Re: Shared medical appointments: further experience in a rheumatology department
Further to your editorial September 23rd 2017, regarding shared medical appointments (BMJ 2017;358:j4043), we have experience of a number of differing models of shared medical appointments within a rheumatology setting, in our hospital.
Longitudinal Regional data has confirmed that the Rheumatology outpatient follow up burden doubles every 5 years. NICE guidelines require that patients with a new diagnosis of an inflammatory arthritis start their Disease Modifying therapies (DMARDs) within 3 weeks of diagnosis. DMARDs and Biologics require regular monitoring and review for safety and efficacy.
Finances in the NHS are tight, thus additional staffing cannot be provided to manage this increase in work, demanding a novel approach be instituted to initiate DMARD and Biologic therapies quickly.
For nearly ten years, our department has extensive experience developed a range of shared medical appointments (SMAs) or group clinics.
Group DMARD clinics
Initially, we began starting patients on DMARDs using SMAs. We run 3 clinics per week to start medications such as Methotrexate, Sulphasalazine and Leflunomide, in groups of 6 patients; the clinic room determining the size of the group. The decision to start a drug is discussed with the patient by the consultant in a standard one-one clinic, written information is given and safety investigations were requested. Once these results are through, the patient is invited to the group DMARD clinic.
Patients are provided with the first six weeks’ supply of their DMARDs from the hospital pharmacy. A shared care agreement is sent to the GP and a follow up letter sent to the patients reminding them that both monitoring and further prescribing is undertaken by their GP.
We audited our practice in 2015. Of 607 patients starting DMARDs, 60% started in a group clinic, 27% were started via a telephone consultation. Only 8% requested an individual face-face consultation with the specialist nurses. Time saved, over one year, was equivalent of 1664 rheumatology nurse appointments (of 30 minutes each), allowing the nurses to see more patients with urgent problems.
Patients were equally satisfied with this new arrangement as they were with a traditional one-one consultations with a specialist nurses in the initiation of their drug therapy. This level of patient satisfaction has continued at the same high level (4.7/5) since 2008.
Average time to starting DMARDs on the above regime was 10 days. Prior to this change in protocol, the average time to start a DMARD in our clinic was > 8 weeks.
Group Biologic Clinics
Recently, we have undertaken a similar approach, to prescribe and monitor patients starting Biologic therapies, such as anti-TNF therapies. We have undertaken this to establish patients onto their Biologic therapy as quickly as possible, given the severity of their disease. These patients cannot afford any delays.
Group Education MDT Clinic
Since January 2017, the department has run group education for patients with newly diagnosed Rheumatoid Arthritis (RA) and Psoriatic Arthritis (PsA), involving the whole rheumatology multi-disciplinary team (MDT). Previously, these patients were invited to see the rheumatology podiatrist, physiotherapist and occupational therapist on a one-one basis, but unfortunately this was time intensive and there were high DNA rates.
Now, up to 18 people with a new diagnosis of RA or PsA, are invited for a monthly group education session. This comprises 5 x 30 minute talks with question and answer sessions, lead by a rheumatology consultant, specialist nurse, podiatrist, physiotherapist and OT. Tea and coffee are available with time for patients to interact with each other, encouraging peer-peer support.
Average attendance per clinic was 12 patients with the addition of some relatives and carers. This regime elicited a Patient satisfaction score averaging 4.8/5 over the 6 clinics audited. As a consequence of this approach, 11 clinics per month have been released for other work for the physiotherapists, OTs and podiatrists. Anecdotal reports suggest, patients have been better educated about their treatment plans and their underlying disease, when seen in follow up clinics.
Group Rheumatology Follow up Clinics
From November 2016, we have run a monthly group clinic to follow up for those with RA and PsA . These clinics are held at 5.15pm, thus everyone can park and avoid missing time from work. Those attending this clinic have consented to be seen in a group environment. Suitable patients for these clinics have either stable disease, often taking a Biologic therapy, and those with early disease, who are starting their treatment plan, requiring frequent follow up.
Before attending, a questionnaire is sent to each patient, enquiring about new medications, new diagnoses, recent illnesses, and a CDAI score and their recent blood test results are to hand. Specialist Rheumatology nurses review the patients, performing a DAS score. I review the questionnaire, investigations, and DAS score following which a treatment plan is made. The group, meanwhile, invariably talk amongst themselves and discuss their rheumatological conditions and medications. Following this there is a group question and answer discussion, talking about important points such as vaccinations, infection risk, new medications, dose reduction etc. The group discussion is led by the patients. Time for peer-peer discussion is strongly encouraged and very valuable.
We have been impressed with the advantage of group medical appointments, particularly from the perspective of peer-peer support. Patient satisfaction has been universally supportive. It has allowed us to continue to provide a responsive service, despite a doubling in workload.
Competing interests: No competing interests