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Case Management in Care of Turkish Rheumatoid Arthritis Patients
Yasemin Tokem, PhD RN Gulumser Argon, PhD RN Gokhan Keser, MD

This study examined the effectiveness of a case management (CM) intervention in the care of patients with rheumatoid arthritis (RA) as a pilot study in a teaching hospital in Turkey. Two groups were compared with respect to disability, quality of life, cost, and patient satisfaction: RA patients who received CM plus usual nursing care and RA patients who received usual nursing care alone. All patients underwent follow-up interviews at 3 and 6 months after being discharged from the hospital. Disability scores were significantly better in the RA group receiving CM, but there were no significant differences between the two groups with regard to quality of life, patient satisfaction, and total healthcare costs. Using CM in the care of patients with RA may favorably affect disease-related outcomes.

The Case Management Society of America defines case management (CM) as “a colloborative process between patient/family and service providers (health professionals) which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs using communication and available resources to promote qualified cost-effective outcomes” (Case Management Society of America, 2010, p. 6). The goals of CM are to manage healthcare quality and cost and to achieve positive patient and organizational outcomes (Fath, 2007). The CM process has some similarities with the nursing process—both involve assessment of patient needs, planning of care, and allocation of resources for the services required to meet those needs. Furthermore, coordination, monitoring, and evaluation of the care provided are important elements of both CM and the standard nursing process (Fraser & Strang, 2004). Nurses are well suited for the case manager role because they have the most frequent and personal contact with the patient compared with other healthcare providers (Tholcken, Clark, & Tschirch, 2004). CM and coordination of comprehensive health services are standards of care for the advanced practice nurse (Fath, 2007). Also, in many rehabilitation settings (inpatient and outpatient clinics), case managers establish relationships with patients upon admission and assess their care needs before collaborating with physicians and other healthcare providers to develop and implement an individualized care plan. Case managers treat the patient as a whole, including family interaction, environment, response to illness, treatment, and rehabilitative approach for the patient with RA. Thus, they can tailor the care plan to best fit the needs of the patient and the family (Arioli, Maddali Bongi, & Pappone, 2008; Blass & Reed, 2003). A study of CM showed that nurses constituted the majority of the CM workforce (Park & Huber, 2009).

The efficacy of CM has previously been studied and reported in many diseases, including myocardial infarction, diabetes mellitus, congestive heart failure, psychiatric disorders, tuberculosis, and chronic obstructive pulmonary disease, as well as in patients undergoing coronary bypass or hip replacement surgeries (Andrews & Sunderland, 2009; Dal & HatipoÄŸlu, 2003; Gabbay et al., 2006; Hickey et al., 2000; June, Lee, & Yoon, 2009; Lopez-Bushnell, Gary, Mitchell, & Reil, 2004; Poole, Chase, Frankel, & Black, 2001; Pugh, Havens, Xie, Robinson, & Blaha, 2001; Stuckey et al., 2009; Tosun & Akbayrak, 2006). In many of these studies, CM was reported to increase patients’ satisfaction and quality of life and to decrease costs and the number of inpatient days (Dal & HatipoÄŸlu; Poole et al.; Pugh et al.; Tosun & Akbayrak).

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune inflammatory disease with progressive joint destruction. It typically is a life-long illness, causing long-term major disability, which often decreases quality of life. Although CM was applied to various diseases in Turkey (Dal & Hatipoglu, 2003; Tosun & Akbayrak, 2006), it has not previously been studied in RA. There is very limited evidence in the literature concerning CM in the care of RA patients. To our knowledge, there is a single study of nurse case management to promote self-efficacy in patients with RA (Barry, McQuade, & Livingstone, 1998). There is no study focusing on quality of life, disability, and direct medical costs related to CM in RA patients. In this study, we applied CM to a group of Turkish RA patients.

The aims of this study were to examine the effectiveness of CM in the care of patients with RA and to compare CM with usual nursing care with respect to disability level, quality of life, patient satisfaction, and direct medical costs.


Sample and Setting

We included 29 RA patients (F/M, 27/2; mean age 56.65 years [SD = 12. 73]; mean disease duration, 14.44 years [SD = 10.27]) who were hospitalized in the inpatient rheumatology department of Ege University Hospital during a period of 22 months. All these patients fulfilled the 1987 American College of Rheumatology (ACR) RA criteria (Arnett et al., 1988). The inclusion criteria were (a) willingness to participate in the study, (b) minimum age of 18 years, (c) the ability to read and speak in Turkish, and (d) absence of audiovisual and major psychiatric disorders or diseases.

