Newly diagnosed with inflammatory arthritis (NISMA)-development of a complex self-management intervention

BACKGROUND

Patients newly diagnosed with inflammatory arthritis (IA) request regular consultations and support from health professionals to manage physiological, emotional, and social challenges. Evidence suggests that providing a tailored multi-component self-management program may benefit disease management. However, there is a lack of evidence of effective interventions with multiple components targeting the needs of this group. Therefore, the aim of this study was to develop a self-management intervention targeting newly diagnosed patients with IA, following the Medical Research Council (MRC) framework for developing complex interventions.

METHODS

The development of the complex self-management intervention covered three steps. First, the evidence base was identified through literature reviews, in which we described a preliminary nurse-led intervention. Secondly, we chose Social Cognitive Theory as the underlying theory along with Acceptance and Commitment Theory to support our communication strategy. Thirdly, the preliminary intervention was discussed and further developed in workshops to ensure that the intervention was in accordance with patients' needs and feasible in clinical practice.

RESULTS

The developed intervention comprises a 9-month nurse-led intervention (four individual and two group sessions). A physiotherapist and an occupational therapist will attend the group sessions along with the nurse. All sessions should target IA-specific self-management with a particular focus on medical, role, and emotional management.

CONCLUSION

Through the workshops, we involved all levels of the organization to optimize the intervention, but also to create ownership and commitment, and to identify barriers and shortcomings of the preliminary intervention. As a result, from the existing evidence, we believe that we have identified effective mechanisms to increase self-management in people newly diagnosed with IA. Further, we believe that the involvement of various stakeholders has contributed significantly to developing a relevant and feasible intervention. The intervention is a nurse-led complex self-management intervention embedded in a multidisciplinary team (named NISMA). The intervention is currently being tested in a feasibility study.

Characteristics of participants and decliners from a randomized controlled trial on physical activity in patients with rheumatoid arthritis: a retrospective register-based cross-sectional study

OBJECTIVE

A randomized controlled trial [Joint Resources - Sedentary Behaviour (JR-SB) intervention] aimed to reduce sedentary behaviour and increase light-intensity physical activity in patients with rheumatoid arthritis (RA) through motivational counselling and text messages. Since a large proportion of invited patients declined to participate, this study aims to compare sociodemographic, clinical, and lifestyle factors between included patients and patients declining to participate (non-participants) in the JR-SB study and to investigate which characteristics were associated with participation.

METHOD

A register-based cross-sectional study was conducted. All patients invited to participate in the JR-SB study were identified in the DANBIO registry, from which patients' clinical and lifestyle data were also retrieved. Data on sociodemography and comorbidity were extracted from national registers. Differences between participants and non-participants were determined by an independent t-test or a chi-squared test. Logistic regression analyses adjusted for various confounders tested the association of patient characteristics with the likelihood of participation in the JR-SB study.

RESULTS

A total of 467 (58%) declined participation in the JR-SB study. Non-participants were older and less educated, more were smokers, fewer performed regular physical activity, and more had comorbidity compared to participants. Regression analyses showed that a higher educational level and absence of comorbidity in particular were associated with participation in the JR-SB study.

CONCLUSION

Patients with RA who are less educated and with certain types of comorbidity are less motivated to participate in a physical activity intervention. The findings may inform the recruitment process and implementation of physical activity interventions in rheumatology clinical practice.

POS1498-HPR NEWLY DIAGNOSED WITH INFLAMMATORY ARTHRITIS – DEVELOPMENT OF A COMPLEX SELF-MANAGEMENT INTERVENTION

Background

People newly diagnosed with inflammatory arthritis (IA) request regular consultations and support from health professionals (HPRs) in rheumatology to manage physiological, emotional, and social challenges. Evidence suggests that providing a tailored tailormade multi-component self-management program may benefit disease management (1). However, there is a lack of evidence in interventions with multiple components targeting people newly diagnosed with IA.

Objectives

To develop a complex evidence- and theory-based intervention in co-creation with patients and HPRs for better self-management in newly diagnosed people with IA in a rheumatology out-patient clinic.

Methods

This study followed the Medical Research Council (MRC) Framework (2,3) for developing a complex intervention. The development phase comprised 1) identifying the evidence base, 2) identifying theory, 3) modelling process and outcomes, resulting in 4) a final description of all components and outcomes of the intervention.

1) Identifying the evidence base

We conducted two literature reviews, on which, we described a preliminary nurse-led intervention.

2) Identifying theory

Given the fact that the theory of Self-management is built upon Social Cognitive Theory (4) this was chosen as the underlying theory along with Acceptance and Commitment Theory (5) to support our communication strategy.

3) Modelling process and outcomes

The preliminary intervention was discussed and further developed in seven workshops to ensure that the intervention was in accordance with patients’ needs and feasible in clinical practice. Three patients and 38 HPRs (nine therapists, 10 rheumatologists, one psychologist, one social worker, and 17 registered nurses) attended.

During the workshops we identified the competencies needed in the HPRs delivering the intervention. In addition, relevant outcomes to measure self-management in a subsequent feasibility study were discussed. Discussions were digitally recorded and analysed using Thematic Analysis (6). Subsequently, the project group discussed the analysis and consensus was reached.

Results

4) Description of all components and outcomes of the intervention

Our intervention, ready for testing in a feasibility study, was a 9-month nurse-led intervention, and consisted of four individual and two group sessions. A physiotherapist and an occupational therapist should attend the group sessions along with the nurse (Figure 1). All sessions should target inflammatory arthritis-specific self-management.

Figure 1.

Intervention activities and

A comprehensive intervention manual has been developed. Our patient research partner and experts in rheumatology and self-management commented on the content to secure content validity. Subsequently, we conducted cognitive interviews with the HPRs to determine the face validity of the manual. In addition, we completed a two-day competence program to train HPRs in delivering the intervention.

The selected patient reported outcomes were: Physical activity levels, Health assessment, Fatigue, Quality of life, Anxiety and depression, Illness intrusiveness, Illness perception, and Self-efficacy, supplemented with objective measures for diseases activity.

Conclusion

NISMA - a nurse-led complex self-management intervention embedded in a multidisciplinary team has been developed and described based on MRC’s framework for the development of complex interventions. The intervention is currently being tested in a feasibility study.

References

[1]Nikiphorou et al., Annals of the Rheumatic Diseases. 1. oct 2021.

[2]Skivington et al., BMJ. 30. sep. 2021.

[3]Craig et al., nt J Nurs Stud. may 2013.

[4]Bandura A. SOCIAL COGNITIVE THEORY.

[5]Newman et al., Lancet. oct 2004.

[6]Braun et al., Springer; 2019.

Acknowledgements

First, I would like to thank the patients and health professionals who attended the workshops.

Secondly, I would like to thank The Novo Nordic Foundation for funding.

Disclosure of Interests

None declared

POS1497-HPR FEASIBILITY OF A PHYSIOTHERAPIST LED, BEHAVIOUR CHANGE INTERVENTION TO IMPROVE PHYSICAL ACTIVITY IN PEOPLE WITH RHEUMATOID ARTHRITIS

Background

Physical activity (PA) is an important component in the management of people with rheumatoid arthritis (RA) (1). Interventions incorporating Behaviour Change (BC) theory are needed to target physically inactive people with RA. The study Physiotherapist-led Intervention to Promote Physical Activity in Rheumatoid Arthritis (PIPPRA) was designed using the Behaviour Change Wheel (BCW) and a pilot study of feasibility undertaken (ClinicalTrials.gov Identifier: NCT03644160).

Objectives

To obtain reliable estimates regarding recruitment rates; participant retention; protocol adherence and possible adverse events, and to producing estimates of the potential effect sizes of the BC intervention on changes in outcomes of physical activity; fatigue; disability and quality of life.

Methods

Participants were recruited at University Hospital (UH) rheumatology clinics and randomly assigned to control group (physical activity information leaflet) or intervention group (four BC physiotherapy sessions in eight weeks). Inclusion criteria were diagnosis of RA (ACR/EULAR 2010 classification criteria), aged 18+ years and classified as insufficiently physically active. Ethical approval was obtained from the UH research ethics committee. Participants were assessed at baseline (T0), 8-weeks (T1), and 24-weeks (T2). Descriptive statistics and t-tests were used to analyse the data with SPSS v22.

Results

320 participants were identified through chart review with direct contact then with people meeting the inclusion criteria at rheumatology clinics. Of the clinic attendees n=183 (57%) were eligible to participate and n=58 (55%) of those consented to participate. The recruitment rate was 6.4 per month and refusal rate was 59%. Due to impact of COVID-19 on the study n=25 (43%) participants completed the study (n=11 (44%) in intervention and n=14 (56%) in control). Of the 25, n= 23 (92%) were female, mean age was 60 years (sd 11.5). Intervention group participants completed 100% of BC sessions 1 & 2, 88% session 3 and 81% session 4. No serious adverse events were reported. Secondary outcome measures data is Table 1.

Table 1.

