Impact of a rheumatology expert nurse on the wellbeing of patients attending a drug monitoring clinic

Examining the impact of video-based outpatient education on patient demand for a rheumatology CNS service

BACKGROUND

Patient demand for education and access to the clinical nurse specialists (CNSs) during the rheumatology clinic at one hospital in Ireland was increasing. Alternative methods of providing patient education had to be examined.

AIMS

To explore the efficacy of video-based outpatient education, and its impact on demand for the CNSs.

METHODS

A video was produced to play in a rheumatology outpatient department. A representative sample of 240 patients (120 non-exposed and 120 exposed to the video) attending the clinic was selected to complete a questionnaire exploring the effect of the video. Data were analysed using chi-square tests with Yates' continuity correction.

FINDINGS

Demand for the CNSs was six times higher in the non-exposed group compared with the exposed group (non-exposed: 25%, exposed: 4.8%) (χ²=15.7, P=0.00007), representing a significant decrease in resource demand.

CONCLUSION

High-quality educational videos on view in the rheumatology outpatient department provide patients with information sufficient to meet their educational needs, thus releasing CNS resources.

The effect of nurse-led care on fatigue in patients with rheumatoid arthritis: A systematic review and meta-analysis of randomised controlled studies

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.

Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme

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.

Patient perceptions of co-morbidities in inflammatory arthritis

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.

The value, impact and role of nurses in rheumatology outpatient care: Critical review of the literature

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.

Current organization of specialist pulmonary hypertension clinics: results of an international survey

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.

Nursing sensitive outcomes in patients with rheumatoid arthritis: A systematic literature review

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.

Patient Satisfaction with Pharmacist-Led Collaborative Follow-Up Care in an Ambulatory Rheumatology Clinic

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.

Efficacy of embedded nurse-led versus conventional physician-led follow-up in rheumatoid arthritis: a systematic review and meta-analysis

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.

Nurse-led Care for Patients with Rheumatoid Arthritis: A Systematic Review of the Effect on Quality of Care

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.

SCORE study: quality indicators for rheumatology nursing clinics

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.

The effectiveness and cost-effectiveness of clinical nurse specialists in outpatient roles: a systematic review

RATIONALE, AIMS AND OBJECTIVES

Increasing numbers of clinical nurse specialists (CNSs) are working in outpatient settings. The objective of this paper is to describe a systematic review of randomized controlled trials (RCTs) evaluating the cost-effectiveness of CNSs delivering outpatient care in alternative or complementary provider roles.

METHODS

We searched CINAHL, MEDLINE, EMBASE and seven other electronic databases, 1980 to July 2012 and hand-searched bibliographies and key journals. RCTs that evaluated formally trained CNSs and health system outcomes were included. Study quality was assessed using the Cochrane risk of bias tool and the Quality of Health Economic Studies instrument. We used the Grading of Recommendations Assessment, Development and Evaluation to assess quality of evidence for individual outcomes.

RESULTS

Eleven RCTs, four evaluating alternative provider (n = 683 participants) and seven evaluating complementary provider roles (n = 1464 participants), were identified. Results of the alternative provider RCTs (low-to-moderate quality evidence) were fairly consistent across study populations with similar patient outcomes to usual care, some evidence of reduced resource use and costs, and two economic analyses (one fair and one high quality) favouring CNS care. Results of the complementary provider RCTs (low-to-moderate quality evidence) were also fairly consistent across study populations with similar or improved patient outcomes and mostly similar health system outcomes when compared with usual care; however, the economic analyses were weak.

CONCLUSIONS

Low-to-moderate quality evidence supports the effectiveness and two fair-to-high quality economic analyses support the cost-effectiveness of outpatient alternative provider CNSs. Low-to-moderate quality evidence supports the effectiveness of outpatient complementary provider CNSs; however, robust economic evaluations are needed to address cost-effectiveness.

A systematic review of the cost-effectiveness of nurse practitioners and clinical nurse specialists: what is the quality of the evidence?

