Validation of a new glucocorticoid-specific Patient-Reported Outcome Questionnaire (the Steroid PRO)

OBJECTIVES

Glucocorticoids used in the treatment of inflammatory rheumatic conditions can impact on health-related quality of life. An underpinning qualitative study developed a long-list of candidate items for a treatment-specific patient-reported outcome (PRO) measure. The objective of this paper is to determine scale structure and psychometric properties of the Steroid PRO.

METHODS

A cross-sectional survey of adults from the UK, USA, Australia and New Zealand, taking glucocorticoids for a rheumatic disease. Initial survey collected demographics, clinical information, 40 Steroid PRO candidate items and EuroQol-5 Dimensions- 5 levels (EQ-5D-5L). Follow-up, 3-5 days later, collected Steroid PRO candidate items and a condition-change ('transition') question. Analysis included Rasch measurement model, exploratory factor analysis (EFA), and hypothesis testing for discriminative validity, convergence validity and test-retest reliability.

RESULTS

Total responses 946: UK n=743 (79%); USA n=139 (15%); Australia/New Zealand n=64 (7%); mean age 57.6 (SD=13.6); 833 (88%) women. Participants with inflammatory arthritis n=197 (21%), connective tissue disease and/or vasculitis n=402 (42%), giant cell arteritis and/or polymyalgia rheumatica n=347 (37%). Twenty-five items were removed due to lack of fit to Rasch model. Of the remaining items, EFA suggested four subscales: Social impact (4 items); Impact on appearance (3 items); Psychological impact (5 items); Treatment concerns (3 items). Rasch modelling supported a four-subscale structure and total score, confirming construct validity and reliability. Hypothesis testing confirmed discriminant and convergence validity. Intraclass correlation coefficient (total score) was 0.809 demonstrating excellent (test-retest) reliability.

CONCLUSIONS

The Steroid PRO is a 15-item, valid and reliable scale for measuring the impact of glucocorticoid therapy in people with rheumatic diseases.

Validation of a patient-reported outcome measure for giant cell arteritis

OBJECTIVES

GCA is systemic vasculitis manifesting as cranial, ocular or large vessel vasculitis. A prior qualitative study developed 40 candidate items to assess the impact of GCA on health-related quality of life (HRQoL). This study aimed to determine final scale structure and measurement properties of the GCA patient reported outcome (GCA-PRO) measure.

METHODS

Cross-sectional study included UK patients with clinician-confirmed GCA. They completed 40 candidate items for the GCA-PRO at times 1 and 2 (3 days apart), EQ-5D-5L, ICECAP-A, CAT-PROM5 and self-report of disease activity. Rasch and exploratory factor analyses informed item reduction and established structural validity, reliability and unidimensionality of the final GCA-PRO. Evidence of validity was also established with hypothesis testing (GCA-PRO vs other PRO scores, and between participants with 'active disease' vs those 'in remission') and test-retest reliability.

RESULTS

The study population consisted of 428 patients: mean (s.d.) age 74.2 (7.2), 285 (67%) female; 327 (76%) cranial GCA, 114 (26.6%) large vessel vasculitis and 142 (33.2%) ocular involvement. Rasch analysis eliminated 10 candidate GCA items and informed restructuring of response categories into four-point Likert scales. Factor analysis confirmed four domains: acute symptoms (eight items), activities of daily living (seven items), psychological (seven items) and participation (eight items). The overall scale had adequate Rasch model fit (χ2 = 25.219, degrees of freedom = 24, P = 0.394). Convergent validity with EQ5D-5L, ICECAP-A and Cat-PROM5 was confirmed through hypothesis testing. Internal consistency and test-retest reliability were excellent.

CONCLUSION

The final GCA-PRO is a 30-item, four-domain scale with robust evidence of validity and reliability in measuring HRQoL in people with GCA.

Measuring the impact of steroid therapy on health-related quality of life in patients with rheumatic diseases: international development of a glucocorticoid treatment-specific patient-reported outcome measure

OBJECTIVES

Glucocorticoids (GCs) ('steroids') are used to treat rheumatic diseases but adverse effects are common. We aimed to explore the impact of GC therapy on health-related quality of life (HRQoL), to inform the development of a treatment-specific patient-reported outcome measure (PROM) for use in clinical trials and practice.

METHODS

Semi-structured qualitative interviews were conducted with patients from the UK, USA and Australia, treated for a rheumatic condition with GCs in the last 2 years. Purposive sampling was used to select participants with a range of demographic and disease features. An initial conceptual framework informed interview prompts and cues. Interviews elicited GC-related physical and psychological symptoms and salient aspects of HRQoL in relation to GC therapy. Interview data were analysed inductively to develop initial individual themes and domains. Candidate questionnaire items were developed and refined.

RESULTS

Sixty semi-structured qualitative interviews were conducted (UK n = 34, USA n = 10, Australia n = 16). The mean age was 58 years; 39/60 were female; and 18 rheumatic diseases were represented. Some 126 individual themes were identified and organized into six domains: physical symptoms; psychological symptoms; psychological impact of steroids; impact of steroids on participation; impact of steroids on relationships; and benefits of steroids. Candidate questionnaire items were tested and refined by piloting with patient research partners, iterative rounds of cognitive interviews and linguistic translatability assessment, informing a draft questionnaire.

CONCLUSION

We describe an international qualitative study to develop candidate items for a treatment-specific PROM for patients with rheumatic diseases. A future survey will enable the validation of a final version of the PROM.

Outcomes in Ankle Replacement Study (OARS)

Aims

The aim of this study was to capture 12-month outcomes from a representative multicentre cohort of patients undergoing total ankle arthroplasty (TAA), describe the pattern of patient-reported outcome measures (PROMs) at 12 months, and identify predictors of these outcome measures.

Methods

Patients listed for a primary TAA at 19 NHS hospitals between February 2016 and October 2017 were eligible. PROMs data were collected preoperatively and at six and 12 months including: Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ (foot and ankle)) and the EuroQol five-dimension five-level questionnaire (EQ-5D-5L). Radiological pre- and postoperative data included Kellgren-Lawrence score and implant position measurement. This was supplemented by data from the National Joint Registry through record linkage to determine: American Society of Anesthesiologists (ASA) grade at index procedure; indication for surgery, index ankle previous fracture; tibial hind foot alignment; additional surgery at the time of TAA; and implant type. Multivariate regression models assessed outcomes, and the relationship between MOXFQ and EQ-5D-5L outcomes, with patient characteristics.

Results

Data from 238 patients were analyzed. There were significant improvements in MOXFQ and EQ-5D-5L among people who underwent TAA at six- and 12-month assessments compared with preoperative scores (p < 0.001). Most improvement occurred between preoperative and six months, with little further improvement at 12 months. A greater improvement in MOXFQ outcome postoperatively was associated with older age and more advanced radiological signs of ankle osteoarthritis at baseline.

Conclusion

TAA significantly benefits patients with end-stage ankle disease. The lack of substantial further overall change between six and 12 months suggests that capturing PROMs at six months is sufficient to assess the success of the procedure. Older patients and those with advanced radiological disease had the greater gains. These outcome predictors can be used to counsel younger patients and those with earlier ankle disease on the expectations of TAA.

Computerized adaptive testing for the Oxford Hip, Knee, Shoulder, and Elbow scores : accurate measurement from fewer, and more patient-focused, questions

AIMS

The aim of this study was to develop and evaluate machine-learning-based computerized adaptive tests (CATs) for the Oxford Hip Score (OHS), Oxford Knee Score (OKS), Oxford Shoulder Score (OSS), and the Oxford Elbow Score (OES) and its subscales.

METHODS

We developed CAT algorithms for the OHS, OKS, OSS, overall OES, and each of the OES subscales, using responses to the full-length questionnaires and a machine-learning technique called regression tree learning. The algorithms were evaluated through a series of simulation studies, in which they aimed to predict respondents' full-length questionnaire scores from only a selection of their item responses. In each case, the total number of items used by the CAT algorithm was recorded and CAT scores were compared to full-length questionnaire scores by mean, SD, score distribution plots, Pearson's correlation coefficient, intraclass correlation (ICC), and the Bland-Altman method. Differences between CAT scores and full-length questionnaire scores were contextualized through comparison to the instruments' minimal clinically important difference (MCID).