Mean (sd) for secondary outcome measures in PIPPRA feasibility study

Outcomes and instrumentsInterventionControlBaseline Mean (sd)Time 1 Mean (sd)Time 2 Mean (sd)Baseline Mean (sd)Time 1 Mean (sd)Time 2 Mean (sd)Physical Activity – self report (YPAS1)146.27 (193.73)120.88 (70.80)132.00 (70.65)91.75 (85.86)58.03 (50.61)124.31 (69.75)Physical Activity – objective (Step Count)32,616.9132,190.0027,793.3330,476.1542,117.2534,288.77(11,415.85)(9,291.57)(7,426.92)(12,642.97)(21,714.67)(17,677.90)Pain (VAS2)4.184.904.503.715.104.79(2.40)(1.91)(1.90)(2.55)(2.77)(4.50)Disability (HAQDI3)0.850.941.030.710.711.52(0.57)(0.57)(0.65)(0.56)(0.52)(0.69)Fatigue (BRAF MDQ4)18.1814.82 (13.15)18.55 (11.84)15.71 (12.29)13.93 (15.27)20.21 (10.85)(8.98)Psychological Constructs (TPB5)22.0019.91 (7.76)20.27 (8.63)21.79 (5.67)15.50 (11.43)25.36 (6.86)(4.84)Quality of Life (RA QoL6)15.1814.73 (7.23)17.09 (7.33)18.4311.50 (10.02)14.86 (6.47)(6.08)(5.06)Sleep (PSQI7)11.558.509.9110.219.0910.14(3.56)(3.27)(3.62)(3.47)(4.32)(4.42)

1YPAS – Yale Physical Activity Scale

2VAS – Visual Analogue Scale

3HAQDI – Health Assessment Questionnaire Disability Index

4BRAF MDQ - Bristol Rheumatoid Arthritis Fatigue Multidimensional Questionnaire

5TPB – Theory of Planned Behaviour Questionnaire

6RA QoL – Rheumatoid Arthritis Quality of Life Scale

7PSQI – Pittsburgh Sleep Quality Index

Conclusion

The PIPPRA study designed using the BCW to improve promote physical activity was feasible and safe. This pilot study provides a framework for larger intervention studies and based on these findings a fully powered trial is recommended.

References

[1]Rausch Osthoff A, Niedermann K, Braun J, et al. (2018) EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Annals of the Rheumatic Diseases 77:1251-1260.

Disclosure of Interests

None declared

OP0198-HPR DEVELOPMENT OF AN INTERDISCIPLINARY NURSE-COORDINATED SELF-MANAGEMENT INTERVENTION (INSELMA) FOR PATIENTS WITH INFLAMMATORY ARTHRITIS

Background

Up to 30% of patients with inflammatory arthritis (IA) do not respond sufficiently or tolerate the pharmacological treatment. Consequently, they may experience a substantial impact of their arthritis in everyday life. Even patients in remission or low disease activity state are at risk of substantial arthritis related symptoms and burden. These patients may need coherent interdisciplinary self-management support to manage symptoms and life with the chronic condition to increase their quality of life. A previous EULAR review on the effectiveness of self-management interventions in patients with IA (1) found that well-structured self-management programmes were lacking or were poorly reported.

Objectives

This study aimed to develop a nurse-coordinated interdisciplinary self-management intervention, delivered in routine clinical care, for patients with inflammatory arthritis and with a substantial impact of their arthritis to support their self-management ability.

Methods

The study was planned across two Danish hospitals following the British Medical Research Councils (MRC) framework for developing and evaluating Complex Interventions (2). The development process consisted of four phases: 1) a comprehensive scoping review on patients support needs and elements in self-management interventions; 2) six workshops involving health professionals (rheumatologists, nurses, physiotherapists, occupational therapists, a social worker and a psychologist) and 2 patient representatives from the two hospitals and staff from primary health care, 40 people in total; the workshops focused on ideas for the content, outline of the intervention and needs for competence development of the staff; 3) self-management, self-efficacy, health literacy and principles of Acceptance and Commitment therapy (ACT) were selected as theories to tailor the intervention and 4) development of a manual through recurrent feedback from patient research partners, clinicians and the involved researchers. Two patient research partners with IA were involved in all phases of the development of the intervention.

Results

A six month nurse-coordinated interdisciplinary self-management intervention was developed (Figure 1) consisting of: 1) an initial holistic assessment is carried out by a coordinating outpatient nurse. Patients are asked to identify up to five important activities they are unable to perform or having difficulty with in accordance with the Patient Specific Functional Scale; 2) a goal-setting and action planning process involving the patient, relatives and the coordinating nurse; 3) Ongoing support to achieve the goals. The opportunities for support include individual consultations by the coordinating nurse (telephone, online or face-to-face, 2.5 hours in total), and a maximum of four consultations by a physiotherapist and or an occupational therapist. Also, support from primary care, and an online session by a social worker about social support opportunities are offered. Two team conferences led by the coordinating nurse can be held during the intervention period. A status consultation will be held after 6 months. A manual for the initial screening, inclusion, detailing the intervention, outcomes and additional materials to support the intervention was developed. Competence development of the health professionals who are to deliver the intervention was planned and completed.

Figure 1.

Illustration of the 6-month INSELMA intervention

Conclusion

A nurse-coordinated interdisciplinary self-management intervention (INSELMA) was developed and described based on MRC’s framework for the development of Complex Interventions. The intervention is ready for feasibility testing before adaptation and test in a subsequent Randomized Controlled Trial.

References

[1]Marques et al. Effectiveness of self-management interventions in inflammatory arthritis (…). RMD Open 2021;7:e001647

[2]Skivington et al. A new framework for developing and evaluating complex interventions. (…) BMJ 2021;374:n2061

Disclosure of Interests

None declared

AB1535-HPR COURSE WITH GROUP SESSIONS TO START SELF-INJECTION OF BIOLOGICAL MEDICINE (ADALIMUMAB)

Background

Denmark decided in 2018 that Adalimumab should be the first-line biological of patients with inflammatory arthritis. Consequently, a higher number of patients needed to be given information about Adalimumab and learn how to do self-injections. The department focused on making optimum use of its resources while at the same time ensuring a high medical standard for this new task.

Objectives

To examine whether group instructions with a structured approach will provide the medical standard required to enable the patients to perform their own treatment at home.

And also to examine whether participation in group sessions where the patients will have an opportunity to exchange experience with other people in a similar situation would be beneficial for them.

Methods

Design: An anonymous questionnaire survey.

Setting: The training sessions took place at the Center for Rheumatology and Spine Diseases, Rigshospitalet, Gentofte, Denmark, and involved patients who were already consulting the outpatient clinic.

Participants: Patients, ≥ 18 year, due to start on their therapy with Adalimumab, were referred to the group sessions irrespective of previous diagnosis, previous experience with other forms of biological therapy and/or experience with self-injection. A group consisted of between two and six participants.

Course structure: Initially the participants were given group instructions in subjects such as effect, adverse effects, storage and precautions to be taken in the event of an infection. The patients were also given theoretic instructions in the administration of injections and an introduction to the injection pen (test model). Following this, the patients administered self-injections individually in private under guidance.

Material: The questionnaire asked about whether the participants felt capable of managing their therapy at home and whether they had benefited from being instructed in a group.

In addition to this, the patients were asked about background data such as gender and previous experience with injection techniques and biological therapy. The questionnaire also left room to offer more detailed comments.

Analysis: Descriptive data analysis, including also the more detailed comments from the questionnaires.

Results

A total of twenty-five patients with inflammatory arthritis divided onto seven groups. Female: 15; male: 10

Bionaïve, no experience with self-injection: 13

Bionaïve, experience with self-injection: 6

Previous biological therapy, no experience with self-injection: 2

Previous biological therapy, experience with self-injection: 4

Figure 1.

After the group sessions, all of the patients felt they were capable of managing their own therapy and administering their own injections going forward.

The patients were very much or to some degree happy that they were taught in groups and most replied that the questions/comments presented by the other participants were very relevant or relevant to some degree.

Gender and previous experience with injection techniques and/or biological medicine did not affect patient satisfaction.

Selected comments made by the patients:

“Found the group approach to be really good. Good to hear what the others said”;

“It was really good to be part of a group. I would never have thought of asking the question that the other patients raised and it was relevant for me too”;

“Nice to listen to other people’s experience because it makes you realize that things may not be all that bad for you”;

“It was really good talking to others”;

“Always good to meet others in the same boat”

Conclusion

Group instructions with a structured approach are found to provide a medical standard which enables the patients to perform their own treatment at home.

Participation in group sessions with others in the same situation as oneself is also found to be beneficial for the patients since this approach creates a space for dialogue and knowledge sharing by the participant.

Disclosure of Interests

None declared

POS1511-HPR “I LEARNT SO MUCH ABOUT MY APPROACH TO BEING ACTIVE”: EXPERIENCES OF PEOPLE WITH RHEUMATOID ARTHRITIS ON THE IMPACT OF A PHYSIOTHERAPIST LED INTERVENTION TO PROMOTE PHYSICAL ACTIVITY

Background

Physical activity is an important component in the management of people with rheumatoid arthritis (RA) [1]. A Physiotherapist-led Intervention to Promote Physical Activity in people with RA (PIPPRA) was undertaken using the Behaviour Change Wheel, with the aim of examining the feasibility of promoting physical activity in RA. This qualitative study involved participants and health care professionals who participated and were involved in a behaviour change pilot RCT intervention.

Objectives

To determine, qualitatively, the acceptability of PIPPRA to participants with RA and health care professionals, in order to capture their reality.

