Specialist nurses as good as doctors in managing rheumatoid arthritis patients

Patients attending clinical nurse specialist clinics do not get inferior treatment to that offered by consultant rheumatologists, the results of a major new clinical trial have revealed.

The results of the multi-centre trial at the University of Leeds, funded by Arthritis Research UK, showed that there may be some clinical benefit to people with rheumatoid arthritis, whose condition is managed in clinics run by rheumatology clinical nurse specialists, especially with respect to their disease activity, pain control, physical function and general satisfaction with their care.

Rheumatoid arthritis is a chronic inflammatory disease, which if untreated may lead to severe disability or death. However, the management of the disease has changed significantly over the past ten years due to better understanding of the disease process, an emphasis on early diagnosis, intensive treatment and the use of more efficacious drug therapies.

The nation-wide trial was led by Dr Mwidimi Ndosi, of the University’s Institute of Rheumatic and Musculoskeletal Medicine, and former University academic Dr Jackie Hill. It compared the outcomes of 180 people with rheumatoid arthritis in 10 out-patient clinics around the UK, half run by clinical nurse specialists, and the other by rheumatologists.

In both groups the nurse or doctor took a patient history, carried out a physical examination, discussed pain control, change of drugs or dose (including steroid injections) and offered patient education and psychosocial support. The nurse-led clinics’ appointment times were on average longer than the consultants’ (20 vs 15 minutes).

The results of the study, published in the Annals of the Rheumatic Diseases, found that although the nurses made fewer changes to a patient’s medication and ordered fewer x-rays and steroid injections, their patients saw greater improvement in disease activity than those under rheumatologists’ care. Nurses also provided patient education and psychosocial support more frequently than rheumatologists, and their patients also had fewer unplanned hospital admissions or visits to accident and emergency units.

“The results of this study show that clinics run by rheumatology clinical nurse specialists can manage many people with rheumatoid arthritis without any reduction in the quality of care and treatment,” said Dr Ndosi.

In addition to better improvements in the disease activity, nurse-led clinics had overall lower healthcare costs, representing a cost-effective service. The economic evaluation took into account healthcare resource use, including consultation costs, investigations, hospital admissions and treatments including over-the-counter medications.

Interestingly, throughout the 12-month follow-up period, the proportion of patients receiving expensive biologic drug treatment remained more or less constant in the nurse-led clinics, while that of rheumatologist-led clinics doubled.

“The development of the role of clinical nurse specialist in rheumatology has resulted in great improvements in rheumatology service, providing a high quality, accessible and person-centred care to people with rheumatoid arthritis,” said Dr Hill.

“The results of this research are encouraging, demonstrating that this model of care is effective, safe, and associated with more patient satisfaction. At a time when deficiencies have come to light in some areas of the NHS, it’s good to know that in rheumatology there are high levels of satisfaction with the care we provide.”

Professor Alan Silman, medical director of Arthritis Research UK commented:  “Rheumatoid arthritis is, despite modern treatment, a chronic condition requiring long-term expert professional care to help patients manage their symptoms and control disease. This care necessarily involves many different healthcare professionals.

“Why this study is so important is that it shows that specialist trained nurses can improve outcome, enhance the patient experience and reduce costs when compared to conventional doctor-led services.

“There will obviously always be a place for specialist medical input at certain times in the patient journey, but this study shows the importance of specialist rheumatology team work, and is a future model of care which requires serious consideration for widespread implementation within the NHS.”