We randomly separated the RA patients into two groups. The first group of RA patients (n = 16) received only usual nursing care (usual care group [UCG]). In the second group (n = 16) of RA patients, we applied a CM model (case management group [CMG]), details of which are given below. Two patients from the CMG and one from the UCG did not complete the study because of death or development of serious comorbid disease. The performance data of the remaining 15 patients in the UCG and 14 patients in CMG were analyzed (Figure 1).


Tokem Figure 1

The study design was approved by the Research Ethics Committee at the Ege University School of Nursing, and written permission was obtained from the university hospital to implement the study. The researcher gave participants verbal and written information about the content of the study, and all participants signed an informed consent form.


A patient assessment form (PAF) included demographic information, socioeconomic status, functional health pattern, and system assessment and care needs of each study participant. This form was used to determine the individual and disease characteristics of the patients and to capture baseline data for follow-up interviews and nursing care plans. The researcher (nurse case manager) completed the PAF on the first day of hospitalization.

After the PAF was developed, it was evaluated by a senior clinical nurse working in the rheumatology department and by a nurse professor at Ege University. To measure its applicability, a pilot study was then conducted with five inpatient participants with RA. In this pilot study, inoperative items and elusive questions were removed, and some items/questions deemed to be more appropriate were added.

The Health Assessment Questionnaire (HAQ) was originally developed by Fries, Spitz, Kraines, and Holman (1980) in 1978. It is widely used and provides a useful measure of the health status, especially in rheumatic diseases (Bruce & Fries, 2003a, 2003b).

The Health Assessment Questionnaire-Disabiliy Index (HAQ-DI) consists of eight dimensions of activities of daily life: dressing and grooming, arising, eating, walking, hygiene, reaching, gripping, and outdoor activities. Each question is scored 0–3 as follows: functions that can be performed without difficulty = 0; any function performed with some difficulty = 1; functions performed with great difficulty = 2; and inability to perform a function = 3. The scores were averaged to create an overall mean score (higher scores indicate greater disability; Bruce & Fries, 2003a, 2003b). The validity and reliability of the Turkish version of HAQ-DI were established by Küçükdeveci, Sahin, Ataman, Griffiths, and Tennant (2004). The construct validity of HAQ-DI was assessed by Rash analysis (mean item fit = 0.205; SD = 0.998), the reliability by internal consistency (coefficient alpha value = 0.97) and the intraclass correlation coefficient, and the external construct validity by association with impairment and functional ACR stage. The researcher administered the HAQ-DI to all patients at admission, at the time of discharge, and at 3 and 6 months after discharge.

Total direct medical costs including hospitalization and follow-up periods were calculated in this study. We first calculated the hospital care costs using an official account summary acquired from the secretary’s computer during the participant’s discharge from the hospital; this account summary also documented length of stay in the hospital. We also calculated the healthcare costs during the 6-month follow-up period after hospital discharge, based on the cost section of the HAQ. All services and procedures were priced using Turkish Lira (TL) according to the hospital pricing system determined by the Turkish government.

The Rheumatoid Arthritis Quality of Life Scale (RAQoL) was developed by Walley, Mc Kenna, de Jong, and van der Heijde (1997) and validated by de Jong, van der Heijde, McKenna, and Whalley (1997). The validity and reliability of the Turkish version of the RAQoL were established by Kutlay, Küçükdeveci, Gönül, and Tennant (2003). The RAQoL comprises 30 items with a yes/no (1/0) response format. The total score is the sum of the individual item scores, with lower scores indicating better quality of life (range = 0–30; Tijhuis et al., 2001). In this study, the RAQoL was administered at admission, at discharge, and at 3 and 6 months after discharge.

The Patient Satisfaction Questionnaire (PSQ) was developed for this study by the research team to determine patient satisfaction with (a) hospital care ¨provided and (b) the health professionals who provided care. The first section of the PSQ (Form A) includes 33 questions related to satisfaction with hospital care; it was completed by participants during discharge from the hospital. The second section (Form B) includes seven questions related to outpatient satisfaction. Form B was completed by patients during outpatient visits at 3 and 6 months after discharge from the hospital. Participants responded to questions using a 5-point scale, with 1 = completely satisfied and 5 = completely dissatisfied. All items were summed to calculate total score. Lower scores indicated greater satisfaction. PSQ scores ranged from 33 to 165 on Form A and from 7 to 35 on Form B.