Methods

A qualitative study design of face-to-face semi-structured interviews was undertaken. The interview schedule explored the following areas: experience of the intervention; unintended consequences; experience and suitability of outcome measures used; views regarding the intervention; perceptions of behaviour change and physical activity. Interviews were transcribed verbatim by a professional transcriber. Thematic analysis was used as an analytical approach [2]. The research team searched for patterns, analysed and coded the data, and generated themes and sub-themes. Themes were reviewed by the research team to check if they worked in relation to the coded extracts and the entire data set. The COREQ checklist provided guidance throughout [3].

Results

Fourteen participants [13 female/1 male; mean age of 59 (SD 6.3); mean RA diagnosis of 8.6 (SD 6.8) years; moderate to severe disability (HAQ-DI: 1.4 (SD 0.50)] and 8 healthcare staff [4 female/4 male; mean age of 41 (SD 5.6)] participated. Three main themes were generated from participants:- 1) Positive experience of behaviour change intervention - “I found it very knowledgeable to help you get stronger”; 2) Improvement in self-management - “…….motivate me maybe to go back to doing a little bit more exercise”; 3) Negative impact of COVID-19 on intervention – “I don’t think doing it online again would be really good at all”. Two main themes from health care professionals:- 1) Positive learning experience of behaviour change delivery – “Really made me realise the importance of discussing physical activity with patients”; 2) Positive approach to recruitment – “Very professional team showing the importance of having a study member on site”.

Conclusion

The findings demonstrated that participants had a positive experience of being involved in a behaviour change intervention in order to improve their physical activity and found it acceptable as an intervention. However, if given the choice they would prefer the intervention delivery face to face rather than telehealth. Healthcare professionals also had a positive experience and in particular found it beneficial to their own development, in particular the importance of recommending PA to patients.

References

[1]Rausch Osthoff A, Niedermann K, Braun J, et al. (2018) EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Annals of the Rheumatic Diseases 77:1251-1260

[2]Clarke, V. and Braun, V., 2014. Thematic analysis. In Encyclopedia of critical psychology (pp. 1947-1952). Springer, New York, NY

[3]Tong, A., Sainsbury, P. and Craig, J., 2007. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International journal for quality in health care, 19(6), pp.349-357

Disclosure of Interests

None declared

OP0295-HPR THE EFFECT OF GROUP-BASED COGNITIVE BEHAVIOURAL THERAPY FOR INSOMNIA IN PATIENTS WITH RHEUMATOID ARTHRITIS: A RANDOMISED CONTROLLED TRIAL

Background

Insomnia is highly prevalent in patients with rheumatoid arthritis (RA) and may exacerbate symptoms and burdens, such as fatigue, depressive symptoms, and pain1. Cognitive behavioural therapy for insomnia (CBT-I) has been shown to produce positive effects on sleep in other clinical populations2,3. However, CBT-I has not previously been investigated in patients with RA.

Objectives

The primary objective was to compare the effect of nurse-led group-based CBT-I to usual care on sleep efficiency, measured by polysomnography (PSG) immediately after the intervention (i.e. seven weeks after baseline) in patients with RA. Secondary objectives included comparing the longer-term effect of CBT-I on sleep and RA-related outcomes at 26 weeks’ follow-up.

Methods

In a randomised controlled trial, using a parallel group design, the experimental intervention was six weeks’ CBT-I; the control comparator was usual care. CBT-I was delivered face-to-face by a CBT-I trained nurse. The primary analyses were based on the intention-to-treat (ITT) population; missing data were statistically handled using repeated-measures linear mixed effects models adjusted for the level at baseline.

Results

The ITT population consisted of 62 patients (89% women), with an average age of 58 years (SD 10), DAS28-CRP of 3.4 (SD 1.0), Insomnia Severity Index (ISI) score of 18.9 (SD 4.4) and median Patient Global Assessment score of 55 (IQR 28;71).

When primary outcome was measured by PSG at week seven, sleep efficiency was 88.7% in the CBT-I group, compared to 83.7% in the control group (difference: 5.0 [95% CI -0.4 to 10.4]; p=0.068) (See Table 1). Secondary outcomes measured by PSG had not improved at week 26 either. However, for all secondary sleep and RA-related patient-reported outcomes, there were statistically highly significant differences between CBT-I and usual care e.g. insomnia (ISI: -9.8 [95% CI -11.8 to -7.9]), RA impact of disease (RAID: -1.4 [95% CI-1.9 to -0.80]) and Patient Global Assessment (-13.0 [95% CI -20.9 to -5.1]) at 26 weeks’ follow-up.

Table 1.

Primary and key secondary outcomes at week 7 and week 26, and differences between treatment groups (based on the ITT population)

CBT-I n=31Usual care n=31Difference between groups (95% CI)P-valueAt week 7Sleep efficiency (PSG, %)188.7 (1.8)83.7 (2.0)5.0 (-0.4 to 10.4)0.068At week 26Sleep efficiency (PSG, %)84.8 (1.9)86.3 (2.0)-1.5 (-7.0 to 3.9)0.577Total sleep time (PSG, minutes)376.5 (11.8)394.6 (12.8)-18.1 (-52.5 to 16.4)0.302Sleep onset latency (PSG, minutes)14.2 (2.2)10.0 (2.4)4.2 (-2.2 to 10.7)0.197Wake after sleep onset (PSG, minutes)52.1 (10.7)41.5 (11.6)10.6 (-20.7 to 41.9)0.505Insomnia severity (ISI 0-28)27.6 (0.7)17.4 (0.7)-9.8 (-11.8 to -7.9)<0.0001Sleep quality global (PSQI 0-21)35.9 (0.5)11.1 (0.5)-5.2 (-6.6 to -3.8)<0.0001Fatigue (BRAF-MDQ 0-70)424.0 (1.4)36.4 (1.5)-12.4 (-16.5 to -8.4)<0.0001RA impact of disease (RAID 0-10)54.2 (0.20)5.5 (0.20)-1.4 (-1.9 to -0.80)<0.0001Depressive symptoms (HADS-D 0-21)63.8 (0.5)6.5 (0.5)-2.7 (-4.1 to -1.3)<0.0001

Values are reported as least squares means (standard errors) by group, while the differences between groups are reported with 95% confidence intervals.

1Polysomnography, 2Insomnia Severity Index, 3Pittsburgh Sleep Quality Index, 4Bristol Rheumatoid Arthritis Fatigue - Multidimensional Questionnaire, 5Rheumatoid Arthritis Impact of Disease, 6Hospital Anxiety and Depression Scale - Depression.

Conclusion

Nurse-led, group-based CBT-I for two hours per week for six weeks, did not improve objectively measured sleep efficiency or any other outcomes measured by PSG. However, CBT-I showed long-term improvement on patient-reported outcomes such as fatigue, impact of disease, depression, pain, and Patient Global Assessment – a finding that could have important clinical implications.

References

[1]PMID: 25620673

[2]PMID: 16804151

[3]PMID: 26434673

Acknowledgements

We thank the participants for their time and commitment and the patient research partners for valuable insight into the process and content of the trial.

Disclosure of Interests

None declared

OP0116-HPR PATIENTS’ EXPERIENCES OF GROUP-BASED COGNITIVE BEHAVIOURAL THERAPY FOR INSOMNIA IN PATIENTS WITH RHEUMATOID ARTHRITIS: A QUALITATIVE STUDY

Background

Despite disease-modifying anti-rheumatic drugs, residual arthritis-related symptoms and burdens are still common in patients with rheumatoid arthritis (RA)1. In addition, insomnia – characterised by reduced sleep quantity and quality – is highly prevalent, occurring in up to 70% of patients with RA2. Insomnia is associated with increased pain, fatigue, and depressive symptoms. Cognitive behavioural therapy for insomnia (CBT-I) is recommended first-line treatment for chronic insomnia3 but has not been evaluated in patients with RA until now.

Objectives

The objective of this study was to explore patients’ experiences of CBT-I and how the components of CBT-I are incorporated in their sleep management.

Methods

Participants were patients with RA who had received CBT-I as experimental treatment for insomnia in a randomised controlled trial (RCT)4. Data were collected during an individual face-to-face interview using a semi-structured interview guide. The analysis was based on reflexive thematic method by Braun and Clarke5.

Results

Eleven participants (10 women and one man) from the intervention group of the RCT were interviewed. Prior to inclusion in the RCT, they had insomnia complaints for 8 years (median; interquartile range: 3;20 years).

Five themes emerged: 1) When knowledge contributes to an altered perception of sleep referring to the reduced misperception and increased motivation that followed sleep education, 2) Overcoming habits and perceptions to accelerate sleep onset referring to barriers related to sleep behaviour and mindset and how stimulus control was enabling them to find meaningful behaviour and rhythm, 3) The sleep window of challenges in learning how to sleep right referring to that payoff from sleep restriction did not come easily or by magic, and commitment led to progress and gave them confidence to continue, 4) Relaxation becomes a behavioural habit and goes beyond sleep referring to a means to achieve a relaxed body and mind and how they thereby coped better with RA-related symptoms, and 5) Break the cycle and regain control referring to how awareness of a vicious cycle was central to their perception of sleep and how trust in one’s own accomplishment was crucial to reducing worrying (See Figure 1).

Figure 1.

The five themes with quotes from participants

Overall, the participants experienced CBT-I as challenging and demanding but at the same time meaningful. The participants considered persistency, stringency, and inflexibility necessary to succeed. After the intervention, the participants had continued using those components that enabled them individually to further improve their sleep.

