Reviews for multimorbidity risk in people with inflammatory conditions: a qualitative study

BACKGROUND

People with inflammatory rheumatological conditions (IRCs) are at high risk of developing other conditions including cardiovascular disease and mood disorders.

AIM

To explore perspectives of people with IRCs and healthcare practitioners (HCPs) on the content and delivery of a review consultation aimed at identification and management of multiple long-term conditions.

DESIGN & SETTING

Semi-structured interviews and focus groups with people with IRCs and HCPs.

METHOD

People with IRCs participated in individual semi-structured interviews by telephone or online platform. HCPs (including primary and secondary care clinicians) participated in online focus groups. Data were transcribed verbatim and analysed using inductive thematic analysis.

RESULTS

15 people with IRCs were interviewed; three focus groups with HCPs were conducted. Two main themes were identified: reflecting on the value of review consultations and what would a new review look like. Overall, people with IRCs and HCPs reflected that access to reviews is inequitable, leading to duplication of reviews and fragmentation in care. People with IRCs, at times, had difficulty conceptualising reviews, especially when discussing their future risk of conditions. People suggested that preparation before the healthcare review could align patient and HCP agendas as part of a flexible and person-centred discussion.

CONCLUSION

Any review introduced for people with IRCs must move beyond a "tick-box" exercise. To gain maximum value from a review, preparation from both patient and HCP may be required alongside a person-centred approach whilst ensuring they are targeted at people most likely to benefit.

The information required by people with inflammatory arthritis to take methotrexate: a mixed-methods systematic review

OBJECTIVES

This mixed-methods systematic review aimed to identify and synthesize knowledge of the characteristics, content, and preferred format of information to support people with inflammatory arthritis (IA) to take methotrexate.

METHODS

A literature search using MEDLINE, The Cochrane Library, Embase, CINAHL, PsychInfo, GreyEU, Web of Science and Open Dissertation was conducted to identify all studies published from 2000 to December 2022. Included studies detailed factors related to methotrexate (MTX) related information needs of people with inflammatory arthritis ≥ 18 years in English. Joanna Briggs Institute Guidelines (JBI) for convergent integrated mixed-methods systematic reviews were followed using validated tools for data extraction and quality. Data was analysed using reflexive thematic analysis.

RESULTS

Thirteen studies (seven quantitative, two mixed-methods and four qualitative) were included involving 3425 adults, mainly female n = 2434 (71%), age 20-84 years. An overarching theme of a requirement for person-centred care was developed with three interlinking themes: 1: Accepting the need for treatment with MTX, 2: Concerns about taking MTX, 3: A need for tailored information and support. Limitations of the evidence were use of heterogeneous outcome measures and instruments to measure information needs.

CONCLUSION

People with IA have individual, multi-faceted information, and support needs about MTX that are often unresolved when a one-size-fits-all approach is used. The findings can inform rheumatology training to support a person-centred approach to identifying and addressing specific needs, concerns and the development of consistent easy-to-understand accessible MTX information.

Factors associated with change in health-related quality of life in people with gout: a 3-year prospective cohort study in primary care

OBJECTIVE

To describe factors associated with change in health-related quality of life (HRQOL) in people living with gout in primary care.

METHODS

In a UK prospective cohort study, adults with a diagnosis of gout registered with 20 general practices completed the Gout Impact Scale (GIS; scale 0-100), 36-item Short Form Physical Function subscale (PF-10; 0-100) and HAQ Disability Index (HAQ-DI; 0-3) via postal questionnaires at baseline and 6, 12, 24 and 36 months. Linear mixed modelling was used to investigate factors associated with changes in HRQOL over 3 years.

RESULTS

A total of 1184 participants responded at baseline (adjusted response 65.6%); 990 (83.6%) were male, with a mean age of 65.6 years (s.d. 12.5). A total of 818, 721, 696 and 605 responded at 6, 12, 24 and 36 months, respectively. Factors associated with worse disease-specific and generic HRQOL over 3 years were flare frequency (five or more flares; GIS subscales, PF-10), oligo/polyarticular flares (GIS subscales, PF-10, HAQ-DI), worse pain (GIS subscales, PF-10, HAQ-DI), body pain (GIS subscales, PF-10, HAQ-DI) and more severe depression (GIS subscales, PF-10, HAQ-DI) (P ≤ 0.05). More severe anxiety was associated with worse disease-specific HRQOL only (GIS subscales). Older age (PF-10), being female (PF-10, HAQ-DI) and BMI (HAQ-DI) were associated with worse generic HRQOL (P ≤ 0.05).

