Specifying a service for the diagnosis and management of rheumatoid arthritis in adults

Service components

The key components of a rheumatoid arthritis (RA) service are:

• early identification and referral for specialist treatment
• access to high-quality multidisciplinary care for people with established rheumatoid arthritis
• treatment of rheumatoid arthritis

Early identification and referral for specialist treatment

NICE CG79 on rheumatoid arthritis recommends that any person with suspected synovitis of undetermined cause should be referred for specialist opinion, and provides clear criteria for when urgent referral is required. Timely referral is important to enable first-line treatment to start as soon as possible, ideally within 3 months of onset of persistent symptoms. At presentation, the diagnosis of RA may not be readily apparent and people with suspected persistent synovitis or RA, or early inflammatory arthritis, who will require care or further investigation, may also be referred to specialist services^[1].

The majority of people with RA delay seeking medical help from their GP for 3 months or more following the onset of symptoms. The median time to first treatment has remained constant at around 9 months since 2003. RA is difficult to diagnose and requires specialist knowledge. Most GPs are likely to see an undiagnosed case of RA less than once a year, and frequently GPs do not feel they have access to support and advice to help them identify new cases^[2].

The National Audit Office (NAO) report Services for people with rheumatoid arthritis recommends that PCTs should improve awareness in primary care, particularly amongst GPs, of how to recognise symptoms and the need to refer suspected cases promptly.

An online education tool on the management of RA has been developed by NICE in collaboration with BMJ Learning. It includes learning on when to suspect rheumatoid arthritis and when to refer to secondary care¹.

Access to high-quality multidisciplinary care for people with established rheumatoid arthritis

NICE CG79 on rheumatoid arthritis identifies that people with RA should have ongoing access to multidisciplinary care including:

• a named member of the multidisciplinary team (MDT)(for example, the specialist nurse) who is responsible for coordinating their care
• specialist physiotherapy
• specialist occupational therapy if they have difficulties with everyday activities or problems with hand function
• psychological interventions
• a podiatrist if they have foot problems
• functional insoles and therapeutic footwear, if indicated

The MDT should provide the opportunity for periodic assessments of the effect of the disease on people's lives (including pain and fatigue) and help to manage the condition.

The NAO report Services for people with rheumatoid arthritis has identified that there is a lack of coordinated holistic care to support people with RA. They recommend that PCTs should work with providers to ensure that people with RA are offered a personalised care plan and support to remain in, or return to, work.

The musculoskeletal services framework has also noted that the integration of the different musculoskeletal specialties varies across providers. Usually, rheumatologists and orthopaedic surgeons work closely with the therapists, but there is little integration of the medical specialties.

Commissioners should work closely with all stakeholders to ensure a multidisciplinary service is in place, which will require good communication and clinical leadership across primary and secondary care. This may need to include those who provide psychological interventions, however the Topic-specific Advisory Group noted the psychological interventions recommended by NICE can generally be provided by the MDT.

Treatment of rheumatoid arthritis

The aim of treatment for people with RA is to achieve disease remission or minimise disease activity, which improves the long-term outcomes, so that disability is less likely to occur ^[1].

Economic modelling suggests that increasing the proportion of people with RA receiving earlier treatment could initially increase costs to the NHS by £11 million over 5 years. This is due to higher expenditure on drugs and the associated costs of monitoring people with the disease. However, after 9 years earlier treatment could become cost-neutral to the NHS. This would improve people's quality of life and improve their chances of remaining in work.

NICE CG79 on rheumatoid arthritis describes in detail the treatment of RA. This includes offering a combination of disease-modifying anti-rheumatic drugs (DMARDs), glucocorticoids and biologic drugs where there is no response to other treatments. The guideline also recommends the use of analgesics where pain control is not adequate.

The NAO report identifies that biologic drugs for the treatment of RA account for the highest pharmaceutical spend within some trusts. Commissioners may wish to work with providers to ensure that eligible patients receive biologic drugs in a timely manner, their outcomes are monitored and treatment is maintained or discontinued as appropriate. The NICE commissioning guide on biologic drugs contains further guidance about commissioning biologic drugs for the treatment of RA.

NICE CG79 on rheumatoid arthritis management recommends:

• that people with RA who wish to know more about their disease and its management should be offered the opportunity to take part in existing education activities, including self-management programmes
• offering people with satisfactorily controlled established RA review appointments at a frequency and location suitable to their needs. In addition make sure they:
  
  
  • have access to additional visits for disease flares
  • know when and how to get rapid access to specialist care
  • have ongoing drug monitoring
• offering people with RA an annual review, see NICE CG79 on rheumatoid arthritis for full details.

The NAO report identified that annual reviews are not available at all trusts. NICE recommends that the annual review should include a check for the development of comorbidities, such as hypertension, ischaemic heart disease, osteoporosis and depression. Commissioners may wish to consider how local pathways across primary and secondary care meet the needs of people with RA and agree with clinicians where annual reviews should take place. It is important that providers recognise that people with RA have a higher risk of cardiovascular disease and that appropriate interventions are in place to manage this risk.