Conclusion

The process towards eliminating insomnia was a bodily experience and involved a changed mindset that altered behaviour and cognitions.

References

[1]PMID: 29251034

[2]PMID: 25620673

[3]PMID: 28875581

[4]PMID: 32471477

[5]https://doi.org/10.1080/2159676X.2019.1628806

Acknowledgements

The authors thank the participants for generously sharing their experiences and the patient research partners for invaluable perspectives and contributions.

Disclosure of Interests

None declared

POS1552-HPR A SYNTHESIS OF GUIDANCE AVAILABLE FOR ASSESSING METHODOLOGICAL QUALITY AND GRADING OF EVIDENCE FROM QUALITATIVE RESEARCH TO INFORM CLINICAL RECOMMENDATIONS: A SYSTEMATIC REVIEW

Background

Qualitative research is crucial to understand key stakeholders experiences and perspectives of care and health services. However, there is a lack of explicit frameworks and guidelines about how best to use qualitative evidence to formulate clinical recommendations. Part of the problem includes uncertainties about the contributions of qualitative research to the evidence, and the empirical and theoretical basis for appraising and synthesizing qualitative evidence in a standardized manner. In addition, most existing grading systems of qualitative research originates from quantitative research, and there is no clear guidance about how to incorporate qualitative research into the evidence hierarchy.

Objectives

To conduct a systematic literature review (SLR) to answer two research questions (RQ):

RQ1) What guidance (e.g., tools, checklists, frameworks) exists to assess the methodological quality of qualitative research employed to inform clinical recommendations?;

RQ2) What methods exist specifically to grade levels of evidence for qualitative research?

Methods

The protocol for this review was registered on www.researchregistry.com (reviewregistry1240). Electronic databases (PubMed/Medline, EMBASE, Web of Science, COCHRANE, Emcare, PsycINFO, ERIC, Academic Search Premier, Sociological Abstracts, ProQuest Dissertations and Thesis Global) were searched for published and unpublished studies. Searches were completed from inception to 23rd October 2020. No restrictions were applied to clinical population. Eligible studies for both questions included primary articles and guideline documents available in English, describing the: i) development; ii) application of validated tools (e.g., checklists); iii) guidance on how to assess methodological quality of qualitive research and iv) guidance on how to grade levels of qualitative evidence. Opinion pieces and conference abstracts were excluded. Manual searches of the reference lists of full text articles were conducted. Two reviewers independently screened the titles, abstracts, and full text. A narrative synthesis was conducted to identify key aspects between the included studies.

Results

9071 records were retrieved (Figure 1). After de-duplication and title/abstract screening, 51 full-articles articles were assessed for eligibility yielding 15 included articles. For RQ1, six articles were included that described six tools (1) The society for Critical Care Medicine Family – Cantered Care Guidelines; 2) Nursing Management of the Second Stage of Labour evidence based clinical practice guidelines; 3) Jonna Briggs Institute Critical Appraisal of Qualitative Studies; 4) Critical Skill’s Appraisal Programme (CASP) and 6) the Modified CASP checklist). All tools ranged from 10 to 30 items, and evaluated research design, recruitment, ethical rigour, data collection and data analysis. Seven articles described one approach (GRADE CER-Qual) to assess methodological quality of qualitative research. This approach advised on the importance for assessing methodological limitations. For RQ2, two articles were included, one described a qualitative hierarchy of evidence, and another described a research pyramid that included a section on qualitative research.

Figure 1.

PRISMA diagram of included papers

Conclusion

This review highlights lack of consensus and limited availability of tools, checklists, and approaches to 1) appraise the methodological quality of qualitative research used to inform clinical recommendations and 2) grade levels of evidence for qualitative research. Current research agendas will need to determine the most relevant and appropriate method for the quality appraisal of qualitative research. This way, qualitative research could be more consistently and appropriately applied to the development of clinical recommendations.

References

N/A

Disclosure of Interests

Mandeep Sekhon: None declared, Annette de Thurah: None declared, George E. Fragoulis: None declared, Tanja Stamm: None declared, T.P.M. Vliet Vlieland: None declared, Bente Appel Esbensen: None declared, Heidi Lempp: None declared, Lindsay Bearne: None declared, Marios Kouloumas: None declared, Polina Pchelnikova: None declared, Thijs W. Swinnen: None declared, Chris Blunt: None declared, Ricardo J. O. Ferreira: None declared, Loreto Carmona: None declared, Elena Nikiphorou Speakers bureau: Celltrion, Pfizer, Sanofi, Gilead, Galapgos, AbbVie, Eli Lilly, Grant/research support from: Pfizer, Eli Lilly

POS0041-HPR OUTCOME MEASURES IN RHEUMATOLOGY APPLIED IN SELF-MANAGEMENT INTERVENTIONS TARGETING PEOPLE WITH INFLAMMATORY ARTHRITIS - A SYSTEMATIC REVIEW OF OUTCOME DOMAINS AND MEASUREMENT INSTRUMENTS

Background

Self-management refers to the patient’s ability to manage a large range of consequences such as symptoms, medication, emotions, and preferable life-style changes coherent with living with a chronic disease. Evaluating the effect of interventions targeting to improve people with inflammatory arthritis (IA) self-management is a challenge because self-management interventions are complex and consensus on important outcomes is lacking. Solutions to these issues could be to consensus on a Core Outcome Set (COS) describing what outcomes are relevant and should be applied in future studies hereby lessening the heterogeneity between future studies. The purpose of this study was therefore to take the first actions in identifying possible candidate outcomes for such a COS.

Objectives

The aim was to identify, and map applied outcome domains and outcome measurement instruments from previous trials measuring the effect of self-management interventions targeting people with IA.

Methods

We performed an informative systematic literature review following guidance from the Handbooks described by ‘Outcome Measures in Rheumatology’ (OMERACT) and ‘Core Outcome Measures in Effectiveness Trials’ (COMET) initiatives. Randomized and non-randomized trials describing their experimental intervention as “self-management” and included a population of adults (≥18 years) with at least 50% diagnoses with IA (Rheumatoid arthritis, Psoriatic arthritis, Spondylarthritis) was included. Both screening of possible trials and data extraction was performed independently by two reviewers. Extracted data included: study characteristics, outcome domains and the corresponding measurement instruments. During analysis two reviewers simultaneously grouped and categorized domains and subdomains, and two senior researchers approved the categorization.

Results

Searches was performed 2021.02.08 on online databases, trial registers, conference abstracts and references of included trials. From a total of 2,502 records, we included 38 trials published between 1988 and 2021. The interventions were heterogenic and patients primarily female, diagnosed with Rheumatoid Arthritis, and a calculated mean age of 54 years. We identified 12 different outcome domains, covering 39 subdomains, collected with 119 different measurement instruments. The most frequently applied outcome domains were self-efficacy, pain, physical functioning/disability, anxiety and depression, quality of life, fatigue, global assessment/disease activity and coping. Please see Figure 1 for all outcome domains identified. The applied measurement instruments varied within each outcome domain with up to 10 different instruments applied to measure the same domain. Instruments were predominantly patient-reported outcomes.

Conclusion

The outcome domains and measurement instruments used in self-management trials were widely diverse and differ from the current general OMERACT Core Outcome Sets (COS) for IA conditions. Further steps towards the establishment of a COS to be reported in all self-management intervention trials will enhance the relevance and the subsequent impact on the body of evidence from these trials.

References

The protocol was registered in PROSPERO (ID CRD42021238749).

[1]OMERACT Handbook 2019. Available at: https://www.dropbox.com/s/fd3673fsma45qe0/OMERACT Handbook Chapter 4 Apr 16 2019.pdf?dl=0.

[2]Williamson PR, Altman DG, Bagley H, Barnes KL, Blazeby JM, Brookes ST, m.fl. The COMET Handbook: Version 1.0, 2017. Available at: https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-017-1978-4

Disclosure of Interests

None declared

AB0885-HPR SLEEP IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Many patients with rheumatoid arthritis (RA) live with the consequences of arthritis in everyday life. Sleep disturbances, including insomnia, are highly prevalent and a complex issue that increases existing RA-related symptoms, such as pain, fatigue, and depressed mood. To our knowledge, only two studies have qualitatively investigated the patient perspective and experiences of sleep in people with RA (1-2).

Objectives:

To investigate how people with RA and concomitant sleep disturbances describe their sleep and experience everyday life with poor sleep.

Methods:

This study is a qualitative phenomenological study. In total, 14 people with RA and sleep disturbance were recruited from an RCT study (3) from the Center for Rheumatology and Spine Diseases at Rigshospitalet in 2012. Semi-structured interviews were performed after the last follow-up in the RCT. The analysis was based on Giorgis’ descriptive phenomenological psychological analysis.

Results:

For the characteristics of participants, see Table 1. We identified six essences; 1) “When sleep is put into words” covered that the participants described their poor sleep experiences simultaneously to their wishes for good sleep still existed. 2) “The struggle to sleep” included participants’ descriptions of difficulties sleeping and how thoughts and worries could interfere with sleep at night. 3) “Pain is a companion day and night” included how pain affected sleep and how participants had problems with pain management. 4) “To take sleep in their own hands” described how the participants tried to create their framework for sleeping and how they also strove to reach out for help from, e.g. of professionals. 5) “Everyday life in the shadow of sleep” included the overwhelming fatigue, a need to rest during the day, and how social relationships were affected negatively. 6) “Adapt to the circumstances,” which meant that the participants tried to seek shelter behind a facade, and at the same time tried to learn to live with the consequences of poor sleep in everyday life.