CONCLUSION

Gout-specific, comorbid and sociodemographic factors were associated with change in HRQOL over a 3-year period, highlighting people at risk of worse outcomes who could be targeted for interventions.

Incorporating FRAX into a nurse-delivered integrated care review: a multi-method qualitative study

BACKGROUND

People with inflammatory rheumatological conditions (IRCs) are at increased risk of common comorbidities including osteoporosis.

AIM

To explore the barriers to and facilitators of implementing nurse-delivered fracture risk assessments in primary care, in the context of multimorbidity reviews for people with IRCs.

DESIGN & SETTING

A multi-method qualitative study in primary care.

METHOD

As part of a process evaluation in a pilot trial, semi-structured interviews were conducted with 20 patients, two nurses, and three GPs. Twenty-four patient-nurse INCLUDE review consultations were audiorecorded and transcribed. A framework analysis was conducted using the Theoretical Domains Framework (TDF).

RESULTS

Nurses reported positive views about the value of the Fracture Risk Assessment Tool (FRAX) and they felt confident to deliver the assessments following training. Barriers to implementation, as identified by TDF, particularly related to the domains of knowledge, skills, professional roles, and environmental context. GPs reported difficulty keeping up to date with osteoporosis guidelines and voiced differing opinions about whether fracture risk assessment was the role of primary or secondary care. Lack of integration of FRAX into IT systems was a barrier to use. GPs and nurses had differing views about the nurse role in communicating risk and acting on FRAX findings; for example, explanations of the FRAX result and action needed were limited. Patients reported limited understanding of FRAX outcomes.

CONCLUSION

The findings suggest that, with appropriate training including risk communication, practice nurses are likely to be confident to play a key role in conducting fracture risk assessments, but further work is needed to address the barriers identified.

Exploring the longer-term impact of the COVID-19 pandemic on physical and mental health of people with inflammatory rheumatic diseases: a cross-sectional survey

OBJECTIVE

To assess the longer term impact of the COVID-19 pandemic on the self-reported physical and mental health of people with inflammatory rheumatic diseases (IRDs).

METHODS

Two thousand twenty-four patients with IRDs were randomly selected from electronic health records. Survey invitations were sent (August 2021 coinciding with relaxation of UK COVID-19 restrictions) using SMS and postal approaches. Self-reported data included demographics, shielding status and physical (MSK-HQ) and mental health (PHQ8 and GAD7).

RESULTS

Six hundred thirty-nine people completed the survey (mean (SD) age 64.5 (13.1) years, 384 (60%) female). Moderate/severe impact of the pandemic on physical and mental health was reported by 250 (41%) and 241 (39%) respectively. One hundred seventy-two (29%) reported moderate/severe depression (PHQ8 ≥ 10) and 135 (22%) moderate/severe anxiety (GAD7 ≥ 10). Females reported greater impacts of the pandemic on physical health (44% vs 34%), mental health (44% vs 34%), arthritis symptoms (49% vs 36%) and lifestyle factors (weight gain and reduced exercise and physical activity) than males. The physical and mental impacts were less in people with RA compared with other IRDs. Physical health impacts did not differ between age groups, but younger patients reported greater impacts on mental health.

CONCLUSION

The COVID-19 pandemic has had a significant impact on the physical and mental health of people with IRDs. These effects were greatest in females. Recovery needs to address the negative impact of the pandemic on lifestyle factors to minimise the long-term impacts for people with IRDs. Key Points • The pandemic had a significant impact on long term physical and mental health in almost 40% of people with IRDs. • The impact of the pandemic was greater in women for physical health, mental health and arthritis symptoms. • Many people reported negative pandemic impacts on lifestyle factors including weight and physical activity.

Digital exclusion as a potential cause of inequalities in access to care: a survey in people with inflammatory rheumatic diseases

Objectives

COVID-19 led to rapid uptake of digital health care. We sought to examine digital access, health and digital literacy, and impact on confidence and satisfaction with remote consultations in people with inflammatory rheumatic diseases (IRDs).

Methods

People with IRDs (n = 2024) were identified from their electronic health record and invited to participate in a cross-sectional survey, using short message service (SMS) and postal approaches. Data were collected on demographics, self-reported diagnosis, access to and use of internet-enabled devices, health and digital literacy, together with confidence and satisfaction with remote consultations. Ethical approval was obtained (Ref 21/PR/0867).

