Exploring practice and perspectives on shared decision-making about osteoporosis medicines in Fracture Liaison Services: the iFraP development qualitative study

Interviews and focus groups with patients, FLS clinicians, and GPs identified challenges relating to clinical and shared decision-making about bone health and osteoporosis medicines. Findings will inform the development of the multicomponent iFraP intervention to address identified training needs and barriers to implementation to facilitate SDM about osteoporosis medicines.

PURPOSE

The iFraP (improving uptake of Fracture Prevention treatments) study aimed to develop a multicomponent intervention, including an osteoporosis decision support tool (DST), to support shared decision-making (SDM) about osteoporosis medicines. To inform iFraP intervention development, this qualitative study explored current practice in relation to communication about bone health and osteoporosis medicines, anticipated barriers to, and facilitators of, an osteoporosis DST, and perceived training needs.

METHODS

Patients attending an FLS consultation (n = 8), FLS clinicians (n = 9), and general practitioners (GPs; n = 7) were purposively sampled to participate in a focus group and/or telephone interview. Data were transcribed, inductively coded, and then mapped to the Theoretical Domains Framework (TDF) as a deductive framework to systematically identify possible barriers to, and facilitators of, implementing a DST.

RESULTS

Inductive codes were deductively mapped to 12 TDF domains. FLS clinicians were perceived to have specialist expertise (knowledge). However, clinicians described aspects of clinical decision-making and risk communication as difficult (cognitive skills). Patients reflected on decisional uncertainty about medicines (decision processes). Discussions about current practice and the proposed DST indicated opportunities to facilitate SDM, if identified training needs are met. Potential individual and system-level barriers to implementation were identified, such as differences in FLS configuration and a move to remote consulting (environmental context and resources).

CONCLUSIONS

Understanding of current practice revealed unmet training needs, indicating that using a DST in isolation would be unlikely to produce a sustained shift to SDM. Findings will shape iFraP intervention development to address unmet needs.

Daily Pain Severity but Not Vertebral Fractures Is Associated With Lower Physical Activity in Postmenopausal Women With Back Pain

Back pain lifetime incidence is 60%-70%, while 12%-20% of older women have vertebral fractures (VFs), often with back pain. We aimed to provide objective evidence, currently lacking, regarding whether back pain and VFs affect physical activity (PA). We recruited 69 women with recent back pain (age 74.5 ± 5.4 years). Low- (0.5 < g < 1.0), medium- (1.0 ≤ g < 1.5), and high-impact (g ≥ 1.5) PA and walking time were measured (100 Hz for 7 days, hip-worn accelerometer). Linear mixed-effects models assessed associations between self-reported pain and PA, and group differences (VFs from spine radiographs/no-VF) in PA. Higher daily pain was associated with reduced low (β = -0.12, 95% confidence interval, [-0.22, -0.03], p = .013) and medium-impact PA (β = -0.11, 95% confidence interval, [-0.21, -0.01], p = .041), but not high-impact PA or walking time (p > .11). VFs were not associated with PA (all p > .2). Higher daily pain levels but not VFs were associated with reduced low- and medium-impact PA, which could increase sarcopenia and falls risk in older women with back pain.

Improving patients' experiences of diagnosis and treatment of vertebral fracture: co-production of knowledge sharing resources

BACKGROUND

Osteoporosis involves changes to bones that makes them prone to fracture. The most common osteoporotic fracture is vertebral, in which one or more spinal vertebrae collapse. People with vertebral fracture are at high risk of further fractures, however around two-thirds remain undiagnosed. The National Institute for Health and Care Excellence (NICE) recommends bone protection therapies to reduce this risk. This study aimed to co-produce a range of knowledge sharing resources, for healthcare professionals in primary care and patients, to improve access to timely diagnosis and treatment.

METHODS

This study comprised three stages: 1. In-depth interviews with primary care healthcare professionals (n = 21) and patients with vertebral fractures (n = 24) to identify barriers and facilitators to diagnosis and treatment. 2. A taxonomy of barriers and facilitators to diagnosis were presented to three stakeholder groups (n = 18), who suggested ways of identifying, diagnosing and treating vertebral fractures. Fourteen recommendations were identified using the nominal group technique. 3. Two workshops were held with stakeholders to co-produce and refine the prototype knowledge sharing resources (n = 12).

RESULTS

Stage 1: Factors included lack of patient information about symptoms and risk factors, prioritisation of other conditions and use of self-management. Healthcare professionals felt vertebral fractures were harder to identify in lower risk groups and mistook them for other conditions. Difficulties in communication between primary and secondary care meant that patients were not always informed of their diagnosis, or did not start treatment promptly. Stage 2: 14 recommendations to improve management of vertebral fractures were identified, including for primary care healthcare professionals (n = 9) and patients (n = 5). Stage 3: The need for allied health professionals in primary care to be informed about vertebral fractures was highlighted, along with ensuring that resources appealed to under-represented groups. Prototype resources were developed. Changes included help-seeking guidance and clear explanations of medical language.

CONCLUSIONS

The study used robust qualitative methods to co-produce knowledge sharing resources to improve diagnosis. A co-production approach enabled a focus on areas stakeholders thought to be beneficial to timely and accurate diagnosis and treatment. Dissemination of these resources to a range of stakeholders provides potential for substantial reach and spread.