Before using the PSQ in this study, we first administered it to 10 inpatient and 10 outpatient participants with RA to test the items in terms of expression and suitability. Based on feedback from this pilot group, elusive statements that could potentially be ¨misunderstood were rewritten. The Cronbach’s alfa coefficient of the tool was .93 for Form A and .87 for Form B.


Control Group: Usual Care Group

When a patient in the UCG was admitted to the rheumatology department, a rheumatologist obtained a medical history, examined the patient, and ordered various tests. Treatment plans were then made and orders were given to the ward nurses. The ward nurses provided treatment to the patients according to the doctor’s orders and implemented usual nursing care. The UCG did not receive any other specific intervention.

Intervention Group: Case Management Group

In addition to the standard nursing procedures provided to the UCG, the nurse case manager, primary physician, and clinical nurses participated in weekly team meetings for all the patients in the CMG. The medical status and treatment plans of these patients were discussed in these meetings, which lasted approximately 20–30 minutes. The final decisions were then added to the patient care and education plan. The nurse case manager provided monthly postdischarge phone counseling and referrals to participants in the CMG.

We managed patient care of the CMG using the Rheumatoid Arthritis Care Protocol (Clinical Pathway) (RACP). RACP was developed by the research team and included intervention lists such as assessment/monitoring, consultation, laboratory/radiologic examination, medications, activity, diet, and patient and family education/discharge planning. This protocol comprised daily and weekly schedules and was administered by the case manager and rheumatology team members. Clinical pathways helped the staff concentrate on patient care from a team perspective. RACP was examined by a rheumatologist, a clinical head nurse, and a ward nurse who were familiar with the clinical procedures; it was then revised according to their suggestions. Before the study began, RACP was administered to five inpatient RA patients to determine its suitability and usability. Thereafter we discussed with the team members any changes to practice and finalized the form. Developing and pilot testing the RACP took approximately 1 month.

Educational Interventions in CMG

Nurses’ Education

We performed educational programs for nurses to review RA disease knowledge and inform them about the current study. A nurse education booklet titled Rheumatoid Arthritis and Nursing Management was prepared for the nurses receiving this education. The booklet presented disease knowledge (e.g., etiology, pathophysiology, clinical manifestations, diagnostic procedures and treatment, and nursing diagnosis/interventions about disease and drugs) and nursing management of RA. Before any CM interventions were carried out, we presented nurse education seminars on three separate occasions. A total of 35 nurses employed in the internal medicine department participated in one of the three seminars, all of whom also participated in this study because they worked in one of the three divisions of the internal medicine department during two shifts. In these seminars, which lasted 40–45 minutes, information about the study was discussed and the nurse education booklet was provided to the nurses as educational material. The goal was to encourage active nurse participation in the case management process.

Patients’ Education

Patient education was provided to the CMG as part of the RACP. Individualized patient/family education (7th domain in RACP) was given both by the rheumatology department nurses and the nurse case manager. The intervention started on the first day of hospitalization and continued until discharge and lasted approximately 15–30 minutes per day for each patient in the CMG, depending on the physical and emotional state of the patient. Booklets, posters, and PowerPoint presentations related to RA were used as educational materials with the CMG. A patient education booklet titled Living with Rheumatoid Arthritis was prepared by the researcher. The booklet included comprehensive knowledge about RA, including signs and symptoms, diagnostic criteria, treatment modalities, medications and side effects, importance of rest and exercise, and joint protection techniques.

The educational booklet Living with Rheumatoid Arthritis was also given to the UCG, but individualized education was given only to the CMG. Spontaneous patient questions about RA were answered for patients in the UCG, but no further individual patient education was provided.

The care, treatment, and education of CMG patients were given in the RACP domains by a nurse case manager and ward nurses. All interventions and procedures were performed promptly and as described by the RACP. If any problems arose regarding patient care, treatment, or education, the nurse case manager attempted to solve them. The aim of the study was to reach better results in disease management by means of patient education.

Data Analysis

The data were analyzed using SPSS version 15.0 package program. Sociodemographic data of the patients were evaluated by descriptive statistics. Repeated measure ANOVA was performed both for dependent and independent variables. The dependent variables were disability and quality of life, and the independent variables were group (CMG vs. UCG) and time (discharge, 3-month follow up, 6-month follow up). The patient satisfaction scores and the costs of the groups were compared using nonparametric statistics (Mann-Whitney U test) (Akgul, 1997).