Background. Improved quality of care and control of healthcare costs are important factors influencing decisions to implement nurse practitioner (NP) and clinical nurse specialist (CNS) roles. Objective. To assess the quality of randomized controlled trials (RCTs) evaluating NP and CNS cost-effectiveness (defined broadly to also include studies measuring health resource utilization). Design. Systematic review of RCTs of NP and CNS cost-effectiveness reported between 1980 and July 2012. Results. 4,397 unique records were reviewed. We included 43 RCTs in six groupings, NP-outpatient (n = 11), NP-transition (n = 5), NP-inpatient (n = 2), CNS-outpatient (n = 11), CNS-transition (n = 13), and CNS-inpatient (n = 1). Internal validity was assessed using the Cochrane risk of bias tool; 18 (42%) studies were at low, 17 (39%) were at moderate, and eight (19%) at high risk of bias. Few studies included detailed descriptions of the education, experience, or role of the NPs or CNSs, affecting external validity. Conclusions. We identified 43 RCTs evaluating the cost-effectiveness of NPs and CNSs using criteria that meet current definitions of the roles. Almost half the RCTs were at low risk of bias. Incomplete reporting of study methods and lack of details about NP or CNS education, experience, and role create challenges in consolidating the evidence of the cost-effectiveness of these roles.

Randomized controlled trial of a nurse-led rheumatology clinic for monitoring biological therapy

AIM

To compare and evaluate the treatment outcomes of a nurse-led rheumatology clinic and a rheumatologist-led clinic in patients with low disease activity or in remission who are undergoing biological therapy.

BACKGROUND

Patients with chronic inflammatory arthritis treated with biological therapy are usually monitored by rheumatologists. Nurse-led rheumatology clinics have been proposed in patients with low disease activity or in remission.

DESIGN

Randomized controlled trial.

METHODS

A 12-month follow-up trial was conducted between October 2009 and August 2011, where 107 patients were randomized into two groups with a 6-month follow-up to a nurse-led rheumatology clinic based on person-centred care (intervention group; n = 53) or to a rheumatologist-led clinic (control group; n = 54). The hypothesis was that the nurse-led clinic outcomes would not be inferior to those obtained from a rheumatologist-led clinic at the 12-month follow-up. The primary outcome was disease activity measured by Disease Activity Score 28.

RESULTS

A total of 47 patients in the intervention group and 50 in the control group completed the 12-month trial. The trial revealed no statistically significant differences between groups in mean change of Disease Activity Score 28, Visual Analogue Scales for pain, the Health Assessment Questionnaire, satisfaction with or confidence in obtaining rheumatology care.

CONCLUSION

Patients with stable chronic inflammatory arthritis undergoing biological therapy could be monitored by a nurse-led rheumatology clinic without difference in outcome as measured by the Disease Activity Score 28.

The nurse's role in addressing unmet treatment and management needs of patients with rheumatoid arthritis: Delphi-based recommendations

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.

Rheumatology assistance care in Catalonia (Spain): year 2012

OBJECTIVE

To determine the current state of Rheumatology in Catalonia (Spain) and to update information regarding previous studies

METHODS

STUDY DESIGN

observational, descriptive and transversal.

SAMPLE

Physicians practicing rheumatology in the public system of Catalonia. An epidemiological questionnaire was sent to all rheumatologists. The results were compared with previously published studies.

RESULTS

Information was obtained on 130 rheumatologists (62 men/68 women, mean age 47±9 years). Seventy five (57.7%) physicians worked at a hospital, 5 (3.8%) in primary care and 50 (38.5%) in both. Seven (11.9%) hospitals had no rheumatologist. Eight hospitals were accredited by the National Commission to develop a training program in Rheumatology. The number of residents accredited by each hospital was variable.

CONCLUSIONS

The number of rheumatologists in the public health sector in Catalonia has increased 4.8% during the last seven years, unlike the 2005 study in which there was an increase of 40% over the previous eight years. There were 7 hospitals without a rheumatologist.

Health-related quality of life, fatigue and mood in patients with SLE and high levels of pain compared to controls and patients with low levels of pain

Objective

The objective of this paper is to investigate health-related quality of life (HRQoL), fatigue, anxiety and depression in patients with systemic lupus erythematosus (SLE) and higher levels of pain and to compare them to patients with lower levels of pain and controls.

