Conducting an annual review is one of the key measures for the National Early Inflammatory Arthritis Audit, as it allows you to find out how patients are managing their condition and what further treatments they need. We speak to Dr Jo Kitchen, consultant rheumatologist at Royal Berkshire NHS Foundation Trust, to find out how the team identify patients for annual review and how they use PROMS to help.
Identifying patients for annual review
We’re a team of five consultants working in general medicine as well as rheumatology. We have five nurse specialists, two physician associates, one specialist physiotherapist and a part-time OT. We also have a pharmacist who's just starting dose escalation clinics for our early arthritis cohort and biologic reduction clinics. We look after a population of around 500,000.
One of my first roles as a consultant in 2014 was to set up the early arthritis clinic. We set up new appointment types on our electronic patient record with set names, such as ‘rheumatology nurse education’ or ‘EIA doctor follow-up’. This means we can differentiate and track early inflammatory arthritis patients. It’s helped us to identify the cohort and aids the administration staff when booking and moving clinics.
A month after the initial doctor appointment, patients have an education and treatment escalation appointment with a specialist nurse. We then provide three, six and nine-month follow up appointments. We’re currently working towards monthly appointments for the first year. Changing the names of the slots has helped us to identify and flag when a patient needs their annual review.
Patients seeing the same clinician
Due to our commitments in general medicine, historically we've had a pool of patients seen by different clinicians in the department. We're moving to a named consultant model to improve continuity of care. This helps with annual review, as the professional relationship has already been established. It helps when you’ve seen the patient on their treatment journey.
Use electronic PROMs
Good patient-reported outcome measures (PROMs) are essential. Historically we sent out paper forms for patients to complete. We’d ask them to either post it back to us or bring it with them to their annual review, but the uptake was poor. A lot of the annual review is based on PROMs, so we needed to look for a way to improve that.
Since the start of 2021, we use a software called Dr Doctor. Patients receive a text message or an email and can complete their questionnaires online at home. There are generic questions for all patients like the Health Assessment Questionnaire and then disease-specific ones, such as PSAID-12.
Over the next year, we're planning to get all our EIA patients on a longitudinal study of ePROMs. We’re now working on getting this integrated into our electronic patient record, as the last thing you want in a busy clinic is to try and access different systems. It’s a work in progress, but we hope to be able to report much better uptake in the next year.
A measure of your success
Our annual reviews are always with a doctor and are a comprehensive look at how the patient is doing. Their ePROMs informs the review and guides us on anything that needs addressing. We assess their function, review their scores and look at the extra-articular elements of their disease. This also allows us to schedule the appropriate timing of their follow-up appointments.
Annual reviews are so important because they provide a snapshot of whether your treatment has been successful. Those not in remission may have other issues, such as fibromyalgia or other patient or disease factors which have delayed successful treatment. If they still have active disease, it might be because escalation hasn’t happened in a timely manner. It flags patients who are still struggling and helps us identify areas for improvement in our early arthritis pathway.
Advice to others
Make sure you have a way of flagging patients for annual review somehow in your hospital system. It can be a challenge to identify those coming up to a year but work with your admin staff to work out a way that suits your service.
In our experience, paper patient questionnaires don’t work. One of the developments because of COVID-19 is that technology has moved forward, so embrace that. Having PROMs in the background during annual review helps identify any problems. The pre-clinic integration of the PROMs data will make the annual review more efficient, effective and beneficial for patient care.
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