Current issues of ACP Journal Club are published in Annals of Internal Medicine


Patients responded better to a nurse practitioner than a consultant rheumatologist in a rheumatology clinic

ACP J Club. 1994 Sept-Oct;121:45. doi:10.7326/ACPJC-1994-121-2-045

Source Citation

Hill J, Bird HA, Harmer R, Wright V, Lawton C. An evaluation of the effectiveness, safety and acceptability of a nurse practitioner in a rheumatology outpatient clinic. Br J Rheumatol. 1994 Mar;33:283-8.



To compare the effectiveness, safety, and acceptability of a rheumatology nurse practitioner (RNP) with a consultant rheumatologist (CR) in caring for patients with rheumatoid arthritis.


48-week single-blind, randomized controlled trial.


Rheumatology outpatient clinic of a teaching hospital in England.


70 patients (mean age 56 y, 74% women) with rheumatoid arthritis who had attended the rheumatology outpatient clinic on at least 3 previous occasions and had not seen the CR or RNP before. Follow-up was 97%.


Patients were randomly assigned to the care of a CR (n = 35) or an RNP (n = 35).

Main outcome measures

Biochemical assessments were plasma viscosity (PV) and C-reactive protein. Clinical assessments included the Ritchie articular index (AI); pain scores and duration of morning stiffness self-recorded on a diary card; physical function and psychological status measured by the Arthritis Impact Measurement Scales; and knowledge of disease process, drug treatment, physiotherapy, and joint protection techniques measured by the Patient Knowledge Questionnaire. Acceptability was measured by the Leeds Satisfaction Questionnaire. Safety was monitored by serial assessment of levels of leukocytes, platelets, and hemoglobin; liver and kidney function tests; and urine tests.

Main results

By study end (week 48), both groups of patients had a similar reduction in mean PV and duration of morning stiffness as well as similar improvements in AI, physical function scores, and psychological assessment scores. Compared with the CR group, the RNP group had a better mean pain score (2.2 vs 2.7, P for the 0.5 difference = 0.05), increased knowledge of their disease (P < 0.001), and higher overall satisfaction with their care (P < 0.001). The groups did not differ for safety outcomes.


Patients with rheumatoid arthritis who were monitored by a rheumatology nurse practitioner had greater improvement in measures of pain, knowledge, and satisfaction than patients receiving conventional care from a consultant rheumatologist.

Source of funding: Not stated.

For article reprint: J. Hill, Chapel Allerton Hospital, Chapeltown Road, Leeds LS7 4SA, England, United Kingdom. FAX 44-113-392-4723.


The recent health care reform proposals in the United States focus on primary care, prevention, and cost. To achieve this goal, an expanded role of nurse practitioners (NPs) in managed care is likely. This raises questions about the effectiveness, safety, and patient acceptance of NP medical service. NPs have been found to effectively provide a wide range of health services as members of a health care team (1) and as independent health care providers. Much evidence exists for positive short-term outcomes in NP-delivered care, but studies of long-term outcome are still lacking (1).

In Great Britain, the role of rheumatology NPs has evolved from carrying out clinical drug trials to monitoring rheumatologic therapy and actually managing the care of patients with rheumatologic disease. NPs also excel in educating and counseling patients with these diseases (2). The British study by Hill and colleagues provides additional evidence for the benefits of NP-delivered care in a rheumatology clinic. It proved not only the effectiveness and safety of NP care but also the higher satisfaction of their patients compared with those of the rheumatologist. Interestingly, the number of patients seen by the rheumatologist during the study period was approximately twice that of the NP. This raises questions about the cost-effectiveness of NP care. Nevertheless, the high level of satisfaction among patients and the improved clinical outcome clearly support the role of NPs in this setting.

Although patient acceptance of expanded NP medical care may differ in the United States, its implementation may be just around the corner.

Roland Staud, MD
University of FloridaGainesville, Florida, USA


1. Ventura MR, Crosby F, Feldman MJ. An information synthesis to evaluate nurse practitioner effectiveness. Mil Med. 1991;156:286-91.

2. Hill J. A nurse practitioner rheumatology clinic. Nurs Stand. 1992;7(11):35-7.