It is now widely accepted that Rheumatoid Arthritis should be treated with disease modifying anti-rheumatic drugs (DMARDs) early in the disease process,1–4 in order to reduce the incidence of erosive change, and improve long term outcome.5
A national Clinical Guideline for Scotland6 has recently been published, which advocates that all patients with disease duration greater than 6–8 weeks “should be considered for referral for Specialist rheumatology opinion and DMARD therapy, preferably within 12 weeks”.
This course of action should, if followed, lead to the early diagnosis and treatment of patients with inflammatory arthritis. There are, however, two inherent difficulties for hospital rheumatology services. Firstly, even if the referral is made promptly, many referral letters contain insufficient clinical information for the Consultant Rheumatologist to determine from the letter whether or not the patient has inflammatory arthritis. Secondly, in many services the waiting time for a first appointment with a consultant is several months long, thus negating the benefit of an early referral.
In an initiative to identify those patients who would benefit from early diagnosis and treatment, a nurse-led rheumatology Pre-assessment clinic was developed in Wolverhampton.
This was run by an experienced Rheumatology Specialist Nurse, supported and supervised by a Consultant Rheumatologist, and complied with professional7,8 and legal guidelines for nursing practice within the UK.
It has been found that the clinic has been effective in identifying patients with inflammatory arthritis and expediting the commencement of DMARD treatment.
Emery P. The Roche Rheumatology Prize Lecture. The optimal management of early rheumatoid disease: the key to preventing disability. Br J Rheumatol. 1994;33:765–8
Emery P. Therapeutic approaches for early rheumatoid arthritis. How early? How aggressive? Br J Rheumatol. 1995;34(Suppl 2):87–90
Hochberg MC. Early aggressive DMARD therapy. The key to slowing disease progression in rheumatoid arthritis. Scand J Rheumatol Suppl. 1999;112:3–7
Irvine S, Munro R, Potter D. Early referral, diagnosis and treatment of rheumatoid arthritis: evidence for changing medical practice. Ann Rheum Dis. 1999;58(8):510–13
Symmon DP, Jones MA, Scott DL, Prior P. Long term mortality outcome in patients with rheumatoid arthritis: early presenters tend to do well. J Rheumatol. 1998;25:1072–7
Scottish Intercollegiate Guidelines network. Management of early rheumatoid arthritis. Edinburgh: Royal College of Physicians, 2000
The Scope of Professional Practice. United Kingdom Central Council for Nursing, Midwifery and Health Visiting, London, 1992
Code of Professional Conduct. United Kingdom Central Council for Nursing, Midwifery and Health Visiting, London, 1992
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