title: Implementing a patient-initiated review system in rheumatoid arthritis: a qualitative evaluation.
abstract: BACKGROUND
  The management of Rheumatoid Arthritis (RA), a chronic relapsing condition primarily affecting joints usually entails regular hospital reviews with a specialist. These reviews can occur when the patient is well. This study forms part of a service evaluation of a system wide implementation of a patient initiated review appointment system which we have called Direct Access (DA). The aim was to explore the experiences of patients and staff of a DA system in order to understand the process of the implementation and to identify potential improvements.
  
  
  METHODS
  Twenty-three patients with RA that had completed one year of follow-up on the DA system and seven healthcare professionals (HCPs) involved in the implementation of the DA review system took part in semi-structured interviews. Thematic analysis was used to analyse the interview data and field notes.
  
  
  RESULTS
  Four themes emerged in the data: (1) building patient confidence and empowerment, (2) right place right time, (3) safety, (4) the everyday challenges of managing change. These show that in order for implementation to be successful the patient needs to have confidence in using a new system of requesting a medical review, which, in turn, needs to be offered quickly and in a setting convenient to both patient and clinician. Embedded in the change process need to be systems for ensuring regular disease monitoring and general issues surrounding team working, communication and ownership of the change process also need to be considered from the outset.
  
  
  CONCLUSIONS
  The clinics offer increased patient autonomy and the opportunity for greater self-management of chronic disease. This fits with new models of care where the patient is considered to be 'the expert'.
authors.affiliation: PenCLAHRC, Plymouth University Schools of Medicine and Dentistry, ITTC Building, Tamar Science Park, Drake Circus, Plymouth, Devon, PL4 8AA, UK. susan.child@plymouth.ac.uk.
authors.forename: Sue
authors.initials: S
authors.lastname: Child
authors.affiliation: PenCLAHRC, University of Exeter Medical School, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, EX2 4SG, UK. V.Goodwin@exeter.ac.uk.
authors.forename: Victoria A
authors.initials: VA
authors.lastname: Goodwin
authors.affiliation: Department of Rheumatology, Plymouth Hospitals NHS Trust, Derriford Road, Plymouth, Devon, PL6 8DH, UK. mark.perry3@nhs.net.
authors.forename: Mark G
authors.initials: MG
authors.lastname: Perry
authors.affiliation: The Wesley Research Institute, University of Queensland Schools of Medicine and Population Health and Queensland Brain Institute, PO Box 499, Brisbane, QLD 4066, Australia. CGericke@wesleyresearch.com.au.
authors.forename: Christian A
authors.initials: CA
authors.lastname: Gericke
authors.affiliation: PenCLAHRC, Plymouth University Schools of Medicine and Dentistry, ITTC Building, Tamar Science Park, Drake Circus, Plymouth, Devon, PL4 8AA, UK. richard.byng@plymouth.ac.uk.
authors.forename: Richard
authors.initials: R
authors.lastname: Byng
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001172:Arthritis, Rheumatoid / Q000534:rehabilitation*; D002908:Chronic Disease / Q000534:rehabilitation*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010347:Patient Care Planning / Q000592:standards*; D010358:Patient Participation; D017060:Patient Satisfaction; D036301:Qualitative Research; D058996:Quality Improvement / Q000458:organization & administration*; D061665:Time-to-Treatment / Q000592:standards*