Method

Patients were dichotomized into two groups based on SLE-related pain score on the visual analog scale (VAS): low-pain group (76%, n = 64, VAS 0–39 mm) and high-pain group (24%, n = 20, VAS 40–100 mm) . Sex- and age-matched controls were randomly selected from the general population. Participants were asked to complete questionnaires regarding self-reported pain, HRQoL, fatigue, anxiety and depression. Medical assessments also were recorded.

Result

Fatigue score in the high-pain group (median, 36.5; interquartile range (IQR), 32.5–39.7) was significantly higher ( p < 0.001) compared to the low-pain group (median, 23; IQR, 14.6–34.1), as well as scores for anxiety (median, 9; IQR, 6.5–11.5) and depression (median, 7.5; IQR, 5.5–9) ( p < 0.001). The high-pain group had significantly lower scores compared to the low-pain group in all dimensions in the SF-36 ( p ≤ 0.001–0.007). No statistical differences were detected between the low-pain group and controls in any measurement except for the dimensions physical function, general health, vitality and social function in SF-36.

Conclusion

Patients with SLE scoring higher degrees of pain were burdened with more fatigue, anxiety and depression and lower levels of HRQoL compared to patients with lower levels of pain who did not differ significantly from the general population in most dimensions. These results elucidate the importance of identifying patients with higher degrees of pain who are probably in need of more extensive multidimensional interventions to decrease symptom burden.

The outcome and cost-effectiveness of nurse-led care in people with rheumatoid arthritis: a multicentre randomised controlled trial

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.

Long-term effects of a nurse-led group and individual patient education programme for patients with chronic inflammatory polyarthritis - a randomised controlled trial

AIMS AND OBJECTIVES

To investigate the long-term effect of a nurse-led hospital-based patient education programme combining group and individual education for patients with chronic inflammatory polyarthritis.

BACKGROUND

Patient education interventions have shown short-term effects, but few studies have investigated whether the effects are sustained for a longer period.

DESIGN

Randomised controlled trial.

METHODS

Patients with rheumatoid arthritis, psoriatic arthritis and unspecified polyarthritis were randomised to the intervention group (n = 71) or a waiting list (n = 70). Primary outcomes were as follows: Global Well-Being and the Arthritis Self-Efficacy Other Symptoms Subscale. Secondary outcomes were as follows: patient activation, physical and psychological health status, patients' educational needs and a Disease Activity Score (DAS28-3).

RESULTS

The intervention group had a statistically significant higher global well-being than the controls after 12 months, mean change score 8·2 (95% CI, 1·6-14·8; p-value = 0·015), but not in the Arthritis Self-Efficacy Other Symptoms Subscale, mean change score 2·6 (95% CI, -1·8 to 7·1; p-value = 0·245). Within each group, analyses showed a statistically significant improvement in DAS28-3, mean change -0·3 (95% CI, -0·5 to -0·1; p-value = 0·001), in the intervention group from baseline to 12 months, but not in the controls. The controls had a statistically significant deterioration in the Arthritis Self-Efficacy Other Symptoms Subscale, mean change -5·0 (95% CI, -8·6 to -1·3; p-value = 0·008), Arthritis Impact Measurement Scales - 2 Social, mean change 0·3 (95% CI, 0·1-0·5; p-value = 0·008), and Hospital Anxiety and Depression Scale total, mean change 1·4 (95% CI, 0·3-2·5; p-value = 0·013).

CONCLUSION

A combination of group and individual patient education has a long-term effect on patients' global well-being.

RELEVANCE TO CLINICAL PRACTICE

Nurses should consider whether a combination of group and individual patient education for patients with chronic inflammatory polyarthritis is an alternative in their clinical practice. This combination is less time-consuming for the patients, and it includes the benefit of group learning in addition to focusing on patient's individual educational needs.

The experience of care at nurse-led rheumatology clinics

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.