Results

Six hundred and thirty-nine (639) people completed the survey [mean (s.d.) age 64.5 (13.1) years, 384 (60.1%) female]. Two hundred and eighty-seven (44.9%) completed it online. One hundred and twenty-six (19.7%) people reported not having access to an internet-enabled device. Ninety-three (14.6%) reported never accessing the internet; this proportion was highest (23%) in people with RA. One hundred and seventeen (18%) reported limited health literacy. Even in those reporting internet use, digital literacy was only moderate. People with limited health or digital literacy or without internet access were less likely to report confidence or satisfaction with remote consultations.

Conclusion

Limited health and digital literacy, lack of digital access and low reported internet use were common, especially in older people with RA. People with limited health literacy or limited digital access reported lower confidence and satisfaction with remote consultations. Digital implementation roll-out needs to take account of people requiring extra support to enable them to access care digitally or risks exacerbating health inequalities.

Exploring the physical, psychological and social well-being of people with rheumatoid arthritis during the coronavirus pandemic: a single-centre, longitudinal, qualitative interview study in the UK

OBJECTIVE

Rheumatoid arthritis (RA) is an autoimmune, inflammatory, systemic condition that requires specific drug treatment to suppress disease activity and prevent joint deformity. To manage the ongoing symptoms of joint pain and fatigue patients are encouraged to engage in self-management activities. People with RA have an increased incidence of serious illness and mortality, with the potential to impact on quality of life. This study explored patients' experiences of living with RA on physical, psychological and social well-being as well as their ability to employ self-management skills during the coronavirus pandemic.

DESIGN

Qualitative, longitudinal (baseline, 16 September to 23 November 2020 and after 2-4 months, 11 January to the 17 January 2021), semistructured telephone interviews.

SETTING

A rheumatology service based in a community hospital.

PARTICIPANTS

15 adults with RA.

MAIN OUTCOMES

Data were analysed using interpretative phenomenological analysis.

RESULTS

Five themes were identified that related to impact on (1) fear: the dominant emotion, (2) social connections and work practices, (3) physical health, (4) identity and (5) self-management as a coping mechanism. The overriding emotion was one of fear, which remained high throughout both interviews. The negative impact on social well-being increased as the pandemic progressed. Conversely, physical health was not affected at either time point, although participants reported difficulty in interpreting whether physical symptoms were attributable to their RA or COVID-19. Recognition of increased vulnerability led to a reassessment of self-identity; however, respondents reported using previously learnt self-management techniques to cope in the context of the pandemic.

CONCLUSIONS

The main impact was on emotional and social well-being. Levels of fear and vulnerability which affected self-identity remained high throughout the pandemic and the impact on social well-being increased over time. Physical health remained largely unaffected. Self-management skills were used to maintain a sense of well-being.

Gait rehabilitation for foot and ankle impairments in early rheumatoid arthritis: a feasibility study of a new gait rehabilitation programme (GREAT Strides)

Background

Foot impairments in early rheumatoid arthritis are common and lead to progressive deterioration of lower limb function. A gait rehabilitation programme underpinned by psychological techniques to improve adherence, may preserve gait and lower limb function. This study evaluated the feasibility of a novel gait rehabilitation intervention (GREAT Strides) and a future trial.

Methods

This was a mixed methods feasibility study with embedded qualitative components. People with early (< 2 years) rheumatoid arthritis (RA) and foot pain were eligible. Intervention acceptability was evaluated using a questionnaire. Adherence was evaluated using the Exercise Adherence Rating Scale (EARS). Safety was monitored using case report forms. Participants and therapists were interviewed to explore intervention acceptability. Deductive thematic analysis was applied using the Theoretical Framework of Acceptability. For fidelity, audio recordings of interventions sessions were assessed using the Motivational Interviewing Treatment Integrity (MITI) scale. Measurement properties of four candidate primary outcomes, rates of recruitment, attrition, and data completeness were evaluated.

Results

Thirty-five participants (68.6% female) with median age (inter-quartile range [IQR]) 60.1 [49.4–68.4] years and disease duration 9.1 [4.0–16.2] months), were recruited and 23 (65.7%) completed 12-week follow-up. Intervention acceptability was excellent; 21/23 were confident that it could help and would recommend it; 22/23 indicated it made sense to them. Adherence was good, with a median [IQR] EARS score of 17/24 [12.5–22.5]. One serious adverse event that was unrelated to the study was reported. Twelve participants’ and 9 therapists’ interviews confirmed intervention acceptability, identified perceptions of benefit, but also highlighted some barriers to completion. Mean MITI scores for relational (4.38) and technical (4.19) aspects of motivational interviewing demonstrated good fidelity. The Foot Function Index disability subscale performed best in terms of theoretical consistency and was deemed most practical.

