A nurse-led rheumatology clinic versus rheumatologist-led clinic in monitoring of patients with chronic inflammatory arthritis undergoing biological therapy: a cost comparison study in a randomised controlled trial

This is a study comparing the differences in resources and costs when substituting a rheumatologist with a rheumatology nurse in monitoring patients with stable CIA undergoing biological therapy. Replacing one of the two annual rheumatologist monitoring visits by a nurse-led monitoring visit resulted in no additional contacts to the rheumatology clinic, but rather a decrease in use of resources and a reduction of costs. This reduction in use of resources and lower costs were not related to any differences between the groups in clinical outcomes as previously reported from this RCT [20].

In rheumatology care, there are only a few studies evaluating the cost-effectiveness of an NLC and almost only in conventional DMARD therapy. These studies reveal that NLCs are more cost-effective regarding cost and disease-related dimensions such as DAS28 or Eq5D, but not clearly in relation to quality-adjusted life years [17, 18, 25]. The present study demonstrated lower resource use and costs when monitoring biological therapy by an NLC compared to an RLC over a 12 month follow-up period. This is mainly due to the fixed monitoring costs, where a visit to rheumatologist is more costly than a visit to a rheumatology nurse. The result also suggests, although not significant, that patients monitored in the NLC in comparison with the RLC had lower use of variable monitoring resources and costs. This may be due to the visit to the NLC with a PCC approach being focused on the patient’s resources and needs. Patients’ narratives create a common understanding of the illness experience, which, together with the symptoms of the disease, provide the nurse with a good foundation for discussing and planning care and treatment together with the patient [23]. This is consistent with previous research showing that an NLC leads to fewer additional contacts with healthcare services [26]. PCC increases patients’ confidence in their own ability and patients become autonomous and independent [27]. Research has shown that PCC in various fields of inpatient care has led to a reduction in the length of the hospital stay by up to 70 % and reduced costs without a negative impact on health-related quality of life [12, 13, 28, 29]. The present study showed more additional blood tests in the RLC. These were predominantly routine test and not expensive special test, and they were ordered despite the fact that the patients had a stable CIA and were monitored every six months. The monitoring visit at the NLC included a dialogue around the pharmacological therapy in terms of administration, adherence, side effects and blood tests. The finding in the present study is in line with that patients with knowledge about their disease and its treatment and monitoring, including blood tests, have been reported to use less health care resources [30]. For annual inpatient rehabilitation there was a non-significant lower cost in the NLC group compared with the RLC group. This was however based on only a small number of patients receiving rehabilitation during the 12 months. Previous studies have reported that rheumatology nurses often refer patients to individual team members based on individual needs [31, 32].

This study also evaluated differences in pharmacological therapy and costs related to this. There was a lower cost in the NLC compared to the RLC. This was due to a greater proportion of patients in the RLC treated with subcutaneous biological therapy, being more expensive than intravenous biological therapy in Sweden (http://​www.​tlv.​se). Other methods of calculating the cost of biological therapy have shown that the annual cost per patient for intravenous infusions is more expensive than for subcutaneous injections [33]. Due to the increasing total rheumatology care costs [19] and the effectiveness of the expensive biological therapies in rheumatology care [34] the present study supports the EULAR recommendations, which argue that interventions and monitoring by nurses could contribute to cost savings in comprehensive disease management [1]. The result is important because it suggests that the annual resource use and costs are lower when monitoring biological therapy in an NLC, based on PCC, in comparison with monitoring in an RLC. The patients were monitored effectively by two annual visits [20], which differs from previous studies on patients undergoing conventional DMARD treatment, where NLCs are based on frequent visits to the nurse, usually every 3 months or more often [14‐17]. When the cost of the rheumatology care can be reduced by replacing rheumatologists with rheumatology nurses in monitoring patients who have a low disease activity or remission, resources can be reallocated to patients who have a high disease activity and do not respond to medical treatment. These patients may need a more tight control of their disease with frequent visits to the rheumatologist, which is an effective strategy in patients with RA [35] as well as in SpA [36], or treatment from a multidisciplinary team [37, 38]. Research demonstrates that treating to the target of remission in early rheumatoid arthritis is cost-effective [39].

This study suggests that implementation of NLC in rheumatology care should be considered as it could save resources and costs, with no differences in disease activity or activity limitations as shown in previous studies [14, 16, 17, 20]. A regular contact with a rheumatology nurse as a complement to a rheumatologist provides added value to the rheumatology care [40]. The rheumatology nurse listens attentively and is sensitive in their conversation so the patients dare to open up and experience confirmation about their illness experience and life situation [21]. An NLC adds value to the rheumatology care in terms of increased satisfaction [15‐17, 41] and empowering patients to achieve a higher level of confidence in their own abilities [42] and participation. This is consistent with the results from the present study. Patients experience participation due to exchange of information, dialogue and respect of their own knowledge and skills [21]. It is important for patients to be seen as individuals [21, 42‐44] and a PCC with a holistic approach is essential in the management of patients with CIA [21, 43], which may have influenced the tendency towards a higher health related quality of life in the NLC. There are still, however, some challenges especially from the rheumatologists, who doubt the nurses’ knowledge, but also from patients, who express fear of losing contact with the rheumatologist [45]. Patients experience, however, a sense of security and describe rheumatology nurses as competent and skilled and point to the nurses’ high level of knowledge [21, 42‐44].

The study has both strengths and limitations. The strengths are the design based on an RCT, the inclusion of all rheumatology care, and that 90.6 % of the randomly assigned participants had complete data and fulfilled the study. A limitation is that this was a single center trial, but with patients from three regions in Sweden. Another limitation is that it focuses on the direct costs of rheumatology care and does not include indirect costs or savings outside healthcare services or for the patients themselves. There could also be additional costs or savings in other healthcare areas but this is not covered by the present study.