By Ed Susman

Nurses trained in rheumatology who took over many of the tasks involved in patient clinic visits typically performed by physicians did not impair effectiveness of therapy – but did appear to reduce waiting times to see a specialist, reported researchers in Germany.

In a controlled trial in which patients were assigned to be seen mainly by a nurse and others were assigned to standard care with mostly rheumatologists, Kirsten Hoeper, PhD, of the Rheumatology Center Lower Saxony and Hannover Medical School, and colleagues found that favorable changes in the Disease Activity Score in 28 joints (DAS28) occurred in both groups.

In her presentation at the European League Against Rheumatism (EULAR) virtual meeting, Hoeper said the mean DAS28 score for the intervention group was 4.36 for patients seen mainly by nurses and 4.51 for those seen mainly by rheumatologists -- a difference that was not significantly different.

She said the findings may allow Germany to join the ranks of other European nations such as Denmark, the Netherlands, and the United Kingdom in allowing nurses to handle most of the heavy lifting in rheumatology office visits.

"What we saw is that our intervention does not undermine the current standard of care," Hoeper said. "In fact, it's really safe to say that for the first time in Germany, we could show that nurse consultation is a very safe way to add to the treatment of patients ... The reality in Germany right now is that we do not have enough rheumatologists to cover all the spaces. We need to roughly double the amount -- just to give you a picture of what we are talking about. The impact is huge, especially for remote clinics."

"It is really difficult for patients to get an appointment," she explained. "We have a window of opportunity of 3 months to start treatment. And waiting times to see a rheumatologist can be 9 months, and in some cases as long as 12 months. If you want to start therapy, you want to see your patients more often to make sure new medication works. These are the guidelines, but we really want to do that. And there is not enough time to cover all the issues or the questions of the patients."

Hoeper said that the idea of performing a clinical trial would be important in convincing authorities and doctors of the "worth of the nurses" -- "You have to make sure it works, but you have to show it's safe to do so, and like with every drug, you have to do that with an intervention."

Christine Stamatos, DNP, of Northwell Health and Hofstra University in Huntington, New York, said the concept of nurse led clinics is not new.

"What the German study looked at and what we do in clinical practice in the United States, is the same," she said. "There are in fact, nurse-led clinics in the United States that treat people with rheumatoid arthritis. Many of these clinics in the U.S. and elsewhere, such as Canada and the United Kingdom, do function fairly autonomously.

"That is how I operate in my practice," she said. "I bring in a physician if there needs to be changes in medication, or if the patients requests a physician's input. In complicated cases, such as with vasculitis, I always bring in a physician in to make sure we are helping the patients to get healthy."

Stamatos noted, however, "There have been studies that compare outcomes between practices that employ nurse practitioners and physician assistants in rheumatology practices, but no comparative trials.... We need to do such a trial here."

For the study, Hoeper and her colleagues recruited 236 patients in 2018 from centers across Germany, with half assigned to standard of care to be seen by rheumatologists, and the other half seen by a specialized nurse, along with a very short contact with a physician.

"The patients really liked it," Hoeper said. "They did not feel abandoned or not treated well ... We looked at a lot of different secondary endpoints. And every endpoint showed it's totally fine and safe for the patient. Extending the team approach to nurses into the care of patients together with a rheumatologist is an exciting new way to improve the care for patients in Germany."

The moderator of a press conference that included the study, Robert Landewe, MD, PhD, of the University of Amsterdam/Amsterdam Medical Center and the chairman of the EULAR meeting, said: "It is time for change in Germany, isn't it? One of the three pillars of rheumatology is health professionals, and that includes rheumatology nurses."

"Dr. Hoeper has shown that rheumatology nurses can indeed help patients with rheumatic and musculoskeletal diseases," Landewe added. "And nurses do not necessarily replace the physician but they definitely have their own additional tasks and their own additional experience."