Provisional guidelines for applying the Department of Health (England) 18-week-patient pathway to specialist rheumatology care

OBJECTIVES: The Government Department of Health (England) has set a target that by 2008 patients on pathways that do or may involve medical or surgical consultant-led care should wait no longer than 18 weeks from referral to start of definitive treatment. Department of Health guidance must be interpreted and applied to patients with rheumatological problems. METHODS: Provisional guidelines have been prepared in collaboration between the British Society for Rheumatology, British Pain Society, Department of Health (England) and other key stakeholders. RESULTS: Definitive rheumatological treatment comprises a package of care rather than a single action. The care package usually requires input from a multidisciplinary team using several modalities in parallel. Actions within the care package that must be taken before treatment can be said to have started, are definitive actions. Definitive actions should be based on evidence of cost-effectiveness, tailored to the individual patient and offered irrespective of local availability or accessibility. They should be agreed between partners in the patient's care. This requires face-to-face consultation between the patient and a health care professional with appropriate expertise and knowledge. All definitive actions specified at the outset of management within specialist care must be initiated or removed by agreement from the patient's care package before the clock can be stopped in the 18-week-patient pathway. CONCLUSIONS: Service redesign may be necessary in order to achieve an 18-week-patient pathway for all patients. A consistent and appropriate definition of clock-stops should ensure that patients will benefit from excellent rheumatology specialist care without unnecessary delay.     

Management of overweight and obesity in primary care—A systematic overview of international evidence‐based guidelines

Overweight and obesity are increasing worldwide. In general practice, different approaches exist to treat people with weight problems. To provide the foundation for the development of a structured clinical pathway for overweight and obesity management in primary care, we performed a systematic overview of international evidence‐based guidelines. We searched in PubMed and major guideline databases for all guidelines published in World Health Organization (WHO) “Stratum A” nations that dealt with adults with overweight or obesity. Nineteen guidelines including 711 relevant recommendations were identified. Most of them concluded that a multidisciplinary team should treat overweight and obesity as a chronic disease. Body mass index (BMI) should be used as a routine measure for diagnosis, and weight‐related complications should be taken into account. A multifactorial, comprehensive lifestyle programme that includes reduced calorie intake, increased physical activity, and measures to support behavioural change for at least 6 to 12 months is recommended. After weight reduction, long‐term measures for weight maintenance are necessary. Bariatric surgery can be offered to people with a BMI greater than or equal to 35 kg/m² when all non‐surgical interventions have failed. In conclusion, there was considerable agreement in international, evidence‐based guidelines on how multidisciplinary management of overweight and obesity in primary care should be performed.     

Obesity services: how best to develop a coherent way forward

Obesity now affects 25% of the UK population. This volume of patients cannot be managed by current NHS services. It really needs a public health approach which encourages an environment where it is easier for the public to take healthy rather than unhealthy actions. However, there remain substantial numbers of patients who will benefit from medical intervention. This needs a joined‐up service which extends from a healthy environment, linking gyms, weight loss groups, community cooking lessons, etc. with pathways connecting primary and secondary healthcare. To date, the National Health Service has not managed to develop a coherent policy that addresses obesity as a major cause of health and social care expenditure. The most important step in primary care is probably to identify the presence of obesity. The medical steps should be in the identification and management of comorbidities. The purpose of treating obesity is not weight loss alone but improving health, so the narrative needs to change from weight to blood pressure, glucose tolerance, physical fitness, etc. Many physicians believe that weight loss is an unwinnable battle but there are several well conducted studies in which primary care, supported by specialists, can deliver successful clinical weight loss. Specialist medical and surgical care for obesity will be required for complex cases and is essential for overseeing long‐term postsurgical follow‐up to prevent and treat nutritional and metabolic complications. Obesity management suffers from a lack of coherent national public health policies, fragmentation of care and a lack of knowledge of what successful treatment entails. Health benefits do not require a return to a healthy BMI.     

