O34 Cost-effectiveness of a clinical nurse specialist performing targeted musculoskeletal ultrasound in the rheumatology clinic

Abstract

Background: Ultrasound can detect sub-clinical inflammation in patients with inflammatory arthritis. The presence of a power Doppler signal in the synovium predicts joint damage in patients with rheumatoid arthritis (RA) and may have a similar role in other inflammatory arthritis. A rheumatology clinical specialist nurse (CNS) was trained in scanning hands and feet as part of the Targeted Ultrasound Initiative (TUI) and was mentored and supervised locally by expert consultant rheumatologists. The purpose of this pilot study was to assess whether a standardised ultrasound (US) scan of hands and feet, performed by a CNS influenced management and, in particular, the decision to escalate treatment, including biologics. Methods: Twenty-five patients referred from CNS and biologic clinics were scanned. All patients had high disease activity scores (DAS: DAS28, PsARC) but little or no clinical evidence of inflammation. Results: The sample included 17 females and eight males, mean age 47 years. Fourteen patients had RA, seven psoriatic arthritis (PsA), one had juvenile idiopathic arthritis and three undifferentiated arthritis. All patients had high activity scores that would direct to escalation of disease modifying antirheumatic drugs (DMARDs) or biologics in local protocols. Hands and feet were scanned following the standard EULAR approach and scored using the OMERACT semi-quantitative scoring for both grey scale and power Doppler. Active inflammation was defined by power Doppler grade 2 or 3. Seven patients had sonographic active inflammation resulting in an increase in current DMARD dose in five patients. Biologics were resumed following a gap in treatment for one patient and one continued on the same biologic. Despite a high DAS, 18 patients had no active inflammation on ultrasound. Two continued on their current biologic. Fifteen patients needed no escalation of treatment. One patient, on no medication, had no evidence of synovitis and was discharged from the service. Escalation to biologic therapy based on DAS was avoided in five patients with an estimated saving of £30-40K/year. Conclusion: Our study shows that a targeted US scan performed by a trained CNS can positively influence the management of patients with inflammatory arthritis. By avoiding unnecessary escalation to expensive biologic therapies it is also highly cost effective.