RESULTS

The CAT algorithms accurately estimated 12-item questionnaire scores from between four and nine items. Scores followed a very similar distribution between CAT and full-length assessments, with the mean score difference ranging from 0.03 to 0.26 out of 48 points. Pearson's correlation coefficient and ICC were 0.98 for each 12-item scale and 0.95 or higher for the OES subscales. In over 95% of cases, a patient's CAT score was within five points of the full-length questionnaire score for each 12-item questionnaire.

CONCLUSION

Oxford Hip Score, Oxford Knee Score, Oxford Shoulder Score, and Oxford Elbow Score (including separate subscale scores) CATs all markedly reduce the burden of items to be completed without sacrificing score accuracy.Cite this article: Bone Jt Open 2022;3(10):786-794.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

POS0003 DEVELOPMENT AND VALIDATION OF A DISEASE SPECIFIC PATIENT REPORTED OUTCOME FOR GIANT CELL ARTERITIS

Background

Giant cell arteritis (GCA) is caused by inflammation of the blood vessels of the head and neck; patients can present with cranial, ocular or large vessel vasculitis involvement. Treatment is with glucocorticoids, steroid sparing agents and biologics to control inflammation and protect sight.

Objectives

The aim of this study was to produce a validated disease specific PROM for patients with GCA, to capture the impact of GCA and its treatment on health-related quality of life.

Methods

Patients with clinician- confirmed GCA from the UK, either diagnosed in the last three years or with a flare in the last year, were included in the survey. A longlist of 40 candidate questionnaire items, each with a 5-point Likert scale, had previously been developed, based on a qualitative study with patients from the UK and Australia [1]. In this cross-sectional survey, patients completed the 40-item draft GCA-PROM alongside EQ5D-5L, CAT-PRO5 and self-report of GCA disease activity. Rasch and factor analysis were used in an iterative manner to determine the underlying construct validity of the new PROM. Items were fitted to the Rasch model to determine its construct validity, reliability, unidimensionality and statistical sufficiency of the total score from the scale. Factor analysis was used to establishing factor structure. Item reduction decisions were be based on clinical importance, lack of fit to the Rasch model, and redundancy detected during principal component analysis. External validity was tested by comparing the scores of the newly validated GCA-PROM (i) in participants who self-identify as having ‘active disease’ versus patients ‘in remission’ (known groups validity) (ii) with scores derived from EQ5D-5L and CAT-PRO5 (convergent validity).

Results

The survey included 428 patients; 327 (76%) cranial GCA, 114 (26.6%) large vessel vasculitis and 142 (33.2%) ocular involvement. 285 (67%) of participants were female with a mean age (SD) of 74.2 (7.2). 167 (39%) temporal artery biopsies and 177 (41.4%) temporal artery ultrasounds, and 51 (11.9%) Positron Emission Tomography and Computed Tomography (PET-CT)s were reported as positive. 108 (25%) received second-line immunosuppressants, and 34 (7.9%) anti-IL6 therapy. Active disease was reported in 197 (46%). Four factors (domains) were identified after deletion of 10 redundant items: Acute symptoms (8 items), Activities of daily living (7 items), Psychological (7 items) and Participation (8 items). The four domains were analysed as ‘super-items’ and shown to fit the Rasch model. The overall scale had an adequate fit to the Rasch model: X2 = 25.219, DF=24, p=0.394 including reliability PSI=0.828. The raw-to-linear transformation scale was calibrated to enable parametric analyses if desired. Each domain was shown to have known-groups validity (p<0.001 patients reporting active versus inactive disease) and correlation with EQ5D-5L and CAT-PRO5 (Rs) ranging between 0.4.42 and 0.778.

Conclusion

The GCA-PROM is a new patient reported outcome measure for patients with GCA which demonstrates good internal and external validity.

References

[1]Robson JC, Almeida C, Dawson J, Bromhead A, Dures E, Guly C, Hoon E, Mackie S, Ndosi M, Pauling J, Hill C. Patient perceptions of health-related quality of life in giant cell arteritis; international development of a disease-specific Patient-Reported Outcome Measure. Rheumatology (Oxford). 2021:keab076. http://dx.doi.org/10.1093/rheumatology/keab076

Disclosure of Interests

Joanna Robson Speakers bureau: Vifor Pharma EULAR 2021 Symposium, Consultant of: Vifor Pharma Advisory board 2021, Grant/research support from: Vifor Pharma Steroid PRO grant, Celia Almeida: None declared, Jill Dawson: None declared, Emma Dures: None declared, Rosemary Greenwood: None declared, Catherine Guly: None declared, Sarah Mackie Speakers bureau: Roche/Chugai Educational talk on GCA., Consultant of: Roche/Chugai

Sanofi

Abbvie (2021-)

AstraZeneca (2021-), Grant/research support from: Vifor Pharma Steroid PRO 2020

Vifor Pharma GTI Validation 2020

Roche GCA Tocilizumab Registry 2019

, Alison Bromhead: None declared, Steve Stern: None declared, Mwidimi Ndosi: None declared

POS0040-HPR PATIENT PERCEPTIONS OF IMPACT OF GLUCOCORTICOID THERAPY IN THE RHEUMATIC DISEASES: INTERNATIONAL DEVELOPMENT OF A TREATMENT-SPECIFIC PATIENT REPORTED OUTCOME MEASURE

Background

Glucocorticoids (GCs) are a key treatment for inflammatory rheumatic diseases, but they cause a wide range of adverse side-effects which are of concern both to patients and clinicians.

Objectives

The objective of this study was to explore the impact of GC therapy on health-related quality of life (HRQoL) during treatment for rheumatic diseases, as a basis for development of a Patient-Reported Outcome Measure (PROM) to be used in clinical trials and practice.

Methods

Patients from the UK, USA and Australia who were treated with GCs in the last two years for a rheumatic condition were invited to take part in semi-structured qualitative interviews. Purposive sampling was used to include participants with a range of demographic and disease features. A steering committee of patient research partners, clinicians and methodologists devised an initial conceptual framework, which informed interview prompts and cues. Interviews were carried out by experienced qualitative researchers who encouraged participants to tell their stories and talk about the effects, both adverse and beneficial, of their experiences and perceptions of treatment with GCs, to identify salient physical and psychological symptoms and aspects of HRQoL. The interview data were organised using NVivo, and inductive analysis identified initial themes and domains. Candidate questionnaire items were developed and refined using cognitive interviewing, linguistic assessment, and input from patient research partners.

Results

Sixty semi-structured qualitative interviews were conducted (UK n=34, USA n=10, Australia n=16). Mean participant age was 58 years; 39 (66.1%) were female. Purposive sampling of participants provided a broad range of demographic features, GC dosages and inflammatory rheumatic conditions, with 27% having connective tissue disease, 25% inflammatory arthritis, 30% systemic vasculitis and 16% other rheumatic conditions.

Initial domains were developed to identify key themes relating to treatment using GCs and their impact on HRQoL; see Figure 1.

Figure 1.

Steroid PRO Initial Themes

A long-list of 134 initial candidate questionnaire items was developed from the individual themes. These items were reviewed by a qualitative working group of patient research partners, researchers and clinicians to reduce duplication and ambiguity of items. The resulting 62 items were tested and refined by piloting with patient research partners, iterative rounds of cognitive interviews with patients with a range of rheumatic conditions from the UK, USA and Australia, and a linguistic translatability assessment, to define a draft questionnaire of 40 items.

Conclusion

This international qualitative study underpins the development of candidate items for a treatment-specific PROM for patients with rheumatic diseases. The draft questionnaire is currently being tested in an online large-scale survey to determine the final scale structure and measurement properties using Rasch analysis, factor analysis, test-retest, comparison with EQ5D, and known groups analysis.

