Nurses Could Fill the Screening Gap in Rheumatoid Arthritis

A nurse-led program of screening for comorbidities among patients with rheumatoid arthritis (RA) resulted in a doubling of the number of diagnostic and therapeutic actions, according to a new study.

Researchers at The Pierre-and-Marie-Curie University (Paris, France) conducted a study that prospectively enrolled 970 patients from 20 centers. Most were women, mean age was 58, disease duration averaged 11 years, and the majority had erosive disease. Most patients were being treated with methotrexate and some had used biologic therapies as well. The intervention consisted of an hour-long session in which nurses interviewed patients asking about adherence to recommendations from the French Society of Rheumatology for screening and managing the four major comorbidities of RA: cardiovascular disease, cancer, infections, and osteoporosis.

In any instance of nonadherence, the patient's physician was informed and was then left to decide on what action to take. Specific actions for cardiovascular disease included the introduction of lipid-lowering or antiplatelet therapy, smoking cessation, blood pressure measurements, patient purchase of a sphygmomanometer, and weight loss. Actions for cancer included mammograms and Pap smears, colonoscopy, and dermatology or urology referral, while actions for infections included pneumococcal, influenza, meningococcal, and hepatitis vaccinations. Actions relating to osteoporosis included dual-energy X-ray absorptiometry, calcium and vitamin D supplementation, and the introduction of anti-osteoporotic therapies.

The results showed that those randomized to the screening intervention had a mean of 4.54 actions, compared with 2.65 actions among controls, resulting in an incidence rate ratio (IRR) of 1.78 for actions resulting from the program. Specifically, for each of the comorbidities, the likelihood of an action being taken was higher in the nurse-led program, with the IRR for cardiovascular disease being 1.44, cancer, 1.65, infections, 1.78, and osteoporosis, 3.43. The study was presented at the annual meeting of the European League Against Rheumatism (EULAR), held during June 2013 in Madrid (Spain).

“Although we now have great treatments for rheumatoid arthritis, there is still a mortality gap compared with the general population. This results in part from the disease itself as well as from the treatments, but clearly it also relates to major comorbidities such as cardiovascular disease, which has an odds ratio of about 1.5 in patients with rheumatoid arthritis,” said lead author and study presenter Laure Gossec, MD, PhD. “For all these comorbidities we know what we should be doing—there are interventions for both screening and treatment; however, some studies have suggested that rheumatologists are not ordering the necessary screening tests, either because they haven't been trained to do so or because of time constraints.”

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