People with RA and sleep disturbances describe several challenges that affect their sleep, e.g., pain, thoughts at night, and many reasons for awakenings. Participants in this qualitative study were not aware of the difference between fatigue and poor sleep, both regarding reasons for occurring and management of the two highly prevalent consequences of RA. At the same time, they believed that health professionals lacked knowledge on sleep disturbances and management hereof in people with RA.

Conclusion:

When people with RA and concomitant sleep disturbance describe their sleep, a struggle to sleep was most often described, characterized by pain, thoughts, difficulty falling asleep, and many and early awakenings. Everyday life experience with sleep disturbances was marked by fatigue and sleep deprivation, negative impact on social skills and relationships, and failure when they reached out for help.

Table 1.

Characteristics of participants

(N=8)Age, median (range)50 (44-60)Sex, Women, n %7 (77,8%)RA-relatedDuration of RA, median (range)14,75 (6-32)DAS28-CRP, median (range)11,9 (1,62-3,03)Physical function, HAQ, median (range)10,5 (0,000 – 2,13)SleepPSQI, median (range)29,5 (6-15)FatigueVAS fatigue, median (range)33,4 (2-65)BRAF-MDQ, median (range)325,5 (4-36)PainVAS pain, median (range)25 (0-60)Quality of LifeVAS global, median (range)45,6 (8-40)

1 Disease activity score-28 C-reactive protein

2Health Assessment Questionnaire, score 0-3 (Higher score indicates worse physical functioning.

2 Pittsburgh Sleep Quality Index, score 0-21 (score of 5 or more indicates sleep disturbances)

3 Visual Analog scale, score 0-100 (higher score is worse)

4 Bristol Rheumatoid Arthritis Fatigue Multidimensional Questionnaire score 0-70(higher score indicates more fatigue)

References:

[1]Short V et al; Annals of the Rheumatic Diseases. 2017;76(Suppl 2):519.

[2]McKenna S, et al; EULAR. 2020; OP0267-HPR (2020).

[3]Løppenthin et al; BMC Musculoskeletal Disorders 2014, 15:49.

Disclosure of Interests:

Camilla Andersen: None declared, Kristine Marie Latocha: None declared, Bente Appel Esbensen Speakers bureau: Bente Appel Esbensen has received speaking fees from Pfizer and Eli Lilly.

OP0159-HPR IMPACT OF NON-PHARMACOLOGICAL INTERVENTIONS TARGETING SLEEP DISTURBANCES OR DISORDERS IN PATIENTS WITH INFLAMMATORY ARTHRITIS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMISED TRIALS

Background:

Patients with inflammatory arthritis (IA) often present limitations in daily life due to unpredictability, severity and chronicity of the disease, reduced functional ability and health-related quality of life. Moreover, sleep disturbances or disorders have been reported in up to 40-90% of patients with IA [1-3]. Sleep disturbances are further associated with pain, fatigue, mental well-being and disease activity [4]. As chronic us of hypnotic drugs are associated with tolerance and side effects, there is growing interest in non-pharmacological management to improve sleep.

Objectives:

With a systematic review and meta-analysis, our primary objective was to evaluate the evidence of non-pharmacological interventions targeting sleep in patients with IA. Primary outcome was sleep domains, while secondary objectives were based on the core outcome domains for IA trials and harms.

Methods:

Following protocol closure, a systematic search was undertaken in MEDLINE, CENTRAL, PsycINFO, CINAHL, ClinicalTrials.gov, ACR and EULAR in September 2020. Eligible studies were randomised trials with adults with IA and concomitant sleep disturbances or disorders, comparing a non-pharmacological intervention targeting sleep disturbances or disorders to another non-pharmacological intervention, a pharmacological intervention or standard care. Screening of titles, abstracts, and subsequent full text assessment were conducted independently by two reviewers using the Covidence tool. Randomisation, blinding, and adequacy of analyses was assessed using the Cochrane’s RoB tool and the overall quality of evidence was rated using GRADE methodology. Disagreements were resolved at consensus meetings with last authors. Effect sizes for continuous outcomes were based on the standardised mean difference (SMD), combined using standard random-effects meta-analysis (all with 95% CIs).

Results:

Six trials (308 patients) were included in the quantitative synthesis. Two trials included patients with the sleep disorder insomnia and the remaining four trials included patients with sleep disturbances. Sleep domains were measured with Pittsburgh Sleep Quality Index (PSQI) or Insomnia Severity index (ISI). Three trials reported improvement on sleep following foot reflexology, auricular plaster therapy, and exercise. The overall meta-analysis presented in the figure of forest plot for self-reported sleep suggests that non-pharmacological interventions have a potentially large effect size of -0.80 (95% CI, -1.33 to -0.28) on sleep. However, the quality of the evidence was assessed as corresponding to low, given that the body of the evidence was rated down twice, due to serious study limitations and inconsistency.

Conclusion:

Although the effect of non-pharmacological interventions targeting sleep disturbances or the sleep disorder insomnia was statistically highly significant, the implication for clinical practice is questionable because of the overall quality evidence. None of the core outcomes used in contemporary IA trials have indicated clinical benefit in favour of non-pharmacological interventions targeting sleep disturbances or disorders.

In conclusion, more rigorous research on non-pharmacological management of sleep disturbances and disorders is urgently needed, also aimed at specific sleep disorders, in order to fully reveal the clinical utility of these novel treatment options. At this point, non-pharmacological treatment of sleep disturbances or disorders is promising and potentially highly effective, and may have the potential to persistently decrease the symptom burden and increase the quality of life of patients with IA.

References:

[1]Li et al., Psychol Health Med. 2019 Sep;24(8):911-924

[2]Haugeberg et al., Arthritis Res Ther. 2020 Aug 26;22(1):198

[3]Wali et al., J Clin Sleep Med. 2020 Feb 15;16(2):259-265

[4]Løppenthin et al., Clin Rheumatol. 2015 Dec;34(12):2029-39

Disclosure of Interests:

Kristine Marie Latocha: None declared, Katrine Løppenthin: None declared, Safa Al-Bazy: None declared, Tannie Albrechtsen: None declared, Helle Jensen: None declared, Mikkel Østergaard Speakers bureau: Abbvie, Celgene, Eli-Lilly, Janssen, Novartis, Pfizer, Roche, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Merck, Celgene, Novartis, Poul Jennum: None declared, Bente Appel Esbensen: None declared, Robin Christensen: None declared

AB0872-HPR IMPACT OF COVID-19 ON A PHYSICAL ACTIVITY FEASIBILITY PILOT STUDY: THE PIPPRA EXPERIENCE

Background:

The PIPPRA (Physiotherapist-led Intervention to Promote Physical Activity in Rheumatoid Arthritis) project is a feasibility project examining the impact of a physical activity behaviour change intervention in people who have rheumatoid arthritis (RA). The PIPPRA study recruitment commenced in October 2019, with participant assessment and intervention commencing in November 2019. In the Republic of Ireland people who have RA are categorised as high risk category for Covid-19, due to immunosuppression [1], although this categorisation contrasts with EULAR’s provisional recommendations [2].

Objectives:

To examine the impact of the Covid-19 pandemic and public health restrictions on a pilot randomised controlled feasibility study in 2020.

Methods:

Participants (aged 18 years+, diagnosis of RA, independently mobile and low levels of physical activity [3]) were recruited from a rheumatology clinic at an urban hospital. Target recruitment was four participants per month for one year (N=48). Assessments were planned at baseline, eight and twenty-four weeks (N=144). Participants were randomised to intervention group or control group. The intervention group received four 1:1 sixty minute sessions with a physiotherapist (N=96). The intervention was delivered over eight weeks. Intervention and control groups received a physical activity information leaflet.

Results:

The Covid-19 pandemic and associated public health restrictions forced the study to be formally paused in April 2020 and the study formally resumed in August 2020. N=48 participants were recruited between October 2019 and March 2020 (six months). N=20 participants have commenced in the study, N=16 are awaiting baseline assessment, N=6 withdrew and N=6 were lost to follow-up prior to baseline. Trial protocol planned for the delivery of N=55 assessments and N=36 intervention sessions for participants who had commenced in the study. N=22 assessments and N=26 intervention sessions were delivered between November 2019 and March 2020. N=5 assessments and N=6 intervention sessions were conducted between August and October 2020. No assessment or intervention delivery occurred in November-December 2020 due to participant hesitancy in attending for assessment and/or intervention with increased public health restrictions. The impact of Covid-19 restrictions resulted in N=33 (60%) deviations from assessment protocol and N=10 (27%) deviations from intervention delivery protocol (Figure 1).

Figure 1.

Deviations from assessment and intervention protocol in the PIPPRA study

Conclusion:

The Covid-19 pandemic has had a significant impact on the delivery of the PIPPRA study. Feasibility study outcomes, including participant retention rate, and study delivery as per protocol, have been affected due to the Covid-19 pandemic. Participant reluctance to attend face-to-face sessions demonstrates the need to consider alternative methods of delivery, e.g. virtual delivery of interventions, where attending in person is not acceptable to participants [4], in future studies.

References:

[1]Health Service Executive. (2019). People at higher risk from COVID-19.Accessed 5th Jan 2020 https://www2.hse.ie/conditions/coronavirus/people-at-higher-risk.html.

