Patient-controlled outpatient follow-up on demand for patients with rheumatoid arthritis: a 2-year randomized controlled trial

Investigating innovations in outpatient services: a mixed-methods rapid evaluation

Background

Within outpatient services, a broad range of innovations are being pursued to better manage care and reduce unnecessary appointments. One of the least-studied innovations is Patient-Initiated Follow-Up, which allows patients to book appointments if and when they need them, rather than follow a standard schedule.

Objectives

To use routine national hospital data to identify innovations in outpatient services implemented, in recent years, within the National Health Service in England. To carry out a rapid mixed-methods evaluation of the implementation and impact of Patient-Initiated Follow-Up.

Methods

The project was carried out in four sequential workstreams: (1) a rapid scoping review of outpatient innovations; (2) the application of indicator saturation methodology for scanning national patient-level data to identify potentially successful local interventions; (3) interviews with hospitals identified in workstream 2; and (4) a rapid mixed-methods evaluation of Patient-Initiated Follow-Up. The evaluation of Patient-Initiated Follow-Up comprised an evidence review, interviews with 36 clinical and operational staff at 5 National Health Service acute trusts, a workshop with staff from 13 National Health Service acute trusts, interviews with four patients, analysis of national and local data, and development of an evaluation guide.

Results

Using indicator saturation, we identified nine services with notable changes in follow-up to first attendance ratios. Of three sites interviewed, two queried the data findings and one attributed the change to a clinical assessment service. Models of Patient-Initiated Follow-Up varied widely between hospital and clinical specialty, with a significant degree of variation in the approach to patient selection, patient monitoring and discharge. The success of implementation was dependent on several factors, for example, clinical condition, staff capacity and information technology systems. From the analysis of national data, we found evidence of an association between greater use of Patient-Initiated Follow-Up and a lower frequency of outpatient attendance within 15 out of 29 specialties and higher frequency of outpatient attendance within 7 specialties. Four specialties had less frequent emergency department visits associated with increasing Patient-Initiated Follow-Up rates. Patient-Initiated Follow-Up was viewed by staff and the few patients we interviewed as a positive intervention, although there was varied impact on individual staff roles and workload. It is important that sites and services undertake their own evaluations of Patient-Initiated Follow-Up. To this end we have developed an evaluation guide to support trusts with data collection and methods.

Limitations

The Patient-Initiated Follow-Up evaluation was affected by a lack of patient-level data showing who is on a Patient-Initiated Follow-Up pathway. Engagement with local services was also challenging, given the pressures facing sites and staff. Patient recruitment was low, which affected the ability to understand experiences of patients directly.

Conclusions

The study provides useful insights into the evolving national outpatient transformation policy and for local practice. Patient-Initiated Follow-Up is often perceived as a positive intervention for staff and patients, but the impact on individual outcomes, health inequalities, wider patient experience, workload and capacity is still uncertain.

Future research

Further research should include patient-level analysis to determine clinical outcomes for individual patients on Patient-Initiated Follow-Up and health inequalities, and more extensive investigation of patient experiences.

Study registration

This study is registered with the Research Registry (UIN: researchregistry8864).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/138/17) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 38. See the NIHR Funding and Awards website for further award information.

The COVID-19 pandemic's impact on rheumatic disease patients' satisfaction with access to medical services

The COVID-19 hurt various lifestyle aspects, especially the treatment and follow-up of patients with chronic diseases such as autoimmune inflammatory rheumatic diseases (RD). The new circumstances changed the frequency of medical examinations and the way patients with rheumatic diseases are followed up. The objective is to study the impact of COVID-19 on RD patients' satisfaction with access to medical services. A national multicenter observational cross-sectional anonymous online survey was conducted on patients with RD using a specially developed web-based platform and structured questionnaire https://rheumatologycovid19.bg/ . The study was carried out with the support of intra-university project №6/2022 MU-Plovdiv. 1288 patients participated, with an average age of 47.03 (SD ± 12.80 years), of whom 992 (81.6%) were women. The questionnaire contained 41 questions grouped into 5 panels. Descriptive statistics were used-mean, alternative analysis, logistic regression and Decision Tree using the CRT (classification and regression trees) method. The study found that RD patients' satisfaction with access to medical services was influenced by communication type and the frequency of visits to the rheumatologist, difficulties in prescribing and finding medicines and the presence of comorbidities. The likelihood of patients' satisfaction with their rheumatologist was 5.5 and 3 times higher for in-person and other means of communication, respectively, compared to those without any communication. The relative share of patients who communicated by phone was larger (59%) compared to pre-pandemic (41%), where direct contact with the physician prevailed (80%). The results of the study confirmed the need to optimize remote access to medical care for patients with RD during the pandemic.

