Nurse-Led Care Improves Disease Activity in Rheumatoid Arthritis

Compared with usual care (UC) and rheumatologist-led care (RLC), nurse-led care (NLC) reduced disease activity and improved self-efficacy in patients with rheumatoid arthritis (RA), according to a study published in BMJ Open Quality.¹

Common clinical manifestations of RA include chronic joint pain, fatigue, morning stiffness, and impaired quality of life. RA disease progression is marked by escalation of joint dysfunction, which becomes increasingly burdensome for patients and their families. Therefore, RA treatment involves pain alleviation, joint damage prevention, and joint function preservation and enhancement.

Typically, physicians are responsible for the follow-up of most patients with RA, escalating their workloads. However, past research has explored the potential of nurses in managing patients with RA to alleviate the strain on rheumatologists,² finding that nurse-led RA management programs offer more holistic care, potentially preventing or delaying RA-related complications. However, these studies have yielded conflicting results, delaying the broader implementation of NLC.¹

Consequently, the researchers conducted a meta-analysis to evaluate the effectiveness of NLC and other alternative care options for patients with RA to provide reliable practical guidelines. They defined NLC as the primary role of nurses in managing patients with RA, involving tasks like monitoring the patient’s condition, tracking their blood results, and providing continuous patient education.

Nurse-led care effectively reduces disease activity and improves self-efficacy in patients with rheumatoid arthritis. | Image Credit: © Rido - stock.adobe.com

The researchers searched PubMed, Embase, and Web of Science between their inception dates and May 2023 for all relevant randomized controlled trial literature on the effectiveness of NLC for patients with RA. Using the population/intervention/comparison/outcome/study framework, 2 independent reviewers assessed their search results for relevant studies.

Relevant studies included patients aged 18 or older with RA and involved all types of NLC; they also contained a control group of patients who received UC or RLC. The researchers meticulously gathered information from these studies, including patient count, intervention methods, and follow-up duration.

The primary outcome was disease activity, measured with the Disease Activity Score (DAS)-28 with C-reactive protein/erythrocyte sedimentation rate scale; lower scores indicated lower disease activity. Secondary outcomes included physical function and psychological status (PFPS), pain, morning stiffness, patient satisfaction, self-efficacy, fatigue, and quality of life.

The 14 included articles involved 3369 RA cases, with 1589 in the observation group and 1780 in the control group. Of the 14 studies, 4 originated from the United Kingdom, 3 from Denmark, 2 from China, and 1 each from the US, Germany, Switzerland, France, and South Korea. They encompassed various NLC interventions, including counseling, briefings, and psychosocial support of outpatients with RA in hospitals or clinics.

Of the 14 studies, 12 evaluated disease activity among 2998 patients. Compared with the control group, the NLC group had a lower DAS28 score (mean difference [MD], −0.09; 95% CI, −0.17 to −0.01; P = .03 < .05). In the subgroup analysis, there was a significant statistical difference between NLC and UC, indicating that NLC was more effective in reducing disease activity (MD, −0.15; 95% CI, −0.26 to −0.04; P = .007 < .05). However, NLC and RLC had similar effects on reducing disease activity, with no statistical significance (P = .33 > .05).

As for the secondary results, 4 studies assessed the impact of NLC on the self-efficacy of patients with RA using the Arthritis Self-Efficacy Scale and the Rheumatoid Arthritis Self-Efficacy Scale; higher scores on these scales indicate higher self-efficacy. Compared with the control group, NLC led to higher self-efficacy levels in patients with RA (MD, 0.40; 95% CI, 0.03-0.77; P = .03 < .05).

However, the subgroup analysis determined that self-efficacy increased to the same extent in patients who received NLC vs UC (standardized mean difference [SMD], 0.56; 95% CI, −0.09 to 1.21) or between patients who received NLC vs RLC (SMD, 0.20; 95% CI, −0.19 to 0.59). Therefore, the researchers deemed these results unstable and noted that they require further data for validation.

Among the remaining 6 secondary outcomes (pain, satisfaction, fatigue, quality of life, stiffness, and PFPS), the level of improvement among patients with RA who received NLC was comparable to that observed in the control group, with no statistically significant distinction.

The researchers acknowledged their study’s limitations, including the small sample sizes and insufficient follow-up durations in many of the included studies; this could have reduced the credibility of their findings and introduced bias. Despite their limitations, they used their findings to make future treatment suggestions.

“…NLC proves to be an effective approach in the nursing care of RA patients, with results comparable to those of RLC,” the authors concluded. “Empowering nurses to engage in the management of certain RA patients, in lieu of doctors, is a feasible and beneficial strategy.”

References

1. Yang L, Xiang P, Pi G, Wen T, Liu L, Liu D. Effectiveness of nurse-led care in patients with rheumatoid arthritis: a systematic review and meta-analysis. BMJ Open Qual. 2025;14(1):e003037. doi:10.1136/bmjoq-2024-003037

2. Barber CEH, Marshall DA, Szefer E, et al. A population‐based approach to reporting system–level performance measures for rheumatoid arthritis care. Arthritis Care & Research. 2021;73(5):640-648. doi:10.1002/acr.24178