Patient‐initiated hospital follow‐up for rheumatoid arthritis

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Abstract
Objectives. To evaluate the clinical efficacy, cost and acceptability of a shared care system of patient‐ or general practitioner (GP)‐initiated hospital review in rheumatoid arthritis (RA). Methods. A 2‐yr randomized controlled trial of routine rheumatologist‐initiated review was compared with a shared care system. Shared care patients had no routine follow‐up but patients or GPs initiated access to rapid review by the multidisciplinary team via a nurse‐run helpline. Control patients had a rheumatologist‐initiated medical review at intervals of 3–6 months. Clinical and psychological status, resource use, and patient and GP satisfaction and confidence were assessed. Three‐monthly clinical data were assessed (blind) for safety monitoring, with failure set at a 20% increase in pain, disability or disease activity. Results. Two hundred and nine established RA patients participated, of whom 182 were evaluable. Safety‐net failures were not different between groups. Shared care patients had less pain (24 months, 3.9 cm on a 10‐cm visual analogue scale vs 4.8 cm for controls; P < 0.05), a smaller increase in pain over 2 yr (+ 0.4 cm vs +1.6 cm for controls; P < 0.01), greater self‐efficacy (6, 15, 18, 21 months, P < 0.05), used 33.5% less resources (£208 per patient per year vs £313 for controls; P < 0.001) and were more confident in the system (6, 9, 12, 18, 21, 24 months, P < 0.01 to P < 0.001). Conclusions. A patient‐initiated system for hospital review over 2 yr offers some clinical benefit compared with the traditional system, using fewer resources and attracting greater patient confidence. Longer‐term assessment of the system would be appropriate.