Nurse-led practice in rheumatology has become commonplace in many parts of the world in response to a shortage of rheumatologists and the rising burden of disease.  But in Australia it is pioneering stuff.

A veteran of 20 years in rheumatology, Nurse Practitioner Linda Bradbury runs a busy clinic at Queensland’s Gold Coast University Hospital (GCUH) managing 25-30 patients per week face to face and more via a telephone service.

Ms Bradbury was endorsed in 2012 as Australia’s first rheumatology nurse practitioner (NP), a status that gives highly qualified registered nurses broad autonomy of practice in one or sometimes two specialties with scope to diagnose, prescribe and treat patients.

She remains a rarity, one of only five rheumatology NPs in the country.  But her clinic at GCUH could offer a template for rheumatology nurses to add to capacity, speed up treatment and manage disease in its early stages – both in the hospital setting and in the community.

“The idea is that I don’t see the rare conditions and complicated patients,” Ms Bradbury tells the limbic. 

“I see patients that are potentially stable but need monitoring. I perform assessments, can order radiology and pathology tests, and review the results.  I can prescribe and change medication as I see fit, or collaborate with a consultant if I think something is outside my scope.”

Recruited to develop the NP-led model at GHUH in late 2019, she says the challenge was to achieve a smooth fit with the hospital’s rheumatology department while proving in the initial six-month period that the position could pay for itself through activity-based funding (ABF).  During the orientation period, all her interactions with patients were tape recorded.

“At the end of the six months, we worked out that I had done way more than my salary cost,” she says, adding that reclassified weightings under the state’s ABF system made the financial case easier and “really gave NPs a chance to prove their worth”.

Evidence for nurse-led care

In a German study of more than 220 rheumatoid arthritis patients, half were randomly assigned to regular check-ups with an RNP and half to see a rheumatologist.

The study, reported at the EULAR 2020 virtual congress, found nurse-led care for rheumatoid arthritis management was “non inferior” to care provided by physician-led care.

Results were measured over 12 months on disease activity, as well as patients’ responses on daily functioning, quality of life and depression, leading the researchers to conclude that more reliance on rheumatology nurses could improve care and doctors’ workflow.

In the area of patient satisfaction, numerous international studies have shown improved outcomes for arthritis patients under nurse-led care.

“I think patients have a perception that nurses have more time, and they find it easier to ask questions of a nurse than a doctor,” says Ms Bradbury

“Recently I had a young woman diagnosed 12 years ago say to me, ‘Finally I understand what’s wrong with me.’ Especially in the public system, patients love the fact that they come into clinic and see the same person.”

GCUH clinic patients also have a direct phone line to Ms Bradbury during clinic hours. For urgent problems, she can schedule a clinic visit and arrange hospital admissions. Unsurprisingly, during COVID-19, she has been busy with immune-suppressed patients seeking clarification about medications and vaccines, saving them a trip to a GP or the ED.

Prescribing barriers

While the Australian definition of NPs is consistent, rules on what they can and can’t do vary between jurisdictions and specialties.  Queensland NPs in rural and remote areas, for example, have greater latitude in prescribing restricted medications.

Ms Bradbury, who chairs the ARA’s Rheumatology Health Professionals Special Interest Group, says it is a “hindrance” that she can write scripts for steroids but not low-dose methotrexate, even if only to continue a patient’s course of treatment. For that, she needs to call on a doctor.

Only four RNPs  are currently practicing in the role in Australia  — a tiny fraction of the country’s 2100 NPs, who are mainly in emergency and acute, primary, aged and palliative, and chronic care.  The growth areas for NPs are mental health and private practice.

Behind the RNPs are another 50 or so registered rheumatology nurses working in advanced practice – 5000 hours of which is required before they can begin a master’s degree and undertake the specialised training to become an NP.

Will these nurses go the extra mile?  Identified barriers include a lack of understanding of the NP role, generally and in the specialty, and the fact that most rheumatologists practice privately.  But the soaring costs of rheumatic disease – counted in welfare payments and early retirements as well as health care – could encourage a public policy intervention.