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

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Abstract

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 Collaboration's 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 1–2 years. 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.

Introduction

Rheumatoid arthritis (RA) is a systemic inflammatory disease characterised by the presence of a destructive polyarthritis with a predisposition for affecting the peripheral joints (Hakim et al., 2006). It most commonly presents in the sixth and seventh decades and it is three times more likely to occur in women than men (Silman and Oliver, 2009). The incidence and prevalence of RA vary considerably between geographic areas and over time. The incidence rates in Anglo-Saxon populations have been reported to range between 0.02 and 0.05% (20–50 cases per 100,000) adults in North America (Doran et al., 2002, Gabriel et al., 1999) and Northern Europe (Aho et al., 1998, Riise et al., 2000, Söderlin et al., 2002, Symmons et al., 1994). Southern European countries have reported a relatively lower incidences 0.01–0.02% (Drosos et al., 1997, Guillemin et al., 1994) and there are no incidence data from developing countries. The prevalence in Northern Europe and North America ranges between 0.5 and 1.1% (MacGregor and Silman, 2003, Riise et al., 2000, Silman and Hochberg, 2001), Southern Europe 0.3–0.7% (Andrianakos et al., 2003, Carmona et al., 2002, Cimmino et al., 1998, Saraux et al., 1999, Stojanović et al., 1998), developing countries between 0.1 and 0.5% (Akar et al., 2004, Darmawan et al., 1993, Pountain, 1991, Silman and Hochberg, 2001, Spindler et al., 2002) and in some rural Africa 0–0.3% (Silman and Hochberg, 2001, Silman et al., 1993). Treatment of RA is multi-disciplinary involving medications, regular follow-up, physiotherapy, joint protection, self-management and psychosocial support.

Increased life expectancy and the rise in chronic diseases in the western world has led to greater demand for health care in both hospitals and the community (Tulchinsky and Varavikova, 2009). This demand has led to innovation in health care where nurses and other allied health professionals undertake extended roles which sometimes include work previously done by doctors. This allows a flexible approach to the delivery of care, where the patient is at the centre and the traditional professional boundaries are less important (Richardson et al., 1998). One example of such innovations is nurse-led care.

Cullum et al. (2005) viewed nurse-led care as a continuum, with nurses undertaking highly protocol driven focused tasks at one end and responding to far more diverse challenges in terms of clinical decision-making, such as first contact care and rehabilitation at the other. Using the definitions of Nurse Practitioner, Advanced Practice Nurse and Advanced Nursing Practitioner (International Council of Nurses, 2001, NMC, 2005); we defined nurse-led care as a model of care where nurses who practice at an extended role, assume their own patient case loads and perform nursing interventions which include monitoring of patients’ condition, providing patient education, giving psychosocial support and referring appropriately. This model of care has been used successfully in other chronic diseases where patients require regular follow-ups and monitoring such as diabetes (Carey and Courtenay, 2007), coronary heart diseases (Page et al., 2005), heart failure (Phillips et al., 2005) and chronic obstructive pulmonary disease (Sridhar et al., 2008).

In the UK, nurse-led care in rheumatology started in Leeds in the late 1980s where patients who had completed their clinical trials and had been returned to the general rheumatology clinics, began seeking further consultations with the nurses (Bird et al., 1980, Hill, 1985). Nurse-led clinics ran alongside rheumatologists’ clinic and they provided follow-up care for stable patients giving patient education, advice and support. This model of care was replicated throughout the UK where rheumatology centres employed clinical nurse specialists and their role included drug monitoring, education of staff, patient education and counselling (Phelan et al., 1992).

Despite this innovative development, the evidence of effectiveness of nurse-led care in RA is limited. A search of the Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA) Database, Cochrane Database of Systematic Reviews (CDSR), NHS Economic Evaluation Database (NHSEED) and Medline produced no systematic review of nurse-led care effectiveness in RA. Yet there were several systematic reviews of effectiveness in primary care (Horrocks et al., 2002, Laurant et al., 2004) and other chronic diseases (Carey and Courtenay, 2007, Page et al., 2005, Phillips et al., 2005, Sridhar et al., 2008, Taylor et al., 2005).

The objective of this current systematic review was to determine the effectiveness of nurse-led care in patients with RA. Effectiveness is defined as the extent to which an intervention produces an outcome under ordinary day-to-day circumstances. One way of assessing effectiveness of an intervention is comparing the intervention in question to another well-established intervention (Higgins and Green, 2009). The effectiveness of any intervention is said to be determined by 4 factors: (i) the populations receiving the intervention, (ii) the characteristics of the interventions, (iii) the comparator – what the intervention is compared with (iv) what outcomes are measured (Guyatt et al., 2008). Therefore we used the “participant-intervention-comparator-outcomes” (PICO) model (Higgins and Green, 2009) to formulate our research question: are clinical outcomes of nurse-led care for patients with RA similar to those produced by usual care?

Section snippets

Methods

We conducted a systematic review in three phases over three years. Phase one was an overview of reviews in order to identify systematic reviews of nurse-led care effectiveness. Phase two was a scoping review which was broad and looked for primary studies of effectiveness of nurse-led care. The search strategy for this phase was developed with a librarian and two reviewers independently screened the titles and abstracts to assess for relevance. Relevant articles were categorised by study design

The search results

The complete search output is summarised in Fig. 1. The search strategy identified 438 publications out of which 60 duplicates were removed and 20 articles published before 1988. A further 302 articles were removed based on titles and abstracts. Full reports were obtained for 56 articles but only 9 described RCTs of nurse-led care in RA, one of which was an economic evaluation and the other a protocol. The remaining 7 articles were retained for the full review.

Characteristics of included studies

The 7 included articles (Hill, 1997

Methods

This review included both nurse-led care substitution and supplementation studies. Supplementation studies have a risk of confounding the aspect of care provided by either the nurse or the doctor. This could be important if details of the interventions were not specified in the reports or if outcome assessors were not blinded. The interventions in this review were mainly follow-up care and monitoring provided by clinical nurse-specialists (or nurse practitioners) and were delivered in a similar

Conclusion

The objective of this systematic review was to determine whether nurse-led care was effective (i.e. produced effects that were similar to those of usual care). Most estimates of the primary outcome and secondary outcomes showed no significant difference between nurse-led care and usual care. While few estimates of secondary outcomes favoured nurse-led care, there is insufficient evidence to conclude whether this is the case. The main limiting factor is the absence of enough studies in this

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