Arthritis Tx Self-Monitoring Can Cut Healthcare Use

Patient safety and disease control were not compromised

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• by Pauline Anderson
  Contributing Writer, MedPage Today

Action Points

• A model of care in which patients with rheumatoid arthritis or psoriatic arthritis monitored their own therapy reduced the use of outpatient services by about half while maintaining clinical and psychosocial well-being.
• Note that despite fewer appointments, this new service was not inferior to standard practice regarding disease activity, pain, fatigue, quality of life, or mood.

A model of care in which patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA) monitored their own therapy reduced the use of outpatient services by about half while maintaining clinical and psychosocial well-being, according to a U.K. study.
Compared with those in the control group, the intervention group initiated 54.6% fewer appointments with their clinical nurse specialist (P<0.0001) compared with controls, reported Stanton Newman, DPhil, of the School of Health Sciences at City University in London, and colleagues.
In addition, they attended 6.8% fewer rheumatologist appointments compared with control group participants, and initiated 38.8% fewer arthritis-related primary care appointments, although these latter results weren't statistically significant (P=0.23 and P=0.07, respectively), the researchers reported in Annals of the Rheumatic Diseases.
Recent decades have seen a considerable increase in the utilization of rheumatology healthcare services, as drug therapy has become more complex and monitoring needs more demanding. Some relief has been seen with the introduction of nurse-led care, but the system remains overburdened and patients continue to experience lengthy waiting times for appointments.
One approach to minimizing this could be through reducing unnecessary appointments, "through the use of patient-initiated services, in which patients are encouraged to take an active role in initiating their own care," Newman and colleagues noted.
"This approach is supported by more than 40% of patients with arthritis, who feel they should be able to decide how frequently they need a check-up and want to take responsibility for organizing their own disease-modifying anti-rheumatic drug [DMARD] monitoring appointments," they wrote.
To explore the feasibility and safety of this, the researchers enrolled 100 patients with RA or PsA whose treatment was stable, defined as at least 6 months of methotrexate plus another 3 months if patients were receiving a self-injecting anti-tumor necrosis factor agent.
These patients were randomized to either an intervention or control group. Those in the intervention group received training on identifying safe or normal ranges of relevant blood levels, side effects, and symptoms. They learned to interpret markers of inflammation (C-reactive protein and erythrocyte sedimentation rate), hemoglobin, white blood cell counts, liver function tests, platelets, and neutrophils.
The intervention group continued to receive routine care from their rheumatologists and routine blood monitoring every 4 to 6 weeks depending on their methotrexate dose.
The control group received standard care, which typically consisted of a blood test every 4-6 weeks, and outpatient appointments with their clinical nurse specialist every 3 months and rheumatologist every 6 months.
The intervention group had a total of 231 telephone consultations, of which 74.7% were initiated appropriately by the patient in response to their lab results, and 25.3% were initiated by the clinical nurse specialist when abnormal blood results were detected but not acted on by the patient. Two patients in the intervention group who were deemed unable to safely self-monitor were removed from the trial.
Despite fewer appointments, this new service was not inferior to standard practice regarding disease activity, pain, fatigue, quality of life, or mood, the study found.
"These results suggest that this model of care could be implemented without compromising the clinical or psychological well-being of patients with either RA or PsA on methotrexate," the authors wrote.
It could be that a large proportion of follow-up appointments in nurse-led DMARD monitoring clinics are made habitually, and may not be clinically necessary, they added.
A parallel reduction in primary care visits is "encouraging" as this indicates that patients weren't redirecting their care but felt better able to manage their arthritis themselves, the authors commented.
Further studies are needed to understand how these reductions translate into cost saving.
A limitation of the study was that data were not available on the length of each phone call, the number of calls control group participants made to the nurse helpline, or the use by any study participant of services such as physiotherapy, occupational therapy, or podiatry.
Moreover, a third of eligible patients did not consent to the study, preferring to have regularly scheduled face-to-face appointments with their clinical nurse specialist.

The study was funded by University College London Hospital Charity's Otto Beit Fund and the Shipley-Rudge Fund. One co-author disclosed a relevant relationship with the Shipley-Rudge Fund.
Newman and co-authors disclosed no relevant relationships with industry.

• Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

last updated 08.28.2015

• Primary Source

  Annals of the Rheumatic Diseases

  Source Reference: McBain H, et al "A patient-initiated DMARD self-monitoring service for people with rheumatoid or psoriatic arthritis on methotrexate: a randomized controlled trial" Ann Rheum Dis 2015; DOI: 10.1136/annrheumdis-2015-207768.