David Memel

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

Abstract 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.

Assessing functional ability is important

GPs pride themselves on taking a holistic view of their patients, and moving from a strict biomedical to a biopsychosocial perspective. This includes moving from seeing diagnosis and treatment in purely medical terms, to include how the patient is able to function and live in society, as outlined in the WHO International Classification of Functioning, Disability and Health (ICF; Figure 1).1 For example, with a patient who has had a stroke one may consider the disease (a clot or bleed in the brain), the impairment (weakness of the left arm and leg), limitation of function (difficulty climbing the stairs), and restriction of participation in society (such as being able to work). Figure 1 WHO International Classification of Functioning, Disability and Health.1 The ICF model stresses the importance of environmental factors (such as whether there is a stairlift at work) and personal factors (such as personality and depression). Moreover, there is not a linear relationship between impairment and restriction, and we have all known patients with apparently minor impairments (such as a skin condition affecting the face) causing them to live a very restricted life, and others with very major impairments who are working and living very full lives. With some patients, such as those with functional somatic syndromes, there is not a clearly definable underlying disorder or disease.2 The role of a good GP is to be able to look at these different levels, often simultaneously. However, the majority of medical endeavour, including in general practice, continues to be concentrated on the biomedical model, looking at …

Guide to education and training for primary care. Yvonne Carter, Neil Jackson (eds). (372 pages, £24.50.) Oxford University Press, 2002. ISBN 0-19-263293-0.

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