Chan Georgina, Goh Fern, Hodgson Timothy, Hsu Erica, Johnstone Deborah, Ly Jasen, Platt Timothy, Rodrigues Edrich, Tsai Wendy, Hider Phil, Gray Andrew, Highton John
Department of Orthopaedics, Timaru Hospital, Timaru.
N Z Med J. 2008 May 23;121(1274):34-41.
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.
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.
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.
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.
类风湿关节炎（RA）的当前治疗涉及使用多种改善病情抗风湿药（DMARDs）和生物反应剂，这需要持续的医疗监督。开展了一项审计，以评估奥塔哥地区类风湿关节炎患者门诊专科随访对治疗监督的充分性。
使用风湿病服务数据库评估2001年10月1日至2006年9月30日期间至少就诊两次的所有患者倒数第二次和最后一次就诊风湿病门诊之间的随访时间。其他记录的数据包括人口统计学信息和临床医生对下次门诊就诊时间的预期。对实际随访间隔、专科医生指示的间隔和新西兰风湿病协会指南推荐的随访间隔进行了比较。根据指南中规定的四组对患者进行分类：A组：新开始使用DMARDs的患者；B组：疾病管理有一些变化的患者；C组：强效药物治疗稳定的患者；D组：病情较轻药物治疗稳定的患者。
根据指南，只有40%的患者在推荐间隔内接受随访。与C组和D组（分别为50%和45.3%）相比，A组和B组（分别为76.9%和70.6%）有显著更高比例的患者随访情况与指南建议不符（p<0.001）。指南推荐的随访间隔与临床医生建议的间隔之间存在明显差异。与指南建议相比，临床医生建议A组和B组随访频率较低，而C组和D组患者随访频率较高。然而，对患者生活质量评分的评估表明，随访仍然适当地针对生活质量较低的患者。
随访差异在可能最有药物相关问题风险的患者组中最为明显，指南建议对这些患者进行更密切的监测。可能需要采取额外策略来促进基于指南的随访安排。进一步的工作应检查其他地区风湿病患者中指南推荐、医生意图和实际随访之间的关系，以评估是否应改变临床医生行为或指南内容。