The Effectiveness of Telemedicine in Patients with Rheumatoid Arthritis: An Overview of Systematic Reviews and Meta-Analysis

Introduction: Although telemedicine is widely used in the field of rheumatoid arthritis (RA), many systematic reviews have evaluated telemedicine, but we still have no clear effect on RA and no evidence summary. Our aim is to determine the effectiveness of telemedicine on different health outcomes of RA. Methods: The following sources were used: PubMed, Cochrane, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and Embase. The publication period was from the establishment of the database to May 12, 2022. Methodological and reporting qualities were assessed using A Measurement Tool to Assess Systematic Reviews 2 and Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Each intervention's evidence of effect was graded in accordance with the Grades of Recommendations Assessment, Development and Evaluation standards. The comparison of systematic reviews and the investigation of the impact of telemedicine on various outcomes were carried out through a meta-analysis of original studies. Results: Eight systematic reviews were included. The results showed that telemedicine imparted significant improvements in patients with RA in terms of disease activity, function, physical activity, self-efficacy, and knowledge. Conclusions: Telemedicine can improve the overall standard of care for patients with RA. In the future, standardized telemedicine processes should be developed to protect patients.

Self-monitoring combined with patient-initiated care in RA patients with low disease activity: cost-effectiveness analysis of an RCT

OBJECTIVES

Self-monitoring and patient-initiated care (PIC) leads to fewer outpatient clinic visits in patients with established RA with low disease activity (LDA) while healthcare outcomes are similar. This study assesses the cost-effectiveness of PIC with self-monitoring.

METHODS

A 12-month randomized controlled trial was performed with 49 patients in the PIC with self-monitoring group (app-group) and 53 in usual care. The usual care group continued with preplanned visits. The app group had one planned follow-up visit after 12 months and monitored their RA disease activity in a smartphone app. Both groups could make additional appointments at liberty. We included adult RA patients with a disease duration of over 2 years, a disease activity score 28 (DAS28) below 3.2 that were stable on medication for at least 6 months. The effect measure, the DAS28, was measured at 12 months and healthcare resource usage and productivity losses were measured at 3, 6, 9 and 12 months.

RESULTS

There was no significant difference in mean change of DAS28 (-0.04 mean difference, 95% CI: -0.39, 0.30), nor a statistically significant difference in total costs (mean difference €514, 95% CI:-€266, €3690) in the app group compared with the usual care group. The probability that the app was cost-effective was 0.37 and 0.57 at a willingness-to-pay threshold of 0 and 50 000 €/point improvement DAS28, respectively.

CONCLUSION

Although rheumatic care costs were significantly lower in the app group, total costs and effects of PIC with self-monitoring were not different from usual care in RA patients with LDA.

Clinical Visit Frequencies in Rheumatology: A Systematic Literature Review

OBJECTIVE

Clinical visits are a fundamental aspect of rheumatic disease care, but recommendations for appropriate visit frequencies are largely absent from guidelines, scarcely studied, and inconsistently reported. The aim of this systematic review was to summarize the evidence pertaining to visit frequencies for major rheumatic diseases.

METHODS

This systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Title/abstract screening, full-text screening, and extraction were carried out by 2 independent authors. Annual visit frequencies were either extracted or calculated and stratified by disease type and country of study. Weighted mean annual visit frequencies were calculated.

RESULTS

A total of 273 relevant manuscript records were screened, and 28 were included after applying selection criteria. The included studies were equally divided between US and non-US and were published between 1985 and 2021. Most (n = 16) focused on rheumatoid arthritis (RA), systemic lupus erythematosus (SLE; n = 5), and fibromyalgia (FM; n = 4). For RA, the average annual visit frequencies were 5.25 for US rheumatologists, 4.80 for US non-rheumatologists, 3.29 for non-US rheumatologists, and 2.74 for non-US non-rheumatologists. For SLE, annual visit frequencies for non-rheumatologists were much higher than for US rheumatologists (12.3 versus 3.24). For FM, annual visit frequencies were 1.80 for US rheumatologists and 0.40 for non-US rheumatologists. There was a decreasing trend of visit frequency to rheumatologists from 1982 to 2019.

