RA patient-initiated review saves time and money, leaves patients more satisfied

[Guest guest]

Rheumawire

June 11, 2004 Zosia Chustecka

RA patient-initiated review saves time and money, leaves patients more

satisfied

Berlin, Germany - In the UK, the standard care for patients with

rheumatoid arthritis (RA) involves routine visits to the

rheumatologists, with appointments arranged some time in advance. But

these visits seldom coincide with periods of disease flare, points out

Dr Kirwan (University of Bristol, UK).

At the EULAR 2004 meeting yesterday, Kirwan presented 6-year data from a

randomized clinical trial comparing this standard care with a new

regimen, in which the RA patients themselves initiate the review, at a

time when they feel that they need it. Earlier results from this trial

have already been published, and this analysis at 6 years confirms the

findings, he said. Patients in both groups fared as well clinically and

psychologically, but the patient-initiated review group was more

satisfied with care and requested fewer appointments, allowing savings

of around 30%. [1]

Standard care often fails the patient, Kirwan told the meeting. To

illustrate the point, he showed a slide showing 1 patient's disease

history, with the familiar peaks and troughs showing disease flare and

periods of quiescence. But when he superimposed on it a schedule of

hospital appointments that the patient had kept, it showed that these

visits rarely coincided with periods of disease flare, and he pointed

out that during 1 particularly bad period, the patient was unable to get

an appointment for 6 weeks. " We failed this patient, as we weren't

seeing and helping her at the times that she needed us most, " Kirwan

commented, and the nods of recognition from other clinicians in the

audience showed that is a common scenario, he added.

To better tailor the specialist care to the needs of the patients,

Kirwan and colleagues tried out a policy of patient-initiated review.

The patients themselves and their general practitioners were given

access to a telephone help line, staffed by a nurse, and were guaranteed

to be seen by a rheumatologist within 10 working days. " At first, we

were concerned that we might be swamped by patients wanting to see us,

or conversely, that patients would stop coming in at all, " Kirwan told

the meeting, but neither happened.

The study began with 209 RA patients randomized to standard care or

direct access. After 6 years, only 120 patients remained; 30 patients

had died, and the remaining 59 who dropped out had a longer duration of

disease than those who remained, Kirwan commented.

Median scores (from 0 to 72 months) showed no difference between the 2

groups for change in clinical status (disability, pain, patient opinion,

early-morning stiffness, inflammatory indices, knee range of movement,

grip strength, bony erosions) or in psychological status (anxiety,

depression, happiness, self-efficacy). In addition, biochemical measures

such as C-reactive protein and hemoglobin were similar between the

groups.

However, the patients in the direct-access group had fewer hospital

appointments. During the 6 years, they had a median of 8 reviews by the

rheumatologist and 8 visits to the GP, while the standard care group had

13 visits to the rheumatologist and 9 visits to the GP. The difference

in the rheumatologist review was significant (p<0.0001), Kirwan

commented, and translates into a considerable saving.

Using published cost data, his group calculated the median cost per

patient in the direct-access group as £221/year, which is 35.4% less

than the median cost of £342/year in the standard-care group. Even when

the cost of employing a nurse part-time to run the help line is included

in the equation, the median costs of the direct access group is still

27% lower.

In addition, the patients in the direct-access group were more satisfied

with the care that they were receiving than those in the standard-care

group, who recorded a 10% decrease in satisfaction and confidence in the

system over the 6 years of the study. " Patient-initiated review has

major implications for service delivery, " Kirwan concluded. A recent

survey of UK rheumatologists found that rheumatoid arthritis takes up

about half the workload, so any reduction in the time spent on these

patients will have a considerable impact, allowing more time for

patients with other conditions.

Although Kirwan acknowledged that the data need to be replicated in

other settings, he told the meeting that his clinic has already changed

over to the direct-access system for all patients with established RA.

The system in use is the same as in the trial, with 2 additionsthe team

added a 1-hour education session for the patient at the very beginning

and introduced a catch into the system where patient are called in for a

review if they haven't been seen for 2 years.

Source

Kirwan JR, Hewlett S, K, et al. RCT of

patient-initiated review versus regular physician-initiated follow-up in

rheumatoid arthritis, extended to 6 years. Presented at: EULAR 2004;

Berlin, Germany; June 9-12, 2004. Abstract OP0060.

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org