A randomized comparison of care provided by a clinical nurse specialist,an inpatient team,and a day patient team in rheumatoid arthritis

OBJECTIVES: To compare in a randomized, controlled trial the clinical effectiveness of care delivered by a clinical nurse specialist, inpatient team care, and day patient team care in patients with rheumatoid arthritis (RA) who have increasing functional limitations. METHODS: Between December 1996 and January 1999, 210 patients with RA were recruited in the outpatient clinic of the rheumatology department of 6 academic and nonacademic hospitals. Clinical assessments recorded on study entry and weeks 6, 12, 26, and 52 included the Health Assessment Questionnaire (HAQ) and the McMaster Toronto Arthritis Patient Preference Disability Questionnaire as primary outcome measures, and the RAND-36 Item Health Survey, the Rheumatoid Arthritis Quality of Life questionnaire, the Health Utility Rating Scale, and the Disease Activity Score as secondary outcome measures. Patient satisfaction with care was measured on a visual analog scale in week 6 in all 3 groups and again in week 12 in the nurse specialist group. RESULTS: Within all 3 groups, functional status, quality of life, health utility, and disease activity improved significantly over time (P < 0.05). However, a comparison of clinical outcome among the 3 groups and a comparison between the nurse specialist group and the inpatient and day patient care groups together did not show any sustained significant differences. Subgroup analysis showed that age had a significant impact on differences between the 3 treatment groups with respect to functional outcome as measured with the HAQ (P < 0.001). With increasing age, the most favorable outcome shifted from care provided by a clinical nurse specialist and inpatient care to day patient care. Patients' satisfaction with care was significantly lower in the nurse specialist group than in the inpatient and day patient care groups (P < 0.001). CONCLUSION: Care provided by a clinical nurse specialist appears to have a similar clinical outcome in comparison with inpatient and day patient team care. Although all patients were highly satisfied with multidisciplinary care, patients who received care provided by a clinical nurse specialist were slightly less satisfied than those who received inpatient or day patient team care. Age appeared to be the only factor related to differences in functional outcome between the 3 treatment groups. The choice of management strategy may, apart from age, further be dependent on the availability of facilities, the preferences of patients and health care providers, and economic considerations.     

Rare genetic causes of obesity: Diagnosis and management in clinical care

Rare genetic forms of obesity are linked to impaired energy balance (i.e., eating behaviour and energy expenditure) involving hypothalamic pathways. More than 60 genes coding for proteins located in the hypothalamic leptin/melanocortin pathway contribute to the development of these rare forms of obesity. The ambition of the French National Protocol for the Diagnosis and Care (PNDS) of Obesity of Rare Causes was to establish practical recommendations for assessment and management at all ages. This report is available on the website of the French Health Authority (HAS). In addition to severe obesity, patients often display obesity-related comorbidities and neuropsychological/psychiatric disorders. These complex conditions make clinical management particularly challenging. Early diagnosis is critical for the organization of coordinated specialized multidisciplinary care, with mandatory interaction between caregivers, social partners and families. Strategies to prevent aggravation of obesity consist in limiting access to food, establishing a reassuring daily eating environment, and the practice of sustained adapted supervised daily physical activity. The implementation of genetic diagnosis in clinical practice now enables a personalized medicine approach with access to new drug therapies, and improves the analysis of the risk/benefit ratio of bariatric surgery.     

Original research: National survey evaluating the provision of gastroenterology dietetic services in England

AimsThe aim of the study was to assess the provision of dietetic services for coeliac disease (CD), irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD).MethodsHospitals within all National Health Service trusts in England were approached (n=209). A custom-designed web-based questionnaire was circulated via contact methods of email, post or telephone. Individuals/teams with knowledge of gastrointestinal (GI) dietetic services within their trust were invited to complete.Results76% of trusts (n=158) provided GI dietetic services, with responses received from 78% of these trusts (n=123). The median number of dietitians per 100 000 population was 3.64 (range 0.15–16.60), which differed significantly between regions (p=0.03). The most common individual consultation time for patients with CD, IBS and IBD was 15–30 min (43%, 44% and 54%, respectively). GI dietetic services were delivered both via individual and group counselling, with individual counselling being the more frequent delivery method available (93% individual vs 34% group). A significant proportion of trusts did not deliver any specialist dietetic clinics for CD, IBS and IBD (49% (n=60), 50% (n=61) and 72% (n=88), respectively).ConclusionThere is an inequity of GI dietetic services across England, with regional differences in the level of provision and extent of specialist care. Allocated time for clinics appears to be insufficient compared with time advocated in the literature. Group clinics are becoming a more common method of dietetic service delivery for CD and IBS. National guidance on GI dietetic service delivery is required to ensure equity of dietetic services across England.     

