Engaged Patients Use Less Healthcare

Patient self-monitoring of disease-modifying anti-rheumatic drug (DMARD) therapy can lead to significant reductions in health care use, while maintaining clinical and psychosocial well-being.

Self-monitoring is used in many long-term chronic conditions, and patient-administered tools are available to monitor psoriatic arthritis (PsA) activity. Many arthritis patients would welcome the opportunity to decide how frequently they need a check-up and to take responsibility for organizing their own DMARD monitoring appointments.

A recent systematic review found that patient-centered services for rheumatoid arthritis (RA) patients could minimize costs without reducing the quality of health care or patient outcomes, and without compromising patient clinical or psychological well-being.

“While the traditional rheumatology system assumes that patients need to be seen on a regular basis as decided by clinicians, patient-initiated services allow the patient to access rheumatology services much like they do in primary care,” says lead author Hayley McBain of the School of Health Sciences, City  University London, London, UK.

Previous patient-initiated services have used symptoms as triggers for contact with rheumatology clinics. McBain and colleagues conducted a study using a patient-initiated DMARD self-monitoring follow-up service in which patients monitored their symptoms and blood test results and used this information to initiate care from their clinical nurse service.

The two-arm, single-center, randomized controlled trial assessed 100 adults with either RA or PsA on a stable dose of methotrexate. The patients were randomly assigned to usual care (48 patients) or the patient-initiated service (52 patients). The self-monitoring patients were trained how to understand and interpret their blood tests and use this information to initiate care from their clinical nurse specialist. The primary outcome was the number of outpatient visits to the clinical nurse specialist.  [[{"type":"media","view_mode":"media_crop","fid":"50533","attributes":{"alt":"©AlexanderRaths/Shutterstock.com","class":"media-image media-image-right","id":"media_crop_5794634390196","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6170","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"©AlexanderRaths/Shutterstock.com","typeof":"foaf:Image"}}]]

Disease activity was measured using the Disease Activity Score in 28 joints or Psoriatic Arthritis Response Criteria (PsARC). Pain and fatigue were measured with a visual numeric scale and the Health Assessment Question-II, Hospital Anxiety and Depression Scale and SF12 were completed to assess disability, mood and quality of life, respectively.

The self-monitoring patients conducted routine blood monitoring every 4–6 weeks depending on their dose of methotrexate, and continued to receive routine care from their rheumatologist with outpatient appointments every 6 months. The controls received standard care consisting of a blood test every 4–6 weeks and optimally outpatient appointments with their clinical nurse specialist every 3 months and rheumatologist every 6 months.

The results show that the patient-initiated DMARD self-monitoring service was associated with 54.55% fewer visits to the clinical nurse specialist, 6.8% fewer visits to the rheumatologist, and 38.8% fewer visits to the general practitioner (GP) as compared with control patients. There was no association between trial arm and any of the clinical or psychosocial outcomes.

“After brief training patients with RA and PsA can successfully understand and interpret their blood test results and use this information along with reports of their symptoms and side effects to initiate appropriate reviews with their rheumatology nurse. Participants in the intervention group had fewer hospital appointments with their nurse specialist with no detrimental effects to their clinical status and with no increase in visits to the rheumatologist or GP. This model of care offers a viable alternative for established RA and PsA patients on DMARD therapy,” says McBain.

There was a reduction in attendance in primary and secondary care services, but this was not inferior to standard practices in regards to disease activity, pain, fatigue, quality of life, or mood. “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 researchers state.

The significant reduction in nurse specialist visits may be an indication that patients were simply in the habit of making follow-up appointments in DMARD monitoring clinics and a proportion of these visits may not be clinically necessary, they state.

The researchers were encouraged by the reduction in GP visits since this “indicates that patients were not redirecting their care, but felt better able to manage their arthritis at home themselves rather than seek help in primary care,” possibly because they knew they had rapid access to a nurse specialist.

More analyses would be needed to determine whether these reductions translate into cost savings.

Two self-monitoring patients returned to usual care because they were unable to accurately initiate care when their blood test results were either outside of the normal range or had changed significantly since their last blood test. At the final blood test, almost 90% of patients were safely initiating care from their nurse specialist, the researchers note.

References:

Burkhard F Leeb, Pia M Haindl, et al.

"Patient-centered psoriatic arthritis (PsA) activity assessment by Stockerau Activity Score for Psoriatic Arthritis (SASPA)," 

BMC Musculoskeletal Disorders

. DOI: 10.1186/s12891-015-0512-7. April 1, 2015. Neame R, Hammond A, Deighton C.

"

Need for information and for involvement in decision making among patients with rheumatoid arthritis: a questionnaire survey," 

Arthritis and Rheumatology.

 April 15, 2005. PMID: 15818715 DOI: 10.1002/art.21071 Rebecca Whear , Abdul-Kareem Abdul-Rahman, et al.

"The Clinical Effectiveness of Patient Initiated Clinics for Patients with Chronic or Recurrent Conditions Managed in Secondary Care: A Systematic Review,"

PLOS One

. October 7, 2013 http://dx.doi.org/10.1371/journal.pone.0074774 Burkhard F Leeb, Pia M Haindl, et al. 

"Patient-centered psoriatic arthritis (PsA) activity assessment by Stockerau Activity Score for Psoriatic Arthritis (SASPA)," 

BMC Musculoskeletal Disorders.

April 1, 2015. DOI: 10.1186/s12891-015-0512-7