Claire Hale

Learning for real life: patient-focused interprofessional workshops offer added value

Objectives  This paper reports relevant findings of a pilot interprofessional education (IPE) project in the Schools of Medicine and Healthcare Studies at the University of Leeds. The purpose of the paper is to make a contribution towards answering 2 questions of fundamental importance to the development of IPE. Is there a demonstrable value to learning together? What types of IPE, under what circumstances, produce what type of outcomes?

The outcome and cost-effectiveness of nurse-led care in people with rheumatoid arthritis: a multicentre randomised controlled trial

Objective To determine the clinical effectiveness and cost-effectiveness of nurse-led care (NLC) for people with rheumatoid arthritis (RA). Methods In a multicentre pragmatic randomised controlled trial, the assessment of clinical effects followed a non-inferiority design, while patient satisfaction and cost assessments followed a superiority design. Participants were 181 adults with RA randomly assigned to either NLC or rheumatologist-led care (RLC), both arms carrying out their normal practice. The primary outcome was the disease activity score (DAS28) assessed at baseline, weeks 13, 26, 39 and 52; the non-inferiority margin being DAS28 change of 0.6. Mean differences between the groups were estimated controlling for covariates following per-protocol (PP) and intention-to-treat (ITT) strategies. The economic evaluation (NHS and healthcare perspectives) estimated cost relative to change in DAS28 and quality-adjusted life-years (QALY) derived from EQ5D. Results Demographics and baseline characteristics of patients under NLC (n=91) were comparable to those under RLC (n=90). Overall baseline-adjusted difference in DAS28 mean change (95% CI) for RLC minus NLC was −0.31 (−0.63 to 0.02) for PP and -0.15 (−0.45 to 0.14) for ITT analyses. Mean difference in healthcare cost (RLC minus NLC) was £710 (−£352, £1773) and −£128 (−£1263, £1006) for PP and ITT analyses, respectively. NLC was more cost-effective with respect to cost and DAS28, but not in relation to QALY utility scores. In all secondary outcomes, significance was met for non-inferiority of NLC. NLC had higher ‘general satisfaction’ scores than RLC in week 26. Conclusions The results provide robust evidence to support non-inferiority of NLC in the management of RA. Trial registration ISRCTN29803766

The effectiveness of nurse-led care in people with rheumatoid arthritis: A systematic review

OBJECTIVES The objective of this systematic review was to determine the effectiveness of nurse-led care in rheumatoid arthritis. DESIGN Systematic review of effectiveness. DATA SOURCES Electronic databases (AMED, CENTRAL, CINAHL, EMBASE, HMIC, HTA, MEDLINE, NHEED, Ovid Nursing and PsycINFO) were searched from 1988 to January 2010 with no language restrictions. Inclusion criteria were: randomised controlled trials, nurse-led care being part of the intervention and including patients with RA. REVIEW METHODS Data were extracted by one reviewer and checked by a second reviewer. Quality assessment was conducted independently by two reviewers using the Cochrane Collaborations Risk of Bias Tool. For each outcome measure, the effect size was assessed using risk ratio or ratio of means (RoM) with corresponding 95% confidence intervals (CI) as appropriate. Where possible, data from similar outcomes were pooled in a meta-analysis. RESULTS Seven records representing 4 RCTs with an overall low risk of bias (good quality) were included in the review. They included 431 patients and the interventions (nurse-led care vs usual care) lasted for 1-2years. Most effect sizes of disease activity measures were inconclusive (DAS28 RoM=0.96, 95%CI [0.90-1.02], P=0.16; plasma viscosity RoM=1 95%CI [0.8-1.26], p=0.99) except the Ritchie Articular Index (RoM=0.89, 95%CI [0.84-0.95], P<0.001) which favoured nurse-led care. Results from some secondary outcomes (functional status, stiffness and coping with arthritis) were also inconclusive. Other outcomes (satisfaction and pain) displayed mixed results when assessed using different tools making them also inconclusive. Significant effects of nurse-led care were seen in quality of life (RAQoL RoM=0.83, 95%CI [0.75-0.92], P<0.001), patient knowledge (PKQ RoM=4.39, 95%CI [3.35-5.72], P<0.001) and fatigue (median difference=-330, P=0.02). CONCLUSIONS The estimates of the primary outcome and most secondary outcomes showed no significant difference between nurse-led care and the usual care. While few outcomes favoured nurse-led care, there is insufficient evidence to conclude whether this is the case. More good quality RCTs of nurse-led care effectiveness in rheumatoid arthritis are required.