Organising care for people with diabetes and renal disease

Diabetes and chronic kidney disease (CKD) are two of the commonest long-term conditions. One-fifth of patients with diabetes will have CKD, and diabetes is the commonest cause of advanced kidney disease. For most patients these comorbidities will be managed in primary care with the focus on cardiovascular prevention. Many patients with more advanced disease and complications require joint care from multidisciplinary specialist teams in diabetes and renal disease to ensure that care is consistent and coordinated. Models of joint speciality care, include joint registry management, parallel clinics, shared consulting and case discussion, but require more evaluation than has currently been performed. These underpin more informal interactions between the specialist teams. A local model of care for diabetes and renal disease that incorporates the roles of primary care, members of multidisciplinary teams and speciality care should be agreed, resourced appropriately and its effectiveness monitored.     

Obesity and the risk for cardiovascular disease

Coronary heart disease (CHD) is the leading cause of mortality in the United States. Hypertension, diabetes mellitus, hypercholesterolemia, and smoking have all been directly related to CHD. Obesity is on the rise in the United States and has also been associated with CHD. This review clearly establishes obesity as an independent risk factor for CHD as demonstrated by the Framingham Heart Study, Nurses' Health Study, Buffalo Health Study, and the Cancer Prevention Study II. Morbid obesity was found to correlate with a significant risk of mortality from CHD, especially in young men. Prevention of obesity, and therefore reduction in risk from cardiovascular disease, is paramount in the management of obesity. New approaches to behavioral, medical, and surgical management of obesity are reviewed, including thalidomide, an antiangiogenic agent. A primary and secondary prevention model details a multidisciplinary approach to reducing risk in obesity.     

Clinical pathways for patients with newly diagnosed hepatitis C - what actually happens

Management of hepatitis C virus (HCV)-infected individuals requires referral to specialist care. To determine whether patients newly diagnosed as anti-HCV positive are appropriately referred for further investigation and management, and if not, to determine why not. We studied patients tested for antibodies to HCV by Nottingham Public Health Laboratory in a 2-year period (2000-2002). The progress of newly diagnosed anti-HCV positive patients into specialist clinics for further management was documented. For patients not referred for specialist care, a questionnaire was sent to the clinician requesting the initial anti-HCV test, to identify reasons for nonreferral. Eleven thousand one hundred and seventy-seven patients were tested for anti-HCV. Two hundred and fifty-six (2.3%) were newly diagnosed as being anti-HCV positive. Two per cent of samples sent from primary care were anti-HCV positive, compared to 18.8, 18.9 and 1.3% sent from prison, drug and alcohol units, and secondary care, respectively. About 64.3% of positive patients diagnosed in primary care were referred to specialist care, compared to 18.4, 42.4 and 62.6% of patients diagnosed in the other three settings. One hundred and twenty-five (49%) newly diagnosed patients were referred appropriately for further management. 68 of these attended clinic, 45 underwent liver biopsy and 26 (10%) began treatment. One hundred and thirty-one patients (51%) were not referred. In 54 cases, there was no evidence that the anti-HCV positive result reached the patient. In 15, referral was considered but rejected, and 20 patients were referred to non-HCV-specialists (their general practitioners or to genito-urinary medicine). Hence less than 50% of newly diagnosed anti-HCV positive patients are referred to an appropriate clinic for further investigation and management. Reasons for this are multifarious and complex, reflecting both systems failure and patient choice. Unless these are understood and addressed, the Department of Health Hepatitis C Strategy (2002) and Action Plan for England (2004) will fail to achieve their intended objectives.     

