The Annual Review Clinic for Rheumatoid Arthritis – A View from Newcastle
The British Society for Rheumatology (BSR) and British Health Professionals in Rheumatology (BHPR) published a 20-point document in 2009 that provided guidelines for the management of RA1. This document has been superseded by the National Institute of Clinical Excellence (NICE) guidelines which were also published in 20092. Both these sets of guidelines recommended that all patients with Rheumatoid Arthritis (RA) have an annual review that incorporates disease assessment, damage, functional outcomes and evaluation of co-morbidity.
Patients should have their cardiovascular risk and fracture risk assessed and should have the opportunity to be referred to other members of the health care team such as physiotherapy or occupational therapy. Quality Statement 7 in the NICE Quality Standard 33 for RA, published in 2013, states: People with RA have a comprehensive annual review that is coordinated by the rheumatology service3.
The quality outcomes framework (QOF) is a framework that provides guidance for GPs about conditions such as cardiovascular disease and diabetes. The aim of the framework is to reward GPs who deliver high quality care to their patients. In 2013/2014, largely based upon evidence and documentation submitted by the BSR, the Primary Care Rheumatology Society and NRAS, four RA indicators were included in QOF:
- The general practitioner (GP) should maintain a register of patients aged 16 or over with RA
- The percentage of patients on the register, who have had a face-to-face review in the preceding 12 months
- The percentage of patients with RA aged between 30 and 85 who have had a cardiovascular risk assessment in the preceding 12 months
- The percentage of patients with RA aged between 50 and 91 who have had a fracture risk assessment in the preceding 24 months
Due to these new indicators, many patients will have been asked to see their GP in the past year for a check-up and review of cardiovascular risk factors and fracture risk assessment. From April 2014, sadly, indicators 3 and 4 have been ‘retired’ from the QOF and therefore there will be less drive for GPs to assess patient’s cardiovascular and fracture risk. We are aware of the increased risk that patients with RA have of cardiovascular disease and fracture risk (largely in those patients with uncontrolled disease or who have taken repeated courses of steroids in the past) and that is where an annual review clinic in hospital fits in.
Currently, the Newcastle Upon Tyne Hospitals NHS Foundation Trust provides an annual review service which is available for all patients with RA. The service is a 40-minute consultation with a Rheumatology Specialist Nurse and allows the patient the opportunity to discuss any problems or concerns that they may have about their condition. During the clinic appointment a number of assessments are carried out including the QRISK2 score for cardiovascular disease and FRAX score for bone health. The assessment also looks at any functional problems the patient may have (such as issues with activities of daily living), the effects of RA on the patient's quality of life and mental health and the possible need for referral to other health care professionals. The clinic also provides an opportunity for the patient’s medication to be reviewed and a disease activity score to be completed. During the consultation, patients can be educated about their condition and a plan of care can be agreed. These aspects of the consultation can be tailored to the individual needs of the patient.
We have recently conducted an audit of our annual review service in Newcastle. The overall consensus from patients is that they have really valued the time spent in the clinic. They felt that 40 minutes was about the right amount of time for the appointment and that they were given the opportunity to discuss things that sometimes they had not had with their GP or Rheumatologist. We continue to assess and further develop the service for our patients.
By Dr Martin Lee, Consultant Rheumatologist, Honorary Clinical Lecturer & Associate Clinical Sub Dean
Newcastle Upon Tyne Hospitals NHS Foundation Trust & Newcastle University
- British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (after the first 2 years). Luqmani R., Hennell S. et al. Rheumatology 2009