Disclosure of Interests

Susan Bridgewater Grant/research support from: Vifor Pharma, Michael A Shepherd Grant/research support from: Vifor Pharma, Jill Dawson: None declared, Pamela Richards: None declared, Christine Silverthorne: None declared, Mwidimi Ndosi: None declared, Celia Almeida: None declared, Rachel J Black: None declared, Jonathan T.L. Cheah: None declared, Emma Dures: None declared, Nilasha Ghosh: None declared, Elizabeth A Hoon: None declared, Suellen Lyne: None declared, Iris Navarro-Millan Consultant of: Honorarium on Swedish Orpham Biovitrum (SOBI) advisory board 2021, Diyu Pearce-Fisher: None declared, Carlee Ruediger: None declared, Joanna Tieu: None declared, Kevin Yip: None declared, Sarah Mackie: None declared, Susan Goodman: None declared, Catherine Hill: None declared, Joanna Robson Speakers bureau: EULAR Symposium 2021 for Vifor Pharma, Consultant of: Honorarium for Vifor Pharma advisory board 2021, Grant/research support from: Vifor Pharma 2020-2022

P092 Patients’ perceptions of glucocorticoid therapy impact on health-related quality of life during treatment for rheumatic diseases: international development of a treatment-specific patient-reported outcome measure (the Steroid PRO)

Background/Aims

Glucocorticoids (GCs) are widely used to treat inflammatory rheumatic diseases. GCs carry a range of adverse effects of concern to patients and clinicians. The objective of this study was to explore the impact of GC therapy on health-related quality of life (HRQoL) during treatment for rheumatic diseases, as a basis for development of a patient-reported outcome measure (PROM) to be used in clinical trials and practice.

Methods

Patients from the UK, USA and Australia who were treated with GCs in the last two years for a rheumatic condition were invited to take part in semi-structured qualitative interviews. A steering committee of patient research partners, clinicians and methodologists devised an initial conceptual framework, which informed interview prompts and cues. Interviews identified physical and psychological symptoms and salient aspects of HRQoL in relation to treatment with GCs. Purposive sampling was used to include a range of demographic and disease features. The interview data were organised using NVivo, and inductive analysis identified initial themes and domains. Candidate questionnaire items were developed and refined using cognitive interviewing, linguistic assessment, and input from patient research partners.

Results

Sixty semi-structured qualitative interviews were conducted (UK n = 34, USA n = 10, Australia n = 16). Mean participant age was 58 years; 39 (66.1%) were female. Detailed demographic and GC use information is provided in Table 1.

The following initial domains were developed to identify key themes relating to treatment using GCs and their impact on HRQoL: benefits of steroids; physical symptoms; psychological symptoms; psychological impact of steroids; impact of steroids on participation and on relationships.

Forty-one candidate questionnaire items were developed from the individual themes. These were tested and refined by piloting with patient research partners, iterative rounds of cognitive interviews with patients with a range of rheumatic conditions from the UK, USA and Australia, and a linguistic translatability assessment, to define a draft questionnaire.

Conclusion

This international qualitative study underpins the development of candidate items for a treatment-specific PROM for patients with rheumatic diseases. The draft questionnaire is now ready for testing in an online large-scale survey to determine the final scale structure, possible item reduction, and measurement properties.

Disclosure

S. Bridgewater: None. M.A. Shepherd: None. J. Dawson: None. P. Richards: None. C. Silverthorne: None. M. Ndosi: None. C. Almeida: None. R.J. Black: None. J.T.L. Cheah: None. E. Dures: None. N. Ghosh: None. E.A. Hoon: None. S. Lyne: None. I. Navarro-Millan: None. D. Pearce-Fisher: None. C. Ruediger: None. J. Tieu: None. K. Yip: None. S. Mackie: None. S. Goodman: None. C. Hill: None. J.C. Robson: None.

P301 Patient reported outcome measure for giant cell arteritis: clinical testing

Background/Aims

Giant cell arteritis (GCA) presents in people over 50, with headaches, visual involvement and large vessel vasculitis. A 30-item GCA-specific patient reported outcome measure (GCA PRO) was developed and tested in a clinical setting to pilot its feasibility and acceptability to patients and clinicians as a communication tool.

Methods

Patients seen in rheumatology or ophthalmology departments in Bristol and Leeds completed the GCA PRO prior to their consultation. Items referred to patients’ health-related quality of life over the past 7 days. Clinicians were given a copy of patients’ responses and a summary sheet highlighting overall scores which they referred to during the consultation. After the appointment, patients and clinicians completed short answer questionnaire (SAQ) plus free-text feedback forms reporting on the experience of use of the GCA PRO within the consultation.

Results

The GCA PRO was piloted during 16 clinic appointments. 16 patients, mean age (SD) of 74.7 (7.0), 11 (68.8%) female, 7 (43.8%) active disease and 5 (31.3%) with ocular involvement took part. Seven clinicians participated - 5 rheumatologists and 2 ophthalmologists. 87% percent of patients agreed that the GCA PRO had helped them to explain their condition; clinicians agreed that the GCA PRO had helped them to understand the patient’s condition 88% of the time (Table 1). Clinicians noted that “it was easier for the patient to convey his anxiety and feelings towards the disease and treatment” and that the GCA PRO “indirectly helped via prompting discussion of patient’s anxieties and worries”. However, they were more equivocal on its impact on decision making: “management plan was informed by symptoms, bloods and stage of illness”. Patients commented that “it helped us to plan how to manage my GCA based on my answers”, and that “the questions seemed relevant and it was helpful to me to be able to think about them before the appointment”.

Conclusion

The GCA-PRO was found to be an acceptable tool for use in clinic by patients and clinicians, especially in terms of explaining and understanding the patient’s condition.

Disclosure

C. Almeida: None. C. Guly: None. S. Mackie: Honoraria; Sept 2021: Roche/Chugai payment to my institution for delivering a talk on giant cell arteritis at an educational day. Grants/research support; MRC Confidence in Concept scheme, 2021 to develop early diagnosis methods for giant cell arteritis, 2018: MRC Proximity to Discovery: Protein biomarkers for polymyalgia rheumatica and giant cell arteritis. (PI: Morgan, University of Leeds), 2019: Roche: giant cell arteritis tocilizumab registry (PI: Morgan, University of Leeds). Other; Site Sub-Investigator on clinical trial in giant cell arteritis for Roche, Site Principal Investigator on clinical trial in giant cell arteritis for GSK, Site Principal Investigator and UK Chief Investigator on clinical trials (giant cell arteritis and polymyalgia rheumatica) for Sanofi. A. Bromhead: None. S. Stern: None. E. Dures: None. J. Dawson: None. M. Ndosi: None. R. Greenwood: None. J.C. Robson: None.

OA23 Patient-reported outcome measure for giant cell arteritis: cross-sectional validation study

Background/Aims

Giant cell arteritis (GCA) presents in people over the age of 50 with cranial, ocular, and large vessel vasculitis. This study aims to validate a disease-specific patient-reported outcome measure (PROM) for patients with GCA, to capture the impact of GCA and its treatment on health-related quality of life.

Methods

This cross-sectional study included UK patients with clinician-confirmed GCA; diagnosed within the last three years or flaring within the last year. Patients completed the 40 candidate PROM items, the EQ5D-5L, CAT-PROM5 and self-report of disease activity. Rasch and factor analysis were used to determine internal validity and factor structure. Item reductions were based on clinical importance, Rasch model fit, and redundancy. Tests of validity included comparison of the GCA-PROM (i) in participants with ‘active disease’ versus patients ‘in remission’ (known groups validity) and (ii) with EQ5D-5L and CAT-PROM5 scores (convergent validity).

Results

The survey included 428 patients, mean age (SD) of 74.2 (7.2), 285 (67%) female. 327 (76%) cranial GCA, 114 (26.6%) large vessel vasculitis and 142 (33.2%) ocular involvement. Positive diagnostic tests included 167 (39%) temporal artery biopsy, 177 (41.4%) temporal artery ultrasound, and 51 (11.9%) Positron Emission Tomography and Computed Tomography (PET-CT). Active disease was reported in 197 (46%). After the initial analysis (40 items), ten items were deleted, and two response categories collapsed to ensure overall fit to the Rasch model. This resulted in a final PROM comprising a 30-item scale with a 4-response category structure. Factor analysis confirmed four factors (domains): Acute symptoms (8 items), Activities of daily living (7 items), Psychological (7 items) and Participation (8 items), all of which individually fitted the Rasch model (X2 = 25.219, DF = 24, p = 0.394 including reliability [Person Separation Index, PSI=0.828]), (construct validity). Each domain correlated, at least moderately, with EQ5D-5L and CAT-PROM5 scores (Spearman’s Correlation Coefficients 0.44 to 0.78) (convergent validity). The new GCA-PRO discriminated between patients with active disease and remission (known groups validity) (Table 1).