Medical strategies for weight loss in the overweight and obese patient

In recent years, obesity has become a major public health problem in Western countries. The World Health Organization has defined obesity as a global epidemic of the third millennium. Treatment options for weight management include dietary intervention, physical activity, behavior modification, pharmacotherapy and surgery. However, the complexity of this chronic condition necessitates a coordinated multidisciplinary team-approach to the care of obese patients who fail weight control. The long-term duration of the treatment and the necessity of monitoring compliance and effectiveness should be considered. The objective of this article was to review the major controlled randomized clinical trials dealing with the different medical strategies for weight loss and its maintenance in overweight and obese patients.     

Review: British Intestinal Failure Alliance (BIFA) guidance - haematological and biochemical monitoring of adult patients receiving home parenteral nutrition

Home parenteral nutrition (HPN) is necessary for patients with prolonged intestinal failure which can be secondary to a variety of pathophysiological mechanisms or surgical resection. HPN is needed to supply micronutrients, macronutrients and water to reduce morbidity and mortality and to maximise the patient’s quality of life.HPN requires close monitoring by a dedicated multidisciplinary team and is vital to minimise complications; both catheter related and metabolic. A regular comprehensive review is required including history, examination including anthropometry and blood testing. The focus of this review is on the monitoring of haematological and biochemical parameters.There is a paucity of evidence-based literature on the biochemical monitoring of HPN and existing guidance is sourced mostly on expert opinion and lower grade studies. Sources offering guidance on the frequency of biochemical monitoring for the stable adult HPN patient are the British Association for Parenteral and Enteral Nutrition, the European Society for Parenteral and Enteral Nutrition, the National Institute for Health and Care Excellence and the Australasian Society of Parenteral and Enteral Nutrition (AuSPEN).The aim of this work is to review and collate this existing guidance into one clear and concise review. It is recommended that biochemical parameters are checked at baseline, thereafter more frequently if concerns arise and less frequently when the patient’s condition is stable, as assessed by the multidisciplinary team with expertise in HPN.     

The developing role of the renal diabetes nurse

Diabetes as a chronic disease is often complicated in its management, particularly when combined with chronic and end-stage renal failure. Patients, carers and health care professionals are unfortunately often confused by either too little or conflicting advice provided by the two specialist teams. Within this context, the Renal Diabetes Nurse (RDN) role serves to bridge the gap by ensuring effective links and communication. Currently, renal referrals are made from surrounding secondary care settings and primary care GP practices. The expansion of renal outreach clinics, the appointment of new consultant nephrologists and the emergence of nurse-led clinics, reflects our continuous growth to meet the demand for renal services. The number of patients with renal failure and diabetes is set to increase as the acceptance criteria are clarified and referral routes made explicit. An ageing population with 21-62% of the renal population over the age of 65 (depending on the location of the renal unit), coupled with an increase in the Asian and African-Caribbean population all contribute to increased patient numbers. It is now well recognised that these patients often experience associated generalised atheroma and vascular calcification from inadequately managed hypertension and diabetes over a number of years. Consequently, this group of patients are often "high maintenance" requiring input from the multidisciplinary team on a continuing basis.     

Feeding Disorders in Food Allergic Children

Feeding disorders are increasingly being recognized in children with food allergy. For some children, symptoms of feeding dysfunction may persist after allergens are removed from the diet secondary to learned associations with food and discomfort and reinforcement of maladaptive feeding behaviors. Many food allergic children require care from a multidisciplinary team of specialists, which includes allergists, gastroenterologists, mental health professionals, and feeding specialists. Early referral for feeding assessment by a pediatric feeding specialist can be a critical component of the food allergic child’s care. This article reviews and discusses the recent literature regarding feeding disorders in food allergic children. A literature review was conducted using the PubMed database for English language articles published between January 1980 and February 2010. Additional information was obtained via review of recent textbooks and review of the general information web page of several established pediatric feeding programs.     

