EULAR RecommendationPoints to Consider Slide set template Slide

EULAR Recommendation/Points to Consider Slide set template Slide set should, if possible, not exceed 20 Slides Please submit slide set along with final manuscript to the EULAR Secretariat for review before manuscript submission to any journal 1 24/10/2020

2018 update of the EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis

Slide 1: Target population/question • Health care professionals working in the field of rheumatology § Rheumatologists § Nurses § Other disciplines • Patients with inflammatory arthritis • Policy makers 3 24/10/2020

Slide 2: Methods/methodological approach • Methods: According to the EULAR Standardized Operating Procedures* Steering committee: prepared SLR (repeat strategy 2010) Fellow: Systematic literature research 2010 -2017 Steering committee: formulated suggestions for updated recommendations Expert consensus meeting: discussion and voting FINAL Recommendations * van der Heijde et al Ann Rheum Dis 2016, 75: 3 -15 4 24/10/2020

Slide 3: Overarching principles • Rheumatology nurses are part of a healthcare team • Rheumatology nurses provide evidence-based care (this principle is an extension of former recommendation 7, and reflects the complexity of nurses’ roles in e. g. deciding on deviations from protocol if necessary) • Rheumatology nursing is based on shared decision making with the patient 5 24/10/2020

Slide 4: Individual Recommendations Patients should have access to a nurse for needs-based education to improve knowledge of CIA and its management throughout the course of their disease Level of evidence 1 B, Grade recommendation A, level of agreement 10 (9 -10) Patient education covers a wide variety of educational activities and besides improving knowledge and disease control, the goal is to enable patients to manage their life with a chronic disease. The updated SLR confirmed high level of evidence for this recommendation. Needs-based was added to former recommendation 1, based on evidence from 1 RCT 6 24/10/2020

Slide 5: Individual Recommendations Patients should have access to nurse consultations in order to enhance satisfaction with care Level of evidence 1 A, Grade recommendation A, level of agreement 9. 7 (8 -10) To patients satisfaction with care reflects quality of care. The level of evidence regarding improved satisfaction as an outcome of nurse consultations was strengthened by a results from a meta-analysis. Compared to former recommendation 2, no new evidence for improved communication and continuity was found, therefore these concepts were removed 7 24/10/2020

Slide 6: Individual Recommendations Patients should have the opportunity of timely access to a nurse for needs-based support; this includes tele-health Level of evidence 1 B, Grade recommendation B, level of agreement 9. 7 (8 -10) The nature of RMDs and expanded treatment options with increasing complexity of strategies, such as T 2 T, require rapid and timely access to care. Tele-health, remote delivery of healthcare by a range of options, enables accessibility and appropriate care and has brought up new modes of communication, in addition to telephone consultations. We therefore reformulated former recommendation 3 8 24/10/2020

Slide 7: Individual Recommendations Nurses should participate in comprehensive disease management to control disease activity, reduce symptoms, and improve patient preferred outcomes; this leads to costeffective care Level of evidence 1 A, Grade recommendation A, level of agreement 9. 7 (8 -10) The level of evidence was from two meta-analyses and one RCT with long-term follow-up. No evidence for cost-savings were found but nurseled care was cost neutral or slightly less costly compared to physicianled care. Former recommendations 4 and 10 were merged 9 24/10/2020

Slide 8: Individual Recommendations Nurses should address psychosocial issues to reduce patients’ symptoms of anxiety and depression Level of evidence 1 B, Grade recommendation A, level of agreement 9. 6 (8 -10) Assessment and identification of psychosocial problems are key components of nursing care in general. The literature supports “reduce”. The task force wanted more emphasis on symptoms, also if there is no formal diagnosis of depression of anxiety. Former recommendation 5 was reworded. 10 24/10/2020

Slide 9: Individual Recommendations Nurses should support self-management skills to increase patients’ self-efficacy Level of evidence 1 A, Grade recommendation A, level of agreement 9. 8 (9 -10) Supporting the patients’ self-management is a collaborative activity that expands the role of the healthcare team from delivering information and traditional patient education to include activities that support selfmanagement. The evidence supported that nurse-led interventions can improve patients’ self-efficacy. Compared to former recommendation 6 no new evidence for empowerment was found and sense of control is included in the concept self-efficacy. Therefore empowerment and sense of control were removed 11 24/10/2020