Conclusion

The 30-item GCA-PROM demonstrates internal and external validity in measuring health-related quality of life in people with GCA.

Disclosure

M. Ndosi: None. C. Almeida: None. J. Dawson: None. E. Dures: None. R. Greenwood: None. C. Guly: None. S. Mackie: Honoraria; Sept 2021: Roche/Chugai payment to my institution for delivering a talk on giant cell arteritis at an educational day. Grants/research support; MRC Confidence in Concept scheme, 2021 Grant to develop early diagnosis methods for giant cell arteritis, 2018: MRC Proximity to Discovery: Protein biomarkers for polymyalgia rheumatica and giant cell arteritis (PI: Morgan, University of Leeds), 2019: Roche: giant cell arteritis tocilizumab registry (PI: Morgan, University of Leeds). Other; Site Sub-Investigator on clinical trial in giant cell arteritis for Roche, Site Principal Investigator on clinical trial in giant cell arteritis for GSK, Site Principal Investigator and UK Chief Investigator on clinical trials (giant cell arteritis and polymyalgia rheumatica) for Sanofi. A. Bromhead: None. S. Stern: None. J.C. Robson: None.

440 Training in Microbiological Sampling for Toe Amputations in Diabetic Foot Disease: A Survey of UK Vascular Trainees

Aim

To determine usual practice and extent of training received by United Kingdom (UK) vascular surgery trainees in microbiological sampling for toe amputations in diabetic patients.

Method

A prospective online survey was distributed via social media networks and trainee organisations. All vascular surgery trainees in the UK were invited to participate. A total of 29 responses were included in the analysis.

Results

86% of respondents have been trained in toe amputations during registrar training. 66% have not been taught which samples to send for microbiological analysis. 10% receive regular training reviews in toe amputations. There is significant variability in the types of samples sent by trainees for microbiological analysis and the majority of trainees did not know how their samples are processed in the laboratory.

Conclusions

Toe amputations appear to be a neglected aspect of training for UK vascular surgery registrars. Lack of consistency in microbiological sampling techniques may prevent optimum antimicrobial stewardship and therefore increase the risk of further complications including major amputation. Inclusion of diabetic foot sepsis as a critical condition in the new vascular surgery curriculum may help to address this issue. A national consensus needs to be reached on how microbiological samples should be taken and processed in order for trainees to be taught in a consistent manner.

Patient perceptions of health-related quality of life in giant cell arteritis: international development of a disease-specific patient-reported outcome measure

Objectives

GCA is a large vessel vasculitis (LVV) presenting with headache, jaw claudication, musculoskeletal and visual involvement. Current treatment is glucocorticoids and anti-IL-6 tocilizumab in refractory disease. The objective of this study was to explore the impact of GCA and its treatment on people’s health-related quality of life (HRQoL), to inform the development of a disease-specific patient-reported outcome measure (PROM) for use in clinical trials and practice.

Methods

Participants from the UK and Australia, with biopsy- or imaging-confirmed GCA, were interviewed to identify salient aspects of HRQoL in relation to GCA and its treatment. Purposive sampling included a range of demographic and disease features (cranial, LVV-GCA and visual involvement). Inductive analysis identified individual themes of importance, then domains. Candidate questionnaire items were developed from the individual themes, refined by piloting, cognitive interviews and a linguistic translatability assessment.

Results

Thirty-six interviews were conducted to saturation with participants with GCA from the UK (25) and Australia (11). Mean age was 74 years, 23 (63.9%) were female, 13 (36.1%) had visual loss and 5 (13.9%) had LVV-GCA. Thirty-nine individual themes within five domains were identified: physical symptoms; activity of daily living and function; participation; psychological impact; and impact on sense of self and perception of health. Sixty-nine candidate items were developed from individual themes; piloting and refinement resulted in a 40-item draft questionnaire.

Conclusion

This international qualitative study underpins the development of candidate items for a disease-specific PROM for GCA. The draft questionnaire is now ready for psychometric testing.

AB0834 DEVELOPMENT OF A CONCEPTUAL FRAMEWORK FOR A PATIENT REPORTED OUTCOME MEASURE TO CAPTURE PATIENTS’ PERCEPTIONS OF GLUCOCORTICOID THERAPY DURING TREATMENT FOR RHEUMATIC DISEASES

Background:

Glucocorticoids (GCs) are a key treatment for the autoimmune rheumatic diseases; however, they produce numerous physical and psychological side effects.1 The Outcome Measures in Rheumatology (OMERACT) Glucocorticoid Working Group have identified that there are no Patient Reported Outcome Measures (PROMs) for assessing the impact of systemic GC therapy across multiple rheumatic diseases from the patient’s perspective.2,3

Objectives:

The aim is to explore the impact of GCs on the symptoms and health-related quality of life of adults with rheumatic inflammatory diseases, to inform items for inclusion in a PROM. Key considerations will include patient perceptions of GC therapy at diagnosis and over the course of treatment, for use in future randomised controlled trials or in clinical practice.

Methods:

An international steering committee comprising researchers, rheumatology clinicians, methodologists and patient partners in the UK, Australia and USA developed an initial conceptual framework informed by a review of the literature. Semi-structured interviews were conducted in each country with patients who had an autoimmune rheumatic disease and had received GC therapy. The interviews explored salient aspects of health-related quality of life associated with being treated with GCs.

Results:

Interviews have been completed in three continents with patients who had a range of demographic features, rheumatological conditions and duration and dosage of GC therapy. Figure 1 shows the initial conceptual framework for developing the GC PROM (Steroid PRO).

Figure 1.

Conclusion:

This conceptual framework will act as an evolving guide in the development of a PROM for assessing patients’ perspectives of systemic glucocorticoid therapy. Future work will include inductive analysis of qualitative transcripts to inform candidate questionnaire items, cognitive interviewing, linguistic translatability assessment, and an international validation survey to define the final PROM questionnaire and its measurement properties.

References:

[1]Cheah JTL, Robson JC, Black RJ, et al. The patient’s perspective of the adverse effects of glucocorticoid use: A systematic review of quantitative and qualitative studies. From an OMERACT working group. Semin Arthritis Rheum. 2020 Oct; 50(5):996-1005.

[2]Black RJ, Robson JC, Goodman SM, et al. A Patient-reported Outcome Measure for Effect of Glucocorticoid Therapy in Adults with Inflammatory Diseases Is Needed: Report from the OMERACT 2016 Special Interest Group. J Rheumatol. 2017; 44(11):1754-8.

[3]Cheah JTL, Black RJ, Robson JC, et al. Toward a Core Domain Set for Glucocorticoid Impact in Inflammatory Rheumatic Diseases: The OMERACT 2018 Glucocorticoid Impact Working Group. J Rheumatol. 2019; 46(9):1179-1182.

Disclosure of Interests:

Susan Bridgewater Grant/research support from: Grant from Vifor Pharma for an independent investigator-led study to develop a PRO for steroids, Jill Dawson: None declared, Mwidimi Ndosi: None declared, Rachel J Black: None declared, Jonathan T.L. Cheah: None declared, Emma Dures: None declared, Nilasha Ghosh: None declared, Elizabeth A Hoon: None declared, Iris Navarro-Millan Consultant of: Received consultant fees from SOBI, Diyu Pearce-Fisher: None declared, Pamela Richards: None declared, Carlee Ruediger: None declared, Christine Silverthorne: None declared, Joanna Tieu Grant/research support from: Vifor Pharma, Sarah Mackie Consultant of: Consultancy on behalf of institution for Roche/Chugai, Sanofi, AbbVie and AstraZeneca, Grant/research support from: Educational grant from Roche to attend EULAR2019, Susan Goodman: None declared, Catherine Hill: None declared, Joanna Robson Speakers bureau: Vifor Pharma for educational webinar, Grant/research support from: Grant from Vifor Pharma for an independent investigator-led study to develop a PRO for steroids

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

The Arthroplasty Candidacy Help Engine tool to select candidates for hip and knee replacement surgery: development and economic modelling

BACKGROUND

There is no good evidence to support the use of patient-reported outcome measures (PROMs) in setting preoperative thresholds for referral for hip and knee replacement surgery. Despite this, the practice is widespread in the NHS.