Conclusion

GREAT Strides was viewed as acceptable by patients and therapists, and we observed high intervention fidelity, good patient adherence, and no safety concerns. A future trial to test the additional benefit of GREAT Strides to usual care will benefit from amended eligibility criteria, refinement of the intervention and strategies to ensure higher follow-up rates. The Foot Function Index disability subscale was identified as the primary outcome for the future trial.

Trial registration

ISRCTN14277030

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01061-9.

Perceptions of risk in people with inflammatory arthritis during the COVID-19 pandemic

Objective

People with inflammatory arthritis have an increased incidence of serious illness and mortality, placing them at risk of poor outcomes from coronavirus disease 2019 (COVID-19). This study explored patients’ perceptions of risk from COVID-19 over a longitudinal period of the pandemic.

Methods

Fifteen adults with inflammatory arthritis attending a National Health Service rheumatology service each took part in three semi-structured telephone interviews conducted between 16 September 2020 and 29 July 2021. Interpretive phenomenological analysis was undertaken by two researchers and two public contributors.

Results

Four main themes relating to perceptions of risk from COVID-19 were identified: inflammatory arthritis; medications and co-morbidities; immediate social environment; health policy communication; and media influence. Participants recognized that having inflammatory arthritis increased their individual risk. Perceptions of risk and associated fear increased during the pandemic, influenced by family/friends who had had COVID-19 and health policy communications. The perceived constant use of negative messages led to many participants disengaging with the media. At the final interviews, when the vaccination programme was well established, participants continued to assess the risk and benefits of engaging in activities.

Conclusion

This study demonstrates the breadth of factors that influenced perceptions of risk in people with an inflammatory arthritis. As health professionals, we have only a small sphere of influence over some of these factors, namely health-care communications. People with inflammatory arthritis appropriately knew that their condition increased their infection risk, but more could be done to consider how and to what extent we involve patients in explaining risk at times of crisis.

P091 Who do we risk leaving behind? A survey of digital access and e-health literacy in people with inflammatory conditions

Background/Aims

The COVID-19 pandemic led to an overnight shift in healthcare delivery and rapid uptake of digital technology. Such approaches risk digital exclusion for people without access to or not confident in their use of technology. We sought to examine digital access and e-health literacy in people with inflammatory conditions.

Methods

People (n = 2,024) were identified from their electronic health record and invited to participate in a survey, using SMS and postal approaches. Data were collected on age, gender, self-reported arthritis diagnosis (RA, PsA, AS, SLE and other), access to an internet-enabled device and frequency of internet access, health literacy (single-item literacy screener) and self-perceived e-health literacy (eHEALs). Ethical approval was obtained (Ref 21/PR/0867).

Results

639 people completed the survey, of whom 287 (44.9%) completed it online. Mean (sd) age was 64.5 (13.1) years and 384 (64.7%) were female. 98.3% were white. Approximately 20% of people did not have access to an internet enabled device (Table). 93 (15.3%) of patients reported never accessing the internet, this proportion was higher in people with RA. Approximately 19% had low health literacy. In those reporting internet use, eHealth literacy was moderate. The most popular options for accessing arthritis advice were telephone helplines or appointments.

Conclusion

Low health literacy, lack of digital access and low reported internet use was common, especially in people with RA, leading to high use of telephone advice and rheumatology appointments. Digital roll-out needs to take account of people requiring extra support to enable them to access care or risks excluding many patients with inflammatory conditions.

Disclosure

S. Hider: None. S. Muller: None. L. Gray: None. F. Manning: None. M. Brooks: None. D. Heining: None. A. Menon: None. J. Packham: None. S. Raghuvanshi: None. E. Roddy: None. S. Ryan: None. I. Scott: None. Z. Paskins: None.

P183 Establishing the epidemiology of rheumatoid arthritis, psoriatic arthritis, and axial spondyloarthritis in England using primary care electronic health record data

Background/Aims

The substantial personal and socioeconomic costs associated with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and axial spondyloarthritis (SpA) make understanding their epidemiology crucial. The Clinical Practice Research Datalink (Aurum) is an electronic healthcare record (EHR) database, containing primary care records from ∼20% of English practices (>13 million patients currently registered). To determine RA/PsA/axial SpA epidemiology using EHR data, validated methods need to be applied to ascertain patients with these diagnoses. To address this, we updated and applied approaches validated in other primary care EHR databases in Aurum and described the annual incidence/point-prevalence of RA/PsA/axial SpA alongside patient characteristics (providing indirect evidence of coding accuracy).

