A mixed methods study to evaluate the effectiveness of nurse training to deliver an integrated care review for patients with inflammatory rheumatic conditions

Problem

People with inflammatory rheumatological conditions (IRCs), including rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, polymyalgia rheumatica and giant cell arteritis, are at an increased risk of comorbidities such as cardiovascular disease (CVD), osteoporosis, anxiety and depression. These are often not recognized or treated and can lead to increased morbidity and mortality. Screening for and managing these comorbidities within a nurse-led review could improve outcomes.The INCLUDE pilot trial aimed to evaluate the feasibility and acceptability of a nurse-led integrated review for people with IRCs based in primary care. This review included an assessment of lifestyle factors, CVD and fracture risk, and case-finding for anxiety and depression.

Approach

Patients identified as having an IRC via their primary care records were invited to a review consultation at their general practice. Two rheumatology nurses participated in training (which included role play with simulated patients) to deliver the review. Consent was gained to conduct interviews with nurses, to explore their experiences of the training. A topic guide was utilized and interviews transcribed verbatim. Thematic analysis using constant comparison was utilized and overarching themes agreed through discussion with the research team.With patient consent, a convenience sample of INCLUDE consultations were digitally-audio- recorded. Fidelity analysis was undertaken using a predefined checklist of 7 components within the review; opening the consultation, assessing physical health, reviewing CVD risk, assessing bone health and fracture risk, case finding for mood problems, communication of a management plan and advice regarding follow-up.

Findings

The nurses reported the training to be comprehensive, informing them how to assess for comorbidities within the review and how to use a computer template to record their findings. They felt that the use of role play with simulated patients provided a safe environment in which to test their consultation skills and build their confidence. Fidelity checks on 24 audio-recorded consultations revealed that diet and exercise were not always explored, whilst some borderline raised body mass index (BMI) and blood pressure (BP) measurements were not acted on further. Occasionally, FRAX risk calculations were not supported by background information, such as a history of steroid use or parental hip fracture, whilst the meaning of responses to the case-finding questions for mood problems were not always explained. The purpose of the review and a final management plan were communicated well.

Consequences

INCLUDE nurses were positive about the comprehensiveness and usefulness of the training, which helped prepare them to deliver the review. Fidelity checks of consultations have highlighted important areas for development of the training in a future randomized controlled trial, including more in-depth discussion of lifestyle factors, BMI and BP, an emphasis on the information required for FRAX risk calculation and communication of the outcome of case-finding questions.