An online clinical decision tool to screen for vertebral fragility fractures (Vfrac) in older women presenting with back pain in general practice: protocol for a feasibility study in preparation for a future cluster randomised controlled trial

This feasibility study for a future definitive randomized trial assesses the use and acceptability of a new clinical decision tool to identify risk of a vertebral fracture and those who should be referred for spinal radiography in women aged 65 or over presenting to primary care with back pain.

PURPOSE

Approximately 12% of older adults have vertebral fragility fractures, but currently fewer than one-third are diagnosed, potentially limiting access to bone protection treatment. Vfrac is a vertebral fracture screening tool which classifies individuals into high or low risk of having a vertebral fracture, allowing targeting of spinal radiographs to high-risk individuals. The objective of this study was to investigate the feasibility of conducting a cluster randomized controlled trial to evaluate the use of an online version of Vfrac in primary care.

METHODS

The study will run in six general practices, with three given the Vfrac tool for use on older women (> 65 years) consulting with back pain and three using standard clinical processes for managing such back pain. Anonymised data covering a 12-month period will be collected from all sites on consultations by older women with back pain. Focus groups will be undertaken with healthcare professionals and patients on whom the tool was used to understand the acceptability of Vfrac and identify factors that impact its use. These patients will be sent a paper version of the Vfrac questionnaire to self-complete at home. Outputs of the self-completion Vfrac (high versus low risk) will be compared with the face-to-face Vfrac (high versus low risk), and agreement assessed using Cohen's kappa.

RESULTS

This study will evaluate the use and acceptability of Vfrac within primary care and determine if data on resource use can be collected accurately and comprehensively.

CONCLUSIONS

This article describes the protocol of the Vfrac feasibility study.

TRIAL REGISTRATION

ISRCTN18000119 (registered 01/03/2022) and ISRCTN12150779 (registered 10/01/2022).

Variation in UK fracture liaison service consultation conduct and content before and during the COVID pandemic: results from the iFraP-D UK survey

We conducted a survey of FLSs' consultation conduct and content which identified marked variation in whether FLS HCPs discussed osteoporosis medicine with patients. A review of service pro formas showed more content related to 'investigating' and 'intervening' than to 'informing'. We propose an expanded FLS typology and model FLS pro forma.

PURPOSE

To investigate the nature of direct patient contact in fracture liaison service (FLS) delivery, examine the use and content of pro formas to guide information eliciting and sharing in FLS consultations, and determine service changes which were implemented as a result of the COVID-19 pandemic.

METHODS

An electronic survey of UK FLS healthcare practitioners (HCPs) was distributed through clinical networks, social media, and other professional networks. Participants were asked to upload service pro formas used to guide consultation content. Documentary analysis findings were mapped to UK FLS clinical standards.

RESULTS

Forty-seven HCPs responded, providing data on 39 UK FLSs, over half of all 74 FLSs reporting to FLS-database. Results showed variation in which HCP made clinical decisions, whether medicines were discussed with patients or not, and in prescribing practice. Services were variably affected by COVID, with most reporting a move to more remote consulting. The documentary analysis of eight service pro formas showed that these contained more content related to 'investigating' and 'intervening', with fewer pro formas prompting the clinician to offer information and support (e.g., about coping with pain). Based on our findings we propose an expanded FLS typology and have developed a model FLS pro forma.

CONCLUSION

There is marked variation in the delivery of services and content of consultations in UK FLSs including discussion about osteoporosis medications. Clinical standards for FLSs should clarify the roles of primary and secondary HCPs and the importance of holistic approaches to patient care.

Automated measurement of size of spinal curve in population-based cohorts: Validation of a method based on total body dual energy X-ray absorptiometry scans

BACKGROUND

Scoliosis is spinal curvature that may progress to require surgical stabilisation. Risk factors for progression are little understood due to lack of population-based research, since radiographs cannot be performed on entire populations due to high levels of radiation. To help address this, we have previously developed and validated a method for quantification of spinal curvature from total body dual energy X-ray absorptiometry (DXA) scans. The purpose of this study was to automate this quantification of spinal curve size from DXA scans using machine learning techniques.

METHODS

To develop the automation of curve size, we utilised manually annotated scans from 7298 participants from the Avon Longitudinal Study of Parents and Children (ALSPAC) at age 9 and 5122 at age 15. To validate the automation we assessed (1) agreement between manual vs automation using the Bland-Altman limits of agreement, (2) reliability by calculating the coefficient of variation, and (3) clinical validity by running the automation on 4969 non-annotated scans at age 18 to assess the associations with physical activity, body composition, adipocyte function and backpain compared to previous literature.

RESULTS

The mean difference between manual vs automated readings was less than one degree, and 90.4 % of manual vs automated readings fell within 10°. The coefficient of variation was 25.4 %. Clinical validation showed the expected relationships between curve size and physical activity, adipocyte function, height and weight.

CONCLUSION

We have developed a reasonably accurate and valid automated method for quantifying spinal curvature from DXA scans for research purposes.