Methods

Diagnosis and synthetic disease-modifying anti-rheumatic drug (DMARD) prescription code lists were constructed, and pre-defined approaches for ascertaining patients with RA/axial SpA/PsA applied. The annual incidence and point-prevalence of RA/PsA/axial SpA were calculated from 2004-2020. Samples were stratified by age/gender, and mean age and gender/ethnic-group relative frequencies described. The study was approved by the CPRD Independent Scientific Advisory Committee (reference 20_000244).

Results

From 2004-2019 the point-prevalence of RA/PsA increased annually, peaking in 2019 (RA 7.79/1,000; PsA 2.87/1,000) then falling slightly. From 2004-2020 the point-prevalence of axial SpA increased annually (except in 2018/2019), peaking in 2020 (1.13/1,000). Annual RA incidence was higher between 2013-2019 (when included in the Quality Outcomes Framework, ranging 0.491 to 0.521/1,000 person-years) than 2004-2012 (ranging 0.345 to 0.400/1,000 person-years). The annual incidence of PsA and axial SpA increased from 2006 (0.108 to a peak of 0.172/1,000 person-years) and 2010 (0.025 to a peak of 0.045/1,000 person-years), respectively. These years were when new disease classification criteria were introduced. Marked falls in the annual incidence of RA, PsA and axial SpA between 2019 and 2020 were seen, reducing by 40.1%, 67.4% and 38.1%, respectively, reflecting the impact of the COVID-19 pandemic on arthritis diagnoses. Stratifying incidence/prevalence by age/gender broadly showed expected patterns (although the incidence of axial SpA/PsA in women increased over time), and the mean age and gender proportions followed those previously reported.

Conclusion

The approaches we used to determine patients with RA, PsA, and axial SpA in Aurum led to incidence/prevalence estimates broadly consistent with published studies, and patient characteristics as would be expected. These data support the potential of the Aurum-updated ascertainment approaches for use in further studies of RA, PsA and axial SpA.

Disclosure

I. Scott: None. R. Whittle: None. J. Bailey: None. H. Twohig: None. S. Hider: None. C. Mallen: None. S. Muller: None. K. Jordan: None.

P064 Impact of COVID-19 on physical and mental health of people with inflammatory conditions: the ICEPAC survey

Background/Aims

Concerns about the risk of COVID-19 infection led to guidelines advocating shielding for many people with inflammatory conditions. We aimed to assess the impact of the pandemic on the self-reported physical and mental health of people with inflammatory conditions.

Methods

2024 patients with inflammatory conditions (RA, PsA, AS, SLE and other) were randomly selected from electronic health records. Survey invites were sent (August 2021 to coincide with relaxation of COVID restrictions) using a combination of SMS and postal approaches. Data collected included demographics, COVID infection and shielding status, physical (MSK-HQ) and mental health (PHQ8 and GAD7) and global impact on physical or mental health (4 options: none-severe). Ethical approval was obtained (REC Ref 21/PR/0867).

Results

639 people completed the survey, of whom 287 (44.9%) completed online. Mean (sd) age was 64.5 (13.1) years and 384 (64.7%) were female. The majority of people had RA although 57 (9%) reported more than one inflammatory condition. 349 (57.9%) of people were advised to shield. Rates of COVID infection were relatively low across the groups (Table 1). 254 (41.2%) reported moderate or severe impact of the pandemic on physical health, which impacted least in people with RA. 244 (39.4%) reported moderate or severe impact of the pandemic on mental health with 175 (28.7%) reporting moderate depression (PHQ8 ≥ &gt;10) and 138 (22.6%) moderate anxiety (GAD-7≥10).

Conclusion

Reported COVID infections were low in our cohort. The pandemic had significant effects on physical and mental health, which appeared less in people with RA than other inflammatory conditions.

Disclosure

S. Hider: None. S. Muller: None. L. Gray: None. F. Manning: None. M. Brooks: None. D. Heining: None. A. Menon: None. J. Packham: None. S. Raghuvanshi: None. E. Roddy: None. S. Ryan: None. I. Scott: None. Z. Paskins: None.

Acceptability of nurse-led reviews for inflammatory rheumatological conditions: A qualitative study

Background:

People with inflammatory rheumatological conditions (IRCs), are at increased risk of comorbidities such as cardiovascular disease, osteoporosis, anxiety and depression. The INCLUDE pilot trial evaluated a nurse-delivered review of people with IRCs which sought to identify and initiate management of comorbid conditions.

Aim:

A nested qualitative study was undertaken to examine the acceptability of the INCLUDE review.

Methods:

A qualitative interview-based design in UK primary care settings. A purposive sample of 20 patients who attended an INCLUDE review, were interviewed. Inductive thematic analysis was undertaken. Themes were agreed through multidisciplinary team discussion and mapped onto constructs of the Theoretical Framework of Acceptability (TFA).

