Background/Purpose: Due to a longer life expectancy in general, the treatment burden of RA is growing, and although treatment is generally becoming more effective and better tolerated, many countries experience an unmet demand for rheumatologists and a current demand for greater cost-effectiveness. For this reason alternatives to conventional outpatient physician-led follow-up have been investigated, i.e. nurse-led follow-up. Thus, the aim was to conduct a systematic review and meta-analysis, investigating the efficacy of nurse- versus physician-led follow-up in the treat to target strategy in RA.  

Methods: A systematic literature search was performed using the databases: Medline, Embase, the Cochrane Central Register of Controlled Trials, PsycINFO, CINAHL, Web of Science, Scopus, and. Eligible trials were all randomized controlled trails reporting on the effect of nurse-led follow-up in managing disease control in RA in comparison to physician-led follow-up at hospitals or medical clinics. This implied nurse-led follow-up for out-patients with RA where nurses performed assessment of tender and swollen joints, evaluated blood-samples and monitored the medical treatment in order to evaluate the patients’ disease activity as part of the consultation. Nurses included rheumatology nurses, nurse practitioners, clinical nurse specialists and advanced nurse practitioners. Physicians included rheumatologists and younger physicians involved in follow-up care of patients with RA.

Results: Eight articles, reporting five studies with 1044 participants in total, were included. All but one study included stable patients who were in remission at baseline.  Overall, no difference in disease activity was found after 48-52 weeks (MD -0.07 (95% CI: -0.23; 0.09)) (Figure 1).  After 84-104 weeks a small statistical, but not clinical relevant difference, was seen in favor of nurse-led follow-up (MD -0.29 (95% CI: -0.53; -0.04). No difference in patient satisfaction was seen after 48-52 weeks (SMD -0.17 (95% CI: -1.00; 0.67). After 84-104 weeks a statistical significant difference was found in favor of nurse consultations.  

Conclusion: Overall no difference was found on the effect of disease activity whether RA patients were offered nurse- or physician led follow-up, but the patients tended to become more satisfied over time in nurse-led follow-up. This evidence supports the understanding that routine disease monitoring of RA patients in stable phase can include specialist nurses. PROSPERO id:CRD42015026151    Figure 1   Forest plot: pooled mean differences for disease activity after one year