By Dawn Homer, Nurse Consultant & Erica Gould, Nurse Practitioner, Rheumatology Enki Medical Practice, Birmingham
In 2008 the NHS published the white paper ‘Care Closer to Home’ marking a move to increase the range and scale of health services delivered within a community rather than in the acute setting. The national audit office report on rheumatology services in 2009 also found that there were failures to deliver high quality care delivery to RA patients. Since the NHS alliance has produced a paper on the Commissioning for Quality in rheumatoid arthritis (CQRA) which recommends that it is essential to have a data set of key commissioning metrics which can be used for ongoing quality, monitoring, management and funding of rheumatology services. They also recommend that the following will improve health outcomes for RA patients:
- Preventing delay in diagnosis and access to treatment
- Improved integration between community and hospital based services
- Arranging services to provide for local need
- An holistic approach to enable patients to self-manage their RA
The Community Rheumatology Service in Birmingham run initially by a GP with a special interest and a nurse consultant was established in response to the aforementioned reports and has now expanded to include a further nurse practitioner, an extended scope physiotherapist and a health care practitioner in training. The service is supported by academic rheumatologists from Sandwell & West Birmingham NHS Trust who provide community clinics. Patients referred into the service are triaged and those with suspected rheumatoid arthritis (RA) are seen by a specialist within two weeks. Once the diagnosis of RA is confirmed the patients are immediately cased managed by the nurse specialists who initiate and escalate disease modifying anti rheumatic therapy ensure the patient achieved low disease activity with the most appropriate drug under tight control principles.
One of the critical success factors for the nurse-led community service is the ability to demonstrate important health and patient recorded outcome measures. By using their existing primary care clinical database (EMiS Web), templates were devised to capture clinical outcomes. The templates developed within the system captures not only how many patients are being managed within the community rheumatology service but also their diagnosis and management and the quality of care that patients receive.
The specialist nurses decided to use the clinical commissioning metrics developed by Commissioning for Quality in Rheumatoid Arthritis (CQRA) to provide this information and to measure and demonstrate the quality of the service in line with National Institute for Health and Clinical Excellence (NICE) guidance.
The CQRA commissioning metrics are as follows:
Metric 1 Percentage of patients with Inflammatory Arthritis, who subsequently have a clinical diagnosis of RA, receive assessment, diagnosis and their first treatment within 6 weeks of referral.
Metric 2 Percentage of patients, with a DAS28 score > 2.6, who receive monthly assessments
Metric 3 Percentage of patients who receive rapid escalation of treatment in line with NICE clinical guidelines until EULAR DAS28 defined remission of DAS28 ≤2.6 is achieved
Metric 4 Percentage of patients who receive a full annual review in line with NICE guidance
With the help of the IT manager, the metrics were incorporated into their IT system so that at each attendance the information is captured automatically during the patient consultation. All the information is READ coded allowing the team to interrogate the data needed for specific patient populations and is web-based to ensure that the data is captured in a central portable database with documentation of each consultation. Three templates were developed for the RA population.
The initial template captures diagnosis, antibody status, time of symptom onset to referral, treatment pathway chosen 1 – Monotherapy or 2 – Combination therapy, Disease activity scores (DAS) and co morbities.
The biologic template includes contra-indications, caution, screening per BSR for biologics, Adherence to NICE guidance, DAS. Alert message indicating a patient is on biologic therapy to all health care professionals involved in their care.
The Annual review template includes disease activity, development or worsening of co-morbidities or extra-articular manifestations; Framingham cardiovascular risk, FRAX bone health, function, leisure, employment status, financial wellbeing and depression.
Exception read codes are use for those with active disease but are either unwilling or unable to escalate to a more appropriate therapy or due to other co-morbidities or contra-indications.
Patient involvement – has been through the Vitality patient panel, the local Birmingham ARMA network who have supported the development and design of the service and outcomes such as the patient satisfaction questionnaire (PSQ) (Appendix 1). The PSQ will be available to patients by paper, via our website or in clinic using an Ipad. PSQ data can be anonymous or identified providing information on areas of patient concern. PSQ will be collected at 3 and 6 month stage of the patient journey and then annually or as frequently as the patient wishes. Patients are also developing their own patient reported outcomes (PROMs) A pick and mix list of measureable and meaningful outcomes will be selected by individual patients for their care plan which will be imbedded in EMIS and will be reviewed at the intervals aforementioned where the domains can be altered to reflect the patients changing frame of reference. We will also modify our outcome set according to future CQRA recommendation
Using the EMIS population manager reporting, the community rheumatology service is able to demonstrate that patients are receiving a quality service and has provided healthcare professionals patient population and patient management data that demonstrates alignment of their clinical practice with best practice. In the changing NHS the ability to demonstrate value for money and the delivery of a high quality service is increasingly important. The information is then readily available for commissioning purposes when required on a continuum and allows us to know how well we are providing the service.
Delivering Care Closer to Home (2008) Department for Health http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_086051.pdf, accessed January 2013
Services for people with RA (2009) National Audit Office http://www.nao.org.uk/publications/0809/services_for_people_with_rheum.aspx, accessed January 2013
Rheumatoid arthritis: The management of rheumatoid arthritis in adults (2009) NICE http://publications.nice.org.uk/rheumatoid-arthritis-cg79, accessed January 2013
Commissioning for Quality in RA (2011) NHS Alliance http://www.nras.org.uk/includes/documents/cm_docs/2013/c/cqra_metrics_dec2012.pdf, accessed January 2013
Framingham 30 year Cardiovascular Risk Calculator http://www.framinghamheartstudy.org/risk/cardiovascular30.html, accessed January 2013
FRAX tool, Sheffield University http://www.shef.ac.uk/FRAX/tool.aspx, accessed January 2013