OBJECTIVES/RESEARCH QUESTIONS

Can clinical outcome tools be used to set thresholds for hip or knee replacement? What is the relationship between the choice of threshold and the cost-effectiveness of surgery?

METHODS

A systematic review identified PROMs used to assess patients undergoing hip/knee replacement. Their measurement properties were compared and supplemented by analysis of existing data sets. For each candidate score, we calculated the absolute threshold (a preoperative level above which there is no potential for improvement) and relative thresholds (preoperative levels above which individuals are less likely to improve than others). Owing to their measurement properties and the availability of data from their current widespread use in the NHS, the Oxford Knee Score (OKS) and Oxford Hip Score (OHS) were selected as the most appropriate scores to use in developing the Arthroplasty Candidacy Help Engine (ACHE) tool. The change in score and the probability of an improvement were then calculated and modelled using preoperative and postoperative OKS/OHSs and PROM scores, thereby creating the ACHE tool. Markov models were used to assess the cost-effectiveness of total hip/knee arthroplasty in the NHS for different preoperative values of OKS/OHSs over a 10-year period. The threshold values were used to model how the ACHE tool may change the number of referrals in a single UK musculoskeletal hub. A user group was established that included patients, members of the public and health-care representatives, to provide stakeholder feedback throughout the research process.

RESULTS

From a shortlist of four scores, the OHS and OKS were selected for the ACHE tool based on their measurement properties, calculated preoperative thresholds and cost-effectiveness data. The absolute threshold was 40 for the OHS and 41 for the OKS using the preferred improvement criterion. A range of relative thresholds were calculated based on the relationship between a patient's preoperative score and their probability of improving after surgery. For example, a preoperative OHS of 35 or an OKS of 30 translates to a 75% probability of achieving a good outcome from surgical intervention. The economic evaluation demonstrated that hip and knee arthroplasty cost of < £20,000 per quality-adjusted life-year for patients with any preoperative score below the absolute thresholds (40 for the OHS and 41 for the OKS). Arthroplasty was most cost-effective for patients with lower preoperative scores.

LIMITATIONS

The ACHE tool supports but does not replace the shared decision-making process required before an individual decides whether or not to undergo surgery.

CONCLUSION

The OHS and OKS can be used in the ACHE tool to assess an individual patient's suitability for hip/knee replacement surgery. The system enables evidence-based and informed threshold setting in accordance with local resources and policies. At a population level, both hip and knee arthroplasty are highly cost-effective right up to the absolute threshold for intervention. Our stakeholder user group felt that the ACHE tool was a useful evidence-based clinical tool to aid referrals and that it should be trialled in NHS clinical practice to establish its feasibility.

FUTURE WORK

Future work could include (1) a real-world study of the ACHE tool to determine its acceptability to patients and general practitioners and (2) a study of the role of the ACHE tool in supporting referral decisions.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Accelerating Rare Disease Drug Development: Lessons Learned from Muscular Dystrophy Patient Advocacy Groups

With scientific and molecular advancements related to disease pathogenesis, advances in gene and stem cell therapies, and the promise of lucrative markets for biopharmaceutical companies, there has been a rapid expansion in the number of potential new muscular dystrophy (MD) treatments. The first champion for a newly diagnosed MD patient and their caregivers is typically an MD-specific patient advocacy group (PAG). Muscular dystrophy PAGs have been among the most active in the rare disease drug development space. Notable achievements in the last decade include promulgating the first U.S. clinical research guidance, setting up registries and natural history studies, and investing in companies-some of which have brought potentially disease-modifying products to the market. This paper will discuss five key strategies that have been successfully employed by MD PAGs to advance treatments: (1) creating a national registry, (2) understanding the barriers to identifying patients with certain subtypes of muscular dystrophy to participate in clinical trials, (3) partnering with the biopharmaceutical industry, (4) collaborating with the regulators, and (5) incorporating market access and use insights early in clinical development. While clearly helpful within the MD community, these tactics could also be employed by PAGs representing other types of rare diseases.

Use of Big Data to Aid Patient Recruitment for Clinical Trials Involving Biosimilars and Rare Diseases

Patient recruitment and retention are arguably the greatest challenges to the timely execution of clinical trials. This is particularly true in the case of trials involving biosimilars and those focused on rare diseases. For biosimilars, recruitment success typically hinges on difficulty of access to reimbursement for the originator product and may be hindered by competition from studies with other biosimilars and those with new chemical entities. For rare diseases, recruitment success depends not only on finding enough patients but also on retaining them for the duration of the trial. Historical success with patient recruitment-in addition to site qualifications-needs to be considered in parallel with current market competition and results in an ever-changing patient recruitment environment. Multiple companies supporting the biopharmaceutical industry, such as Contract Research Organizations, have begun to leverage sophisticated data modeling tools and techniques to find additional patients for biosimilar and rare disease trials and/or to find patients more quickly. In addition, these companies seek to better understand the population of interest and refine their statistical assumptions when conducting clinical trials or real-world analyses. The largest and most well-established companies that support the biopharmaceutical industry now have unparalleled access to big data from clinical trials, electronic health records, medical claims, laboratory tests, and prescriptions. This paper will discuss how big data can be harnessed to aid patient recruitment with a focus on clinical trials for biosimilars and orphan rare diseases.

THU0542 THE IMPACT OF GLUCOCORTICOID INITIATION ON THE DIAGNOSTIC ACCURACY OF ULTRASOUND IN GIANT CELL ARTERITIS: EXPERIENCES FROM A DISTRICT GENERAL HOSPITAL IN THE UK

Background:

Temporal and axillary artery ultrasound (US) has been recommended by EULAR as the first-line investigation in patients with suspected giant cell arteritis (GCA).1US is reported as having a 77% sensitivity and 96% specificity for GCA.1However, these figures have largely been derived from studies carried out in specialist centres where US was performed rapidly following the onset of symptoms. When performed by highly experienced sonographers, halos can still be detected on US weeks after initiation of glucocorticoid treatment.2Little is known about the relationship between the dose and duration of glucocorticoid and diagnostic accuracy of US in real-world experience.

Objectives:

We evaluated the impact of glucocorticoid initiation on the diagnostic accuracy of US in patients with suspected GCA in routine clinical practice in a district general hospital.

Methods:

This is a single-centre retrospective study of all temporal and axillary artery US performed since its inception in November 2015 until October 2019. Patients who were aged ≥50 years and assessed by a rheumatologist were included in the study. US was performed by either a musculoskeletal consultant radiologist, musculoskeletal sonographer or vascular sonographer. US was considered positive for GCA when a halo, occlusion or stenosis was seen. Patients’ medical records and investigation results were reviewed in a systematic manner. The reference standard for GCA was the final clinical diagnosis after a minimum of 3-month rheumatology follow up.

Results:

311 US performed on 305 patients were included. 62% of the scans were requested by rheumatologists, the rest by ophthalmologists and general physicians. 57 of these episodes had a final clinical diagnosis of GCA. US had an overall sensitivity of 39% and specificity of 100% for GCA. Overall positive and negative predictive values were 100% and 88%, respectively. Sensitivity was 31% for US done in the first 2 years (n=160) which was lower than sensitivity of 45% in the latter 2 years (n=151) (p=0.2663). Specificity remained the same in the two periods. When performed on patients who were not on any glucocorticoids, US had a sensitivity of 89% which was significantly higher than sensitivity of 29% in those who had been treated with any dose or duration of steroids (p=0.0007).

Compared to US-negative GCA patients, US-positive GCA patients are older and more likely to have jaw claudication (Table 1).

Table.

