Background: Rheumatoid Arthritis (RA) is a chronic, autoimmune, inflammatory disease that may cause progressive joint damage and deformity, leading to functional disability and reduced quality of life. However, there is often a long waiting time for the first assessment in Rheumatology Clinic by doctor. Development of rheumatology nurse-led clinic allows early assessment by qualified rheumatology nurse for patients with suspected RA. It may potentially facilitate the decision and treatment plan in the first doctor clinic. A nurse-led Early Arthritis Clinic (EAC) for RA patients had been established in Caritas Medical Centre (CMC) since January 2018.
Objectives: To determine the effectiveness of the EAC by early identification of new cases of RA and to facilitate decision in early initiation of disease-modifying anti-rheumatic drugs (DMARDs) during the first doctor clinic assessment.
Methods: New cases were screened and recruited by Rheumatology nurse from January to December 2018 to nurse-led EAC. The recruited new cases were seen in EAC around 1 to 4 weeks before the first doctor clinic. Rheumatology nurse performed nursing assessment in EAC according to the 2010 ACR-EULAR Classification of RA. These cases will be reviewed by Rheumatologist during the first doctor clinic for confirmation of diagnosis and formulation of treatment plan. If urgent problems were identified during assessment in EAC, patients would be prioritized to have an earlier doctor clinic appointment or hospitalization may be arranged.
Results: A total of 128 patients with articular symptoms were seen in nurse-led EAC during the study period. Nursing assessment revealed that 71 patients were required further evaluation for the diagnosis of RA (26 males and 45 females, mean age for males: 51, mean age for females: 56) and they were recruited into the study. 36 of these 71 patients were confirmed with the diagnosis RA by rheumatologist during the first consultation of doctor clinic. 13 of 36 patients were prescribed with DMARDs on the same day of consultation. Before the establishment of EAC, the mean time of confirmation of RA by rheumatologist was 8 weeks (range from 4 to 12 weeks). Therefore, EAC facilitates both the early diagnosis of RA and the prompt initiation of treatment after confirmation of diagnosis. Reduction in disease activity was also noted after treatment. The mean Disease Activity Score of 28 joints (DAS 28) during the assessment in EAC was 4.66 (range 3.22 to 6.54) while post treatment after EAC and the first doctor clinic was 3.30 (range 2.08 to 5.16) with mean difference of -1.36 (p<0.01). Other diagnoses were also made among the 71 patients. 8 patients were diagnosed of Spondyloarthropathy, 2 patients were diagnosed of psoriatic arthritis and 2 patients were diagnosed of systemic lupus erythematosus. 3 of these 71 patients were identified urgent medical problems required early intervention. Among these 3 cases, two patients with liver function derangement and one of them needed hospital admission for assessment of acute hepatitis. Another patient was arranged hospitalization to rule out sepsis due to raised total white cell count and erythrocyte sedimentation rate.
Conclusion: Rheumatology nurse assessment in EAC is effective in assessing patients with suspected diagnosis of RA. It shortened the time to confirm the diagnosis of RA, and facilitated the decision on treatment plan. It effectively improved the disease activity of patients due to the prompt initiation of DMARDs by Rheumatologist.
References: Aletaha et al. 2010 Rheumatoid arthritis classification criteria: An American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis and Rheumatism 2010; 62(9): 2569-2581.
Mok CC et al. Management of rheumatoid arthritis: 2019 updated consensus recommendations from the Hong Kong Society of Rheumatology. Clin Rheumatol 2019. (in press)
Acknowledgments: DR DANIEL KAM HUNG NG
Disclosure of Interests: None declared
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