Intervenções de enfermagem para o cuidado de pacientes com artrite: revisão integrativa da literatura

Esta revisão integrativa buscou analisar a produção científica relacionada aos cuidados de enfermagem para pacientes com artrite. Foram incluídos 12 estudos experimentais, randomizados e controlados, publicados nas bases de dados CINAHL, MEDLINE, SciELO e LILACS, utilizando os descritores controlados "arthritis" e "nursing". Os resultados apontaram a efetividade de musicoterapia, estimulação elétrica neuromuscular, toque terapêutico e imagem guiada associada a relaxamento, para o tratamento da dor. Ser atendido por enfermeira especialista aumentou a satisfação com o atendimento, melhorou o impacto da doença e aumento a procura por serviços de saúde. Programas educativos específicos para portadores de artrite estimularam a prática de exercícios físicos e aqueles direcionados a pessoas com problemas crônicos em geral mostraram-se efetivos para controlar a dor e a incapacidade funcional. Concluímos que existe um conjunto de intervenções que podem subsidiar a prática de enfermagem baseada em evidências junto aos idosos com artrite.

The Nurse's Role in Addressing Unmet Treatment and Management Needs of Patients With Rheumatoid Arthritis: Delphi-Based Recommendations

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.

Improving the standard of care for people with ankylosing spondylitis and a new approach to developing specialist ESP-Led AS clinics

OBJECTIVES

In the UK, there is a wide variation in the quality of care that people with ankylosing spondylitis (AS) receive. People with AS require early diagnosis and referral to a specialist team to commence treatment and optimize outcome.

METHODS

At East Kent Hospitals University Foundation Trust, a specialist clinic led by an extended scope practitioner (ESP) physiotherapist has been set up for the assessment and monitoring of patients with AS. This report describes the service provided by the AS clinic.

RESULTS

Over eight years, the number of patients seen has risen from 62 to 352, and annual consultations from 186 to 986, with an average of 2.8 visits per patient per year. Ninety-seven patients have started treatment with a Tumour Necrosis Factor (TNF) blocker. The service has expanded by the addition of a support worker and biologic clinics.

CONCLUSION

For the Trust, the specialist service provides an improved quality of care and cost-effective use of staff resources. Evaluation has demonstrated that patients welcome the new service.

The impact on self-efficacy of different types of follow-up care and disease status in patients with rheumatoid arthritis--a randomized trial

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.

An evaluation of rheumatology practitioner outreach clinics: a qualitative study

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.

Qualitative insights into the role and practice of Epilepsy Specialist Nurses in England: a focus group study

AIM

  This article is a report of a study that aimed to explore Epilepsy Specialist Nurses' perceptions of their professional role and the factors that may affect their practice.

BACKGROUND

  Previous studies have demonstrated high patient satisfaction with the Epilepsy Specialist Nurse. Although UK national guidelines recommend that all individuals with epilepsy should have access to an epilepsy specialist nurse, many National Health Service trusts disregard these guidelines. The need to introduce cost efficiencies in the National Health Service means that the future of some epilepsy specialist nurses is threatened.

DESIGN

  A qualitative study using focus groups was designed to elicit a rich understanding of the epilepsy specialist nurse role and its current challenges.

METHODS

  Three focus groups were held with a total of 19 participants in the summer of 2009. Data were subjected to thematic framework analysis.

FINDINGS

  The work was underpinned by high commitment to nursing values, which helped to define the role. Epilepsy specialist nurses were often the sole providers of expert and personalized care to meet patients' complex needs. Policy and financially driven changes undermined professional identity and led to service diminution.

CONCLUSION

.  The provision of epilepsy care in England remains variable and access to epilepsy specialist nurses is inequitable. Trusts are being seduced by the cost savings of reducing a specialist service but consequent gaps in service may drive up costs elsewhere. The challenge is for epilepsy specialist nurses to demonstrate their unique place in enhancing patient care and in improving health and well-being.

Perspectives on specialist nursing in Saudi Arabia: a national model for success

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.

Interpreting clinical trial results for moderate-to-severe rheumatoid arthritis: practical applications for rheumatology healthcare providers

PURPOSE

To provide a general overview of clinical trials and more specifically define measurements common to rheumatoid arthritis clinical trials for the purpose of providing a foundation for rheumatology healthcare providers to translate clinical trial findings into their clinical practice and enhance their patient education discussions.

