title: Implementing a patient-initiated review system for people with rheumatoid arthritis: a prospective, comparative service evaluation.
abstract: OBJECTIVE
  The management of rheumatoid arthritis (RA) usually entails regular hospital reviews with a specialist often when the patient is well rather than during a period of exacerbation. An alternative approach where patients initiate appointments when they need them can improve patient satisfaction and resource use whilst being safe. This service evaluation reports a system-wide implementation of a patient-initiated review appointment system called Direct Access (DA) for people with RA. The aim was to establish the impact on patient satisfaction of the new system versus usual care as well as evaluate the implementation processes.
  
  
  METHODS
  As all patients could not start on the new system at once, in order to manage the implementation, patients were randomly allocated to DA or to usual care. Instead of regular follow-up appointments, DA comprised an education session and access to a nurse-led telephone advice line where appointments could be accessed within two weeks. Usual care comprised routine follow-ups with the specialist. Data were collected on patient satisfaction, service use and outcomes of any contact to the advice line.
  
  
  RESULTS
  Three hundred and eleven patients with RA were assessed as being suitable for DA. In terms of patient satisfaction, between-group differences were found in favour of DA for accessibility and convenience, ease of contacting the nurse and overall satisfaction with the service. Self-reported visits to the general practitioner were also significantly lower. DA resulted in a greater number of telephone contacts (incidence rate ratio = 1.69; 95% confidence interval 1.07 to 2.68). Hospital costs of the two different service models were similar. Mean waiting time for an appointment was 10.8 days
  
  
  CONCLUSIONS
  This service evaluation found that DA could be implemented and it demonstrated patient benefit in a real-world setting. Further research establishing the broader cost-consequences across the whole patient pathway would add to our findings.
authors.affiliation: University of Exeter Medical School, Exeter, UK.
authors.forename: Victoria A
authors.initials: VA
authors.lastname: Goodwin
authors.affiliation: Brighton and Sussex Medical School, Brighton, UK.
authors.forename: Priyamvada
authors.initials: P
authors.lastname: Paudyal
authors.affiliation: Plymouth Hospitals NHS Trust, Plymouth, UK.
authors.forename: Mark G
authors.initials: MG
authors.lastname: Perry
authors.affiliation: Plymouth Hospitals NHS Trust, Plymouth, UK.
authors.forename: Nikki
authors.initials: N
authors.lastname: Day
authors.affiliation: University of Exeter Medical School, Exeter, UK.
authors.forename: Annie
authors.initials: A
authors.lastname: Hawton
authors.affiliation: Wesley Research Institute, Brisbane, UK.
authors.forename: Christian
authors.initials: C
authors.lastname: Gericke
authors.affiliation: University of Exeter Medical School, Exeter, UK.
authors.forename: Obioha C
authors.initials: OC
authors.lastname: Ukoumunne
authors.affiliation: Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK.
authors.forename: Richard
authors.initials: R
authors.lastname: Byng
mesh_terms: D000368:Aged; D001172:Arthritis, Rheumatoid; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D018802:Patient-Centered Care / Q000458:organization & administration*; D015397:Program Evaluation; D011446:Prospective Studies; D011795:Surveys and Questionnaires
keywords: follow-up; implementation; person-centred care; rheumatoid arthritis; service evaluation