on 2-sided 95% confidence interval evaluation of between-group differences in DAS28 change scores averaged over 4 equidistant follow up time points (13, 26, 39 and 52 weeks). Cost effectiveness will be evaluated assessing the joint parameterisation of costs and effects. RESULTS The study started in July 2007 and the results are expected after July 2011. TRIAL REGISTRATION The International Standard Randomised Controlled Trial Number ISRCTN29803766.
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Affiliation(s)
- Mwidimi Ndosi
- Academic & Clinical Unit for Musculoskeletal Nursing, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK.
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Primdahl J, Wagner L, Hørslev-Petersen K. Being an outpatient with rheumatoid arthritis--a focus group study on patients' self-efficacy and experiences from participation in a short course and one of three different outpatient settings. Scand J Caring Sci 2010; 25:394-403. [PMID: 21175732 DOI: 10.1111/j.1471-6712.2010.00854.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND A Danish study compared three different outpatient settings for persons with rheumatoid arthritis (RA). All participants completed a short course before random allocation to one of three groups. A third of the patients continued with planned medical consultations. A third was allocated to a shared care setting with no planned consultations. The final third was allocated for planned nursing consultations every 3 months. Little knowledge exists of patients' experiences at different outpatient settings. AIMS (1) To explore the patients' experiences of participation in the course and one of the three different outpatient settings and (2) to explore whether some of these experiences can explain possible changes in self-efficacy beliefs. METHOD In total six focus group interviews were carried out with 33 participants from the three settings. The interviews and the analysis were inspired by phenomenological philosophy. RESULTS On the short course the participants felt understood, gained new insights and some changed behaviours after attendance. Important themes in experiences from the three outpatient settings were: (1) continuity and relationships with health professionals, (2) a need for others to take control, and (3) contact with health professionals. SPECIFIC FINDINGS: The nursing consultations were experienced as less factual and less authoritarian than the medical consultations. The participants in the shared care setting had a lack of confidence in the GP's competence to manage their RA. However, they felt responsible for taking action in case of a flare up. The study provided opportunities to enhance the participants' self-efficacy beliefs. CONCLUSION When planning follow-up care, the focus needs to be on continuity, the interpersonal relationship and easy access to health professionals with thorough knowledge of RA. A short course and consultations with nurses and hospital doctors can enhance patients' self-efficacy and thereby strengthen their confidence to assess and manage their own disease.
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Affiliation(s)
- Jette Primdahl
- King Christian X's Hospital for Rheumatic Diseases, Graasten, Denmark.
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The user patient journey. Rheumatology (Oxford) 2010. [DOI: 10.1016/b978-0-443-06934-5.00002-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Vriezekolk J, Eijsbouts A, Evers A, Stenger A, Van Den Hoogen F, van Lankveld W. Poor psychological health status among patients with inflammatory rheumatic diseases and osteoarthritis in multidisciplinary rehabilitation: Need for a routine psychological assessment. Disabil Rehabil 2009; 32:836-44. [DOI: 10.3109/09638280903323250] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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