Patient-initiated services that incorporate self-monitored disease-modifying antirheumatic drugs (DMARD) therapies have been linked to significant reductions in use of healthcare services and well-maintained clinical and psychological well being in patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA), according to research published in the Annals of Rheumatic Disease

Hayley McBain, MSc, PhD, School of Health Sciences, City University London, and colleagues, conducted a 2-arm, single-center, randomized controlled trial to asses the superiority of patient-initiated DMARDs in relation to healthcare use and clinical and psychological outcomes.

High Yield Data Summary

  • Patient-initiated DMARD therapy was linked to 6.8% fewer visits to rheumatologists and 38.8% fewer visits to general practitioners

Participants included 100 adults diagnosed with either RA or PsA, who were undergoing treatment with a stable does of methotrexate (MTX). Patients were randomly assigned to receive either usual care, or the patient-initiated service.


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Intervention participants were trained to understand and interpret their blood tests, and to use that data to initiate care via a clinical nurse specialist (CNS). Primary outcome was the number of outpatient visits to the CNS during the trial period.

Patient-initiated DMARD self-monitoring was associated with 54.55% fewer visits to the CNS (p<.001), 6.8% fewer visits to the rheumatologist (P=.23) and 38.8% fewer visits to the general practitioner (GP) (P=.07), when compared to control participants.

Patients in this group also participated in a total of 231 telephone consultations with CNS (mean per participant, 4.43), and all intervention participants required at least 1 telephone consultation during the length of the trial. 

Summary & Clinical Applicability

“The primary findings of this [randomized control trial] indicated that this novel model of care led to significant reductions in outpatients visits to the CNS and a reduction in visits to the GP, while maintaining the regularity with which patients saw their rheumatologist,” Dr McBain noted. Despite this reduction in attendance in primary and secondary care services, this new service was not inferior to standard practices.

“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 MTX, and are consistent with previous studies of patient-initiated services in the UK and Denmark.”

Limitations & Disclosures

Study limitations relate to the rates of refusal and study methodology. No data surrounding the length of each telephone call to a CNS was available, which, the researchers note, is an important factor “when considering the capacity to take on such activities, particularly as many rheumatology nurses are being asked to take on extra work that nurses themselves have described as ‘increased activity without increased resources.’”

Data were also not available regarding the number of phone consultations within the control group.

This study was funded by UCLH Charity, specifically the Otto Beit Fund and the Shipley-Rudge Fund, for which Michael Shipley is a principal donor. 

Reference

McBain H, Shipley M, Olaleye A, 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. 2016;75:1343-1349; doi: 10.1136/annrheumdis-2015-207768

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