How to improve DAS28 use in daily clinical practice?--a pilot study of a nurse-led intervention.
OBJECTIVE
To determine whether DAS28 measurements by a specialized nurse, before the rheumatologist visit, in combination with the advice to rheumatologists to reach a DAS28 < or = 3.2, had beneficial effects on disease activity and medication prescription in patients with RA and to explore possible predictors for variation in medication changes and reasons for non-adherence to the advice to reach a DAS28 < or = 3.2.


METHODS
In this pilot study, rheumatologists were randomized to 'usual care' (n = 3) or DAS28 measurement by a nurse prior the rheumatologist visit (n = 4). In the usual care group, the DAS28 was measured but not provided to rheumatologists. Mixed model analyses were used for analysing between-group differences and for the prediction model. Rheumatologists in the intervention group were asked to provide reasons in cases of non-adherence to the advice.


RESULTS
After 18 months, DAS28 was reduced by - 0.69 and - 0.66 (P = 0.70) in, respectively, the intervention (144 patients) and the usual care (104 patients) groups. In the intervention group, medication was changed by rheumatologists in 35% of the visits with a DAS28 > 3.2; in the usual care group this was 33% (P = 0.99). Baseline DAS28 (OR 1.6; P< or =0.0001) and HAQ (OR 1.3; P = 0.03) were positively related to a medication change. The most frequently mentioned reason not to change medication was patient refusal (26%).


CONCLUSIONS
DAS28 measurement by a nurse was as effective as usual care; however, this intervention without protocolized treatment adjustments is not sufficient to lead to a considerable reduction in disease activity compared with trials with protocolized treatment adjustments.
van Hulst
Laura T C
LT
Department of Rheumatology, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. l.vanhulst@reuma.umcn.nl
Creemers
Marjonne C W
MC
Fransen
Jaap
J
Li
Linda C
LC
Grol
Richard
R
Hulscher
Marlies E J L
ME
van Riel
Piet L C M
PL
D000203:Activities of Daily Living; D000368:Aged; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000175:diagnosis / Q000188:drug therapy*; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009723:Nurse-Patient Relations; D010865:Pilot Projects; D057184:Practice Patterns, Nurses' / Q000458:organization & administration*; D011787:Quality of Health Care / Q000458:organization & administration / Q000592:standards*; D012044:Regression Analysis; D012219:Rheumatology / Q000379:methods; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome
D018501:Antirheumatic Agents