See a summary of NICE guidance which may be useful to inform the provision of annual reviews for people with RA.

NICE CG79 on rheumatoid arthritis identifies criteria for when people with RA should be offered referral for a specialist surgical opinion, for example when they do not respond to optimal non-surgical management or following complications.

The guidance notes that providers should inform people with RA who wish to experiment with their diet that there is no strong evidence that their arthritis will benefit. It also states that although some complementary therapies may provide short-term symptomatic benefit, there is little or no evidence for their long-term efficacy.

In order to achieve optimal use of resources and to support NHS Quality, innovation, productivity and prevention (QIPP), commissioners should be aware of those assessments and interventions that are not recommended for the treatment of RA in NICE CG79 on rheumatoid arthritis: Do not avoid referring urgently any person with suspected persistent synovitis of undetermined cause whose blood tests show a normal acute-phase response or negative rheumatoid factor (1.1.1.2) Do not use anakinra, except in the context of a controlled, long-term clinical study (1.4.3.1) Do not offer the combination of tumour necrosis factor-α (TNF-α) inhibitor therapy and anakinra for RA (1.4.3.3) Do not let concerns about the long-term durability of prosthetic joints influence decisions to offer joint replacements to younger people with RA (1.6.1.6)

Service models

Commissioners may wish to consider delivering an RA service in a number of different ways, and mixed models of provision may be appropriate across a local health economy.

The current Department of Health strategy for managing long-term conditions is to move towards a patient-centred primary care approach. However, the NAO report has recently identified that only 12% of PCTs manage RA in a primary care setting. Findings also showed that the majority of PCTs had not analysed the costs and benefits of moving services and that the current pathway for RA, including managing flare-ups, is not as efficient or effective as it could be^[2].

PCTs should assess the number of people with RA in their population and identify the specialist and multidisciplinary services and the configuration of services that best meets local needs and resources. Commissioners should consider how to best integrate service models and include education for primary care and input from the MDT within service models.

There are a variety of service models that may support improving access to early treatment while maintaining ongoing support for people with RA. Developing a service that is more patient focused through providing an annual review can help to release capacity to provide rapid access during a disease flare. Service models could include:

• Early arthritis clinics, which include nurse specialist roles and support from the MDT^[2], however few such specialist nurse roles currently exist.
• Patient initiated direct-access services, where GPs or people with RA can access speedy support during a flare-up and GPs provide routine monitoring^[3]. Structured patient education and self-management guidelines can help people with RA know when to seek further support to manage their condition.
• Community-based services, which include MDT support, and are led by a GP with specialist interest (GPwSI) or a consultant. GPwSI roles can include providing joint injections, patient monitoring, patient education, support for local GPs^[2], and screening and prioritising referrals.
• Nurse-led telephone follow-up.
• Locally enhanced services or shared-care arrangements.
• Self-management of drug administration for patients treated with methotrexate and biologic drugs, supported by monthly monitoring appointments and attendance at the specialist service when dose adjustment is required^[2].

The NAO have estimated that early referral and diagnosis could initially increase costs in some acute trusts. However, blood tests for rheumatoid factor detect less than half of people who will eventually be diagnosed with RA and avoidance of unnecessary diagnostic tests could generate some cost savings in primary care. The NAO estimate that once a steady state is reached, this approach could generate annual savings for the NHS of around £2 million^[2].

Service specification

Local stakeholders, including service users, should be involved in determining what is needed from an RA service in order to meet local needs. The service should be patient-centred and integrated with other elements of care for adults with RA.

The service specification needs to consider:

• the required competencies of, and training for, staff responsible for providing the service
• the expected number of patients (this should take into account how quickly any changes in service provision are likely to take place)
• ease of access and service location; commissioners should engage with service users and other relevant individuals and organisations locally
• care and referral pathways, see the NICE CG79 quick reference guide
• information and audit requirements, including IT support and infrastructure
• planned service improvement, including redesign, quality and equitable access
• service monitoring criteria.

Useful sources of information may include:

• The standard NHS contracts for acute hospital, mental health, community and ambulance services.
• Patient perceptions of rheumatoid arthritis care: a consultancy report by The King's Fund for the Rheumatology Futures Group outlining key priorities for improving care for people with RA.
• The Clinical Knowledge Summary for RA
• The NICE shared learning database offers examples of how organisations have implemented NICE guidance locally.
• Implementation advice for NICE CG79 on rheumatoid arthritis including an RA algorithm.

Footnotes

The tool is free to use and only requires a simple registration process with the BMJ Learning website.

References

1. National Collaborating Centre for Chronic Conditions (2009) Rheumatoid arthritis. National clinical guideline for management and treatment in adults. London: Royal College of Physicians.
2. National Audit Office (2009) Services for people with rheumatoid arthritis. London: The Stationery Office.
3. Kirwan JR, Mitchell K, Hewlett S et al. (2003) Clinical and psychological outcome from a randomized controlled trial of patient-initiated direct-access hospital follow-up for rheumatoid arthritis extended to 4 years.
   Rheumatology 42: 422-6.