Original research: Implementation of a care bundle improves the management of patients with non-alcoholic fatty liver disease

BackgroundNon-alcoholic fatty liver disease (NAFLD) is common and is associated with liver-related and cardiovascular-related morbidity. Our aims were: (1) to review the current management of patients with NAFLD attending hospital clinics in North East England (NEE) and assess the variability in care; (2) develop a NAFLD ‘care bundle’ to standardise care; (3) to assess the impact of implementation of the NAFLD care bundle.MethodsA retrospective review was conducted to determine baseline management of patients with NAFLD attending seven hospitals in NEE. A care bundle for the management of NAFLD was developed including important recommendations from international guidelines. Impact of implementation of the bundle was evaluated prospectively in a single centre.ResultsBaseline management was assessed in 147 patients attending gastroenterology, hepatology and a specialist NAFLD clinic. Overall, there was significant variability in the lifestyle advice given and management of metabolic risk factors, with patients attending an NAFLD clinic significantly more likely to achieve >10% body weight loss and have metabolic risk factors addressed. Following introduction of the NAFLD bundle 50 patients were evaluated. Use of the bundle was associated with significantly better documentation and implementation of most aspects of patient management including management of metabolic risk factors, documented lifestyle advice and provision of NAFLD-specific patient advice booklets.ConclusionThe introduction of an outpatient ‘care bundle’ led to significant improvements in the assessment and management of patients with NAFLD in the NEE and could help improve and standardise care if used more widely.     

Core competencies for cardiac rehabilitation/secondary prevention professionals: 2010 update: position statement of the American Association of Cardiovascular and Pulmonary Rehabilitation

Cardiac rehabilitation/secondary prevention (CR/SP) services are typically delivered by a multidisciplinary team of health care professionals. The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recognizes that to provide high-quality services, it is important for these health care professionals to possess certain core competencies. This update to the previous statement identifies 10 areas of core competencies for CR/SP health care professionals and identifies specific knowledge and skills for each core competency. These core competency areas are consistent with the current list of core components for CR/SP programs published by the AACVPR and the American Heart Association and include comprehensive cardiovascular patient assessment; management of blood pressure, lipids, diabetes, tobacco cessation, weight, and psychological issues; exercise training; and counseling for psychosocial, nutritional, and physical activity issues.     

A working paradigm for the treatment of obesity in gastrointestinal practice

Obesity is a chronic, relapsing, multifactorial disease characterized by abnormal or excessive adipose tissue accumulation that may impair health and increase disease risks. Despite the ever-increasing prevalence and economic and societal burden, the current approaches to treat obesity are not standardized or generally effective. In this article, we describe a current working paradigm developed by a consensus approach for the multidisciplinary treatment of obesity in the gastrointestinal practice. Obesity should be managed as a continuum of care focusing on weight loss, weight loss maintenance, and prevention of weight regain. This approach needs to be disseminated throughout the health care system, coordinated by a multidisciplinary team, and include gastroenterologists who are in a unique position to address obesity. Gastroenterologists are in the front line of managing the morbidity resulting from obesity, and have expertise in use of the essential tools to manage obesity such as nutrition, pharmacology, endoscopy, and surgery.     

A randomized comparison of care provided by a clinical nurse specialist,an inpatient team,and a day patient team in rheumatoid arthritis

Objectives

To compare in a randomized, controlled trial the clinical effectiveness of care delivered by a clinical nurse specialist, inpatient team care, and day patient team care in patients with rheumatoid arthritis (RA) who have increasing functional limitations.

Methods

Between December 1996 and January 1999, 210 patients with RA were recruited in the outpatient clinic of the rheumatology department of 6 academic and nonacademic hospitals. Clinical assessments recorded on study entry and weeks 6, 12, 26, and 52 included the Health Assessment Questionnaire (HAQ) and the McMaster Toronto Arthritis Patient Preference Disability Questionnaire as primary outcome measures, and the RAND‐36 Item Health Survey, the Rheumatoid Arthritis Quality of Life questionnaire, the Health Utility Rating Scale, and the Disease Activity Score as secondary outcome measures. Patient satisfaction with care was measured on a visual analog scale in week 6 in all 3 groups and again in week 12 in the nurse specialist group.

Results

Within all 3 groups, functional status, quality of life, health utility, and disease activity improved significantly over time (P < 0.05). However, a comparison of clinical outcome among the 3 groups and a comparison between the nurse specialist group and the inpatient and day patient care groups together did not show any sustained significant differences. Subgroup analysis showed that age had a significant impact on differences between the 3 treatment groups with respect to functional outcome as measured with the HAQ (P < 0.001). With increasing age, the most favorable outcome shifted from care provided by a clinical nurse specialist and inpatient care to day patient care. Patients' satisfaction with care was significantly lower in the nurse specialist group than in the inpatient and day patient care groups (P < 0.001).

