The first systematic review to assess the effect of nurse-led care in patients with rheumatoid arthritis (RA) on multiple dimensions of quality provided evidence that, compared with other models, nurse-led care is effective, acceptable, and safe.1
The care of patients with rheumatic diseases has historically been provided by fellowship-trained rheumatologists. However, there is a significant shortage of rheumatologists in the United States, and the trend is worsening. In 2015, there were 5595 rheumatologists in the United States, a number that, according to supply and demand modeling, will drop by 31% to 3455 by the year 2030.2 The reduction in the rheumatologist workforce is expected to coincide with an increased demand for rheumatic care as the US population ages and become more female-predominant.
According to results from a 2015 survey involving 564 adult rheumatology patients, more than one-third had to wait longer than 4 months to see a rheumatologist after onset of their symptoms, and one-fifth reported that they were unable to obtain routine appointments with rheumatologists within recommended timeframes.3 The expanded use of midlevel providers such as physician assistants and nurse practitioners in rheumatology may provide a solution to gaps in the rheumatology workforce.4
Nurse-led care is defined as “a practice in which nurses (eg, registered nurses, clinical nurse specialists, or nurse practitioners) working in collaboration with physicians and other team members have their own patients for whom they provide services such as monitoring, educating, and support.”1,5 The models of nurse-led care included in the review varied. In all of the models, the nurses provided patient education, while only 2 of the models specified that the nurse was responsible for suggesting or initiating medication changes.
Review co-author James A. Rankin ACNP, PhD, professor and nurse practitioner at the University of Calgary, Alberta, Canada, told Rheumatology Advisor that the patients selected for nurse-led care as provided by registered nurses are typically stable and uncomplicated, while advanced practice nurses may independently manage patients with more complicated disease. He noted that the review did not distinguish between levels of nursing providers. “We have to better define what we mean by nurse-led care. Researchers in this area should ideally make the distinction between the care provided [by] registered nurses and the care provided by nurse practitioners.”
To perform the review, Stephanie Garner, MD, MD, MSc, Department of Medicine, McMaster University, Hamilton, Ontario, Canada, and colleagues searched the medical literature for articles on nurse-led care in patients with RA that included 1 or more quality measures in their outcomes.1 Of these studies, 10 ultimately met the inclusion criteria for the review. The researchers then mapped the measures of quality of care used as outcomes in the studies to the Alberta Quality Matrix for Health, a comprehensive framework for quality of care. The Alberta Quality Matrix for Health includes 6 measures: acceptability (the degree to which services are patient-centered), accessibility (the level of effort required to access services) appropriateness (evidence-based practice in accordance with patient needs and preferences), effectiveness (efficacy in providing optimal outcomes), efficiency (prudent use of resources), and safety (use of processes designed to reduce risk).6
The authors concluded that evidence was not sufficient to determine the efficiency, accessibility, and appropriateness of nurse-led care. The efficiency domain was of special interest, given the resource constraints in the current healthcare environment. Lower costs are frequently used as a justification for nurse-led care. Although 3 out of 4 studies provided some evidence that the cost of nurse-led care was the same or lower than other models, nurse-led care was also associated with increased resource consumption, including longer appointment times and more time spent on physician conferrals and re-referrals. “To account for this and to understand whether increased resource consumption within [nurse-led care] was worth an additional health benefit, studies on the cost-effectiveness of [nurse-led care] should incorporate the cost of the nurses’ time and conferral/re-referral time,” wrote the researchers.
The review did not include studies on nurse-led care that aggregated the inflammatory arthritides (RA, psoriatic arthritis, juvenile idiopathic arthritis, ankylosing spondylitis, and undifferentiated polyarthritis) or that examined nurse-led models for monitoring biologic therapy in patients with those conditions because they did not report disaggregated results in patients with RA. However, Dr Garner and colleagues noted that the results of these studies comported with their own findings.
“This concept of nurse practitioners and physician assistants working together with physicians —sometimes independently, often collaboratively with physicians — helping to meet the needs of patients with rheumatic disease, including [RA], is becoming much more common. The numbers have increased significantly over the last couple of decades because of the recognition that these health professionals can contribute in a team that provides quality care for persons with rheumatic disease,” said Benjamin J Smith, MPAS, PA-C, DFAAPA, a physician assistant in rheumatology at the McIntosh Clinic, PC in Thomasville, Georgia, in an interview with Rheumatology Advisor. He noted that nurse-led care in rheumatology is consistent with a growing consensus that healthcare professions should be empowered to practice to the highest degree of their licensure and the highest degree of their training.7 “When that happens, quality care should follow suit.”
Interviews were lightly edited for clarity.
- Garner S, Lopatina E, Rankin JA, Marshall DA. Nurse-led care for patients with rheumatoid arthritis: a systematic review of the effect on quality of care. J Rheumatol. 2017;44(6):757-765.
- Battafarano D, Monrad S, Fitzgerald J, et al. 2015 ACR/ARHP Workforce Study in the United States: adult rheumatologist supply and demand projections for 2015-2030 [published online February 5, 2018]. Arthritis Rheumatol. doi:10.1002/acr.23518
- Monrad S, Imundo L, Battafarano D, Ditmyer M. Access to care: the patient perspective from the 2015 ACR/ARHP Workforce Study [abstract]. Arthritis Rheumatol. 2016;68(suppl 10).
- Solomon DH, Bitton A, Fraenkel L, Brown E, Tsao P, Katz JN. Roles of nurse practitioners and physician assistants in rheumatology practices in the US. Arthritis Care Res (Hoboken). 2014;66(7):1108-1113.
- Ndosi M, Vinall K, Hale C, Bird H, Hill J. The effectiveness of nurse-led care in people with rheumatoid arthritis: a systematic review. Int J Nurs Stud. 2011;48(5):642-654.
- Health Quality Council of Alberta. The Alberta Quality Matrix for Health. http://hqca.ca/about/how-we-work/the-alberta-quality-matrix-for-health-1/. Accessed September 25, 2018.
- Cesta T. Case Management insider. The top ten mistakes you may be making in your case management department: Part 1. Hosp Case Manag. 2015;23(6):71-74.