Developing an Annual Review Clinic for People with Rheumatoid Arthritis

The aim of developing an Annual Review (AR) for people with Rheumatoid Arthritis (RA) was to implement Quality Statement 7 from NICE QS33 and to ensure NICE CG79 was being followed. The objectives were to ensure that people with RA were offered a comprehensive, holistic AR by a Rheumatology Specialist Nurse incorporating assessment of disease activity (DAS) and functional ability (HAQ), assessing comorbidities such as bone health (FRAX), cardiovascular risk (QRISK2) and depression, assessing for complications of RA, assessing the need to cross refer to other members of the multi-disciplinary team (MDT) or for surgery, assessing symptom control and pain management, disease education and medication review.

Prior to the development and implementation of our AR clinic, patients were seen in Secondary Care on an ad hoc basis by their named Rheumatologist or by a Rheumatology Specialist Nurse. It was clear that a holistic and comprehensive AR was not taking place, mainly due to pressure on appointment times. In 2013-2014, the Quality and Outcomes Framework (QOF) for Primary Care included an AR with specific outcomes related to assessment of bone health and cardiovascular risk. In 2014-2015, these assessments were removed from the Primary Care QOF and we saw this as an ideal opportunity to implement our AR. It enabled us to address these issues and provide a quality service for our patients with RA by introducing a comprehensive AR by a Rheumatology Specialist Nurse.
We are aware that patients with RA are at an increased risk of cardiovascular disease related to their inflammatory burden and also at an increased risk of osteopaenia, osteoporosis and fractures. By assessing for these conditions, screening for risk factors, medication review and patient education that occurs during an AR appointment, we hope to improve patient care and prevent future cardiovascular events and fractures.

In 2013, our trust employed a new, full-time Rheumatology Specialist Nurse. The main remit for this nurse was to work alongside myself to develop and implement an AR service in accordance with Statement 7 from NICE QS33. We developed a clinic proforma and clinic template consisting of 40-minute appointments run by the Rheumatology Nurse Specialist under my supervision. In early 2014, we started the process of inviting patients to attend for their AR. The AR is still in the process of evolution and the next step is to get the AR clinic linked in to our intranet so that we can print copies of to give to patients / send to primary care and to highlight when patients last had an annual review and when they are next due one.

In terms of quantitative benefits of the Annual Review clinic, looking over the last quarter of the year: - 3% of patients have had a new diagnosis of osteoporosis and have been started on treatment as a result of Annual Review.
- 17% of people were found to have an increased risk of cardiovascular disease (as based on QRISK2 modelling) and have been referred back to their GP for further investigation / management as appropriate (we picked up 2 new cases of diabetes and we referred 1 patient direct to cardiology for exercise tolerance testing / angiogram as appropriate due to cardiac sounding chest pain).
- Other referrals include 1 patient referred directly to gastroenterology, 1 to the deaf society and 3 patients have been referred to community Occupational Therapy.
We have recently audited our AR service and the overall consensus from patients was that they really valued the time spent in clinic. They felt that they were given the opportunity to discuss matters that they had not previously discussed with their primary care physician or Rheumatologist. Comments included: - "I felt the very first appointment in Rheumatology was a bit too much information to take in. on the whole, my experience has been very positive and a fantastic service. Thank-you"
- "Think you are doing a great job"
- "Confirmation of how you feel and an opportunity to discuss issues that are not worth an appointment on their own"
- "Gave me the feeling that something was being done about my condition"
The AR clinic has highlighted a number of patients who are at a higher risk for cardiovascular disease and this information is fed back to the primary care physician. We have diagnosed several patients with Diabetes Mellitus and have had the opportunity to discuss lifestyle issues such as smoking cessation and healthy living. We found that many patients did not understand the role of other Health Care Professionals (HCPs) such as Occupational Therapists (OTs) and this has led to an increased number of cross referrals within the MDT. It is difficult to get a accurate grasp of the AR to patients and indeed potential cost savings to the NHS as it is difficult to get a full picture of secondary benefits (ie. how many cardiovascular events or osteoporotic fractures have be prevented by the AR). We are conducting a further audit this year to further assess patient satisfaction with AR.

Developing an AR clinic pro-forma that all physicians agree on has proved difficult, particularly in a large department with a number of consultant Rheumatologists. Speaking to the local Diabetes team is valuable as AR clinics have been active in Diabetes checking for complications of the disease for a number of years so a service could be modelled upon their local expertise. Ideally in order to save time and secretarial work as well as make the AR clinic easier to audit and implement, the AR should be electronic from day one. This was not an option in our AR clinic and is the next step in its evolution.