Research priorities to reduce the impact of musculoskeletal disorders: a priority setting exercise with the child health and nutrition research initiative method

Involving research users in setting priorities for research is essential to ensure the outcomes are patient-centred and maximise its value and impact. The Musculoskeletal Disorders Research Advisory Group Versus Arthritis led a research priority setting exercise across musculoskeletal disorders. The Child Health and Nutrition Research Initiative (CHNRI) method of setting research priorities with a range of stakeholders was used, involving four stages and two surveys, to: (1) gather research uncertainties, (2) consolidate these, (3) score uncertainties against importance and impact, and (4) analyse scoring for prioritisation. 213 people responded to the first survey and 285 people to the second, representing clinicians, researchers, and people with musculoskeletal disorders. Key priorities included developing and testing new treatments, better treatment targeting, early diagnosis, prevention, and better understanding and management of pain, with an emphasis on understanding underpinning mechanisms. We present a call to action to researchers and funders to target these priorities.

Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis

Exercise and physical activity can improve bone strength and the risk of falls, which may offer benefits in the prevention and management of osteoporosis. However, uncertainty about the types of exercise that are safe and effective instigates lack of confidence in people with osteoporosis and health professionals. Existing guidelines leave some questions unresolved. This consensus statement aimed to determine the physical activity and exercise needed to optimise bone strength, reduce fall and fracture risk, improve posture and manage vertebral fracture symptoms, while minimising potential risks in people with osteoporosis. The scope of this statement was developed following stakeholder consultation. Meta-analyses were reviewed and where evidence was lacking, individual studies or expert opinion were used to develop recommendations. A multidisciplinary expert group reviewed evidence to make recommendations, by consensus when evidence was not available. Key recommendations are that people with osteoporosis should undertake (1) resistance and impact exercise to maximise bone strength; (2) activities to improve strength and balance to reduce falls; (3) spinal extension exercise to improve posture and potentially reduce risk of falls and vertebral fractures. For safety, we recommend avoiding postures involving a high degree of spinal flexion during exercise or daily life. People with vertebral fracture or multiple low trauma fractures should usually exercise only up to an impact equivalent to brisk walking. Those at risk of falls should start with targeted strength and balance training. Vertebral fracture symptoms may benefit from exercise to reduce pain, improve mobility and quality of life, ideally with specialist advice to encourage return to normal activities. Everyone with osteoporosis may benefit from guidance on adapting postures and movements. There is little evidence that physical activity is associated with significant harm, and the benefits, in general, outweigh the risks.

Revision and 90-day mortality following hip arthroplasty in patients with inflammatory arthritis and ankylosing spondylitis enrolled in the National Joint Registry for England and Wales

AIM

To assess revision rates and postoperative mortality in patients undergoing hip arthroplasty (HA) for inflammatory arthritis compared to hip osteoarthritis (OA).

METHODS

The analysis was conducted among cases of HA that were recorded in the National Joint Registry for England and Wales (NJR) between April 2003 and December 2012 and linked to Office for National Statistics mortality records. Procedures were identified where the indication for surgery was listed as seropositive rheumatoid arthritis (RA), ankylosing spondylitis (AS), other inflammatory arthritis (otherIA), or OA. 5-year revision risk and 90-day postoperative mortality according to indication were compared using Cox regression models adjusted for age, sex, American Society of Anaesthesiologists (ASA) grade, year of operation, implant type, and surgical approach.

RESULTS

The cohort included 1457 HA procedures conducted for RA, 615 for AS, 1000 for otherIA, and 183,108 for OA. When compared with OA, there was no increased revision risk for any form of inflammatory arthritis (adjusted HRs: RA: 0.93 (0.64-1.35); AS: 1.14 (0.73-1.79); otherIA: 1.08 (0.73-1.59)). Postoperative 90-day mortality was increased for RA when compared with OA (adjusted HR: 2.86 (1.68-4.88)), but not for AS (adjusted HR: 1.56 (0.59-4.18)) or otherIA (adjusted HR: 0.64 (0.16-2.55)).

CONCLUSIONS

The revision risk in HA performed for all types of inflammatory arthritis is similar to that for HA performed for OA. The 3-fold increased risk of 90-day mortality in patients with RA compared with OA highlights the need for active management of associated comorbidities in RA patients during the perioperative period.

P100 Research priorities to reduce the impact of musculoskeletal disorders

Background/Aims

Involving research users in setting priorities for research is essential to ensure research outcomes are patient-centred and to maximise research value and impact. In 2019, Versus Arthritis convened a Musculoskeletal Disorders (MSKD) Research Advisory Group (RAG) which included 25 members: people with musculoskeletal conditions, researchers and healthcare professionals. The RAG identified a need for a research prioritisation exercise for adult non-inflammatory MSKD.

Methods

The Child Health and Nutrition Research Initiative (CHNRI) method was selected. The MSKD RAG identified, through consensus, four research Domains: Mechanisms of Disease; Diagnosis and Impact; Living Well with MSK disorders and Successful Translation. Following ethical approval, an initial electronic survey was distributed to stakeholders (people with musculoskeletal conditions, researchers, healthcare professionals, industry, research funders, healthcare providers, government and charities) asking for important research uncertainties in the four domains. Uncertainties were organised into themes and refined into research questions using a series of MSKD RAG workshops. Research questions underwent lay review to optimise readability. A second e-survey was distributed to stakeholders as above, where participants were asked to score each research question for two criteria, importance and impact, on a 1-10 numeric rating scale. Median criterion scores for impact and importance were calculated for each question and summed to create a total score. Research questions were ranked according to total score.