Characteristics of patients with a final clinical diagnosis of GCA

All GCA (n=57)US positive (n=22)US negative (n=35)p-valueAge, mean years7478720.01Sex, no of females41 (72%)13 (59%)27 (77%)0.15Any head pain present, no of patients49 (86%)18 (82%)31 (89%)0.50Jaw claudication, no of patients26 (46%)15 (68%)14 (40%)0.04Ocular ischaemia, no of patients8 (14%)3 (14%)5 (14%)0.94ESR, mm/hour,* mean6766680.78CRP, mg/L,* mean8585840.96Days of high-dose glucocorticoid pre-US, mean5460.11

* ESR was determined in n=55 patients and CRP in n=53 patients. ESR and CRP were measured before initiation of high-dose steroid treatment.

Table 2.

Diagnostic accuracy of US stratified by duration of high dose glucocorticoid* pre-scan

Steroid durationnSensitivity, %Specificity, %PPV, %NPV, %0-1 day15471100100972-3 days34†22100100774-5 days32†33100100796-7 days181310010059>7 days413310010072

*>30mg of oral prednisone or equivalent

†included episodes when patients were treated with intravenous methylprednisone

Conclusion:

US has an 89% sensitivity and 100% specificity for GCA when performed before initiation of glucocorticoid. Its sensitivity rapidly decreases within a day of starting high dose steroid but up to one-third of GCA cases can still be detected after over 1 week of treatment.

References:

[1]Dejaco C, Ramiro S, Duftner C,et al. EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice.Ann Rheum Dis2018;77:636-43.

[2]De Miguel E, Roxo A, Castillo C,et al. The utility and sensitivity of colour Doppler ultrasound in monitoring changes in giant cell arteritis.Clin Exp Rheumatol2012;30:S34-8.

Disclosure of Interests

None declared

Updating the Clinical Picture of Facioscapulohumeral Muscular Dystrophy: Ramifications for Drug Development With Potential Solutions

BACKGROUND

Facioscapulohumeral muscular dystrophy (FSHD) is a complex, inheritable, and rare muscle disease that affects the entire body. The major symptom of FSHD is progressive weakening and loss of skeletal muscles. The usual location of these weaknesses at onset is the origin of the name: face (facio), shoulder girdle (scapulo), and upper arms (humeral). FSHD appears to have varying molecular and genetic determinants with commensurate differences in disease progression.

METHODS

Facioscapulohumeral muscular dystrophy (MD) is probably the most prevalent form of MD but has neither disease-modifying treatments nor a cure. As the mechanism of action becomes further elucidated, more biopharmaceutical companies are investing capital into finding treatments for patients with FSHD. Sponsors of treatments for FSHD patients should be aware of some of the common misconceptions associated with FSHD drug development with the goal of optimizing the chance to prove safety and efficacy for each potential treatment for FSHD in the clinical trial setting.

RESULTS

Four major topics with potential clinical manifestations for patients with FSHD will be discussed related to muscle weakness, respiratory issues, animal models and prevalence.

CONCLUSION

The authors offer multiple solutions to help counteract misconceptions with each scenario during clinical trial drug development.

Feasibility and Construct Validation of the Patient Reported Outcomes Measurement Information System in Systemic Vasculitis

OBJECTIVE

The Patient Reported Outcome Measurement Information System (PROMIS) is a collection of item banks of self-reported health. This study assessed the feasibility and construct validity of using PROMIS instruments in vasculitis.

METHODS

Data from a multicenter longitudinal cohort of subjects with systemic vasculitis were used. Instruments from 10 PROMIS item banks were selected with direct involvement of patients. Subjects completed PROMIS instruments using computer adaptive testing (CAT). The Medical Outcomes Study Short Form-36 (SF-36) was also administered. Cross-sectional construct validity was assessed by calculating correlations of PROMIS scores with SF-36 measures and physician and patient global scores for disease activity. Longitudinal construct validity was assessed by correlations of between-visit differences in PROMIS scores with differences in other measures.

RESULTS

During the study period, 973 subjects came for 2306 study visits and the PROMIS collection was completed at 2276 (99%) of visits. The median time needed to complete each PROMIS instrument ranged from 40 to 55 s. PROMIS instruments correlated cross-sectionally with individual scales of the SF-36, most strongly with subscales of the SF-36 addressing the same domain as the PROMIS instrument. For example, PROMIS fatigue correlated with both the physical component score (PCS; r = -0.65) and with the mental component score (MCS; r = -0.54). PROMIS physical function correlated strongly with PCS (r = 0.81) but weakly with MCS (r = 0.29). Weaker correlations were observed longitudinally between change in PROMIS scores with change in PCS and MCS.

CONCLUSION

Collection of data using CAT PROMIS instruments is feasible among patients with vasculitis and has some cross-sectional and longitudinal construct validity.

Systemic vasculitis and patient-reported outcomes: how the assessment of patient preferences and perspectives could improve outcomes

The systemic vasculitides are a group of multisystem diseases, which can be life and organ threatening. High-dose immunosuppressants are required to control inflammation in vital organs, such as the kidneys, lungs, skin, joints, and eyes. Patients report a range of impacts on their health-related quality of life due to symptoms, irreversible damage, and the adverse effects of medications. The measurement of patient perspectives within clinical studies in vasculitis is essential to capture outcomes of greatest importance to patients. Validated generic, disease-specific and symptom-specific patient-reported outcomes available for use in patients with systemic vasculitis are reviewed here.

Updating OMERACT Core Set of Domains for ANCA-associated Vasculitis: Patient Perspective Using the International Classification of Function, Disability, and Health

OBJECTIVE

Aspects of antineutrophil cytoplasmic antibodies-associated vasculitis (AAV) prioritized by patients with AAV were described using the International Classification of Function, Disability, and Health (ICF).

METHODS

Items identified during 14 individual interviews were incorporated into an ICF-based questionnaire administered to participants of 2 vasculitis patient symposia: 36 in the United Kingdom and 63 in the United States.

RESULTS

Categories identified as at least "moderately relevant" by ≥ 5% of subjects included 44 body functions, 14 body structures, 35 activities and participation, 31 environmental factors, and 38 personal factors.

CONCLUSION

Identified categories differ from those identified by the current Outcome Measures in Rheumatology (OMERACT) core set and those prioritized by vasculitis experts.

Validation of the ANCA-associated vasculitis patient-reported outcomes (AAV-PRO) questionnaire

OBJECTIVES

To finalise and validate a disease-specific patient-reported outcome (PRO) measure: the ANCA-associated vasculitis patient-reported outcome (AAV-PRO) questionnaire. Using a 35-item candidate questionnaire developed following 50 qualitative interviews in the UK, USA and Canada, a longitudinal survey was conducted to determine the final scale structure and validate the AAV-PRO.

METHODS

Participants were recruited via Vasculitis UK and the Vasculitis Patient-Powered Research Network. The 35-item candidate questionnaire was completed at baseline and 3 months; UK participants completed the EuroQol-5D-5L (EQ-5D-5L), while US participants completed a test-retest exercise, 3-5 days after baseline. Scale structure was defined using exploratory factor analysis (EFA) and Rasch analysis. Convergent and known groups validity, test-retest reliability and longitudinal construct validity were assessed.

RESULTS

There were 626 participants with AAV; >25% reporting 'active disease'. EFA and Rasch analysis supported a 29-item profile measure comprising six domains: 'organ-specific symptoms', 'systemic symptoms', 'treatment side effects', 'social and emotional impact', 'concerns about the future' and 'physical function'. Mean domain scores were higher for participants with 'active disease' versus 'remission' (p<0.001). Construct validity was demonstrated by correlations between domain scores and the EQ-5D-5L (range r=-0.55 to 0.78), all p<0.0001. In participants reporting 'no change' (n=97) during the test-retest, intraclass correlation coefficient values were high (range 0.89-0.96) for each domain.

CONCLUSIONS

The AAV-PRO, a new disease-specific PRO measure for AAV, has good face and construct validity, is reliable, feasible and discriminates among disease states.

Health-related quality of life in ANCA-associated vasculitis and item generation for a disease-specific patient-reported outcome measure

Objective

The antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) are multisystem diseases of the small blood vessels. Patients experience irreversible damage and psychological effects from AAV and its treatment. An international collaboration was created to investigate the impact of AAV on health-related quality of life (HRQoL), and develop a disease-specific patient-reported outcome measure to assess outcomes of importance to patients.

