Acceptability of a nurse-led integrated primary care review for people with inflammatory rheumatological conditions: a qualitative evaluation

Problem

People with inflammatory rheumatological conditions (IRCs), including rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, polymyalgia rheumatic and giant cell arteritis, are at an increased risk of comorbidities such as cardiovascular disease, osteoporosis, anxiety and depression. An assessment of these common comorbidities within a nurse-led review in primary care could lead to improved control of the IRC and reduced morbidity and mortality.The INCLUDE pilot cluster randomised controlled trial aimed to evaluate the feasibility and acceptability of a nurse-led integrated primary care review for people with IRCs, to identify and manage comorbidities.

Approach

A qualitative study was embedded within the INCLUDE trial. A purposive sample of 20 patients (IRC, age and gender) who attended an INCLUDE review appointment, were invited to participate in a face-to-face interview to reflect on their experience of the INCLUDE review. A topic guide was utilized. Interviews were transcribed verbatim. Thematic analysis using constant comparison was undertaken. Overarching themes were agreed by discussion between members of the qualitative research team, and then mapped onto the constructs of the new Theoretical Framework of Acceptability (TFA).

Findings

Four overarching themes were developed, mapping onto four constructs of the TFA: including expectations of the review, experiences of the review, usefulness of the review, and burden. Affective attitudesParticipants appreciated the opportunity to learn more about comorbidities linked to their condition. The personal qualities of the nurse, such as being approachable and having time to listen, were valued and were reported to facilitate patients to disclose health concerns. Patients recognised the value of the integrated approach, which allowed them to discuss multiple areas of health in one consultation.Intervention coherenceMany patients reported attending the review for altruistic reasons, to help with research, rather than perceiving it to be relevant to themselves or their IRC. Few patients were initially aware of their increased risk of comorbidities and did not expect this to be the focus of the review.Perceived effectivenessPatients reported the review to be effective by identifying and initiating management of previously unrecognised comorbid conditions, or by providing reassurance when no comorbidities were identified. Some patients reported barriers to following recommendations, such as lifestyle modifications, suggested by the nurse.BurdenSeveral patients felt the review added extra burden when new medications were suggested to deal with newly identified comorbidities.

Consequences

This study is novel as we have used the new TFA to assess acceptability of the INCLUDE review. Many patients with IRCs lacked knowledge about their risk of comorbidities. The findings suggest an integrated review which recognises multimorbidity is acceptable to patients. However, some patients identified examples of added extra burden and barriers to following recommendations.