Sample Characteristics

The demographic features of the RA patients in CMG and UCG are shown in Table 1. Mean age of all patients was 56.65 years (SD = 12.73; median = 57), ranging from 29 to 75 years. Most participants were female (93.1%) and had only primary education (79.3%). Functional status of almost half of the patients was Class III (44.8%), based on the American College of Rheumatology revised criteria for classification of functional status in patients with RA (Hochberg et al., 1992). When we compared the two groups for disease characteristics and outcome measurements on the first day of hospitalization, we found no statistically significant difference (morning stiffness, p = .535; pain, p = .247; functional class, p = .530; disability, p = .541; quality of life, p = .264 [p > .05]).


Tokem Table 1

Outcome Measurement

The disability and quality-of-life scores are summarized in Table 2. Disability and quality-of-life scores for the CMG were lower than those for the UCG. We performed repeated analyses for interaction between group and time (discharge, 3 months and 6 months). For disability and quality of life, there were no interactions between group and times (disability, p = .842; quality of life, p = .102); on the other hand, we found a statistically significant difference between the two groups for disability (p = .047; p < .05; Table 2).


Tokem Table 2

Total health care costs for the CMG (mean ± SD; 1265 ± 660.03 TL) were lower than for the UCG (1599 ± 852.97 TL; 1 USD = 1.51 TL). However, the difference between the groups was not statistically significant (U = 80.00; p = .275). There was no difference in length of stay (LOS) between the CMG (mean = 16 days; SD = 9.080) and the UCG (mean = 20.60 days; SD = 7.808) when we examined length of stay (LOS) in the hospital for the whole study sample (U = 64; p = .073).

The distributions of both hospital and outpatient satisfaction scores are shown in Table 3. The mean scores of hospital care satisfaction in the CMG (64.42 ± 14.12) were better (i.e., lower) than in the UCG (67.86 ± 14.50) but not statistically significantly. In the CMG, the mean outpatient satisfaction scores at the 3- and 6-month follow up were better (i.e., lower) than for the UCG; however, only the 6-month mean score of the CMG (13.21 ± 3.80) reached statistical significance compared with the UCG (15.66 ± 3.33; U = 53.00; p = .022).


Tokem Table 3


This is the first study comparing CM procedures with usual nursing care in Turkish RA patients, showing partially beneficial effects of the CM. In this study, only disability scores were significantly better in the CMG compared with the UCG. Although other parameters (i.e., quality of life, patient satisfaction, direct healthcare costs) were also slightly better in the CMG, we could not find a significant difference in these three parameters between the two groups.

We believe that the patient-nurse relationship is very important in routine daily practice because patients generally can reach a nurse more readily than a doctor for their complaints and problems. However, nurses usually are unable to listen to their patients because of time limitations and heavy workloads. The ideal nurse-to-patient ratio of 5:1 unfortunately is not available in Turkey. In addition, nurses in Turkey do not specialize in rheumatology and rehabilitation; rather, they provide care for all internal medicine patients, including patients with diabetes, renal failure, and malignancies. Nurses in Turkey generally do not have sufficient medical knowledge regarding basic rheumatology and management of rheumatic diseases. As such, they cannot knowledgably answer many disease-specific questions asked of them by rheumatology patients. In this study, the principle investigator functioned as the case manager and worked together with a team of nurses who were educated for this study. The team of nurses listened to the patients in the CMG, learned about their complaints, discussed these complaints in team sessions, and communicated these problems to the doctor when necessary. The principle investigator and her team also trained the CMG patients during discharge planning about home arrangements, organizing daily work, and adapting to their disease. The case manager also encouraged the CMG patients to use supportive devices. These organized nursing educational activities coupled with the discharge planning provided to the CMG in the context of the RA clinical pathway might have helped these patients better cope with RA, thus leading to lower pain and disability scores.

In addition to improved disability scores, improved quality of life was also expected in the CMG. Physical and psychosocial support and education provided to the CMG by the healthcare professionals were expected to help the patients cope with their illness and thus perceive a better quality of life. These assumptions are in line with previous studies that report beneficial effects of education for preventing disability and pain, improving knowledge, and enhancing overall quality of life for patients with RA (Gordon, Thompson, Madhok, & Capell, 2002). We found that the quality of life of patients in the CMG was better than for those in the UCG in all measurements, but our data did not reach statistical significance. Because it is well-documented that poor quality of life is an important problem for many RA patients from different countries (Husted, Gladman, Farewell, & Cook, 2001; Kutlay et al., 2003; Tanner & Bullough, 2003), a nurse case manager seems to be a promising resource to help ameliorate quality-of-life issues for patients with RA.