[2]Landewé RB et al (2020). EULAR provisional recommendations for the management of rheumatic and musculoskeletal diseases in the context of SARS-CoV-2. Annals of the Rheumatic Diseases 79:851-858.

[3]Godin, G. (2011). The Godin-Shephard leisure-time physical activity questionnaire. The Health & Fitness Journal of Canada, 4(1):18-22.

[4]Inan, OT et al. (2020). Digitizing clinical trials. npj Digit. Med. 3:10.

Disclosure of Interests:

None declared

Validation of the Danish versions of the Bristol Rheumatoid Arthritis Fatigue Multi-Dimensional Questionnaires (BRAFs)

Objective: This study aimed to validate the Danish versions of the Bristol Rheumatoid Arthritis Fatigue Multi-Dimensional Questionnaire (BRAF-MDQ) and BRAF Numerical Rating Scale version 2 (NRSv2).Method: We tested face and content validity, internal consistency, criterion validity, construct validity, and reproducibility for the BRAF-MDQ, and face and criterion validity and reproducibility for the BRAF-NRS.Results: In all, 224/236 patients (95%) completed the questionnaires [70% female, mean ± sd age 59 ± 13.04 years, disease duration 11.2 ± 9.49 years, Health Assessment Questionnaire (HAQ) 0.724 ± 0.70, and 28-joint Disease Activity Score-C-reactive protein 2.55 ± 1.24]. The unidimensionality for the physical and cognitive fatigue subscales was confirmed, whereas the living with fatigue and emotional fatigue subscales were not unidimensional. Cronbach's α was 0.94 for the BRAF-MDQ total and 0.78-0.92 for the four subscales. The correlations between BRAF-MDQ and various measures were: 36-item Short Form Health Survey (SF-36) vitality subscale, 0.75; Hospital Anxiety and Depression Scale (HADS) anxiety subscale, 0.65; HADS depression subscale, 0.62; visual analogue scale (VAS) pain, 0.62; VAS global, 0.73; and HAQ, 0.62. The intraclass correlation coefficient for agreement was 0.995. A Bland-Altman plot showed a mean ± sd difference of -1.9 ± 3.62 for BRAF-MDQ. Correlation coefficients between the BRAF-NRSv2 subscales and other subscales were: BRAF-MDQ subscales, 0.57-0.93; SF-36 vitality subscale, 0.54-0.68; and VAS fatigue, 0.66-0.82.Conclusions: The Danish BRAFs are considered valid and reliable for use among Danish patients with rheumatoid arthritis, despite the subscales living with fatigue and emotional fatigue not being unidimensional, as they are in the original version.

SAT0651-HPR BARRIERS IN DIAGNOSING RHEUMATOID ARTHRITIS – A FOCUS GROUP STUDY ON THE GENERAL PRACTITIONERS’ PERSPECTIVES

Background:

Early treatment, before three months from symptom onset of rheumatoid arthritis (RA), is essential to increase the likelihood of remission and to prevent permanent joint damage (1). However, it has been shown that only 20% of the patients are seen within the first three months, and the median delay in general practice has been estimated to 4 months (range 2–9) (2).

Objectives:

To explore the barriers in diagnosing RA from the general practitioners’ (GPs) perspective.

Methods:

We conducted a qualitative study based on focus group interviews. We recorded the interviews digitally and transcribed verbatim. The transcribed interviews were analyzed based on content analysis (3), by using Nivo 12. Sample size was determined by thematic saturation.

Results:

In total ten GPs participated in three different focus groups. 40 % were female, mean age was 53 years (range 37-64), and mean year since specialist authorization as GP was 16 years (range 5-23). 60 % of the GPs worked in a practice located within the referral area of a university hospital; the remaining within the referral area of a regional hospital.

Four themes emerged in the analysis: 1) When the patient is not a text book example, referring to the difficulty of identifying relevant symptoms among all clinical manifestations from the joints as described by the patients, 2)The importance of maintaining the gatekeeper function, referring to the societal perspective, and the GPs responsibility to refer the right patients to secondary care, 3)Difficulties in referral of patients to the rheumatologist,referring to perceived differences in the collaboration with rheumatologists. The GPs experienced that it was sometimes difficult to be assisted by rheumatologists, especially when the clinical picture was not ‘clear cut’. Finally, (4)Para-clinical testing, can it be trusted?referring to challenges on the evaluation of especially biomarkers.

The overarching theme was:Like finding a needle in a haystack, covering the GPs difficulties in detecting RA among the many patients in general practice who appear to be well and at the same time have symptoms very similar to RA.

Conclusion:

The GPs experienced that RA was a difficult diagnosis to make. The immediate challenge was that RA patient’s initial symptoms often resembled those of more common and less serious conditions, and that investigative findings such as biomarkers can be negative at the early state of the disease. At the same time, the collaboration with rheumatologists was sometimes seen as a hurdle, when the clinical picture was not ‘clear cut’.

In order to facilitate earlier diagnosis of RA in general practice, the GPs and rheumatologists need to focus on these barriers by strengthening mutual information and collaboration.

Physicians should remain vigilant to patients who have conditions that do not resolve as expected with treatment, who have symptoms that persist, or who do not look well despite negative investigative findings.

References:

[1]Aletaha D, et al. JAMA, Oct 2018.

[2]Kiely P, et al. Rheumatology, Jan 2009.

[3]Braun V. Qualitative research in psychology. 2006, 3(2), 77-101

Disclosure of Interests:

Anne Sofie Lundberg: None declared, Bente Appel Esbensen: None declared, Ellen-Margrethe Hauge Speakers bureau: Fees for speaking/consulting: MSD, AbbVie, UCB and Sobi; research funding to Aarhus University Hospital: Roche and Novartis (not related to the submitted work)., Annette de Thurah Grant/research support from: Novartis (not relevant for the present study)., Speakers bureau: Lily (not relevant for the present study).

SAT0606-HPR HOW DO THE PATIENTS THAT DECLINE TO PARTICIPATE IN A LIFESTYLE INTERVENTION STUDY DIFFER FROM THOSE WHO ACCEPT? A REGISTER-BASED CROSS-SECTIONAL STUDY

Background:

A recently conducted randomized controlled trial (Joint Resources Sedentary Behavior Intervention study (JR-SB)) aimed to reduce sedentary behavior and increase light-intensity physical activity in patients with rheumatoid arthritis (RA). Patients were recruited from a rheumatology outpatient clinic and the intervention consisted of three motivational counselling sessions followed by text message reminders. The results showed highly significant between-group differences on behavioral, patient-reported and cardio-metabolic outcomes, both on a short- and long-term basis (1;2). Since a relatively large fraction (58%) of invited patients initially declined to participate in the trial, we decided to explore if and how the declining patients differed from the included patients. The findings may inform which patient characteristics to consider in implementing a lifestyle intervention in clinical practice.

Objectives:

To compare socio-demographic, clinical and lifestyle factors between included patients and patients declining to participate in the JR-SB study at the time where study inclusion commenced.

Methods:

We conducted a retrospective register-based cross-sectional study. All patients with RA, who had been invited to participate in the JR-SB study during 2013-2014 were identified in the DANBIO registry. Patients’ clinical and lifestyle data were also retrieved from DANBIO while data on socio-demography was extracted from Statistics Denmark. Differences between participants and decliners were determined by an independent t-test or chi-square test.

Results:

Of invited patients (n=801), a total of 467 (58%) declined participation in the JR-SB study during 2013-2014. See Table 1 for characteristics and comparison of participants and decliners.

Table 1.

Participants’ and decliners’ characteristics; (n (%) unless otherwise stated)

Participants(n=150)Decliners(n=467)P-value(x2)Women121 (80.7)358 (76.7)0.30Age (years), mean (SD)58.5 (11.7)60.8 (12.9)0.045aLiving with partner96 (64)293 (62.7)0.78Working57 (38)157 (33.6)0.15RA duration (years), mean (SD)13.8 (11.1)13.7 (10.8)0.92aPain (VAS), mean (SD)34.4 (21.8)29.1 (24.5)0.046aFatigue (VAS), mean (SD)44.2 (26.0)39.5 (28.4)0.14aSmoking(n=61)27 (44.2)(n=220)130 (59.1)0.041Regular exercise (min 1-2 times/week)(n=29)23 (79.3)(n=89)50 (56.2)0.026

VAS – Visual Analogue Scale

Numbers in bold indicate the total number of responders on smoking and exercise status

aDetermined by an independent t-test

Conclusion:

Patients who declined to participate in a randomized controlled trial aiming at reducing sedentary behavior were often smokers, had less regular exercise habits and were older than those who accepted to participate. This indicates that the intervention did not appeal to all patients with RA. The findings should be considered in the implementation of lifestyle interventions in clinical rheumatology practice.

References:

[1]Thomsen T et al. Ann Rheum Dis 2017 Sep;76(9):1603-6.

[2]Thomsen T, et al. Arthritis Care Res (Hoboken) 2019 Sep 10.

Disclosure of Interests:

Tanja Thomsen: None declared, Mette Aadahl: None declared, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Bente Appel Esbensen: None declared

PARE0006 WORK PRODUCTIVITY LOSS IN PATIENTS WITH INFLAMMATORY ARTHRITIS

Background:

Limited data exist of work productivity loss in patients with Rheumatoid Arthritis (RA), Psoreatic Arthritis (PsA) and Spondyloarthritis (axSpA).

