BHPR Clinical Prize122. Nurse-led Annual Review Service for Stable Inflammatory Arthritis

Abstract

Background: In response to demands on rheumatology outpatient services at East and North Herts Trust, an opportunity to reconfigure services, addressing delayed appointments while improving quality of care, was recognized. An annual review service was designed and initiated for patients with stable inflammatory arthritis. Compliance with National Institute for Clinical Excellence (NICE) CG79 recommendations for RA was audited. Method(s): Six hundred patients seen by a senior nurse practitioner reducing 10% of follow-up appointments for consultants in 2013. The nurse consultations were template based, following criteria established in NICE CG79 Guidance. Fifty patients (n=50) with RA were randomly selected. Data collected included: assessment of disease activity, damage, functional measurements, comorbidities and potential complications of RA. Cross referral with multidisciplinary teams, surgical needs and assessment of social, psychosexual and employment issues were considered. Result(s): Overall 41/50 had no tender joints and 35/50 no swollen joints. DAS 28 ranged from 1.6 to 3.36, with 34/50 in remission (DAS 28 <2.6). 15/50 had low disease activity scores of 2.6-3.2. 1/50 had a moderate score of 3.36. None had high disease activity. 28/50 were on MTX (monotherapy or combination), 17/50 were on alternative DMARDs while 5/50 were not on DMARDs. Treatment dosage was not altered in 33/50, while escalation was recommended in 7/50. All those not on a DMARD stayed off therapy and 5/50 reduced dose. Cardiovascular assessment highlighted 16/50 with QRISK2 <20%. Of the 12/50 with QRISK2 >20%, none were on statins, 2/12 had known hypertension, 4/12 de novo hypertension. BMI ranged from 17 to 44.4 (median 26.4) for all 50 patients. Osteoporosis assessment using FRAX, identified 18/50 requiring DXA, with 6/18 new diagnoses of osteoporosis, 7/18 osteopenia and 5/18 normal results. 41/50 did not require a new multidisciplinary team referral. 2/50 had iritis. 2/50 had chronic obstructive pulmonary disease and 7/50 had mild breathless under investigation. 16/50 were still working while 32/50 had retired. 1/ 50 worked reduced hours due to arthritis. 1/50 did not feel able to work. 36/50 had no issues with depression and 5/50 were already treated for depression. 9/50 had mild work or home related depressive symptoms. Conclusion(s): Nurse-led annual reviews facilitate detailed assessment for patients with RA which are time-consuming (40min), but give greater autonomy to both patient and nurse. Reducing treatment for those in remission was possible as well as escalation for those with active disease. Time to reflect on psychosocial issues, comorbidities and complications of RA led to important actions, particularly detecting osteoporosis. Nurse-led annual assessments enabled consultants to review more complex patients while simultaneously enhancing the quality of follow-up reviews. Patients have adequate time to discuss their global health needs. This model's success has seen the nurse-led annual review clinic become a cornerstone of our outpatient service.