Nurse-led programmes can help to identify comorbidities and train patients to monitor their disease activity, improving clinical outcomes.
Rheumatoid arthritis is a chronic inflammatory disease that affects a person’s joints, causing pain and disability. People with rheumatoid arthritis have an increased risk of suffering from comorbidities (other diseases) such as heart attacks, heart failure or stroke. This is because the inflammation involved in rheumatoid arthritis can have an effect on other systems in the body, as well as the joints. People with rheumatoid arthritis are also more likely to suffer from infections, and it is recommended that they receive vaccinations to protect them against pneumococcal diseases and ‘flu. In France, patients receiving biologic drugs are usually attending an educational programme to make sure that they use their medicine properly and understand the risks and side effects, such as injection site reactions or increased risk of infection. A key topic is making sure that all vaccines are up to date in order to prevent infections.
WHAT DID THE AUTHORS HOPE TO FIND?
The authors hoped to find out whether having a special programme run by a nurse could help to identify comorbidities in patients with rheumatoid arthritis or support patients in self-assessment of their disease.
WHO WAS STUDIED?
The study included 967 patients aged between 18 and 80 who had stable rheumatoid arthritis for at least 3 months.
HOW WAS THE STUDY CONDUCTED?
This was a prospective randomised trial, which means that consecutive patients who agreed to be included were assigned by chance to one of two nurse-led groups – either the comorbidity programme or the disease self-assessment group. Using chance in this way means that the groups will be similar and will allow the variable under investigation to be compared objectively. The study took place at 20 hospitals across France over 6 months. In the comorbidities group, the nurses recorded pre-existing diseases other than rheumatoid arthritis, checked for risk factors such as hypertension or high cholesterol, and implemented any relevant recommendations and necessary treatment. In the self-assessment group, patients watched a video and the nurse taught them how to calculate their disease activity score (DAS). Patients were asked to calculate and record their score at least monthly and to discuss the results with their rheumatologist.
WHAT WERE THE MAIN FINDINGS OF THE STUDY?
The comorbidity part of the study confirmed that patients with rheumatoid arthritis typically have many risk factors for cardiovascular disease, such as high blood pressure and cholesterol. Additionally, despite the fact that the majority of the patients had previously participated in an educational programme, the nurse-led programme dramatically improved the proportion of vaccinated patients. The self-assessment part of the study found that patient assessment of disease activity is possible, and suggested that allowing patients to calculate this themselves enabled better discussion with their rheumatologist and subsequent adjustment and optimisation of their treatment.
ARE THESE FINDINGS NEW?
The usefulness of a nurse-led programme for comorbidities has been shown before, but this study is novel in that it used a much shorter visit time than the previous studies. The self-assessment findings are new and may provide a very innovative way for doctors to manage patients with rheumatoid arthritis.
HOW RELIABLE ARE THE FINDINGS?
There are some limitations in the study. The duration was quite short and did not allow the authors to investigate all clinical outcomes. It was also difficult to recruit and train specialist rheumatology nurses. This might mean that there is some bias in the results as patients were included only from hospital-based rheumatologyclinics. We also do not know how many people declined the invitation to participate in the study, which might be important when trying to work out if nurse-led programmes could benefit all patients.
WHAT DO THE AUTHORS PLAN ON DOING WITH THE INFORMATION?
A longer 3-year study is underway to see whether the results can be sustained, and also to check whether the self-assessment programme might help to improve patients’ function in the long term.
WHAT DOES THIS MEAN FOR ME?
Nurse-led programmes help to improve patient care. The results of this study may encourage doctors and patients to arrange and attend annual reviews to systematically check for comorbidities and risk factors. In the future some clinics may use a self-assessment programme, and you may be asked to help to record and monitor your own disease activity.
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Date summary prepared: September 2015
Summary based on research article published on: 28th May 2014
From: Dougados, M. et al. Impact of a nurse-led programme on comorbidity management and impact of a patient self-assessment of disease activity on the management of rheumatoid arthritis: results of a prospective, multicentre, randomised, controlled trial (COMEDRA). Ann Rheum Dis 2015;74:1725–33. doi:10.1136/ annrheumdis-2013-204733LaySummary
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