Direct and indirect costs are important factors that should be considered in planning better treatment strategies for RA. In previous studies from other countries, annual direct costs of RA were reported to be much higher, ranging from $1,812 to $11,792 USD (Doyle, 2001; March & Lapsley, 2001; Michaud, Messer, Choi, & Wolfe, 2003; Pugh et al., 2001; Rat & Boisser, 2004; Ruof et al., 2003). The high medical expenses of RA patients are covered not only by the government-funded social security companies but also by the patients and families. The direct and indirect costs of RA are important for both the individuals and society. As previously shown in the context of other diseases, we believe that CM has the potential to decrease direct medical costs in the treatment of RA patients.

In this study we found that direct healthcare costs for the CMG were lower than for the UCG, however the study results do not show a significant difference. This may be due to the limited number of patients and similar hospital LOS for each group. Specifically, shorter LOS may be expected for patients who are receiving CM, however, in the current study, LOS was similar for the CMG and the UCG. There are many factors that influence hospital LOS for patients with RA in addition to the application of CM. For example, living alone, waiting for medicine, or reparation of medical devices in the hospital may cause longer hospitalization periods. Because LOS affects the costs of RA, similar LOS for the CMG and UCG might have contributed to the lack of significant total medical cost differences between the two groups.

In this study, patient satisfaction was measured to assess the effects CM would have on quality of physician and nursing care and general services. Although only the scores for patient satisfaction determined at the CMG 6-month follow-up consultation reached statistical significance compared with the UCG, CMG satisfaction scores at discharge and at 3 months were somewhat better than UCG satisfaction scores. The close relationship between the case manager and the RA patients in the CMG might have led to greater satisfaction among these patients. In addition, the positive and supportive communication among patients, their families, health professionals, and the nurse case manager encouraged patients to participate in their care and treatment. Counseling and referrals (by telephone or in person) delivered to the patients in the CMG after discharge also might have contributed to reaching significant difference in CMG at 6 months.

Positive effects of CM on patient satisfaction have previously been shown in the context of other diseases (Bristow & Herrick, 2002; Hickey et al., 2000; Reimanis, Cohen, & Redman, 2001; Tosun & Akbayrak, 2006). In addition, nurse specialists in rheumatology units in England were reported to play a key role in improving the education and the physical and psychological status of RA patients (Ryan, Hassell, Dawes, & Kendall, 2003). One study indicates that patients who received care from rheumatology nurse specialists in a nurse-led clinic reported high satisfaction (Arthur & Clifford, 2004).

Our study has some important limitations. Because this is a pilot study, the number of RA patients in each group was limited, and the follow-up period was relatively short. We might have found better quality of life, patient satisfaction, and significantly lower total healthcare costs in the CMG if we had included a sufficient number of RA patients in each group. In the future, CM should be implemented in a larger sample of RA patients and for longer period of time. Another factor that may have limited the usefulness of our results is the fact that all nurses working with the patients in this study received the RA educational program, which might have affected the care of patients in the UCG as well, but only when these nurses were asked questions about the disease and its treaments; nurses did not spontaneously provide information to the patients in the UCG group.


According to results of this study, nurse CM may be effective in reducing disability level in RA. However, results examining CM’s affect on quality of life, direct costs, and patient satisfaction were similar in both groups of RA patients. In Turkey this pilot study has been considered a pioneering work showing the importance of patient education and cooperation and team work in the treatment of patients with RA.

Implications for Practice

The national health policies of many countries, including Turkey, aim to offer high-quality and cost-effective medical care to patients. The satisfaction of patients and their families is the goal in this context. In the management of chronic diseases such as RA, a multidisiciplinary approach is very important, and nurses may contribute to and play a special role in the effective management in RA by means of CM. Rehabilitation nurses who are working in inpatient and outpatient clinics are suitable for implementing CM, a patient-centered care model. Nurses may provide RA patients with the information, education, and support they need to cope with the disease and to experience less disability and better quality of life.

About the Authors

Yasemin Tokem, PhD RN, is an assistant professor at the Ege University School of Nursing in Izmir, Turkey. Address correspondence to her at yasemin.tokem.batmaz@ege.edu.tr.

Gulumser Argon, PhD RN, is a professor at the Ege University School of Nursing in Izmir, Turkey.

Gokhan Keser, MD, is a professor at the Ege University School of Medicine, department of internal medicine, division of rheumatology, in Izmir, Turkey.


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