Results

The first survey had 209 respondents, who described 1290 research uncertainties, which were refined into 68 research questions. 285 people responded to the second survey, of which 189 fully completed. 74(39.2%) were public/lay responders, 48(25.4%) researchers, 43(22.8%) clinicians, 24(12.6%) other/unrecorded. The research questions, total scores and rankings are summarised in Table 1. Total scores ranged from 12 to 18 (maximum possible score 20).

Conclusion

For the first time, we have summarised priorities for research across MSKD, from discovery science to applied clinical and health research, including translation. Key priorities include developing and testing new treatments, better targeting of treatments, early diagnosis, prevention and better understanding and management of pain, with an emphasis on understanding the underpinning mechanisms. We present a call to action to researchers and funders to target these priorities.

Disclosure

Z. Paskins: Grants/research support; NIHR, Versus Arthritis, Royal Osteoporosis Society. C.E. Farmer: None. R.K. Jones: None. A. Clark: None. L. Troeberg: Grants/research support; Versus Arthritis. H. Pandit: Consultancies; Depuy J&J, Zimmer Biomet, Smith and Nephew, Medacta International, Meril Life, JRI Orthopaedics, Invibio and Kennedy’s Law. Grants/research support; NIHR, VA (Versus Arthritis) and UKIERI (UK India Education and Research Initiative). S.M. Richardson: None. J. Loughlin: None. C.A. Brown: Grants/research support; Versus Arthrtitis. E.J. Taylor: None. C.L. Le Maitre: None. R.K. Wilcox: Grants/research support; EPSRC, Versus Arthritis, NIHR, DePuy Synthes. F.L. Bishop: None. E. Salt: None. E.M. Clark: Grants/research support; Versus Arthritis, NIHR. Other; I am Associate Editor of Journal of Bone and Mineral Research Plus for which I receive a salary, I am part of the Lot 2 provider for analysis of the national Joint Registry of England and Wales, funded by HQIP. D.A. Andersson: None. M. McCarron: None. D.J. Mason: None. C.M. Wilkinson: None. T. Barlow: None. G.M. Peat: None. F.E. Watt: Consultancies; Pfizer.

Digital health interventions for osteoporosis and post-fragility fracture care

The growing burden from osteoporosis and fragility fractures highlights a need to improve osteoporosis management across healthcare systems. Sub-optimal management of osteoporosis is an area suitable for digital health interventions. While fracture liaison services (FLSs) are proven to greatly improve care for people with osteoporosis, such services might benefit from technologies that enhance automation. The term 'Digital Health' covers a variety of different tools including clinical decision support systems, electronic medical record tools, patient decision aids, patient apps, education tools, and novel artificial intelligence (AI) algorithms. Within the scope of this review are AI solutions that use algorithms within health system registries to target interventions. Clinician-targeted, patient-targeted, or system-targeted digital health interventions could be used to improve management and prevent fragility fractures. This review was commissioned by The Royal Osteoporosis Society and Bone Research Academy during the production of the 2020 Research Roadmap (https://theros.org.uk), with the intention of identifying gaps where targeted research funding could lead to improved patient health. We explore potential uses of digital technology in the general management of osteoporosis. Evidence suggests that digital technologies can support multidisciplinary teams to provide the best possible patient care based on current evidence and to support patients in self-management. However, robust randomised controlled studies are still needed to assess the effectiveness and cost-effectiveness of these technologies.

A clinical tool to identify older women with back pain at high risk of osteoporotic vertebral fractures (Vfrac): a population-based cohort study with exploratory economic evaluation

BACKGROUND

osteoporotic vertebral fractures (OVFs) identify people at high risk of future fractures, but despite this, less than a third come to clinical attention. The objective of this study was to develop a clinical tool to aid health care professionals decide which older women with back pain should have a spinal radiograph.

METHODS

a population-based cohort of 1,635 women aged 65+ years with self-reported back pain in the previous 4 months were recruited from primary care. Exposure data were collected through self-completion questionnaires and physical examination, including descriptions of back pain and traditional risk factors for osteoporosis. Outcome was the presence/absence of OVFs on spinal radiographs. Logistic regression models identified independent predictors of OVFs, with the area under the (receiver operating) curve calculated for the final model, and a cut-point was identified.

RESULTS

mean age was 73.9 years and 209 (12.8%) had OVFs. The final Vfrac model comprised 15 predictors of OVF, with an AUC of 0.802 (95% CI: 0.764-0.840). Sensitivity was 72.4% and specificity was 72.9%. Vfrac identified 93% of those with more than one OVF and two-thirds of those with one OVF. Performance was enhanced by inclusion of self-reported back pain descriptors, removal of which reduced AUC to 0.742 (95% CI: 0.696-0.788) and sensitivity to 66.5%. Health economic modelling to support a future trial was favourable.