Methods

Patients with AAV from the UK, USA, and Canada were interviewed to identify salient aspects of HRQoL affected by AAV. The study was overseen by a steering committee including four patient research partners. Purposive sampling of interviewees ensured representation of a range of disease manifestations and demographics. Inductive analysis was used to identify themes of importance to patients; these were further confirmed by a free-listing exercise in the US. Individual themes were recast into candidate items, which were scrutinized by patients, piloted through cognitive interviews and received a linguistic and translatability evaluation.

Results

Fifty interviews, conducted to saturation, with patients from the UK, USA, and Canada, identified 55 individual themes of interest within seven broad domains: general health perceptions, impact on function, psychological perceptions, social perceptions, social contact, social role, and symptoms. Individual themes were constructed into >100 candidate questionnaire items, which were then reduced and refined to 35 candidate items.

Conclusion

This is the largest international qualitative analysis of HRQoL in AAV to date, and the results have underpinned the development of 35 candidate items for a disease-specific, patient-reported outcome questionnaire.

Tuberculosis serosurveillance and management practices of captive African elephants (Loxodonta africana) in the Kavango-Zambezi Transfrontier Conservation Area

Transfrontier conservation areas represent an international effort to encourage conservation and sustainable development. Their success faces a number of challenges, including disease management in wildlife, livestock and humans. Tuberculosis (TB) affects humans and a multitude of non-human animal species and is of particular concern in sub-Saharan Africa. The Kavango-Zambezi Transfrontier Conservation Area encompasses five countries, including Zimbabwe, and is home to the largest contiguous population of free-ranging elephants in Africa. Elephants are known to be susceptible to TB; thus, understanding TB status, exposure and transmission risks to and from elephants in this area is of interest for both conservation and human health. To assess risk factors for TB seroprevalence, a questionnaire was used to collect data regarding elephant management at four ecotourism facilities offering elephant-back tourist rides in the Victoria Falls area of Zimbabwe. Thirty-five working African elephants were screened for Mycobacterium tuberculosis complex antibodies using the ElephantTB Stat-Pak and the DPP VetTB Assay for elephants. Six of 35 elephants (17.1%) were seropositive. The risk factor most important for seropositive status was time in captivity. This is the first study to assess TB seroprevalence and risk factors in working African elephants in their home range. Our findings will provide a foundation to develop guidelines to protect the health of captive and free-ranging elephants in the southern African context, as well as elephant handlers through simple interventions. Minimizing exposure through shared feed with other wildlife, routine TB testing of elephant handlers and regular serological screening of elephants are recommended as preventive measures.

Patient perceptions of glucocorticoids in anti-neutrophil cytoplasmic antibody-associated vasculitis

Granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA) are multisystem diseases of small blood vessels, collectively known as the anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV). This study explores the patient’s perspective on the use of glucocorticoids, which are still a mainstay of treatment in AAV. Patients with AAV from the UK, USA, and Canada were interviewed, using purposive sampling to include a range of disease manifestations and demographics. The project steering committee, including patient partners, designed the interview prompts and cues about AAV, its treatment, and impact on health-related quality of life. Interviews were transcribed and analysed to establish themes grounded in the data. A treatment-related code was used to focus analysis of salient themes related to glucocorticoid therapy. Fifty interviews were conducted. Individual themes related to therapy with glucocorticoids emerged from the data and were analysed. Three overarching themes emerged: (1) Glucocorticoids are effective at the time of diagnosis and during relapse, and withdrawal can potentiate a flare, (2) glucocorticoids are associated with salient emotional, physical, and social effects (depression, anxiety, irritation, weight gain and change in appearance, diabetes mellitus, effect on family and work); and (3) patient perceptions of balancing the risks and benefits of glucocorticoids. Patients identified the positive aspects of treatment with glucocorticoids; they are fast-acting and effective, but, they voiced concerns about adverse effects and the uncertainty of the dose-reduction process. These results may be informative in the development of novel glucocorticoid-sparing regimens.

The Oxford knee score and its subscales do not exhibit a ceiling or a floor effect in knee arthroplasty patients: an analysis of the National Health Service PROMs data set

PURPOSE

In this study, we examined whether the OKS demonstrated a floor or a ceiling effect when used to measure the outcome of knee replacement surgery in a large national cohort.

METHODS

NHS PROMs database, containing pre- to 6 month post-operative OKS on 72,154 patients, mean age 69 (SD 9.4), undergoing knee replacement surgery, was examined to establish the proportion of patients achieving top or bottom OKS values pre- and post-operatively.

RESULTS

Pre-operatively, none of patients achieved the maximum/'best' (48) and minimum (0) scores. Post-operatively, no patients (0 %) achieved the minimum/'worst' score, but the percentage achieving the maximum score increased to 2.7 %. Subgroup analyses demonstrated that the highest post-operative overall ceiling percentage was 3 %, in a subgroup of patients between 60 and 79 years of age and 13.7 % in a group of patients who had a pre-operative OKS above 41. Furthermore, 10.8 % of patients achieved the top post-operative OKS-PCS and 4.7 % top post-operative OKS-FCS.

CONCLUSION

Based on NHS PROMs data, the OKS does not exhibit a ceiling or floor effect overall, or for both its pain and function subscales, and remains a valid measure of outcomes for patients undergoing TKA.

LEVEL OF EVIDENCE

Large-scale retrospective observations study, Level II.

OMERACT Endorsement of Patient-reported Outcome Instruments in Antineutrophil Cytoplasmic Antibody-associated Vasculitis

OBJECTIVE

The antineutrophil cytoplasmic antibody-associated vasculitides (AAV) are multiorgan diseases. Patients with AAV report impairment in their health-related quality of life (HRQOL) and have different priorities regarding disease assessment compared with physicians. The Outcome Measures in Rheumatology (OMERACT) Vasculitis Working Group previously received endorsement for a core set of domains in AAV. Two approaches to measure patient-reported outcomes (PRO) were presented at OMERACT 2016.

METHODS

A novel 5-step tool was used to facilitate assessment of the instruments by delegates: the OMERACT Filter 2.0 Instrument Selection Algorithm, with a red-amber-green checklist of questions, including (1) good match with domain (face and content validity), (2) feasibility, (3) do numeric scores make sense (construct validity)?, (4) overall ratings of discrimination, and (5) can individual thresholds of meaning be defined? Delegates gave an overall endorsement. Three generic Patient-Reported Outcomes Measurement Information System (PROMIS) instruments (fatigue, physical functioning, and pain interference) and a disease-specific PRO, the AAV-PRO (6 domains related to symptoms and HRQOL), were presented.

RESULTS

OMERACT delegates endorsed the use of the PROMIS instruments for fatigue, physical functioning, and pain interference (87.6% overall endorsement) and the disease-specific AAV-PRO instrument (89.4% overall endorsement).

CONCLUSION

The OMERACT Vasculitis Working Group gained endorsement by OMERACT for use of the PROMIS and the AAV-PRO in clinical trials of vasculitis. These instruments are complementary to each other. The PROMIS and the AAV-PRO need further work to assess their utility in longitudinal settings, including their ability to discriminate between treatments of varying efficacy in the setting of a randomized controlled trial.

A unified multi-level model approach to assessing patient responsiveness including; return to normal, minimally important differences and minimal clinically important improvement for patient reported outcome measures

OBJECTIVE

This article reviews and compares four commonly used approaches to assess patient responsiveness with a treatment or therapy (return to normal (RTN), minimal important difference (MID), minimal clinically important improvement (MCII), OMERACT-OARSI [Outcome Measures in Rheumatology-Osteoarthris Reseach Society International] (OO)) and demonstrates how each of the methods can be formulated in a multilevel modelling (MLM) framework.

DESIGN

Cohort study.

SETTING

A cohort of patients undergoing total hip and knee replacement were recruited from a single UK National Health Service hospital.

POPULATION

400 patients from the Arthroplasty Pain Experience cohort study undergoing total hip (n=210) and knee (n=190) replacement who completed the Intermittent and Constant Osteoarthritis Pain questionnaire prior to surgery and then at 3, 6 and 12 months after surgery.

PRIMARY OUTCOMES

The primary outcome was defined as a response to treatment following total hip or knee replacement. We compared baseline scores, change scores and proportion of individuals defined as 'responders' using traditional and MLM approaches with patient responsiveness.