DATA SOURCES

English-language publications cited in the MEDLINE database were used to develop the content of this review article.

CONCLUSIONS

The role of rheumatology healthcare providers has evolved to include numerous vital functions, such as expanding communication between specialists and primary care providers, patient education and counseling, assistance with coping strategies, monitoring response to therapy, and administration of therapy. Education regarding clinical trial design, rationale, and discussion of endpoints has not been strongly emphasized for rheumatology healthcare providers who are increasingly introduced to novel agents and need to assimilate findings from clinical trials into daily practice.

IMPLICATIONS FOR PRACTICE

Familiarity with the basics of clinical trial design and efficacy endpoints of new rheumatoid arthritis therapeutics, translation and application of that knowledge into daily practice, and the ability to explain this information with patients will further enhance the ability of the rheumatology healthcare provider to optimize care for their patients with rheumatoid arthritis.

Extended roles of non-physician health professionals and innovative models of care within Europe: results from a web-based survey

BACKGROUND AND OBJECTIVE

Due to the increasing prevalence of rheumatic diseases, extended roles of non-physician health professionals and innovative models of care may be important options in rheumatology in the future. Extended roles have been pioneered in the UK, Canada, USA and Australia and been found to be effective and safe. However, few data are available about mainland Europe, so the aim of this study was to explore the current status of the extended roles undertaken by health professionals within Europe, and the corresponding models of care used.

METHODS

Non-physician health professionals from various European countries were asked to complete a web-based survey using convenience and snowball sampling techniques. Data analysis involved calculating descriptive statistics and frequencies based on the countries where the participants currently worked.

RESULTS

Of the 479 health professionals who filled in the survey, 430 (92%) indicated that they were performing extended roles. Considerable differences between the 27 participating countries existed, in terms of which extended roles and which innovative models of care were being used. Barriers to performing extended roles were cited as the attitude of rheumatologists in all but eight countries, while attitudes of patients were less common barriers. Lack of knowledge, education and educational opportunities were also experienced in several countries.

CONCLUSION

The present study produced the first data on extended roles for non-physician health professionals and corresponding innovative models of care in rheumatology within Europe. We recommend increasing educational opportunities, as well as developing strategies to limit the barriers experienced.

The effectiveness of nurse-led care in people with rheumatoid arthritis: a systematic review

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.

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

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.

The sources of disease-related information for Estonia's rheumatoid arthritis patients: a qualitative study

OBJECTIVE

To describe rheumatoid arthritis patients' perceptions of being informed and of the value of the information obtained.

BACKGROUND

About the accessibility of the disease-specific information to the patients, a prerequisite for any kind of the patient empowerment, can be considered as a priority area for investigation.

DESIGN

Six focus groups (involving 27 patients) were conducted. For analysing the data, thematic analysis was applied.

RESULTS

The participants referred to the media and the Internet, in-patient units, physicians at out-patient consultations, patients organisations, fellow patients and their own experience as the sources of disease-related information. The information delivered by the physicians was valued highest; satisfaction with the information received from the in-patient units was expressed. The knowledge acquired through the experience was mentioned as being important for coping with the disease. The media was an easily accessible information channel, although the information from this source was less trusted. The access to the Internet was seen as being limited for certain patients groups. The availability of physician-delivered information was described as unsatisfactory due to the organisation of information transmittal in out-patient settings.

CONCLUSIONS

The results indicated the current balance of information sources as being incongruous with the provision of systematic and reliable disease-related information. The available information may also be qualitatively incomplete.

RELEVANCE TO CLINICAL PRACTICE

Recognition of the weak and strong points of the structure of information provision is valuable when considering the development of educational opportunities for rheumatoid arthritis patients.

Mid-level providers in gastroenterology

One response to the challenges of modern day clinical practice has been to employ "mid-level providers" (MLPs), such as physician assistants and nurse practitioners. MLPs may complement physicians by supporting patient self-management and performing routine, protocol-guided management. In turn, MLPs may improve health outcomes and simultaneously lower costs. Within gastroenterology, the prevalence of MLPs remains unknown, though it appears to be significant and increasing. Additionally, professional organizations predict that in the future, MLPs will play a central role in digestive disease care. Although incorporating MLPs into gastroenterology has great potential, numerous challenges exist, and their specific roles must first be defined and evaluated.