CONCLUSIONS

the Vfrac clinical tool appears to be valid and is improved by the addition of self-reported back pain symptoms. The tool now requires testing to establish real-world clinical and cost-effectiveness.

Opportunistic diagnosis of osteoporosis, fragile bone strength and vertebral fractures from routine CT scans; a review of approved technology systems and pathways to implementation

Osteoporosis causes bones to become weak, porous and fracture more easily. While a vertebral fracture is the archetypal fracture of osteoporosis, it is also the most difficult to diagnose clinically. Patients often suffer further spine or other fractures, deformity, height loss and pain before diagnosis. There were an estimated 520,000 fragility fractures in the United Kingdom (UK) in 2017 (costing £4.5 billion), a figure set to increase 30% by 2030. One way to improve both vertebral fracture identification and the diagnosis of osteoporosis is to assess a patient's spine or hips during routine computed tomography (CT) scans. Patients attend routine CT for diagnosis and monitoring of various medical conditions, but the skeleton can be overlooked as radiologists concentrate on the primary reason for scanning. More than half a million CT scans done each year in the National Health Service (NHS) could potentially be screened for osteoporosis (increasing 5% annually). If CT-based screening became embedded in practice, then the technique could have a positive clinical impact in the identification of fragility fracture and/or low bone density. Several companies have developed software methods to diagnose osteoporosis/fragile bone strength and/or identify vertebral fractures in CT datasets, using various methods that include image processing, computational modelling, artificial intelligence and biomechanical engineering concepts. Technology to evaluate Hounsfield units is used to calculate bone density, but not necessarily bone strength. In this rapid evidence review, we summarise the current literature underpinning approved technologies for opportunistic screening of routine CT images to identify fractures, bone density or strength information. We highlight how other new software technologies have become embedded in NHS clinical practice (having overcome barriers to implementation) and highlight how the novel osteoporosis technologies could follow suit. We define the key unanswered questions where further research is needed to enable the adoption of these technologies for maximal patient benefit.

Trajectories of pain and function in the first five years after total hip and knee arthroplasty : an analysis of patient reported outcome data from the National Joint Registry

AIMS

To determine the trajectories of patient reported pain and functional disability over five years following total hip arthroplasty (THA) or total knee arthroplasty (TKA).

METHODS

A prospective, longitudinal cohort sub-study within the National Joint Registry (NJR) was undertaken. In all, 20,089 patients who underwent primary THA and 22,489 who underwent primary TKA between 2009 and 2010 were sent Oxford Hip Score (OHS) and Oxford Knee Score (OKS) questionnaires at six months, and one, three, and five years postoperatively. OHS and OKS were disaggregated into pain and function subscales. A k-means clustering procedure assigned each patient to a longitudinal trajectory group for pain and function. Ordinal regression was used to predict trajectory group membership using baseline OHS and OKS score, age, BMI, index of multiple deprivation, sex, ethnicity, geographical location, and American Society of Anesthesiologists grade.

RESULTS

Data described two discrete trajectories for pain and function: 'level 1' responders (around 70% of cases) in whom a high level of improvement is sustained over five years, and 'level 2' responders who had sustained improvement, but at a lower level. Baseline patient variables were only weak predictors of pain trajectory and modest predictors of function trajectory. Those with worse baseline pain and function tended to show a greater likelihood of following a 'level 2' trajectory. Six-month patient-reported outcome measures data reliably predicted the class of five-year outcome trajectory for both pain and function.

CONCLUSION

The available preoperative patient variables were not reliable predictors of postoperative pain and function after THA and TKA. Reviewing patient outcomes at six months postoperatively is a reliable indicator of outcome at five years. Cite this article: Bone Joint J 2021;103-B(6):1111-1118.

P117 Exploring experiences of Fracture Liaison Services and perceptions of a new decision tool to support patient and clinician decisions: a focus group study

Background/Aims 

The iFraP study (Improving uptake of Fracture Prevention Treatments) is developing a computerised decision-support tool to support clinician decision-making, risk communication and informed patient decision-making in Fracture Liaison Service (FLS) consultations. To inform iFraP intervention development, this study explored 1) patient and clinician experiences of FLSs and 2) perspectives towards the new iFraP tool.

Methods 

Four focus groups and supplementary interviews included 9 FLS clinicians, 7 General Practitioners (GPs), and 8 patients who recently attended an FLS consultation. Theoretically-informed thematic analysis was conducted to facilitate understanding of current FLS practice, potential intervention acceptability and possible barriers to, and facilitators of, implementation.

