RESEARCH - How to improve DAS28 use in daily clinical practice? - a pilot study of a nurse-led intervention

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Rheumatology Advance Access published online on January 18, 2010

Rheumatology, doi:10.1093/rheumatology/kep407

How to improve DAS28 use in daily clinical practice?—a pilot study of

a nurse-led intervention

T. C. van Hulst1,2, Marjonne C. W. Creemers2, Jaap Fransen2,

C. Li3, Grol1, Marlies E. J. L. Hulscher1 and Piet L. C.

M. van Riel2

1Department of Rheumatology, Scientific Institute for Quality of

Healthcare, 2Department of Rheumatology, Radboud University Nijmegen

Medical Centre, Nijmegen, The Netherlands and 3Department of Physical

Therapy, University of British Columbia and Arthritis Research Centre

of Canada, Vancouver, British Columbia, Canada.

Abstract

Objectives. To determine whether DAS28 measurements by a specialized

nurse, before the rheumatologist visit, in combination with the advice

to rheumatologists to reach a DAS28 3.2, had beneficial effects on

disease activity and medication prescription in patients with RA and

to explore possible predictors for variation in medication changes and

reasons for non-adherence to the advice to reach a DAS28 3.2.

Methods. In this pilot study, rheumatologists were randomized to

‘usual care’ (n = 3) or DAS28 measurement by a nurse prior the

rheumatologist visit (n = 4). In the usual care group, the DAS28 was

measured but not provided to rheumatologists. Mixed model analyses

were used for analysing between-group differences and for the

prediction model. Rheumatologists in the intervention group were asked

to provide reasons in cases of non-adherence to the advice.

Results. After 18 months, DAS28 was reduced by – 0.69 and – 0.66 (P =

0.70) in, respectively, the intervention (144 patients) and the usual

care (104 patients) groups. In the intervention group, medication was

changed by rheumatologists in 35% of the visits with a DAS28 > 3.2; in

the usual care group this was 33% (P = 0.99). Baseline DAS28 (OR 1.6;

P0.0001) and HAQ (OR 1.3; P = 0.03) were positively related to a

medication change. The most frequently mentioned reason not to change

medication was patient refusal (26%).

Conclusions. DAS28 measurement by a nurse was as effective as usual

care; however, this intervention without protocolized treatment

adjustments is not sufficient to lead to a considerable reduction in

disease activity compared with trials with protocolized treatment

adjustments.

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http://rheumatology.oxfordjournals.org/cgi/content/abstract/kep407v1?papetoc

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