RESULTS

Using existing approaches, baseline and change scores are underestimated, and the variance of baseline and change scores overestimated in comparison with MLM approaches. MLM increases the proportion of individuals defined as responding in RTN, MID and OO criteria compared with existing approaches. Using MLM with the MCII criteria reduces the number of individuals identified as responders.

CONCLUSION

MLM improves the estimation of the SD of baseline and change scores by explicitly incorporating measurement error into the model and avoiding regression to the mean when making individual predictions. Using refined definitions of responsiveness may lead to a reduction in misclassification when attempting to predict who does and does not respond to an intervention and clarifies the similarities between existing methods.

A Simple Composite Dynamic Digital Tool to Communicate Complex Physical and Mental Health needs and Measure Outcomes: The Cornwall Health Radar

Introduction

Clinician-patient communication is a major factor in influencing outcomes of healthcare. Complexity increases if an individual has multiple health needs requiring support of different clinicians or agencies.

Aim

To develop and evidence a simple dynamic computerised tool to capture and communicate outcomes of intervention or alteration in clinical need in patients with multiple chronic health needs.

Method

A MS Excel algorithm was designed for swift capture of clinical information discussed in an appointment using pre-designed set of evidenced based domains. An instant personalized single screen visual is produced to facilitate information sharing and decision-making. The display is responsive to compare changes across time. A prototype was conceptually tested in an epilepsy clinic for people with Intellectual disability (ID) due to the unique challenges posed in this population.

Results

Evidence across 300 patients with ID and epilepsy showed the tool works by enhancing reflective communication, compliance and therapeutic relationship. Medication and appointment compliance was 95% and patient satisfaction over 90%.

Conclusion

To discuss all influencing health factors in a consultation is a communication challenge esp. if the patient has multiple health needs. A picture equals 1000 words and helps address the cognitive complexity of verbal information. The radar offers an evidenced based common framework to host care plans of different health conditions. It provides individualised easy view person centred care plans to allow patients to gain insight on how the different conditions impact on their overall well being and be active participants. The tool will be practically demonstrated.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

GPR91 deficiency exacerbates allergic contact dermatitis while reducing arthritic disease in mice

Background

Succinate, in addition to its role as an intermediary of the citric acid cycle, acts as an alarmin, initiating and propagating danger signals resulting from tissue injury or inflammatory stimuli. The contribution of this immune sensing pathway to the development of allergic and inflammatory responses is unknown.

Methods

Ear thickness of wild‐type (wt) and Sucnr1‐deficient (Sucnr1^−/−) mice, sensitized and challenged with oxazolone, was used as a criterion to assess the relevance of SUCNR1/GPR91 expression mediating allergic contact dermatitis (ACD). Results obtained in this system were contrasted with data generated using passive cutaneous anaphylaxis, ovalbumin‐induced asthma and arthritis models.

Results

We found augmented ACD reactions in Sucnr1^−/− mice. This observation correlated with increased mast cell activation in vitro and in vivo. However, exacerbated mast cell activation in Sucnr1^−/− mice did not contribute to the enhancement of asthma or arthritis and seemed to be due to alterations during mast cell development as augmented mast cell responses could be recapitulated in wt mast cells differentiated in the absence of succinate.

Conclusions

A deficiency in succinate sensing during mast cell development confers these cells with a hyperactive phenotype. Such a phenomenon does not translate into exacerbation of asthma or mast cell‐dependent arthritis. On the contrary, the fact that Sucnr1^−/− mice developed reduced arthritic disease, using two different in vivo models, indicates that GPR91 antagonists may have therapeutic potential for the treatment of allergic and autoimmune diseases.

An Overview of Factors Relevant to Undertaking Research and Reviews on the Effectiveness of Treatment for Frozen Shoulder

This review summarizes recent research relevant to assessing the effectiveness of treatment for frozen shoulder, including the natural history, the prevalence of frozen shoulder, and other conditions sometimes associated with it. We searched Medline, the Cochrane Database of Systematic Reviews and Embase databases for systematic reviews and randomized controlled trials published in English from 1999 to 2009. Frozen shoulder is of unknown aetiology and has three distinct phases: (1) the painful phase; (2) the stiff (‘frozen’) phase; and (3) recovery (‘thawing’). Frozen shoulder is more common in women and within the age-range 40 years to 60 years. The prevalence of frozen shoulder is between 2% and 5%, but between 10% and 31% in people with diabetes. Diagnosis can prove difficult, particularly within primary care. The many treatment options involve little consensus on usage and in relation to different phases of frozen shoulder. There is limited evidence of the effectiveness of different forms of treatment used for frozen shoulder. Many studies evaluating treatment effects carry a moderate to high risk of bias and omit details of the duration of symptoms or the phase of the condition. The outcome measures used may all lack sufficient specificity. Data on economic outcomes concerning patterns of care, treatment and treatment effects for frozen shoulder are limited.

Effectiveness of open and arthroscopic rotator cuff repair (UKUFF): a randomised controlled trial

AIMS

The appropriate management for patients with a degenerative tear of the rotator cuff remains controversial, but operative treatment, particularly arthroscopic surgery, is increasingly being used. Our aim in this paper was to compare the effectiveness of arthroscopic with open repair of the rotator cuff.

PATIENTS AND METHODS

A total of 273 patients were recruited to a randomised comparison trial (136 to arthroscopic surgery and 137 to open surgery) from 19 teaching and general hospitals in the United Kingdom. The surgeons used their usual preferred method of repair. The Oxford Shoulder Score (OSS), two years post-operatively, was the primary outcome measure. Imaging of the shoulder was performed at one year after surgery. The trial is registered with Current Controlled Trials, ISRCTN97804283.

RESULTS

The mean OSS improved from 26.3 (standard deviation (sd) 8.2) at baseline, to 41.7 (sd 7.9) two years post-operatively for arthroscopic surgery and from 25.0 (sd 8.0) to 41.5 (sd 7.9) for open surgery. Intention-to-treat (ITT) analysis showed no statistical difference between the groups at two years (difference in OSS score -0.76; 95% confidence interval (CI) -2.75 to 1.22; p = 0.452). The confidence interval excluded the pre-determined clinically important difference in the OSS of three points. The rate of re-tear was not significantly different between the two groups (46.4% for arthroscopic and 38.6% for open surgery; 95% CI -6.9 to 25.8; p = 0.256). Healed repairs had the most improved OSS. These findings were the same when analysed per-protocol.

CONCLUSION

There is no evidence of difference in effectiveness between open and arthroscopic repair of rotator cuff tears. The rate of re-tear is high in both groups, for all sizes of tear and ages and this adversely affects the outcome. Cite this article: Bone Joint J 2017;99-B:107-15.

A comparison of the Oxford shoulder score and shoulder pain and disability index: factor structure in the context of a large randomized controlled trial

Background

To explore and compare the factor structure of the 12-item Oxford shoulder score (OSS) and 13-item shoulder pain and disability index (SPADI).

Methods

Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) of data from 660 patients attending 46 hospitals in the UK. Complete OSS and SPADI data were available for 648 (98.2%) and 628 (95.2%) participants, respectively.

Results

For both instruments, either one or two factors were indicated, depending on the extraction method. On EFA, most OSS items loaded saliently on either of two “Pain” (4 items) and “Function” (8 items) factors, although some items cross-loaded. Cronbach’s alphas were 0.75, 0.90, and 0.91 for “Pain” and “Function” subscales, and all 12 OSS items, respectively. CFA suggested marginally better fit for two factors, with neither one- nor two-factor models rejected. EFA indicated two factors for the SPADI, with three of the eight “Disability” items contributing to an 8-item “Pain factor”, with 2 items within the 5-item “Disability factor” cross-loading. Cronbach’s alpha was 0.87 and 0.93 for the original 5- and 8-item pain and disability scales; 0.94 for all 13 SPADI items, respectively. CFA suggested marginally better fit for the two-factor (original conceptualization) model of the SPADI, with neither one- nor two-factor models rejected.

Conclusion

EFA and CFA demonstrated that, in addition to single summary scales usage, separate information on pain and self-reported disability/function can be extracted in a meaningful way, as subscales, from both the OSS and the SPADI. This information can help researchers in choosing primary study endpoints appropriately.