The prevalence of foot ulceration in patients with rheumatoid arthritis

OBJECTIVE To establish the prevalence of foot ulceration in patients with rheumatoid arthritis (RA) in secondary care. METHODS A postal survey of all patients with RA (n = 1,130) under the care of rheumatologists in Bradford, West Yorkshire, UK was performed. The prevalence data were validated through clinical examination, case-note review, and contact with health professionals. The false-negative rate was investigated in a subsample of patients (n = 70) who denied any history of ulceration. RESULTS The postal survey achieved a 78% response rate. Following validation, the point prevalence of foot ulceration was 3.39% and the overall prevalence was 9.73%. The false-positive rate was initially high at 21.21%, but use of diagrammatic questionnaire data to exclude leg ulceration reduced the rate to 10.76%. The false-negative rate was 11.76%. The most common sites for ulceration were the dorsal aspect of hammer toes, the metatarsal heads, and the metatarsophalangeal joint in patients with hallux abducto valgus, with 33% of patients reporting multiple sites of ulceration. Patients with open-foot and healed-foot ulceration had significantly longer RA disease duration, reported significantly greater use of special footwear, and had a higher prevalence of foot surgery than ulcer-free patients. CONCLUSION Foot ulceration affects a significant proportion of patients with RA. Further work is needed to establish risk factors for foot ulceration in RA and to target foot health provision more effectively.

Effects of needs-based patient education on self-efficacy and health outcomes in people with rheumatoid arthritis: a multicentre, single blind, randomised controlled trial

Objectives The Educational Needs Assessment Tool (ENAT) is a self-completed questionnaire, which allows patients with arthritis to prioritise their educational needs. The aim of this study was to evaluate the effects of needs-based patient education on self-efficacy, health outcomes and patient knowledge in people with rheumatoid arthritis (RA). Methods Patients with RA were enrolled into this multicentre, single-blind, parallel-group, pragmatic randomised controlled trial. Patients were randomised to either the intervention group (IG) where patients completed ENAT, responses of which were used by the clinical nurse specialist to guide patient education; or control group (CG) in which they received patient education without the use of ENAT. Patients were seen at weeks 0, 16 and 32. The primary outcome was self-efficacy (Arthritis Self Efficacy Scale (ASES)-Pain and ASES-Other symptoms). Secondary outcomes were health status (short form of Arthritis Impact Measurement Scale 2, AIMS2-SF) and patient knowledge questionnaire-RA. We investigated between-group differences using analysis of covariance, adjusting for baseline variables. Results A total of 132 patients were recruited (IG=70 and CG=62). Their mean (SD) age was 54 (12.3) years, 56 (13.3) years and disease duration 5.2 (4.9) years, 6.7 (8.9) years for IG and CG, respectively. There were significant between-group differences, in favour of IG at week 32 in the primary outcomes, ASES-Pain, mean difference (95% CI) −4.36 (1.17 to 7.55), t=−2.72, p=0.008 and ASES-Other symptoms, mean difference (95% CI) −5.84 (2.07 to 9.62), t=−3.07, p=0.003. In secondary outcomes, the between-group differences favoured IG in AIMS2-SF Symptoms and AIMS2-SF Affect. There were no between-group differences in other secondary outcomes. Conclusions The results suggest that needs-based education helps improve patients’ self-efficacy and some aspects of health status. Trial registration number ISRCTN51523281.

Tai Chi exercise and auricular acupressure for people with rheumatoid arthritis: an evaluation study

AIMS AND OBJECTIVES (i) To assess the effectiveness of Tai Chi exercise in people with rheumatoid arthritis (RA). (ii) To ascertain if Tai Chi and auricular acupressure have a potentiation effect in controlling pain. (iii) To evaluate the acceptability and enjoyment of the classes. BACKGROUND Tai Chi has been suggested as a suitable exercise for people with arthritis and specific programmes have been developed. Auricular acupressure is a therapeutic method by which points on the ear are stimulated to treat various disorders. DESIGN A pragmatic non-randomised before/after study to compare the effects of the interventions. METHODS People with RA (n=21) were recruited and allocated into two groups. Both groups followed a Tai Chi exercise programme, twice a week for 12 weeks, but one group (n=14) had, in addition, the auricular acupressure. Physical symptoms and function, pain, quality of life and self-efficacy were measured in both groups before and after the programme. Acceptability and enjoyment were assessed at the end. RESULTS At 12 weeks, both groups had achieved statistically significant improvements in balance, grip strength, pinch strength, 50 foot walk time self reported joint pain, swollen joint count, tender joint count and in self efficacy in relation to pain control. All participants stated that they enjoyed the classes. There was no evidence to suggest that the auricular acupressure enhanced the effects of the Tai Chi intervention. CONCLUSION The classes appeared to be mentally as well as physically helpful to participants. RELEVANCE TO CLINICAL PRACTICE People with a chronic debilitating disease such as RA should be encouraged to undertake gentle strengthening exercise such as Tai Chi because of its potential for physical and psychological improvements.

A review of design and reporting issues in self-reported prevalence studies of leg ulceration

OBJECTIVE The aim of this review was to examine design and reporting issues that affect prevalence estimates of leg ulceration obtained using self-report and outline strategies to strengthen the validity and reliability of research in this area. STUDY DESIGN AND SETTING We identified leg ulcer prevalence studies and evaluated them against the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement. The authors draw upon the wider literature and their own empirical work in discussing strategies to overcome design and reporting issues. RESULTS Common deficiencies in the design and reporting of studies include wide variations in diagnostic criteria and age parameters for participant selection, a lack of description of efforts to address bias/study size rationale, and low participation rates in clinical examination stages. These factors and differences in statistical methods of analysis affect the validity and reliability of findings and hinder interpretation, making comparisons across populations difficult. Opportunities for subgroup analyses are frequently missed. CONCLUSION Self-report is a valuable means of capturing leg ulcer prevalence, but the future design and reporting of studies need to be strengthened, including addressing weaknesses in validation strategies. Capture-recapture analysis or a multiple-methods approach has the potential to yield the most valid and reliable prevalence estimates.