Objectives:

The objective of this research was to assess productivity loss and absenteeism in patients with RA, PsA and axSpA.

Methods:

The study was designed as a cross-sectional study aimed to collect patient-reported outcomes from patients with RA, PsA and axSpA in Denmark via a nurse administered questionnaires and patient journals. Patients ≥18 years with RA, PsA or axSpA were consecutively recruited for the study over a 6-month period via routine visits to outpatient rheumatology clinics. Descriptive statistics were analyzed using SAS.

Results:

Of 488 respondents, 62% were women and mean age was 53.5 years (RA:57.4; PsA:52.6; axSpA:43.6). Average time since diagnosis was 11-15 years, however, for PsA and axSpA most patients answered 6-10 and 0-5 years, respectively. 280 (57%) answered that they had a job and completed the WPAI questionnaire (RA: 149 (51%); PsA: 48 (56%); axSpA: 83 (75%)). Average work hours was 31.9 in the last week (RA:31.2; PsA:33; axSpA:32.4). Average missed work hours were 4.3 in the last 7 days ((RA:4.0; PsA:4.2; axSpA:4.8), of which 32% was missed due to their inflammatory arthritis (RA:30%; PsA:38%; axSpA:32%). Mean absenteeism was highest for patients with PsA (mean=6.8; SD=17.7) followed by patients with axSpA (mean=5.4; SD=15.1) and with RA (mean=3.4; SD=12.2). Mean productivity loss was 20.5 (SD=23.8) for patients with RA, 27.6 (SD=25.8) for PsA and 26.3 (SD=25.8) for axSpA

Conclusion:

We found that patients with PsA or axSpA miss more hours of work compared with patients with RA and when they are at work they have a higher absenteeism/lower productivity. This even though that both the group of patients with PsA and the axSpA were younger and had lived less time with their diagnosed disease compared with the group with RA.

Disclosure of Interests:

Trine Pilgaard Shareholder of: Pfizer, Employee of: Pfizer, Bente Appel Esbensen: None declared, Sandra Elkjær Stallknecht Consultant of: Pfizer

AB1326-HPR TOBACCO ADDICTION IN PEOPLE WITH RHEUMATOID ARTHRITIS – FROM THE PERSPECTIVE OF PATIENTS

Background:

Smoking is one of the most significant modifiable exosomes risk factors for rheumatoid arthritis (RA) (1). Studies suggest that 25-30% of people with RA in Denmark smoke (2). This is almost twice as many as in the background population in Denmark. People with RA have a significant increased risk of severe comorbidity including cardiovascular disease. In addition, there are indications that smokers with RA have a poorer effect of the medical inflammatory treatment compared to non-smokers, and consequently more difficult to achieve remission of the disease activity (3). Tobacco addiction is complex and can be a challenge in smoking cessation. In addition to physiological dependence, habits and social and environmental factors may influence addiction. Tobacco smoking is associated with an addiction to nicotine and it is unexplored how this addiction appears in people with RA.

Objectives:

The aim of this study was to examine from the patient’s perspective how tobacco addiction appears in people with rheumatoid arthritis.

Methods:

We conducted a qualitative study based on a hermeneutics approach. People with RA who previously had participated in a randomized controlled study (4) about smoking cessation conducted at the Center for Rheumatology and Spine Diseases at Rigshospitalet, Denmark were recruited for semi-structured interviews.

Results:

In total, 12 people with RA (50% female) were included in the study. The median age was 62 years and median RA disease duration was 12 years. The degree of physical dependence measured by Fagerströms Test for Nicotine dependence (FTND) was on average: 4.9 (score: 0-10, 0=nonphysical dependence).

Three categories of how tobacco addiction appeared emerged during the analysis: 1)It develops into ingrown habitsreferring to the fact that smoking already in adolescence contributes to the development of specific physical, mental and social smoking behavior. Not all individuals considered themselves addicted to nicotine as they did not necessarily connect the nicotine to the ingrown habits. 2)The body craves for nicotinereferring to nicotine proved calming, while a lacking or insufficient dose caused withdrawal symptoms. Furthermore, smoking became a habit where a craving for smoking occurred in certain situations. 3)Ambivalence – for and againstreferring to the physical dependence and smoking habits making a smoking cessation difficult. Dependency to nicotine and challenges to quit smoking led to a feeling of ambivalence and a lack of control.

Conclusion:

Tobacco addiction appeared as a physical dependence and a habit, which, during a smoking cessation, led to ambivalent feelings. Therefore, based on this study, there is still a need for health professionals to talk to patients about smoking. But also, a need to articulate the complexity of addiction in order to support for smoking cessations. Information should be strengthened in the clinical practice in relation to nicotine’s implication in tobacco addiction as well as the consequences of tobacco smoking for individuals with RA.

References:

[1]Scott DL, Wolfe F, Huizinga TW. Lancet. 2010 ###

[2]Loppenthin K, Esbensen BA, Jennum P, Ostergaard M, Tolver A, Thomsen T, et al. Clin Rheumatol. 2015. ###

[3]Roelsgaard IK, Ikdahl E, Rollefstad S, Wibetoe G, Esbensen BA, Kitas GD, et al. Rheumatology (Oxford). 2019. ###

[4]Roelsgaard IK, Thomsen T, Ostergaard M, Christensen R, Hetland ML, Jacobsen S, et al. Trials. 2017;18(1):570.###

Disclosure of Interests:

None declared

OP0267-HPR “I NEVER THOUGHT EXERCISE COULD HELP IMPROVE MY SLEEP”: EXPERIENCES OF PEOPLE WITH RHEUMATOID ARTHRITIS ON THE IMPACT OF EXERCISE ON SLEEP

Background:

OMERACT has identified sleep quality as one of the key outcomes for people with RA [1]. Poor sleep and reduced total sleep time (TST) are common complaints among people with RA. Poor sleep can in turn lead to deterioration in function, reduce activity levels and also impact mental health. Although sleep and mental health outcomes have been identified as important, they are frequently not measured in clinical trials. Involving key stakeholders, like people with RA, is important when designing exercise interventions as it allows consideration of particular issues that may influence future intervention delivery. This study involved people with RA who participated in a pilot RCT group exercise class to improve sleep quality.

Objectives:

To explore participants experiences of an exercise intervention in improving sleep quality and TST, to capture their reality.

Methods:

A descriptive qualitative study design of face-to-face semi-structured interviews was employed. The interview schedule explored a number of areas: experience of the intervention; outcome measures used; views regarding the intervention; perceptions regarding exercise and sleep and the impact on sleep. Interviews were transcribed verbatim by a professional transcriber. Inductive thematic analysis was used as an analytical approach. Interview transcripts were read, notes made, and ideas formulated to facilitate coding. The research team searched for patterns, analysed and coded the data, and generated themes and sub-themes. Themes were reviewed by the research team to check if they worked in relation to the coded extracts and the entire data set. The COREQ checklist provided guidance.

Results:

Twelve females participated with a mean age of 58 (SD 7.4); mean RA diagnosis of 9.9 (SD 7.4) years; moderate to severe disability (HAQ-DI: 1.5 (SD 0.60). Four main themes were generated: 1) Positive impact of exercise on sleep -“I really didn’t think any type of exercise would help me sleep better if I’m honest.”;2) Positive experiences of exercise intervention to improve sleep-“I learnt so much regarding walking that I didn’t even think about.”;3) Clear mental health benefits –“If you don’t sleep well then it will have a knock-on effect to your mental health”; 4) Achieving empowerment and ownership when exercising -“I feel empowered now and confident that I’m not doing harm to myself”.The findings demonstrated that participants were clearly surprised that exercise could improve sleep.

Conclusion:

In a variety of inflammatory conditions exercise is recommended as an effective intervention for the treatment of sleeping disorders. Although there is a growing consensus that exercise will benefit sleep, research is severely lacking in those with RA. This study demonstrates that participants were clearly surprised that exercise could improve their sleep. Due to the multifactorial nature of RA, engaging in exercise may not only improve sleep quality but also mitigate some of its symptoms.

References:

[1]Kirwan JR, Boonen A, Harrison MJ, Hewlett SE, et al (2011) OMERACT 10 Patient Perspective Virtual Campus: Valuing health; measuring outcomes in rheumatoid arthritis fatigue, RA sleep, arthroplasty, and systemic sclerosis; and clinical significance of changes in health. The Journal of Rheumatology;38:1728–34.

Disclosure of Interests:

None declared

Cognitive behavioural therapy for insomnia in patients with rheumatoid arthritis: protocol for the randomised, single-blinded, parallel-group Sleep-RA trial

BACKGROUND

More than half of patients with rheumatoid arthritis complain of insomnia, which is predominantly treated with hypnotic drugs. However, cognitive behavioural therapy for insomnia is recommended as the first-line treatment in international guidelines on sleep. Patients with rheumatoid arthritis suffer from debilitating symptoms, such as fatigue and pain, which can also be linked to sleep disturbance. It remains to be determined whether cognitive behavioural therapy for insomnia can be effective in patients with rheumatoid arthritis. The aim of the Sleep-RA trial is to investigate the efficacy of cognitive behavioural therapy for insomnia on sleep and disease-related symptoms in patients with rheumatoid arthritis. The primary objective is to compare the effect of cognitive behavioural therapy for insomnia relative to usual care on changes in sleep efficiency from baseline to week 7 in patients with rheumatoid arthritis. The key secondary objectives are to compare the effect of cognitive behavioural therapy for insomnia relative to usual care on changes in sleep onset latency, wake after sleep onset, total sleep time, insomnia, sleep quality, fatigue, impact of rheumatoid arthritis and depressive symptoms from baseline to week 26 in patients with rheumatoid arthritis.

