Department of Rheumatology, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
Rheumatology (Oxford). 2010 Apr;49(4):741-8. doi: 10.1093/rheumatology/kep407. Epub 2010 Jan 18.
To determine whether DAS28 measurements by a specialized nurse, before the rheumatologist visit, in combination with the advice to rheumatologists to reach a DAS28 < or = 3.2, had beneficial effects on disease activity and medication prescription in patients with RA and to explore possible predictors for variation in medication changes and reasons for non-adherence to the advice to reach a DAS28 < or = 3.2.
In this pilot study, rheumatologists were randomized to 'usual care' (n = 3) or DAS28 measurement by a nurse prior the rheumatologist visit (n = 4). In the usual care group, the DAS28 was measured but not provided to rheumatologists. Mixed model analyses were used for analysing between-group differences and for the prediction model. Rheumatologists in the intervention group were asked to provide reasons in cases of non-adherence to the advice.
After 18 months, DAS28 was reduced by - 0.69 and - 0.66 (P = 0.70) in, respectively, the intervention (144 patients) and the usual care (104 patients) groups. In the intervention group, medication was changed by rheumatologists in 35% of the visits with a DAS28 > 3.2; in the usual care group this was 33% (P = 0.99). Baseline DAS28 (OR 1.6; P< or =0.0001) and HAQ (OR 1.3; P = 0.03) were positively related to a medication change. The most frequently mentioned reason not to change medication was patient refusal (26%).
DAS28 measurement by a nurse was as effective as usual care; however, this intervention without protocolized treatment adjustments is not sufficient to lead to a considerable reduction in disease activity compared with trials with protocolized treatment adjustments.
确定在风湿科就诊前，由专科护士进行 DAS28 测量，并结合向风湿科医生提出的 DAS28<或=3.2 的建议，是否对 RA 患者的疾病活动度和药物治疗产生有益影响，并探讨药物变化差异的可能预测因素以及不遵守达到 DAS28<或=3.2 的建议的原因。
在这项初步研究中，将风湿科医生随机分为“常规护理”（n=3）或就诊前由护士进行 DAS28 测量（n=4）组。在常规护理组中，测量了 DAS28，但未提供给风湿科医生。采用混合模型分析进行组间差异分析和预测模型分析。干预组的风湿科医生被要求在不遵守建议的情况下提供原因。
18 个月后，干预组（144 例患者）和常规护理组（104 例患者）的 DAS28 分别降低了-0.69 和-0.66（P=0.70）。在干预组中，当 DAS28>3.2 时，有 35%的就诊时风湿科医生会改变药物治疗；而在常规护理组中，这一比例为 33%（P=0.99）。基线 DAS28（OR 1.6；P<或=0.0001）和 HAQ（OR 1.3；P=0.03）与药物治疗变化呈正相关。最常提到的不改变药物治疗的原因是患者拒绝（26%）。
护士进行 DAS28 测量与常规护理一样有效；然而，这种没有协议化治疗调整的干预措施不足以导致与有协议化治疗调整的试验相比，疾病活动度显著降低。
