No abstract

The audit has highlighted gaps between NICE standards and delivery of care, as well as substantial geographic variability.

The first national audit for rheumatoid and early inflammatory arthritis has benchmarked care for the first three months of follow up activity from first presentation to a rheumatology service. Access to care, management of early RA and support for self care were measured against NICE quality standards and impact of early arthritis and experience of care were measured using patient reported outcome and experience measures. The results demonstrate delays in referral and accessing specialist care and the need for service improvement in treating to target, suppression of high levels of disease activity and support for self-care. Improvements in patient -reported outcomes within three months and high levels of overall satisfaction were reported but these results were affected by low response rates. Here we present a summary of the national data from the audit and discuss the implications for nursing practice.

This audit demonstrates that most RA patients have severe disease at the time of presentation to rheumatology services and that a significant number continue to have high disease activity after 3 months of specialist care. There is a clear need for the National Health Service to develop better systems for capturing, coding and integrating information from outpatient clinics, including measures of patient experience and outcome and measures of ability to work.

BackgroundEvidence from a national clinical audit of early inflammatory arthritis (EIA) shows considerable variability between hospitals in performance, unexplained by controlling for case-mix.ObjectiveTo explore the macro-level, meso-level and micro-level barriers and facilitators to the provision of good quality EIA care.MethodsA qualitative study within 16 purposively sampled rheumatology units across England and Wales. Quality was assessed in relation to 11 quality indicators based on clinical opinion, evidence and variability observed in the data. Data from semi-structured interviews with staff (1–5 from each unit, 56 in total) and an online questionnaire (n=14/16 units) were integrated and analysed using the framework method for thematic analysis using a combined inductive and deductive approach (underpinned by an evidence-based framework of healthcare team effectiveness), and constant comparison of data within and between units and its relationship with the quality criteria.FindingsQuality of care was influenced by an interplay between macro, meso and micro domains. The macro (eg, shared care arrangements and relationships with general practitioners) and meso (eg, managerial support and physical infrastructure) factors were found to act as crucial enablers of and barriers to higher quality service provision at the micro (team) level. These organisational factors directly influenced team structure and function, and thereby EIA care quality.ConclusionsVariability in quality of EIA care is associated with an interplay between macro, meso and micro service features. Tackling macro and meso barriers is likely to have a significant impact on quality of EIA service, and ultimately patient experience and outcomes.