Patients in focus awards 2006

Anne Meadows. RGN, BSc (Hons), Rheumatology Nurse Specialist, Peterborough and Stamford Hospitals NHS Foundation Trust

Screening for cardiovascular disease in a rheumatology outpatient clinic.

Background

Peterborough & Stamford NHS Foundation Trust consists of a district general hospital split over two sites within Peterborough, Cambridgeshire, and a small community hospital in Stamford, 12 miles away in Lincolnshire. Rheumatology is an outpatient service only, as we have lost all inpatient space over the last few years. Staffing comprises of two consultants, supported by two hospital practitioners conducting a clinic each per week, and one nurse specialist. There is also a DEXA service provided by the equivalent of a full time radiographer. Support staff includes a part-time IV nurse for day case treatments and three healthcare assistants to run the outpatient clinics.

The department provides a rheumatology service for a large geographic area covering five counties and a catchment population of 350,000.

We have been aware of the increased risk of mortality due to cardiovascular (CV) disease in rheumatoid arthritis patients for a number of years. We wanted to actively encourage patients to minimise modifiable risk factors for CV disease. Four years ago a nurse–led cardiovascular clinic for rheumatoid arthritis patients began in the outpatient department.

Why set up a cardiovascular health screening clinic in rheumatology?

It is well known that mortality is increased in rheumatoid arthritis and that this is partly due to an increased incidence of cardiovascular disease (1), which in turn is due to a combination of traditional risk factors and independent risk factors associated with the rheumatic inflammatory process. In developing the service for our patients we wanted to address their general health needs as well as optimising control of their arthritis. Thus in 2001 we set up a nurse-led clinic to screen for cardiovascular risk factors. The purpose of the screening clinic was not only to identify abnormalities which required additional treatment but also to encourage changes in lifestyle and behaviour where appropriate.

Patient selection and assessment

  • Patients with RA between the ages of 45-60 attending the outpatient clinic were identified and invited to attend a 45 minute appointment with the rheumatology nurse specialist.
  • A lifestyle questionnaire was completed with the nurse, covering diet, smoking, alcohol and exercise habits. Blood pressure (BP) and body mass index (BMI) were measured and blood taken for lipids and inflammatory markers. A chest x-ray was performed, and also a urine dipstick test for glycosuria.
  • Diet and exercise were discussed and, if appropriate, NHS smoking cessation leaflets were given.
  • Referrals to the multidisciplinary team were made at this point if required. These included physiotherapy and dietetics.
  • Results were sent to the GP and a letter to the patient advising them if any additional treatment was necessary, in which case they were encouraged to see the GP or practice nurse.

Auditing the service

Over 130 patients were initially seen in the clinic. Audits were carried out at six months (2) and one year (3), firstly to see if the clinic had made any impact on reducing risk factors, and secondly to see whether the changes had been maintained over a longer period.
Follow up of 45 patients with CV risk factors (some had more than one risk factor)

We were pleased that many patients had taken steps to reduce BP and lipid levels by diet, medication or both, BUT it was obvious that lifestyle changes were proving difficult. Initially there was a slight reduction in those smoking and in those making an effort to lose weight, but these were short term changes and old habits and lifestyles soon resumed.

Problems encountered

Initially, an appointment was sent to the patient without an explanation. The letters were standard outpatient letters generated by the hospital booking centre. Several patients phoned me asking why I needed to see them as they already had a follow up appointment for their arthritis management. After an explanation most were happy to attend but, we did have a number who did not attend (DNA). I now send a preliminary letter before the appointment is made, explaining the purpose of the appointment, and the DNA rate has fallen to almost zero.

Where to go with the service from here?

Most patients are appreciative of the service as they feel that we are interested in their overall health rather than just their RA. The majority are not aware of the increased CV risks. Due to other work pressures, the service was temporarily suspended for two years, but it was restarted two months ago with some innovations.

In view of patients’ difficulty giving up smoking and losing weight, I have become more actively involved in helping them alter their lifestyle. We have direct access and referral systems in place for the NHS smoking cessation clinics in the area. We also have links to PCT run exercise classes for those with a chronic illness, and the council-run “Walking for Health” programme which organises supervised walks at set times and places throughout the week.

I have presented the results in poster form at the 2003 and 2004 BSR Annual Meeting (2,3). I have also put up a display in the waiting area of the rheumatology outpatient department which has generated interest from patients, with many asking when they will be seen in the clinic.

An assessment tool to evaluate cardiovascular risk in patients with RA and SLE has recently been developed in Cambridge by Dr Francis Hall and Dr N Dalbeth (4). Dr Hall and I give joint presentations to GPs to make them more aware of the CV risks and also to inform them of what we are doing locally. Some GPs have shown an interest in monitoring their patients themselves. We are planning to incorporate the assessment tool into our health screening clinic to target patients at greater risk, although we will also continue to educate and inform those at low risk.

Patient benefits

This nurse-led clinic identifies risk factors for cardiovascular disease in patients with RA before symptoms of heart disease appear, and, through timely and appropriate intervention, we can treat and educate those with modifiable risks.

Conclusion

This was the first reported nurse-led clinic in the country set up specifically to screen patients with RA for CV risk, and to treat and advise them as necessary on lifestyle changes. There is good evidence to show that we have succeeded in reducing some risk factors, and, with a more pro-active stance to lifestyle changes, we will continue to improve the overall health of our patients with RA.

References

1. Kitas GD, Erb N. Tackling ischaemic heart disease in rheumatoid arthritis. Rheumatology 2003;42:607-613.

2. Meadows A, Sheehan NJ. Screening for cardiovascular risk factors and systemic complications in patients with rheumatoid arthritis. Do the results justify the time and effort? Rheumatology 2003;42 (Suppl 1):45(77).

3. Meadows A, Sheehan NJ. Health screening interventions are partially successful in reducing cardiovascular risk factors in patients with rheumatoid arthritis. Rheumatology 2004;43 (Suppl 2):145 (379).

4. Hall FC and Dalbeth N. Disease modification and cardiovascular risk reduction: two sides of the same coin? Rheumatology 2005;44:1473-1482.


Update: 2007

"Since winning the award 12 months ago, I have been asked to share information with a number of departments around the country on how to set up a cardiovascular/health screening clinic. This includes departments outside of rheumatology, for example, dermatology.

We have also taken this opportunity to promote the good work of NRAS. A display has been placed in the waiting area of the outpatient department explaining what the award is, and at the same time displaying the work and literature of NRAS.

The award has been recognised at local and regional meetings, which is a good feeling, especially when you feel the hard work is being acknowledged by peers. The managers at the Trust are now more aware of the work I am involved in and are keen for me to continue the clinic.

As with most departments, we have limited income and the prize money has been used for staff educational purposes. I submitted a poster to the RCN Rheumatology Forum conference in Newcastle in October 2006, and was asked to give an oral presentation. I was able to pay for the trip and take a staff nurse from the outpatient department who has an interest in rheumatology. This was her first ever conference after 30 years of nursing: she thoroughly enjoyed the experience and is grateful that she was given the opportunity to attend."

 

Anne Meadows, Rheumatology Nurse Specialist, Rheumatology Department Peterborough and Stamford NHS Foundation Trust, Edith Cavell Hospital explains what winning this award has meant to her and her rheumatology department.