Nurse-Led Programs Improve Outcomes in Rheumatoid Arthritis

Alice Goodman

June 18, 2013

MADRID, Spain — When nurses screen patients with rheumatoid arthritis (RA) for comorbidities and teach them the skills to self-assess disease activity, outcomes improve, according to 2 analyses of data from the COMEDRA study.

"Rheumatologists are not screening for comorbidities in their patients," explained Laure Gossec, MD, from Pierre-and-Marie-Curie University and Pitié-Salpétrière Hospital in Paris, France.

The COMEDRA study involved 488 patients with stable RA attending 1 of 20 treatment centers in France. Patients were randomly assigned to a nurse-led screening program for comorbidities or to a nurse-led program that taught disease self-management.

The investigators first evaluated outcomes in the nurse-led comorbidity screening program; patients in the self-management program served as the control group for the analysis.

Dr. Gossec presented the results to reporters attending a news conference here at the European League Against Rheumatism (EULAR) Congress 2013.

In the comorbidity screening program, nurses screened patients for cardiovascular disease, infection, cancer, and osteoporosis. They made recommendations for interventions — such as medications for osteoporosis or for lowering lipid levels or blood pressure, vaccinations, dual-energy x-ray absorptiometry scans, and mammography screening — which the rheumatologist could either consider or reject.

The investigators found that rheumatologists ordered twice as many medical interventions per patient in the screening group as in the control group (4.54 vs 2.00; < .001).

Patients with RA have high rates of comorbidity that often go undetected.

"Patients with RA have high rates of comorbidity that often go undetected. Screening by nurses is feasible, and our results show it is valuable. Screening each patient took 90 minutes. Rheumatologists need to recognize the value of nurse-led programs that align with EULAR's projects to promote nurse involvement in patient management," said Dr. Gossec.

The investigators then evaluated the effect of a nurse-led self-assessment program for disease management, in which nurses taught patients to monitor their disease activity. Patients in the comorbidity screening program served as the control group for this analysis.

"Treat-to-target and EULAR recommendations suggest that we promote self-management skills so that patients can regularly assess their disease activity. Nurses can teach patients these skills. Within 6 months, the assessments that patients made actually resulted in many changes in treatment," said Susan Oliver, RGN, clinical nurse specialist in rheumatology at North Devon Healthcare Trust in the United Kingdom.

She presented the results of the self-assessment program here at the meeting.

Multidisciplinary Approach

Nurses used lectures and videos to teach patients to measure their inflamed joints and to record their disease activity score in 28 joints (DAS28) in a booklet, which they then brought to clinic appointments to share with their rheumatologists, she explained.

Oliver reported that DMARD therapy was changed more often in the self-assessment group than in the control group (17.2% vs 10.2%; = .0012).

"We know the treat-to-target regimen is based on the DAS score. If patients understand how that works, it makes it easier for them to comply and become partners in treatment," she explained.

"COMEDRA demonstrates the utility and benefit of a multidisciplinary approach to the management of patients with RA. This is more effective management because it empowers patients," said Maya Buch, MD, from the University of Leeds, United Kingdom, who was asked by Medscape Medical News to comment on the analyses.

Dr. Buch noted that nurse-led programs for RA have taken hold in the United Kingdom to varying degrees. "In many practices, rheumatologists recognize that if we want to treat to target, we need the input of nurses," she said. "It is complementary to what we rheumatologists do."

Dr. Gossec, Ms. Oliver, and Dr. Buch have disclosed no relevant financial relationships.

European League Against Rheumatism (EULAR) Congress 2013: Abstracts P0284 and OP0234. Presented June 14, 2013.


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