Slide 10: Individual Recommendations Nurses should have access to and undertake continuous education in the specialty of rheumatology to improve and maintain knowledge and skills Level of evidence 2 C, Grade recommendation B, level of agreement 9. 8 (7 -10) The TF recognised a need for both generic and rheumatology specific training, but also an urgent need to raise awareness of the nursing specialty to provide a workforce that is able to meet evolving needs in rheumatology and therefore added ‘in the specialty of rheumatology’ to former recommendation 8 12 24/10/2020

Slide 11: Individual Recommendations Nurses should be encouraged to undertake extended roles after specialised training and according to national regulations Level of evidence 1 A, Grade recommendation A, level of agreement 9. 7 (9 -10) The wording of this recommendation remained unchanged. However, the level of evidence increased based on two meta-analyses showing the effectiveness of nurse-led follow-up, which represents an advanced level 13 24/10/2020

Slide 12: Summary Table Oxford Level of Evidence* 1 B Grade of Recommendation* A Level of agreement† (0 -10) 10. 0 ± 0. 2 [9 -10] Patients should have access to nurse consultations in order to enhance satisfaction with care Patients should have the opportunity of timely access to a nurse for needs-based support; this includes tele-health 1 A A 1 B B 9. 7 ± 0. 6 [8 -10] 4 Nurses should participate in comprehensive disease management to control disease activity, reduce symptoms, and improve patient preferred outcomes; this leads to costeffective care 1 A A 9. 7 ± 0. 5 [8 -10] 5 Nurses should address psychosocial issues to reduce patients’ symptoms of anxiety and depression Nurses should support self-management skills to increase patients’ self-efficacy Nurses should have access to and undertake continuous education in the specialty of rheumatology to improve and maintain knowledge and skills Nurses should be encouraged to undertake extended roles after specialised training and according to national regulations 1 B A 1 A A 2 C B 1 A A 9. 6 ± 0. 7 [8 -10] 9. 8 ± 0. 4 [9 -10] 9. 8 ± 0. 7 [7 -10] 9. 7 ± 0. 6 [8 -10] Recommendations 1 Patients should have access to a nurse for needs-based education to improve knowledge of CIA and its management throughout the course of their disease 2 3 6 7 8 14 24/10/2020 †

Slide 13: Summary of Recommendations in bullet point format • Patients should have access to a nurse for needs-based education to improve knowledge of CIA and its management throughout the course of their disease • Patients should have access to nurse consultations in order to enhance satisfaction with care • Patients should have the opportunity of timely access to a nurse for needs-based support; this includes tele-health • Nurses should participate in comprehensive disease management to control disease activity, reduce symptoms, and improve patient preferred outcomes; this leads to cost-effective care 15 24/10/2020

Slide 14: Summary of Recommendations in bullet point format • Nurses should address psychosocial issues to reduce patients’ symptoms of anxiety and depression • Nurses should support self-management skills to increase patients’ self-efficacy • Nurses should have access to and undertake continuous education in the specialty of rheumatology to improve and maintain knowledge and skills • Nurses should be encouraged to undertake extended roles after specialised training and according to national regulations 16 24/10/2020

Slide 15: Summary of Recommendations in lay format Recommendation * Not yet available, Alzbeta Goehmann has been contacted Read the full lay summary (add hyperlink if provided) 1 star (*) means it is a weak recommendation with limited scientific evidence; 2 stars (**) means it is a weak recommendation with some scientific evidence; 3 stars (***) means it is a strong recommendation with quite a lot of scientific evidence; 4 stars (****) means it is a strong recommendation supported with a lot of scientific evidence. Recommendations with just 1 or 2 stars are based mainly on expert opinion and not backed up by appropriate clinical studies, but may be as important as those with 3 and 4 stars. 17 24/10/2020

Slide 16: Acknowledgements • EULAR for granting the project • Dr. Bente Appel Esbensen, senior researcher and associate professor and Ms. Heidi Morsø Schrøder, RN, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet - Glostrup, Copenhagen, Denmark for their substantial financial support of the fellow. 18 24/10/2020