Outpatient follow-up for patients with rheumatoid arthritis in relation to New Zealand Rheumatology Association guidelines at Dunedin Hospital

Abstract

Aim: Current treatment for rheumatoid arthritis (RA) involves the use of various disease-modifying anti-rheumatic drugs (DMARDs) and biologic response agents which require ongoing medical supervision. An audit was undertaken to assess the adequacy of outpatient specialist follow-up for supervision of treatment in patients with RA in the Otago region.

Methods: The Rheumatology Service database was used to assess time between follow-up for the penultimate and last visit to rheumatology outpatient clinic for all patients who made at least two visits between 1 October 2001 and 30 September 2006. Other recorded data included demographic information and clinician expectations for the timing of the next outpatient visit. Comparisons were made between actual follow-up intervals, those indicated by specialists and the follow-up intervals recommended by the New Zealand Rheumatology Association Guidelines. Patients were characterised according to four groups specified in the guidelines: Group A: patients newly started on DMARDs; Group B: patients with some change in disease management: Group C: patient stable on potent medications: Group D: patients stable on less severe medication.

Results: According to the guidelines only 40% of patients were followed up within the recommended intervals. Groups A and B (76.9% and 70.6% respectively) had a significantly greater proportion of patients with follow-up at variance to guideline recommendations compared to groups C and D (50% and 45.3% respectively) (p<0.001). There were marked discrepancies between the guideline recommended follow-up intervals and those suggested by the clinicians. Compared with guideline recommendations clinicians advised less frequent follow-up for groups A and B but more frequent for patients in Groups C and D. However, an assessment of the quality of life scores amongst the patients suggested that follow-up was still appropriately targeted to those patients with lower quality of life.

Conclusion: Discrepancies in follow-up were most marked in the patient groups potentially most at risk of medication-related problems in whom guidelines suggested more intensive monitoring. Additional strategies to promote guideline-based follow-up arrangements may be indicated. Further work should examine the relationships between guideline recommended, physician intended and actual follow-up among rheumatology patients in other regions in order to assess whether modifications should occur to clinician behaviour or guideline content.