Results:

Six themes mapped onto six of the seven TFA constructs. Patients reported the review to be effective by identifying and initiating management of previously unrecognised comorbid conditions. Some participants reported barriers to following recommendations, such as lifestyle modifications or taking more medication.

Conclusion:

A nurse-delivered review to identify comorbidities is acceptable to patients with IRCs. The TFA provided a novel analytical lens.

Outcomes Measured in Polymyalgia Rheumatica and Measurement Properties of Instruments Considered for the OMERACT Core Outcome Set: A Systematic Review

OBJECTIVE

To systematically identify the outcome measures and instruments used in clinical studies of polymyalgia rheumatica (PMR) and to evaluate evidence about their measurement properties.

METHODS

Searches based on the MeSH term "polymyalgia rheumatica" were carried out in 5 databases. Two researchers were involved in screening, data extraction, and risk of bias assessment. Once outcomes and instruments used were identified and categorized, key instruments were selected for further review through a consensus process. Studies on measurement properties of these instruments were appraised against the COSMIN-OMERACT (COnsensus-based Standards for the selection of health Measurement Instruments-Outcome Measures in Rheumatology) checklist to determine the extent of evidence supporting their use in PMR.

RESULTS

Forty-six studies were included. In decreasing order of frequency, the most common outcomes (and instruments) used were markers of systemic inflammation [erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)], pain [visual analog scale (VAS)], stiffness (duration in minutes), and physical function (elevation of upper limbs). Instruments selected for further evaluation were ESR, CRP, pain VAS, morning stiffness duration, and the Health Assessment Questionnaire. Five studies evaluated measurement properties of these instruments, but none met all of the COSMIN-OMERACT checklist criteria.

CONCLUSION

Measurement of outcomes in studies of PMR lacks consistency. The critical patient-centered domain of physical function is poorly assessed. None of the candidate instruments considered for inclusion in the core outcome set had high-quality evidence, derived from populations with PMR, on their full range of measurement properties. Further studies are needed to determine whether these instruments are suitable for inclusion in a core outcome measurement set for PMR.

P148 Gastrointestinal symptoms and proton pump inhibitor use in patients with polymyalgia rheumatica: results from the PMR Cohort study

Background

Polymyalgia Rheumatica (PMR) is a common disorder of older adults, characterised by pain and stiffness in the shoulders and hips. PMR is one of the commonest indications for long-term glucocorticoid use. Because of the well-recognised side effects of glucocorticoids including gastrointestinal disturbances and bleeding, guidelines recommend consideration of gastrointestinal prophylaxis. The aim of this study was to assess the proportion of PMR patients who report 1) gastrointestinal disturbances; and 2) appropriate prophylactic treatment, and to investigate other factors that may be associated with the development of gastrointestinal disturbances.

Methods

652 people diagnosed in primary care with incident PMR were recruited. Participants all responded to a baseline postal survey and were followed up postally at 1, 4, 8, 12, 18 and 24 months. At each time point, participants answered a range of questions relating sociodemographic, general health and their PMR. At baseline, respondents reported proton pump inhibitors (PPI) use and at 4, 12 and 24 months the presence and extent of any gastrointestinal symptoms (ulcer, wind, indigestion, heartburn; not bothered, bothered a little, bothered a lot). The association of gastrointestinal symptoms with age, gender and PPI use was quantified using proportional odds regression.

Results

Overall, 51% of people reported PPI use at baseline. Reporting of gastrointestinal symptoms was commoner at all time points in people prescribed a PPI at baseline (Table 1). There was no association between age and bothersomeness of gastrointestinal symptoms (odds ratio 0.98 (0.96, 1.00)), but more bothersome symptoms were more likely in females (2.44 (1.72, 3.45)). PPI use at baseline was significantly associated with a high level of bothersomeness compared to no/little bother (2.45 (13.39, 4.36)), but not with being bothered compared to not being bothered (1.23 (0.87, 1.74)).

Conclusion

Around half of patients with PMR report gastrointestinal symptoms. Symptoms are more prevalent in females and those prescribed a PPI. This suggests that GPs are prescribing PPIs in those they consider at higher risk of experiencing gastrointestinal symptoms. However, almost half of those without a PPI reported such symptoms within 4 months. Clinicians should be more aware of the potential for gastrointestinal symptoms in PMR.

