BMJ  2005;330:171 (22 January), doi:10.1136/bmj.38265.493773.8F (published 16 November 2004)

Paper

Patient initiated outpatient follow up in rheumatoid arthritis: six year randomised controlled trial

¹ University of Bristol Academic Rheumatology Unit, Bristol Royal Infirmary, Bristol BS2 8HW, ² Faculty of Health and Social Care, University of the West of England, Bristol BS16 1DD, ³ University of Bristol Institute of Child Health, UBHT Education Centre, Bristol Royal Infirmary, Bristol, ⁴ Air Balloon Surgery, Bristol BS5 7PD

Objectives To determine whether direct access to hospital review initiated by patients with rheumatoid arthritis would result in improved clinical and psychological outcome, reduced overall use of healthcare resources, and greater satisfaction with care than seen in patients receiving regular review initiated by a rheumatologist.

Design Two year randomised controlled trial extended to six years.

Setting Rheumatology outpatient department in teaching hospital.

Participants 209 consecutive patients with rheumatoid arthritis for over two years; 68 (65%) in the direct access group and 52 (50%) in the control group completed the study (P = 0.04).

Main outcome measures Clinical outcome: pain, disease activity, early morning stiffness, inflammatory indices, disability, grip strength, range of movement in joints, and bone erosion. Psychological status: anxiety, depression, helplessness, self efficacy, satisfaction, and confidence in the system. Number of visits to hospital physician and general practitioner for arthritis.

Results Participants were well matched at baseline. After six years there was only one significant difference between the two groups for the 14 clinical outcomes measured (deterioration in range of movement in elbow was less in direct access patients). There were no significant differences between groups for median change in psychological status. Satisfaction and confidence in the system were significantly higher in the direct access group at two, four, and six years: confidence 9.8 v 8.4, 9.4 v 8.0, 8.7 v 6.9; satisfaction 9.3 v 8.3, 9.3 v 7.7, 8.9 v 7.1 (all P < 0.02). Patients in the direct access group had 38% fewer hospital appointments (median 8 v 13, P < 0.0001).

Conclusions Over six years, patients with rheumatoid arthritis who initiated their reviews through direct access were clinically and psychologically at least as well as patients having traditional reviews initiated by a physician. They requested fewer appointments, found direct access more acceptable, and had more than a third fewer medical appointments. This radical responsive management could be tested in other chronic diseases.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    StumbleUpon    Technorati    What's this?

Relevant Article

Patients with direct access fix fewer outpatient appointments
BMJ 2005 330: 0. [Full Text]

This article has been cited by other articles:

• Vliet Vlieland, T. P M, Huizinga, T. W J (2009). Quality indicators in rheumatology: valid for whom?. Ann Rheum Dis 68: 1797-1799 [Full text]  
• KIRWAN, J. R., NEWMAN, S., TUGWELL, P. S., WELLS, G. A. (2009). Patient Perspective on Outcomes in Rheumatology -- A Position Paper for OMERACT 9. The Journal of Rheumatology 36: 2067-2070 [Abstract] [Full text]  
• Luqmani, R., Hennell, S., Estrach, C., Basher, D., Birrell, F., Bosworth, A., Burke, F., Callaghan, C., Candal-Couto, J., Fokke, C., Goodson, N., Homer, D., Jackman, J., Jeffreson, P., Oliver, S., Reed, M., Sanz, L., Stableford, Z., Taylor, P., Todd, N., Warburton, L., Washbrook, C., Wilkinson, M., on behalf of the British Society for Rheumatology, (2009). British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (after the first 2 years). Rheumatology (Oxford) 48: 436-439 [Full text]  
• PINCUS, T. (2009). Dr. Pincus replies. The Journal of Rheumatology 36: 443-444 [Full text]  
• Rosenthal, T. C. (2008). The Medical Home: Growing Evidence to Support a New Approach to Primary Care. J Am Board Fam Med 21: 427-440 [Abstract] [Full text]  
• Scott, D. L., Symmons, D. P. M. (2008). The role of specialists in managing established rheumatoid arthritis. Rheumatology (Oxford) 47: 237-238 [Full text]  
• Bukhari, M., Bamji, A. N., Deighton, C. (2007). Is it ever appropriate to discharge patients with rheumatoid arthritis?. Rheumatology (Oxford) 46: 1631-1633 [Full text]  
• Hill, J. (2007). Rheumatology nurse specialists--do we need them?. Rheumatology (Oxford) 46: 379-381 [Full text]  
• Pace, A. V., Dowson, C. M., Dawes, P. T. (2006). Self-referral of symptoms (SOS) follow-up system of appointments for patients with uncertain diagnoses in rheumatology out-patients. Rheumatology (Oxford) 45: 201-203 [Abstract] [Full text]  
• (2005). Is Patient-Initiated Outpatient Follow-Up a Good Idea?. JWatch General 2005: 5-5 [Full text]  

Rapid Responses:

Read all Rapid Responses

Patient-initiated follow-up in RA - the pitfalls

Andrew N Bamji
bmj.com, 24 Jan 2005 [Full text]

Limitations on generalizibility of remarkble study on new strategy of treatment in patients with rheumatoid arthritis

Willem F Lems, et al.
bmj.com, 4 Mar 2005 [Full text]

Look before you leap!

John Ryan, et al.
bmj.com, 17 Jun 2005 [Full text]

Online poll

Find out more on doc2doc >>