CONCLUSION

Evidence for rheumatology clinical visits was limited and heterogeneous on a global scale. However, general trends suggest more frequent visits in the US and less frequent visits in recent years.

A scoping review of shared care models for rheumatoid arthritis with patient-initiated follow-up

OBJECTIVE

An emerging strategy to address access challenges to rheumatologists for patients with RA is shared care between primary and specialist care, with patient-initiated rheumatologist follow-up as needed. The objective of this scoping review was to explore studies implementing this model of care.

METHODS

Four electronic databases were searched from 01/01/2000-31/03/2022 using three main concepts (RA, shared care, patient-initiated follow-up). English-language studies of any design were included if they described the implementation and/or outcomes of shared care model for RA with patient-initiated follow-up. Two authors reviewed and selected articles in duplicate and extracted data on study characteristics, care model implementation and outcomes according to a pre-specified protocol.

RESULTS

Following duplicate removal, 1578 articles were screened for inclusion and 58 underwent full-text review. Sixteen articles were included, representing 10 unique studies. Five studies had qualitative outcomes and two were pre-implementation studies. Model implementation varied significantly between studies. Effectiveness data was available in 10 studies and demonstrated equivalent outcomes for the model of care (disease activity, radiographic damage, quality of life). Health system costs were equivalent or lower than usual care. While satisfaction with care was equivalent or improved in shared care models with patient-initiated follow-up, some concerns were expressed in qualitative evaluation around appropriate patient selection for such models, and information for health equity evaluation was not reported.

CONCLUSIONS

While shared care models with patient-initiated follow-up may offer comparable outcomes for RA, further work is required to understand patient preferences, health equity considerations and longer-term outcomes for such models of care.

Smartphone-Assisted Patient-Initiated Care Versus Usual Care in Patients With Rheumatoid Arthritis and Low Disease Activity: A Randomized Controlled Trial

OBJECTIVE

We developed a smartphone application for patients with rheumatoid arthritis (RA) that allows them to self-monitor their disease activity in between clinic visits by answering a weekly Routine Assessment of Patient Index Data 3. This study was undertaken to assess the safety (noninferiority in the Disease Activity Score in 28 joints using the erythrocyte sedimentation rate [DAS28-ESR]) and efficacy (reduction in number of visits) of patient-initiated care assisted using a smartphone app, compared to usual care.

METHODS

A 12-month, randomized, noninferiority clinical trial was conducted in RA patients with low disease activity and without treatment changes in the past 6 months. Patients were randomized 1:1 to either app-supported patient-initiated care with a scheduled follow-up consultation after a year (app intervention group) or usual care. The coprimary outcome measures were noninferiority in terms of change in DAS28-ESR score after 12 months and the ratio of the mean number of consultations with rheumatologists between the groups. The noninferiority limit was 0.5 difference in DAS28-ESR between the groups.

RESULTS

Of the 103 randomized patients, 102 completed the study. After a year, noninferiority in terms of the DAS28-ESR score was established, as the 95% confidence interval (95% CI) of the mean ΔDAS28-ESR between the groups was within the noninferiority limit: -0.04 in favor of the app intervention group (95% CI -0.39, 0.30). The number of rheumatologist consultations was significantly lower in the app intervention group compared to the usual care group (mean ± SD 1.7 ± 1.8 versus 2.8 ± 1.4; visit ratio 0.62 [95% CI 0.47, 0.81]).

CONCLUSION

Patient-initiated care supported by smartphone self-monitoring was noninferior to usual care in terms of the ΔDAS28-ESR and led to a 38% reduction in rheumatologist consultations in RA patients with stable low disease activity.

Nationwide, large-scale implementation of an online system for remote entry of patient-reported outcomes in rheumatology: characteristics of users and non-users and time to first entry

Aims

In May 2020, a nationwide, web-based system for remote entry of patient-reported outcomes (PROs) in inflammatory rheumatic diseases was launched and implemented in routine care (DANBIO-from-home). After 1.5 years of use, we explored clinical characteristics of patients who did versus did not use the system, and the time to first entry of PROs.