Results 

FLS clinicians and GPs suggested that FLSs worked well to identify patients at high risk of future fracture and to recommend medication. FLS clinicians were confident in their role and felt their consultations were person-centred and addressed information needs. However, some FLS clinicians described communicating risk as difficult and gave examples of when they are uncertain whether medication should be recommended (e.g. patient with osteopenic bone mineral density). FLS clinicians had varying perceptions of their roles in discussing medications, with some not viewing this as their responsibility; whereas GPs reported that medication discussions were an important aspect of the FLS clinician role. When medication recommendations (and discussion) were delivered, the setting varied across services including face-to-face in clinic or at the patient’s home, by letter, or by telephone. On the whole, patients reflected positively on their FLS appointment. However, some patients described unmet information needs, such as risk of future fractures, potential benefits and risks of medications, and information about follow-up.Many FLS clinicians and GPs reflected upon the potential value of the tool, including the inclusion of visual images to facilitate understanding of fracture risk, and to promote consistent messages across FLSs and between primary and secondary care. Barriers to intervention implementation were also identified. Clinicians expressed concern that evidence-based Cates plots to support explanations of medication effectiveness may make patients believe medications are not ‘worthwhile’. This suggests that clinicians prioritised promotion of medication adherence over informed decision-making, highlighting that the goal of FLS clinicians and iFraP may not align. Furthermore, concern was expressed that use of a computerised tool may detract from the clinician-patient relationship.

Conclusion 

These novel findings illustrate the experience of FLS consultations from three perspectives. They highlight FLS clinicians’ clinical decision-support needs and patients’ unmet need for clear information that addresses their medication concerns. Overall, the iFraP intervention was viewed as acceptable, with the potential to support clinicians’ decision-making and to facilitate informed decision-making. Differences in FLS configuration and a move to more remote consulting may mean the intervention needs to be adaptable to different settings to address barriers to implementation.

Disclosure 

L. Bullock: None. C. Jinks: Grants/research support; CJ is part funded by the NIHR Applied Research Collaboration (ARC) West Midlands. A. Hawarden: Grants/research support; AH is a NIHR funded Academic Clinical Fellow. F. Crawford-Manning: Grants/research support; FCM is part funded by the NIHR Clinical Research Network Scholar Programme. S. Leyland: None. J. Fleming: None. E.M. Clark: None. E. Cottrell: None. J. Edwards: Grants/research support; JE is an NIHR Academic Clinical Lecturer in Primary Care (CL-2016-10-003). Z. Paskins: Grants/research support; ZP is funded by the NIHR, Clinician Scientist Award (CS-2018-18-ST2-010)/NIHR Academy.

P118 Co-design of a model Fracture Liaison Service consultation: a Delphi survey with patients and clinicians

Background/Aims 

Fracture Liaison Services (FLSs) are recommended to deliver best practice in secondary fracture prevention. As part of the iFraP (Improving uptake of Fracture Prevention drug Treatments) research programme this study aimed to 1) co-design content for a ‘model FLS consultation’ and 2) gain consensus on the appropriateness of osteoporosis clinical guidelines in the context of FLSs.

Methods 

Three rounds of modified Delphi survey were sent to patients with osteoporosis and/or fragility fractures, carers, and clinicians. Participants were presented with potential consultation content derived from an evidence synthesis of current guidelines, frameworks and theories of shared decision-making, communication and medicine adherence, and stakeholder consultation. Participants were asked to rate their perception of the importance of each statement on a 5-point Likert scale and elaborate using free-text boxes. In Round 2, participants were shown mean scores of importance from Round 1. Statements identified as of ‘low importance’ at the end of Rounds 1 and 2 were discussed by the study team, including patient contributors, and were removed or amended. In Round 3, participants were asked whether the statement was ‘essential’ or ‘optional’ in a time-limited FLS consultation. Percentage agreement with each statement was ranked. The threshold for ‘essential’ versus ‘optional’ was determined by the study team.

Results 

391 invitations to participate were sent, with 72, 49, and 52 responders to Rounds 1, 2 and 3 respectively. Throughout Rounds 1-3 participants considered 122 statements. By Round 3, 81 statements were deemed essential, with an additional 14 optional statements. Essential statements were distilled into 18 recommendations constituting the ‘model FLS consultation’. Statements related to stages of the consultation, including: introductions; gather information; consider therapeutic options; elicit patient perceptions; establish shared decision-making preferences; share information about condition and treatment; check understanding; and signpost next steps. There was consensus that FLS clinicians should discuss the benefits and risks of oral and intravenous bisphosphonates and denosumab. Optional consultation content included a statement suggesting clinicians should observe the patient to look for signs of fractures in their spine, with free-text responses suggesting that FLS clinicians may not ‘be best qualified’ to perform physical examinations. Removed statements included those relating to the discussion of Hormone Replacement Therapy, Raloxifene and Teriparatide, with free-text statements suggesting that ‘specialists’ (e.g. Rheumatologists) should discuss these medications. Additionally, statements that described the potential consequences of fracture (e.g. ‘the clinician should explain that one in ten patients with a hip fracture will die within 12 months of fracture.’) were removed. Free-text comments described these statements as potentially ‘scary’.

Conclusion 

The Delphi survey has informed iFraP intervention development by highlighting essential and optional FLS consultation content. Findings also provide insight into aspects of current osteoporosis clinical guidelines deemed appropriate in nurse/allied health professional led FLSs.

Disclosure 

L. Bullock: None. C. Jinks: Grants/research support; CJ is part funded by the NIHR Applied Research Collaboration (ARC) West Midlands. F. Crawford-Manning: Grants/research support; FCM is part funded by the NIHR Clinical Research Network Scholar Programme. S. Leyland: None. J. Fleming: None. E.M. Clark: None. E. Cottrell: None. J. Edwards: Grants/research support; JE is an NIHR Academic Clinical Lecturer in Primary Care (CL-2016-10-003). Z. Paskins: Grants/research support; ZP is funded by the NIHR, Clinician Scientist Award (CS-2018-18-ST2-010)/NIHR Academy.