Disclosures

H. Feddah None. S. Muller None. S. Hider None. C. Hay None. C. Mallen None.

P142 Factors associated with change in health-related quality of life in people living with gout: a three-year prospective cohort study in primary care

Background

Gout affects 2.5% of adults in the UK but is often poorly managed. It can impair health-related quality of life (HRQOL), yet little is known about which people with gout are at risk of worse outcomes. We investigated factors associated with change in HRQOL over a three-year period in people living with gout in primary care.

Methods

People with gout registered with 20 general practices in the West Midlands completed the Gout Impact Scale (GIS), Short-Form-36 Physical Function subscale (PF10) and health assessment questionnaire disability index (HAQ-DI) at five time-points (baseline & 6, 12, 24 and 36 months) via postal questionnaire. Linear mixed modelling (LMM) with multivariate adjustment for baseline and time-varying covariates was used to investigate gout-specific, comorbid and socio-demographic factors associated with change in the Concern Overall (GIS-CO), PF10 and HAQ-DI over three years. Higher scores are worse for GIS-CO and HAQ-DI, but better for PF10.

Results

Of 1,184 baseline respondents, 818 (80%), 721 (73%), 696 (75%), 605 (68%) responded at 6, 12, 24 and 36 months respectively. Mean age (SD) at baseline was 65.6 (12.5) years. 990 (84%) were male, 494 (42%) reported &gt;2 gout flares in the previous year, 624 (54%) were taking allopurinol and 318 (27%) had an eGFR&lt;60mL/min/1.73m2. Factors identified as being associated with a deterioration in HRQOL over three years (table), were gout flare frequency (GIS-CO, PF10), history of oligo/polyarticular flares (GIS-CO, HAQ-DI), having a flare currently (GIS-CO), allopurinol use (PF10), having body pain (GIS-CO, PF10, HAQ-DI), higher pain severity (GIS-CO, PF10, HAQ-DI), number of comorbidities (PF10), eGFR &lt;60mL/min/1.73m2 (PF10, HAQ-DI), anxiety (GIS-CO), depression (PF10, HAQ-DI), and older age (PF10, HAQ-DI). Factors associated with an improvement in HRQOL were longer gout duration (GIS-CO), older age (GIS-CO), lower socioeconomic deprivation (PF10, HAQ-DI) and more frequent alcohol consumption (PF10, HAQ-DI).

Conclusion

Gout-specific, comorbid and socio-demographic factors associated with change in HRQOL over a three-year period in people living with gout in primary care were identified, highlighting people at risk of worse outcomes over three years and at greatest need of urate-lowering therapy and other targeted interventions.

Disclosures

L. Watson None. J. Belcher None. E. Nicholls None. P. Chandratre None. M. Blagojevic-Bucknall None. S. Hider None. S.A. Lawton None. C.D. Mallen None. S. Muller None. K. Rome None. E. Roddy None.

P193 Experiences of delivering a nurse-led fracture risk assessment for patients with inflammatory rheumatological conditions in primary care

Background

The INCLUDE (INtegrating and improving Care for patients with infLammatory rheUmatological DisordErs in the community) pilot trial aimed to evaluate the feasibility and acceptability of a nurse-delivered review in primary care for people with inflammatory rheumatological conditions (IRCs), to identify and manage common comorbidities including anxiety and depression, cardiovascular and fracture risk. We report analysis of data focusing on the fracture risk assessment component of the review.

Methods

Ethical approvals obtained. Semi-structured interviews were conducted to explore experiences of participating in INCLUDE, with 20 patients, the two nurses delivering the intervention and three General Practitioners (GPs) within participating practices. 24 consenting patients had their INCLUDE review recorded for fidelity checking. Selected extracts were played within some interviews to stimulate discussion (tape-assisted recall). Extracts from recorded consultations relating to fracture risk assessment were transcribed and coded. Interviews were digitally recorded, with consent, transcribed and anonymised. Thematic analysis of the interview data was followed by mapping to the Theoretical Domains Framework (TDF).

Results

Findings mapped to 10/14 TDF domains relating to knowledge, skills, social/professional role and identity, beliefs about capabilities, optimism, beliefs about consequences, reinforcement, intentions, memory attention and decision processes and environmental context/resources. GPs and nurses identified a lack of knowledge and skills in relation to the identification and management of osteoporosis, due to lack of exposure and repeated changes in clinical guidance. GPs reported differing opinions about whether osteoporosis screening was the role of primary or secondary care. GPs and nurses had differing views about the limits of the nurse role in communicating risk. The INCLUDE nurses reported confidence (self-efficacy) in undertaking FRAX assessments. Nurses valued the opportunity to learn new skills and believed that they were improving patient care. They described practical barriers using FRAX including the difficulty navigating between different IT systems. Nurses described uncertainty over when to refer to the GP. Fidelity checks of recorded reviews, showed that FRAX was appropriately calculated for 22/24 patients; whilst INCLUDE nurses introduced the reason for calculating fracture risk, explanations of the meaning of risk were limited, and patients’ understanding was not always checked and queries not responded to; patient interview findings confirmed patients had limited understanding of the meaning of FRAX. Life-style advice related to bone health was given in few consultations.