Methods

All patients followed in DANBIO were informed about DANBIO-from-home by electronic invitations or when attending their clinic. Characteristics of patients who did/did not use DANBIO-from-home in the period after implementation were explored by multivariable logistic regression analyses including demographic and clinical variables (gender, age group, diagnosis, disease duration, use of biological disease-modifying agent (bDMARD), Health Assessment Questionnaire (HAQ), Patient Acceptable Symptom Scale (PASS)). Time from launch to first entry was presented as cumulative incidence curves by age group (<40/40–60/61–80/>80 years).

Results

Of 33 776 patients, 68% entered PROs using DANBIO-from-home at least once. Median (IQR) time to first entry was 27 (11–152) days. Factors associated with data entry in multivariate analyses (OR (95% CI)) were: female gender (1.19 (1.12 to 1.27)), bDMARD treatment (1.41 (1.33 to 1.50)), age 40–60 years (1.79 (1.63 to 1.97)), 61–80 years (1.87 (1.70 to 2.07), or age >80 years (0.57 (0.50 to 0.65)) (reference: age <40 years), lower HAQ (0.68 (0.65 to 0.71)) and PASS ‘no’ (1.09 (1.02 to 1.17). Diagnosis was not associated. Time to first entry of PROs was longest in patients <40 years of age (119 (24–184) days) and shortest in the 61–80 years age group (25 (8–139) days).

Conclusion

A nationwide online platform for PRO in rheumatology achieved widespread use. Higher age, male gender, conventional treatment and disability were associated with no use.

Artritis reumatoide y telemedicina en tiempos de COVID-19

La artritis reumatoide es una afección autoinmune, crónica y multisistémica que requiere manejo multidisciplinar, siendo la supervisión continua fundamental para controlar su progresión. Tanto la artritis como el tratamiento generan un estado inmunosupresor que predispone a sufrir infecciones. Por la actual emergencia sanitaria ocasionada por el Sars-Cov2, los pacientes con estas enfermedades crónicas e inmunológicas son más susceptibles de contagio, por ello se ha requerido el uso de nuevas tecnologías como la telemedicina, que en los años previos a la pandemia venía incrementándose su uso, para permitir el control de patologías crónicas. El objetivo del presente estudio es revisar qué implicaciones ha tenido el uso de la telemedicina en el manejo de la artritis reumatoide durante la actual pandemia COVID-19 y cuál ha sido la importancia de la implementación de estas tecnologías en la enfermedad.  

Effects of e-health interventions on health outcomes in patients with rheumatoid arthritis: a systematic review and meta-analysis

AIMS AND OBJECTIVES

To evaluate the effects of e-health interventions on disease activity, self-efficacy, pain and quality of life among patients with rheumatoid arthritis (RA).

BACKGROUND

Prior systematic reviews have only reported the quality and features of e-health interventions in patients with RA. However, the effect of e-health interventions in patients with RA is unclear.

DESIGN

Systematic review and meta-analysis.

METHODS

This review was conducted following the PRISMA guideline. We searched 5 databases, including PubMed, EMBASE, CINAHL, Scopus and the Cochrane library. The risk of bias was assessed using the Cochrane risk of bias tool. The quality of the evidence was assessed via the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. Using a random-effects model adopted the standardised mean difference (SMD) with a 95% confidence interval (CI). A chi-squared test and an I² test were used to assess heterogeneity. Subgroup analyses were conducted based on different controls.

RESULTS

A total of 9 randomised control trials were included in this study. Compared with the control group, disease activity of the e-health group significantly decreased (SMD with 95% CI: -.17 [-.30, -.04], p = .01, I²  = 1%). Meanwhile, trials with usual care control had a larger effect on disease activity (SMD with 95% CI: -.21 [-.40, -.02], p = .03, I²  = 38%). The effect of e-health interventions on self-efficacy was controversial; pain and quality of life were negative in the currently included studies. The quality of evidence was rated as low for disease activity and very low for pain, self-efficacy and quality of life.

CONCLUSIONS

The effect of e-health interventions on disease activity was statistically significant. More well-designed randomised controlled trials are still needed to verify the effects in the future.

RELEVANCE TO CLINICAL PRACTICE

This study shows the potential value of e-health in improving health outcomes in patients with RA.