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

Abstract

ObjectiveTo determine the clinical effectiveness and cost-effectiveness of nurse-led care (NLC) for people with rheumatoid arthritis (RA).MethodsIn 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.ResultsDemographics 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.ConclusionsThe results provide robust evidence to support non-inferiority of NLC in the management of RA.Trial registrationISRCTN29803766

A multi-centre study of interactional style in nurse specialist- and physician-led Rheumatology clinics in the UK

“…Despite wide-scale adoption, evidence of the effectiveness of nurse specialists and their clinics is limited. Recent work has addressed this gap with two recent multi-centre studies undertaken in the UK of effectiveness and economic value [3] and, in France, of co-A c c e p t e d M a n u s c r i p t morbidity management [4]. Results provide robust evidence to support nurse-led clinics in the management of Rheumatoid Arthritis and co-morbidity detection with nurse-led clinics having higher 'general satisfaction' than physician-led clinics [5].…”

“…This study was conducted in parallel with the RCT of outcome and cost effectiveness for RA patients attending nurse-led Rheumatology clinics: a nationwide multi-centre study conducted in the UK [3]. Whilst the trial assessed whether there were any difference in outcomes of patients attending nurse-led clinics or physician-led clinics, the current study examined processes of care, focussing on the interactional style observed within consultations.…”

Rheumatoid Nodules

“…RA is a chronic inflammatory arthritis that affects nearly 1.5 million adults in the United States 1 and 2 million in Europe. 2 It was traditionally a debilitating disease, but with advances in treatment, RA is now a manageable chronic disease state. The predominant feature of RA is synovial inflammation manifested as swelling and tenderness of small, medium, and large joints in a symmetric pattern, with a predilection for the smaller joints of the hands and feet.…”

Effectiveness of nursing consultations in people with rheumatoid arthritis: systematic review

“…Apesar de, tradicionalmente, as pessoas com AR serem monitorizadas periodicamente em consultas médicas (Primdahl et al, 2014;Sorensen et al, 2015), vários estudos e a síntese narrativa evidenciam resultados favoráveis quando este seguimento é realizado também por enfermeiros, nomeadamente na capacidade funcional, na qualidade de vida, na dor (Ndosi et al, 2014), e na satisfação global (Koksvik et al, 2013;Ndosi et al, 2014;Primdahl et al, 2014). Para além destes resultados é ainda evidente a não-inferioridade (não existindo diferenças estatisticamente significativas) das CE em relação às CR, por exemplo, nos outcomes: atividade da doença, capacidade funcional (Larsson et al, 2014;Primdahl et al, 2014;Sorensen et al, 2015), fadiga (Koksvik et al, 2013;Primdahl et al, 2014), qualidade de vida (Koksvik et al, 2013;Primdahl et al, 2014;Sorensen et al, 2015) e dor (Koksvik et al, 2013;Larsson et al, 2014;Primdahl et al, 2014).…”

“…Resultados desfavoráveis são reportados apenas para o outcome capacidade funcional, no grupo das CE (Watts et al, 2015) e para o outcome fadiga (Ndosi et al, 2014 …”