Evaluation of Rheumatology Nurse led Clinic in

Managing Patients with Rheumatoid Arthritis: A Retrospective Study

HA Convention Oral Presentation

Date: 16 May 2017 Speaker: Leung Yee Mei, Emily

NTEC, PWH, M&T, APN 1

Introduction

• Rheumatoid arthritis (RA): chronic, systemic, inflammatory, autoimmune disease associated with swelling and pain in multiple joints

• Affecting 0.5-1.0% of the population worldwide and 0.35% in Hong Kong

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Introduction • RA had negative impact on individual’s

physical, social and psychological functioning

Physical impact: pain and stiffness Psychological impact: depression • Decrease quality of life • Reduce life expectancy

• Co-morbidities such as osteoporosis, interstitial lung disease, infection, pericarditis etc

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RA Classification

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Assessment of disease activity DAS28 (ESR)= 0.56 √ (TEN28) + 0.28 √ (SW28) + 0.70Ln (ESR) + 0.014 (GH) DAS28 (CRP)= 0.56 *√ (TEN28) + 0.28 *√ (SW28) + 0.36*In (CRP+1) + 0.014 (GH) + 0.96

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TEN28 28 joints of tenderness SW28 28 joints of swelling ESR Erythrocyte Sedimentation Rate CRP C- Reactive Protein GH Patient’s Global Assessment of disease activity of 100mm

Introduction

DAS28 <2.6 Remission

DAS28 ≤ 3.2 Well-controlled disease

DAS28 >3.2 to ≤ 5.1 Moderate disease

DAS 28 > 5.1 Active disease

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According to NICE guideline (2009), DAS28 was a widely use and endorsed in disease activity.

Introduction • Multidisciplinary team approach with

rheumatology nurse was recommended to undertake the extended roles

• Effectiveness of nurse led care in other chronic diseases such as diabetes, coronary heart disease and chronic obstructive pulmonary disease

• Nurse-led care has significant value in holistic care to patients.

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EULAR recommendation for the role of nurse

• Patient education • Disease and drug monitoring • Telephone helpline • Comprehensive disease management • Promote self management skills to have greater

empowerment and self efficacy • Cost saving

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Introduction

• Management of RA patients are usually provided by rheumatologists only.

• Enhanced care provided by rheumatology nurses between rheumatologist consultations may have beneficial effects in terms of symptom control.

• In Hong Kong, whether rheumatology nurse care model can lead to favorable patient outcomes remained uncertain.

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Objectives

• To examine the clinical effectiveness of rheumatology nurse led clinic in controlling disease activity as expressed in change of Disease Activity Score in 28 joints (DAS28) in RA patients compared with usual care led by rheumatologists only.

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Method

• This was a retrospective study. • Two historical groups of RA patients (30

patients at each group) were identified from attendance records between 1/1/2015 and 20/7/2015 at the rheumatology outpatient clinics of a regional hospital.

• Primary outcomes were the changes in disease activity (DAS28) at follow-up visit after the doctor clinic and nurse clinic.

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Method • Nurse clinic group: comprised of patients who

attended rheumatology nurse clinic in between the customary doctor clinic consultations. Patient education: included disease mechanism,

assessment of disease activity, medication adherence was checked and the importance of medication adherence was reinforced. RA treatment could also be intensified if needed.

• Doctor’s clinic group: comprised of patients

managed by rheumatologists only 12

Result

Total: 1001 records reviewed

Doctor ‘s clinic group

896 records reviewed 499: rheumatoid arthritis 56% RA patients

Nurse-led clinic group 105 records reviewed 79: rheumatoid arthritis 75% RA patients

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Result

• Both group are around their 50s • Female number are greater that male (66-

87%) • Body weight are similar ( ~ less than 60Kg) • Most of them were lived with family (83-

100%)

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Result • They have comorbidities, e.g. hypertension (n=12 in

nurse clinic, n= 10 in Dr clinic group) • Few of them have extra-articular features

− C1/C2 subluxation (n=1) − Carpal tunnel syndrome (n=1) − Pulmonary fibrosis (n= 1)

• However, nearly half of them have erosion on their x-rays e.g. hands and wrists stated in the radiological report / consultation notes.

• Most of them are using DMARDs (oral medication) in treating rheumatoid arthritis

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Result

• Follow up duration in Doctor’s clinic group: 24.2 ± 5.2weeks (median: 24 weeks)

• Follow up duration in nurse clinic group: 16.3± 11.0 weeks (median: 11.7 weeks)

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The main result

Result • The mean follow-up duration for the study cohort was 20

weeks (median: 22.5 weeks). • Patient global assessment and DAS 28 were similar for

both groups at baseline. At follow-up, patient global assessment and in the nurse group decreased from mean ± SD: 42 ± 24.7 at baseline to 28.7 ± 24.6 at follow-up, which was approaching the minimal clinically important improvement (MCII= -15).

• With regards to DAS28, there was a 8.2% decrease (absolute change: -0.38 ± 1.14) in DAS28 in nurse group suggesting a trend of improvement (p=0.081). The corresponding decrease in Doctor’s clinic group was 1.2% (absolute change: -0.05 ± 1.47) and such decrease was not significant (p=0.863). Changes in DAS28 did not exceed minimal clinically important improvement in both groups (MCII= -1.2). 19

Tender Joint Count

2

3

4

5

6

7

8

Baseline Follow-up

Cha

nges

of t

ende

r joi

nt c

ount

20

Doctor clinic group (dashed line) Nurse clinic group (solid line).

Swollen Joint Count

1.0

1.5

2.0

2.5

3.0

3.5

Baseline Follow-up

Cha

nges

of s

wol

len

join

t cou

nt

Doctor clinic group (dashed line) Nurse clinic group (solid line).

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Patient Global Health

21

26

31

36

41

46

51

Baseline Follow-up

Cha

nges

of P

atie

nt g

loba

l ass

essm

ent

22

Doctor clinic group (dashed line) Nurse clinic group (solid line).

ESR

30

32

34

36

38

40

42

44

46

48

Baseline Follow-up

Cha

nges

of E

SR

leve

l, m

m/h

r

23

Doctor clinic group (dashed line) Nurse clinic group (solid line).

C- Reactive Protein

0

2

4

6

8

10

12

14

16

Baseline Follow-up

Cha

nges

of C

RP

leve

l

24

Doctor clinic group (dashed line) Nurse clinic group (solid line).

Disease Activity Score (DAS28)

3.7

3.9

4.1

4.3

4.5

4.7

4.9

Baseline Follow-up

Cha

nges

of D

AS

28 s

core

25

Doctor clinic group (dashed line) Nurse clinic group (solid line).

Conclusion

• This study demonstrates the short-term benefit of a nurse-led program on RA disease management. Future multi-center studies with a randomized controlled design and a larger sample will be required to confirm the findings.

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Reference

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Thank You

Acknowledgement: Professor Frances Wong Professor Tam Lai Shan

Ms Angela Kwok PWH, M&T, Nursing Team

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