METHODS

The Sleep-RA trial is a randomised controlled trial with a two-group parallel design. Sixty patients with rheumatoid arthritis, insomnia and low-to-moderate disease activity will be allocated 1:1 to treatment with cognitive behavioural therapy for insomnia or usual care. Patients in the intervention group will receive nurse-led, group-based cognitive behavioural therapy for insomnia once a week for 6 weeks. Outcome assessments will be carried out at baseline, after treatment (week 7) and at follow-up (week 26).

DISCUSSION

Data on treatment of insomnia in patients with rheumatoid arthritis are sparse. The Sleep-RA trial is the first randomised controlled trial to investigate the efficacy of cognitive behavioural therapy for insomnia in patients with rheumatoid arthritis. Because symptoms of rheumatoid arthritis and insomnia have many similarities, we also find it relevant to investigate the secondary effects of cognitive behavioural therapy for insomnia on fatigue, impact of rheumatoid arthritis, depressive symptoms, pain, functional status, health-related quality of life and disease activity. If we find cognitive behavioural therapy for insomnia to be effective in patients with rheumatoid arthritis this will add weight to the argument that evidence-based non-pharmacological treatment for insomnia in rheumatological outpatient clinics is eligible in accordance with the existing international guidelines on sleep.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03766100. Registered on 30 November 2018.

Nursing staffs self-perceived outcome from a rehabilitation 24/7 educational programme - a mixed-methods study in stroke care

Background

During the past two decades, attempts have been made to describe nurses’ contributions to the rehabilitation of inpatients following stroke. There is currently a lack of interventions that integrate the diversity of nurses’ role and functions in stroke rehabilitation and explore their effect on patient outcomes. Using a systematic evidence- and theory-based design, we developed an educational programme, Rehabilitation 24/7, for nursing staff working in stroke rehabilitation aiming at two target behaviours; working systematically with a rehabilitative approach in all aspects of patient care and working deliberately and systematically with patients’ goals. The aim of this study was to assess nursing staff members’ self-perceived outcome related to their capability, opportunity and motivation to work with a rehabilitative approach after participating in the stroke Rehabilitation 24/7 educational programme.

Methods

A convergent mixed-method design was applied consisting of a survey and semi-structured interviews. Data collection was undertaken between February and June 2016. Data from the questionnaires (N = 33) distributed before and after the intervention were analysed using descriptive statistics and Wilcoxon sign rank test. The interviews (N = 10) were analysed using deductive content analysis. After analysing questionnaires and interviews separately, the results were merged in a side by side comparison presented in the discussion.

Results

The results from both the quantitative and qualitative analyses indicate that the educational programme shaped the target behaviours that we aimed to change by addressing the nursing staff’s capability, opportunity and motivation and hence could strengthen the nursing staff’s contribution to inpatient stroke rehabilitation. A number of behaviours changed significantly, and the qualitative results indicated that the staff experienced increased focus on their role and functions in rehabilitation practice.

Conclusion

Our study provides an understanding of the outcome of the Rehabilitation 24/7 educational programme on nursing staff’s behaviours. A mixed-methods approach provided extended knowledge of the changes in the nursing staff members’ self-percived behaviours after the intervention. These changes suggest that educating the nursing staff on rehabilitation using the Rehabilitation 24/7 programme strengthened their knowledge and beliefs about rehabilitation, goal-setting as well as their role and functions.

Motivational counselling and SMS-reminders for reduction of daily sitting time in patients with rheumatoid arthritis: a descriptive randomised controlled feasibility study

Background

Patients with rheumatoid arthritis (RA) spend a high proportion of their waking time in sedentary behaviour (SB) and have an increased risk of cardiovascular disease. Reduction of SB and increase in light intensity physical activity has been suggested as a means of improvement of health in patients with mobility problems. Short-term intervention studies have demonstrated that SB can be reduced by behavioural interventions in sedentary populations. To evaluate descriptively the feasibility of recruitment, randomisation, outcome assessments, retention and the acceptability of an individually tailored, theory-based behavioural intervention targeting reduction in daily sitting time in patients with RA.

Methods

A randomised, controlled trial with two parallel groups. RA patients >18 years of age and Health Assessment Questionnaire (HAQ) score < 2.5 were consecutively invited and screened for daily leisure time sitting > 4 h. The 16-week intervention included 1) three individual motivational counselling sessions and 2) individual text message reminders aimed at reducing daily sitting time. The control group was encouraged to maintain their usual lifestyles. Outcomes were assessed at baseline and after the 16 week intervention. Daily sitting time was measured using an ActivPAL3^TM activity monitor. The study was not powered to show superiority; rather the objective was to focus on acceptability among patients and clinical health professionals.

Results

In total, 107 patients were invited and screened before 20 met eligibility criteria and consented; reasons for declining study participation were mostly flares, lack of time and co-morbidities. One patient from the control group dropped out before end of intervention (due to a RA flare). Intervention participants completed all counselling sessions. All procedures regarding implementation of the trial protocol were feasible. The daily sitting time was reduced on average by 0.30 h in the intervention group unlike the control group that tended to increase it by 0.15 h after 16 weeks.

Conclusions

This study shows that an individually tailored behavioural intervention targeting reduction of SB was feasible and acceptable to patients with RA.

Trial registration

The Danish Data Protection Agency (ref.nb. 711-1-08 - 20 March 2011), the Ethics Committee of the Capital Region of Denmark (ref.nb. H-2-2012-112- 17 October 2012), clinicaltrials.gov (NCT01969604 - October 17 2013, retrospectively registered).

Physical activity maintenance in patients with rheumatoid arthritis: a qualitative study

Objective:

To describe the experience of physical activity maintenance in patients with rheumatoid arthritis.

Design:

A qualitative salutogenic-oriented interview study.

Setting:

A rheumatology outpatient clinic.

Subjects:

A purposive sample of 16 physically active patients (mean age 50, range 37–67) diagnosed with rheumatoid arthritis on average 21 years previously (range 4–46 years).

Methods:

In-depth interviews were conducted using a semi-structured interview guide to illuminate how the phenomenon ‘physical activity maintenance’ was experienced by patients with rheumatoid arthritis. The interviews were analysed using systematic text condensation, inspired by Giorgi’s descriptive phenomenological methodology.

Results:

The analysis revealed three categories: (1) knowing and enjoying the body; (2) responsibility and challenges; (3) autonomy and social belonging. On the basis of these categories, the essential meaning of the phenomenon of physical activity maintenance for patients with rheumatoid arthritis was summarized into ‘striving for a transparent body and participation’, pointing to experiences of sensations of wellbeing, liberation from restrictions and social participation on equal terms with non-arthritis populations.

Conclusion:

This study demonstrates that physical activity in patients with rheumatoid arthritis may be understood as a resource to resist disability and to feel and stay healthy while creating and sustaining meaningfulness in life.

The meaning of having to live with cancer in old age

Little is known about how older people with cancer experience their life situation. To increase the understanding of how illness is experienced in older people with cancer, the aim of this study was to investigate the meaning of living with cancer in old age. The hermeneutic phenomenological method as described by van Manen and referred to as 'phenomenology of praxis' was used. Ten persons (seven women and three men) aged 75 and over, who had a diagnosis of cancer and who had just completed cancer treatment, were interviewed in their own homes. The analysis revealed a life world affected to varying degrees by the cancer disease. The lived experiences across the interviews were revealed in four overarching essential themes: transition into a more or less disintegrated existence, sudden awareness of the finiteness of life, redefinition of one's role in life for good and for bad, meeting disease and illness. To provide individual support and appropriate care to older people with cancer it is important for health care professionals to identify and take care of disabilities and to support the reorientation in the disintegrated life situation. It is also important to have preparedness to meet the old person's thoughts about death. Thus, it is important to encourage the old person to describe her/his illness experience to increase understanding about what is meaningful for her/him.

Quality of life of elderly persons with newly diagnosed cancer

The aim was to investigate quality of life (QoL) in elderly persons newly diagnosed with cancer (65+ years) in relation to age, contact with the health-care system, ability to perform activities of daily living (ADL), hope, social network and support, and to identify which factors were associated with low QoL. The sample consisted of 101 patients (75 women and 26 men) newly diagnosed with cancer. EORTC QLQ-C30, Nowotny's Hope Scale, Katz ADL and the Interview Schedule for Social Interaction (ISSI) were used. The analysis was carried out in four age groups and revealed no significant differences in QoL. Compared with the other age groups, those of a high age (80+ years) more often lived alone, used more home-help service and had a smaller social network. Factors associated with low QoL were 'no other incomes than retirement pension', 'low level of hope' and 'lung cancer'. In addition, 'being told that the cancer disease has not come to an end', 'needing more help in activities of daily living', 'getting help from grown-up children' and 'needing help with PADL' were associated with low QoL. Those at risk of inferior QoL, that is, having poor economy, low level of hope and lung cancer need special attendance and specific interventions to improve QoL.