Evaluation of educational programmes for paediatric cancer nursing in England

The results of part of a larger study to evaluate educational provision for paediatric oncology and palliative care nursing in England are presented here. Mapping of cancer care provision, based upon the English National Board 240 programme, was undertaken by analysis of relevant curriculum documents. Prescribed programme outcomes were reviewed against expected course outcomes proposed by the European Oncology Nursing Society. Particular attention was also paid to expected processes of assessment of clinical practice, consideration of adolescent patients, and opportunities for shared learning. Widespread compliance with the European Oncology Nursing Society standard was found, with only two of the 19 areas substantially neglected. These related to the prevention and early detection of cancer (less relevant in paediatric cancer than for adults), and understanding the principles of cancer clinical trials (probably due to lack of explicit statement in curriculum documents rather than actual failure to address the topic). A range of prescribed assessment practices were noted, but the degree to which direct observation was involved was variable, and indirect measures appeared to predominate. There was little specific recognition of adolescence as a discrete topic to be addressed in the programmes. Shared learning tended to be introduced for logistical reasons of small class numbers rather than for any perceived intrinsic value.

Patients and nursing staff views of using the education needs assessment tool in rheumatology clinics: a qualitative study

AIMS AND OBJECTIVES To evaluate the usability of the educational needs assessment tool in clinical practice, from a practitioner and patient perspective and to establish whether patients perceive that they are getting an equally good or equally inadequate education service for their needs. BACKGROUND The educational needs assessment tool was developed to enable patients with Rheumatoid Arthritis to assess their education needs prior to a consultation with a health professional. The educational needs assessment tool has been translated into nine languages and measurement properties have been established, however, its usability in clinical practice has not been studied. DESIGN A qualitative study embedded into a multicentre RCT in which patients had been randomised into either educational needs assessment tool-focused education (Experimental Group) or usual care (control group). METHODS Both groups were seen by a clinical nurse specialist. Sixteen patients and four clinical nurse specialists were recruited from the Rheumatology Outpatient Departments of three Acute Hospitals within the U K. Data were collected by interviews with patients and clinical nurse specialist. Analysis followed the Framework approach. RESULTS Patients and clinical nurse specialist found completion of the educational needs assessment tool straightforward, comprehensive and easy to use. Completing the educational needs assessment tool helped patients to focus on what they needed to know from the clinical nurse specialist. Patients in both the control group and the experimental group felt supported and reassured by their clinical nurse specialist and perceived that they received a good and adequate education provision. CONCLUSION This study provides useful insights into the ability of the educational needs assessment tool to assess the educational needs of patients with rheumatoid arthritis in routine clinical practice. RELEVANCE TO CLINICAL PRACTICE The educational needs assessment tool would be useful as a structured guide for nurses when assessing and meeting individual patient educational needs. This has the potential to improve patient-centred care, involve patients more actively in their care and enhance the long-term effects of patient education provision.

A randomised, controlled study of outcome and cost effectiveness for RA patients attending nurse-led rheumatology clinics: Study protocol of an ongoing nationwide multi-centre study

Background The rise in the number of patients with arthritis coupled with understaffing of medical services has seen the deployment of Clinical Nurse Specialists in running nurse-led clinics alongside the rheumatologist clinics. There are no systematic reviews of nurse-led care effectiveness in rheumatoid arthritis. Few published RCTs exist and they have shown positive results for nurse-led care but they have several limitations and there has been no economic assessment of rheumatology nurse-led care in the UK. Objective This paper outlines the study protocol and methodology currently being used to evaluate the outcomes and cost effectiveness for patients attending rheumatology nurse-led clinics. Design and methods A multi-centred, pragmatic randomised controlled trial with a non-inferiority design; the null hypothesis being that of ‘inferiority’ of nurse-led clinics compared to physician-led clinics. The primary outcome is rheumatoid arthritis disease activity (measured by DAS28 score) and secondary outcomes are quality of life, self-efficacy, disability, psychological well-being, satisfaction, pain, fatigue and stiffness. Cost effectiveness will be measured using the EQ-5D, DAS28 and cost profile for each centre. Power calculations In this trial, a DAS28 change of 0.6 is considered to be the threshold for clinical distinction of ‘inferiority’. A sample size of 180 participants (90 per treatment arm) is needed to reject the null hypothesis of ‘inferiority’, given 90% power. Primary analysis will focus on 2-sided 95% confidence interval evaluation of between-group differences in DAS28 change scores averaged over 4 equidistant follow up time points (13, 26, 39 and 52 weeks). Cost effectiveness will be evaluated assessing the joint parameterisation of costs and effects. Results The study started in July 2007 and the results are expected after July 2011. Trial registration The International Standard Randomised Controlled Trial Number ISRCTN29803766.