Conclusion

Care provided by a clinical nurse specialist appears to have a similar clinical outcome in comparison with inpatient and day patient team care. Although all patients were highly satisfied with multidisciplinary care, patients who received care provided by a clinical nurse specialist were slightly less satisfied than those who received inpatient or day patient team care. Age appeared to be the only factor related to differences in functional outcome between the 3 treatment groups. The choice of management strategy may, apart from age, further be dependent on the availability of facilities, the preferences of patients and health care providers, and economic considerations.

     

Multidisciplinary care of the patient with chronic obstructive pulmonary disease

The National Emphysema Treatment Trial used a multidisciplinary team approach to implement the maximum medical care protocol, including adjustment of medications and outpatient pulmonary rehabilitation for all patients and nutritional and psychological counseling as needed. This article discusses the benefits of such an approach in the care of the patient with chronic obstructive pulmonary disease. Team member roles complement each other and contribute to the goal of providing the highest-quality medical care. The primary focus of the team is to reinforce the medical plan and to provide patient education and support. This article reviews the elements of the initial patient assessment and the functional and nutritional assessment. Patient education focuses on medication use, recognition and management of chronic obstructive pulmonary disease exacerbation symptoms, smoking cessation, advance directives, and travel.     

Nurse-led intervention for the management of bariatric surgery patients: A systematic review

The prevalence of obesity has become a global health concern, and severe obesity is associated with various chronic diseases and decreased quality of life. Bariatric surgery has shown success in treating obesity. Nevertheless, some patients experience weight regain and unsatisfactory outcomes. Multidisciplinary interventions have been shown to improve postoperative outcomes. Case managers, often specialized nurses, play a crucial role in patient support and coordination of care. However, the diverse design of case-managing interventions hinders the assessment of their success. Thus, the aim of this review is to identify the most successful structural characteristics of case-managing interventions, with or without the support of e-Health, in the process of perioperative management of bariatric surgery patients. A systematic literature review was conducted following the PRISMA guidelines. PubMed, MEDLINE, EBSCOhost, and CINAHL databases were searched for relevant studies published in the last 10 years. Eligible studies included randomized controlled trials, controlled clinical studies, case studies, or observational studies that evaluated perioperative care in bariatric surgery. The PICO framework was used to frame the search strategy. The initial search yielded 225 articles, of which 10 studies met the inclusion criteria. Nurse-led case-managing interventions with a multidisciplinary approach showed positive results in weight loss, physical activity, and quality of life. Patient-centered care models were found to promote adherence to treatment and patient satisfaction. E-Health technologies improved quality of life but not weight loss. The duration of behavioral interventions and the long-term outcomes after surgery remained unclear. Nurse-led case-management interventions, with a focus on behavioral change and multidisciplinary approaches, show promise in improving outcomes in bariatric surgery patients. Patient-centered care models and longer term interventions may contribute to sustained weight loss and better postoperative outcomes. Further research is needed to determine the optimal duration of interventions and the long-term effects on weight maintenance.     

Patients' views on the quality of health care for rheumatoid arthritis

OBJECTIVE: To study the experiences and views of patients with rheumatoid arthritis (RA) on the quality of health care received in primary and secondary care. METHOD: Semi-structured interviews with 26 individual patients with RA; these were stratified by sex, ethnicity and disease duration, based on the treated prevalence cohort of patients attending two outpatient clinics in South East England. RESULTS: Patients highlighted four main factors which influenced their attitude and approach towards hospital staff and the treatment offered: (i) their past experiences with the National Health Service (NHS), (ii) their own health beliefs, (iii) professional attitudes (e.g. listening to patients, receiving feedback on disease processes) and (iv) organizational aspects (e.g. good communication between health professionals) which would make their visits to the outpatient clinic easier. CONCLUSION: Most patients no longer see themselves as passive recipients of care. They appreciate acknowledgement from health care professionals of their contribution towards management of their own chronic illness, and welcome a more equal dialogue with health care staff. This is consistent with the emphasis of the Department of Health document on 'Supporting People with Long-term Conditions' such as RA.