Non-drug therapies in early rheumatoid arthritis

Non-pharmacological treatment modalities are often used as an adjunct to drug therapy in patients with rheumatoid arthritis (RA). The aim of this overview is to summarize the available evidence on the effectiveness of these modalities in early RA. The few available randomized controlled trials that have specifically investigated patients with early RA support the effectiveness of dynamic exercise and cognitive behavioural interventions, and to a lesser extent of joint protection programmes and foot orthoses. The effectiveness of multidisciplinary team-care programmes, specialist nurse care, electro-physical modalities (including passive hydrotherapy), wrist orthoses, and dietary interventions have not been studied in patients with early RA. Current recommendations on the usage of non-pharmacological treatment modalities in sets of guidelines on the management of early RA vary with respect to their scope, strength and level of detail. The results of this review indicate a need for further investigation into the most clinically effective and cost-effective strategies to deliver non-pharmacological treatment modalities as well as comprehensive arthritis care models in early RA.

Do OA patients gain additional benefit from care from a clinical nurse specialist?--a randomized clinical trial

OBJECTIVES

To assess whether OA patients attending a clinical nurse specialist (CNS) clinic gain 'additional benefit' compared with those attending a traditional junior hospital doctor (JHD) clinic.

METHODS

A total of 100 patients with OA attending rheumatology clinics at a UK teaching hospital were randomly allocated to a CNS or JHD clinic and seen at 0, 16, 32 and 48 weeks. The study assessed (i) non-inferiority of the CNS with respect to clinical outcomes (pain, morning stiffness, self-efficacy, physical function and psychological status) and (ii) superiority of the CNS in terms of patient knowledge and satisfaction.

RESULTS

Average pain at follow-up was lower in the CNS group: unadjusted mean difference for the JHD group minus the CNS group was 5.3 (95% CI -4.6, 15.2); adjusted was 1.6 (95% CI -5.7, 8.9). The corresponding effect size estimates were 0.20 (95% CI -0.17, 0.57) and 0.06 (95% CI -0.21, 0.33), respectively. There were similar outcomes in morning stiffness, physical function and self-efficacy. Patient knowledge and satisfaction were statistically significant at the 5% level attaining moderate to large effect sizes in favour of the CNS.

CONCLUSIONS

Our findings demonstrate that the clinical outcome of CNS care is not inferior to that of JHD care, and patients attending CNS gain additional benefit in that they are better informed about their disease and significantly more satisfied with care than are their counterparts.

Rheumatoid arthritis patients' knowledge of the disease and its treatments: a descriptive study

OBJECTIVE

The purpose of rheumatoid arthritis (RA) patient education is to increase patients' knowledge levels. However, there are only a limited number of studies available concerning these patients' knowledge of their disease and its various treatments. The purpose of this study was to describe RA patients' understanding of their disease and its treatments.

METHODS

A total of 252 RA patients participated in this survey in August 2004 (response rate 53.2%). The knowledge levels of the patients and their physical functioning were measured using self-reported questionnaires. The data were analysed using descriptive and non-parametric statistical methods.

RESULTS

RA patients' knowledge of the disease and its treatments was, on average, good. However, the total scores of the Patient Knowledge Questionnaire ranged from 2 to 29 (maximum score 30). The patients knew well the aetiology and symptoms of RA, the blood tests and the physical exercise; they knew moderately well the facts relating to joint protection, energy conservation and how to use anti-rheumatic drugs and non-steroidal anti-inflammatory drugs. Young patients, women and patients with a long disease duration knew the most. There was a weak correlation between patient knowledge and physical functioning: the weaker the patient's functioning, the higher the knowledge level.

CONCLUSIONS

RA patients' knowledge of their disease and its treatments varied from poor to good in this group. These results can be used for advancing RA patient education. However, more research is needed to evaluate RA patients' knowledge levels.