Developing a model Fracture Liaison Service consultation with patients, carers and clinicians: a Delphi survey to inform content of the iFraP complex consultation intervention

Fracture Liaison Services are recommended to deliver best practice in secondary fracture prevention. This modified Delphi survey, as part of the iFraP (Improving uptake of Fracture Prevention drug Treatments) study, provides consensus regarding tasks for clinicians in a model Fracture Liaison Service consultation.

PURPOSE

The clinical consultation is of pivotal importance in addressing barriers to treatment adherence. The aim of this study was to agree to the content of the 'model Fracture Liaison Service (FLS) consultation' within the iFraP (Improving uptake of Fracture Prevention drug Treatments) study.

METHODS

A Delphi survey was co-designed with patients and clinical stakeholders using an evidence synthesis of current guidelines and content from frameworks and theories of shared decision-making, communication and medicine adherence. Patients with osteoporosis and/or fragility fractures, their carers, FLS clinicians and osteoporosis specialists were sent three rounds of the Delphi survey. Participants were presented with potential consultation content and asked to rate their perception of the importance of each statement on a 5-point Likert scale and to suggest new statements (Round 1). Lowest rated statements were removed or amended after Rounds 1 and 2. In Round 3, participants were asked whether each statement was 'essential' and percentage agreement calculated; the study team subsequently determined the threshold for essential content.

RESULTS

Seventy-two, 49 and 52 patients, carers and clinicians responded to Rounds 1, 2 and 3 respectively. One hundred twenty-two statements were considered. By Round 3, consensus was reached, with 81 statements deemed essential within FLS consultations, relating to greeting/introductions; gathering information; considering therapeutic options; eliciting patient perceptions; establishing shared decision-making preferences; sharing information about osteoporosis and treatments; checking understanding/summarising; and signposting next steps.

CONCLUSIONS

This Delphi consensus exercise has summarised for the first time patient/carer and clinician consensus regarding clearly defined tasks for clinicians in a model FLS consultation.

Commercial weight management programmes for patients living with overweight or obesity prior to elective orthopaedic surgery: an evidence review

BACKGROUND

Increased body mass index is associated with increased operative risk during elective joint replacement surgery. Commercial weight management programmes are designed to achieve weight loss. It is not known whether commercial weight management programmes are effective at achieving weight loss in patients awaiting planned hip or knee replacement surgery, or whether achieving significant planned weight loss prior to surgery is associated with changes in surgical outcome.

METHODS

A systematic literature search of seven databases was conducted. Reference lists and grey literature were searched, including commercial weight management programme and medical association websites. Four relevant primary interventional studies were identified.

RESULTS

There is weak, low-quality evidence from four small studies, of which three demonstrated that commercial weight management programmes initiated between 3 and 6 months prior to elective joint replacement surgery are associated with a statistically significant weight loss and body mass index reduction. There is a weak evidence from two studies that peri- and post-operative complications are similar between control and commercial weight management programme groups.

CONCLUSION

There is a paucity of studies investigating commercial weight management programmes aiming to reduce weight in patients living with overweight or obesity awaiting total joint replacement. Further, high-quality research is urgently needed.

Correction to: Lean mass and lower limb muscle function in relation to hip strength, geometry and fracture risk indices in community-dwelling older women

The original version of this article, published on 14 December 2018, unfortunately contained a mistake.

Correction to: Identifying Scoliosis in Population‑Based Cohorts: Automation of a Validated Method Based on Total Body Dual Energy X‑ray Absorptiometry Scans

In the original version of the article, the co-author would like to add to the acknowledgements section to highlight their funding stream (EPSRC). The revised acknowledgements is given below.

P104 Longitudinal patient reported outcome data collected from a smartphone app can map group level trajectories of disease activity over time

Background

Patient-reported outcome measures are a cornerstone of the current early inflammatory arthritis audit and part of the best practice tariff. However, outcome data are collected infrequently meaning longitudinal changes in disease activity cannot be accurately examined. We report results of a twelve-month clinical pilot of a cloud-enabled commercial smartphone app to record patient self-reported disease activity outcome measures to evaluate trends of disease activity in a routine rheumatology setting.

Methods

Patients with a clinical diagnosis of inflammatory arthritis attending routine rheumatology clinic were offered the opportunity to use a smartphone app to record their disease activity between hospital appointments using the RAPID3. Data from the first twelve months (July 2018 - July 2019) was extracted and latent class modelling using aggregate data was undertaken to explore the trends of disease activity experienced by our patients at a group level. Standard analysis recommendations were followed.

