The development and evaluation of a self-monitoring and patient-initiated follow-up service for people with rheumatoid or psoriatic arthritis on methotrexate
This thesis describes the development and evaluation of a self-monitoring and patient-initiated follow-up service for people with rheumatoid arthritis (RA) or psoriatic arthritis (PsA) on methotrexate. Using a mixed methods approach including a randomised controlled trial (RCT) and qualitative semi-structured interviews. The overall aims of this thesis were to design an alternative model of care which could be delivered in rheumatology outpatients by clinical nurse specialists (CNS) in order to reduce the burden of established patients in clinic. This is followed by an evaluation of intervention effectiveness and safety, along with an exploration of the mechanisms of action and patient acceptability. One hundred patients from University College Hospital London (UCLH) with either RA or PsA on methotrexate were recruited into the trial and were followed for six consecutive blood tests. Patients randomised to the intervention group were required to monitor their symptoms, side effects and laboratory results and use this information to initiate care from the CNS. The results indicated that patients were able to accurately initiate a consultation with their nurse on approximately 75% of occasions. The intervention led to 55% fewer appointments with the CNS (p<0.0001) and 39% fewer GP appointments (p=0.07) compared to usual care, with tentative evidence to suggest cost savings. There were no significant differences in clinical or psychosocial well-being, including function, pain, quality of life and mood. Intervention participants were positive about the new model of care, valuing its efficiency and tailored approach. The service allowed patients to gain new knowledge and use this information along with the skills they obtained to take control of their health and arthritis. This model of care may, therefore, be a viable alternative for established RA and PsA patients on methotrexate in order to reduce healthcare utilisation without compromising clinical or psychosocial well-being.
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