title: Clinical and psychological outcome from a randomized controlled trial of patient-initiated direct-access hospital follow-up for rheumatoid arthritis extended to 4 years.
abstract: BACKGROUND
  Patients with rheumatoid arthritis (RA) are traditionally seen regularly as out-patients, irrespective of whether it is appropriate or timely to see them. A randomized controlled trial has shown that over 2 yr, seeing patients only when they or their general practitioner (GP) request a review saves time and resources and is more convenient. This study aimed to assess clinical and psychological outcomes when the trial was extended to 4 yr.
  
  
  METHODS
  A total of 209 patients were randomized into either 'routine review' (control) or 'no routine follow-up' but access to rapid review on request (direct access). Clinical and psychological status and patient satisfaction and confidence were reviewed after 24 and 48 months.
  
  
  RESULTS
  Mean age at entry was 56 yr and mean disease duration 11 yr, and 134 patients remained in the study after 48 months. There were no differences between the groups, nor between those who completed the study and those who did not. There were no major differences in clinical or psychological status between the groups at 24 or 48 months. However, self-efficacy for function was stronger at 48 months for direct access patients (mean 64.0 vs 52.0, P=0.005), as was self-efficacy for other symptoms (mean 67.8 vs 59.3, P=0.009). Satisfaction at 48 months was increased in direct access compared with control (mean 8.7 vs 7.6, P=0.01) as was confidence in the system (8.9 vs 7.6, P<0.01).
  
  
  CONCLUSIONS
  It is effective for patients with rheumatoid arthritis to have no regular follow-up, provided they have access to rapid review when they or their GP request it. Patients using a self-referral system of care had higher self-efficacy and greater satisfaction and confidence than those using the traditional system.
authors.affiliation: Academic Rheumatology, University of Bristol Division of Medicine, Bristol Royal Infirmary, Bristol, UK. john.kirwan@Bristol.ac.uk
authors.forename: J R
authors.initials: JR
authors.lastname: Kirwan
authors.forename: K
authors.initials: K
authors.lastname: Mitchell
authors.forename: S
authors.initials: S
authors.lastname: Hewlett
authors.forename: M
authors.initials: M
authors.lastname: Hehir
authors.forename: J
authors.initials: J
authors.lastname: Pollock
authors.forename: D
authors.initials: D
authors.lastname: Memel
authors.forename: B
authors.initials: B
authors.lastname: Bennett
mesh_terms: D000328:Adult; D001172:Arthritis, Rheumatoid / Q000523:psychology / Q000628:therapy*; D004739:England; D005260:Female; D005500:Follow-Up Studies; D006297:Health Services Accessibility; D006801:Humans; D008134:Long-Term Care / Q000458:organization & administration; D008297:Male; D008875:Middle Aged; D010044:Outpatient Clinics, Hospital / Q000458:organization & administration; D017060:Patient Satisfaction