title: Patient initiated outpatient follow up in rheumatoid arthritis: six year randomised controlled trial.
abstract: OBJECTIVE
  To determine whether direct access to hospital review initiated by patients with rheumatoid arthritis would result in improved clinical and psychological outcome, reduced overall use of healthcare resources, and greater satisfaction with care than seen in patients receiving regular review initiated by a rheumatologist.
  
  
  METHODS
  Two year randomised controlled trial extended to six years.
  
  
  METHODS
  Rheumatology outpatient department in teaching hospital.
  
  
  METHODS
  209 consecutive patients with rheumatoid arthritis for over two years; 68 (65%) in the direct access group and 52 (50%) in the control group completed the study (P = 0.04).
  
  
  METHODS
  
  
  
  RESULTS
  pain, disease activity, early morning stiffness, inflammatory indices, disability, grip strength, range of movement in joints, and bone erosion. Psychological status: anxiety, depression, helplessness, self efficacy, satisfaction, and confidence in the system. Number of visits to hospital physician and general practitioner for arthritis.
  
  
  RESULTS
  Participants were well matched at baseline. After six years there was only one significant difference between the two groups for the 14 clinical outcomes measured (deterioration in range of movement in elbow was less in direct access patients). There were no significant differences between groups for median change in psychological status. Satisfaction and confidence in the system were significantly higher in the direct access group at two, four, and six years: confidence 9.8 v 8.4, 9.4 v 8.0, 8.7 v 6.9; satisfaction 9.3 v 8.3, 9.3 v 7.7, 8.9 v 7.1 (all P < 0.02). Patients in the direct access group had 38% fewer hospital appointments (median 8 v 13, P < 0.0001).
  
  
  CONCLUSIONS
  Over six years, patients with rheumatoid arthritis who initiated their reviews through direct access were clinically and psychologically at least as well as patients having traditional reviews initiated by a physician. They requested fewer appointments, found direct access more acceptable, and had more than a third fewer medical appointments. This radical responsive management could be tested in other chronic diseases.
authors.affiliation: University of Bristol Academic Rheumatology Unit, Bristol Royal Infirmary, Bristol BS2 8HW. Sarah.Hewlett@bristol.ac.uk
authors.forename: Sarah
authors.initials: S
authors.lastname: Hewlett
authors.forename: John
authors.initials: J
authors.lastname: Kirwan
authors.forename: Jon
authors.initials: J
authors.lastname: Pollock
authors.forename: Kathryn
authors.initials: K
authors.lastname: Mitchell
authors.forename: Maggie
authors.initials: M
authors.lastname: Hehir
authors.forename: Peter S
authors.initials: PS
authors.lastname: Blair
authors.forename: David
authors.initials: D
authors.lastname: Memel
authors.forename: Mark G
authors.initials: MG
authors.lastname: Perry
mesh_terms: D000368:Aged; D000553:Ambulatory Care / Q000458:organization & administration*; D001071:Appointments and Schedules; D001172:Arthritis, Rheumatoid / Q000628:therapy*; D005260:Female; D006297:Health Services Accessibility / Q000458:organization & administration; D006784:Hospitals, Teaching; D006801:Humans; D008297:Male; D010358:Patient Participation; D017060:Patient Satisfaction; D016896:Treatment Outcome