Results

Over the course of twelve-months, 58 patients used the app to record their disease activity using the RAPID3. These patients had a mean age of 53 and were 76% female. 35 patients had rheumatoid arthritis, 15 patients had psoriatic arthritis and 8 had another inflammatory arthritis. The median number of RAPID3 scores completed per patient was 8 (interquartile range 14), and a total of 706 RAPID3 scores were submitted over the 12 months. Three different trajectories of disease activity were identified among our cohort of patients. The first trajectory showed a low stable plateau of disease activity for six months before further improvement (27 patients:47%) over six months. The second trajectory (23 patients; 40%) showed an initial moderate disease activity which gradually declined over six months before improving markedly in the last three months, returning to moderate disease activity. The final trajectory (8 patients; 14%) identified patients with the highest disease activity which showed a gradual but slow improvement of disease activity over twelve months. These different trajectories show the changing burden of inflammatory arthritis over time.

Conclusion

Regular longitudinal data collection of patient-reported outcomes via a smartphone app can be used to show distinct group level trajectories of disease activity and could be used to examine changes in outcomes of patients over time. Data such as these could be used at a departmental level to examine the burden of inflammatory arthritis experienced by patients, assist planning future service requirements, and help anticipate the timings of future appointments more accurately for patients.

Disclosures

P.D.H. Hamann Consultancies; Living With Ltd. Royalties; PH has provided consultancy for and has an options and limited royalty agreement with, Living With Ltd. software company for the development of the smartphone application described in this abstract. N. Minaur None. J.H. Tobias None. E.M. Clark None.

Identifying Scoliosis in Population-Based Cohorts: Automation of a Validated Method Based on Total Body Dual Energy X-ray Absorptiometry Scans

Scoliosis is a 3D-torsional rotation of the spine, but risk factors for initiation and progression are little understood. Research is hampered by lack of population-based research since radiographs cannot be performed on entire populations due to the relatively high levels of ionising radiation. Hence we have developed and validated a manual method for identifying scoliosis from total body dual energy X-ray absorptiometry (DXA) scans for research purposes. However, to allow full utilisation of population-based research cohorts, this needs to be automated. The purpose of this study was therefore to automate the identification of spinal curvature from total body DXA scans using machine learning techniques. To validate the automation, we assessed: (1) sensitivity, specificity and area under the receiver operator curve value (AUC) by comparison with 12,000 manually annotated images; (2) reliability by rerunning the automation on a subset of DXA scans repeated 2-6 weeks apart and calculating the kappa statistic; (3) validity by applying the automation to 5000 non-annotated images to assess associations with epidemiological variables. The final automated model had a sensitivity of 86.5%, specificity of 96.9% and an AUC of 0.80 (95%CI 0.74-0.87). There was almost perfect agreement of identification of those with scoliosis (kappa 0.90). Those with scoliosis identified by the automated model showed similar associations with gender, ethnicity, socioeconomic status, BMI and lean mass to previous literature. In conclusion, we have developed an accurate and valid automated method for identifying and quantifying spinal curvature from total body DXA scans.

P85 The effectiveness of group physiotherapy interventions for hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD): a service evaluation project

Background

HSD and hEDS are complex and multisystemic disorders of connective tissue with arthralgia and other musculoskeletal features being acknowledged in the 2017 diagnostic criteria. Physiotherapy is a core component of management but there is no clear consensus regarding its effectiveness. For the last 21/2 years we have run an NHS group-based physiotherapy intervention consisting of four sessions focussing on patient education, exercises and lifestyle advice. The aim of this medical student-led project was to evaluate this service by canvassing patients' opinions and experiences and asking them to propose ways of improving care.

Methods

The physiotherapy intervention is open to all adults diagnosed with HSD and hEDS by rheumatologists or physiotherapists. 90 patients were invited to attend, and eleven groups were run between July 2017 and February 2019. To evaluate the service, patients were asked to complete an anonymised questionnaire which contained Likert scales (poor, average, good, very good or excellent) for four areas: (1) information on hypermobility; (2) pace of sessions; (3) physiotherapist's knowledge; and (4) relevance. In addition, free-text boxes asked about the patients' experiences of the course (likes, dislikes and suggested changes for future courses), and lessons learnt (lifestyle changes implemented, and take-home messages from the course). Results were recorded and analysed for recurring themes.

Results

43 patients attended all four classes and 40 questionnaires were completed and returned. 100% rated the information on hypermobility and physiotherapist's knowledge as good, very good or excellent. Similarly, 94% rated the pace of sessions, and 97% the relevance of sessions as good, very good or excellent. Analysis of the free-text fields revealed three major themes: meeting people; effectiveness of the course; and lack of written information. Patients found it particularly valuable to meet others with similar concerns and experiences. They felt able to support each other by sharing and learning together, making them feel more comfortable with their condition. In terms of effectiveness of the course, they valued the information delivered about the condition and fatigue management. Patients reported benefit from learning exercises and relaxation techniques that they have built into their daily routines. Some patients came to realise that they can be active without causing injury and therefore incorporated regular exercise into their lifestyle. All patients reported actively implementing advice provided throughout the course. However, there was a lack of written information: patients requested leaflets relevant to the contents of classes. They also highlighted lack of information about the widespread effects of HSD/hEDS that they could share with friends, family and work colleagues.

Conclusion

Patients particularly valued learning alongside others with the same condition, and many reported actively implementing advice provided. An important area for development was written patient education and a resource pack needs generating to improve this.

Disclosures

D.M. Paxton None. R. Lewis None. S. Palmer None. E.M. Clark None.