Conclusion

Screening for fracture risk in people with IRCs in a review consultation is acceptable and feasible, although explanations of the meaning of risk assessment could be improved. Integration of a fracture risk assessment tool within GP software would facilitate risk calculation. More work is needed to understand barriers to risk assessment, including clarity over roles and professional boundaries, and develop management pathways to optimise management of fracture risk in people with IRCs.

Disclosures

A.W. Hawarden None. Z. Paskins None. E. Ediriweera Desilva None. D. Herron None. A. Machin None. C. Jinks None. S. Hider None. C. Chew-Graham None.

P125 A mixed methods feasibility study of a gait rehabilitation programme for people with early rheumatoid arthritis and foot pain

Background

Foot pain, a hallmark feature of rheumatoid arthritis (RA), is associated with slow and unsteady gait patterns, and persistent walking disability is common. Great Strides is a new gait rehabilitation programme designed to improve/preserve lower limb function in early RA. It is delivered by physiotherapists or podiatrists over 12-weeks and is supplemented with a home programme and support materials (DVD and illustrated booklet). It consists of a 6-task gait circuit and is underpinned by behaviour change techniques driven by motivational interviewing. The aims of this feasibility study were to 1) evaluate patient acceptability, adherence to, and safety of Great Strides, and 2) identify a suitable primary outcome measure for the main trial.

Methods

This study was a multi-centre (n = 3), single arm, repeated measures (pre- and post-intervention) design, with interviews exploring participants’ intervention perceptions. People with early (&lt;2 years) RA who had foot pain were invited to participate. Intervention acceptability was evaluated using a 3-item intervention acceptability questionnaire. Adherence was evaluated using the Exercise Adherence Rating Scale (EARS). Safety was monitored using case report forms. Complementary mixed methods integrated descriptive quantitative acceptability, adherence, safety and thematic analyses to corroborate findings. Measurement properties of candidate primary outcomes (10-metre walking time, Foot Function Index disability subscale [FFI-DS], Recent Onset Arthritis Disability lower extremity subscale, and Patient-Reported Outcomes Measurement Information System physical function short-form) were evaluated against a 7-point Change in Walking Ability scale (CWA).

Results

35 participants (68.6% female) with median age (inter-quartile range [IQR]) 60 [49-68] years and disease duration 9 [4-16] months), were recruited over 9 months and 23 (67%) completed 12-week follow-up. 12 participants completed interviews after the 12-week intervention period. Intervention acceptability was excellent; 21/23 were confident that it could help the problem; 21/23 reported that they would recommend it to a friend; 22/23 indicated it made sense to them. Intervention adherence was moderate, with a median [IQR] EARS score of 12/24 [7-19]. 1 participant reported transient post-exercise soreness. No serious adverse events were reported that were related to the intervention. From interviews, 10/12 participants reported they had continued with the intervention after 12-weeks. Participants revealed that the intervention provided structure and control to their day/week. Additional perceptions of benefit reported included improvements to lower limb joint health, and feelings of increased confidence to return to, or progress to further exercise in the community. The main challenge identified by some participants was lack of space to do the intervention at home. Correlations with the CWA were better for FFI-DS change-scores.

Conclusion

Great Strides has excellent acceptability and appears safe for people with early RA. Levels of adherence may be improved by intervention refinement. FFI-DS scores were theoretically consistent for selection as primary outcome for the main trial.

Disclosures

G.J. Hendry None. L. Bearne None. N. Foster None. E. Godfrey None. S. Hider None. M. van der Leeden None. H. Mason None. A. McConnachie None. I. McInnes None. A. Patience None. C. Sackley None. M. Sekhon None. A. Williams None. J. Woodburn None. M. Steultjens None.

P146 Undertaking an integrated nurse led review (INCLUDE) for patients with inflammatory conditions: does it change management of morbidities?

Background

People with inflammatory rheumatological conditions (IRCs), including rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), polymyalgia rheumatica (PMR) and giant cell arteritis (GCA), are at an increased risk of common comorbidities, such as cardiovascular disease (CVD), osteoporosis and mood problems, which result in poorer patient outcomes. The INCLUDE study assessed the feasibility of conducting a randomised controlled trial (RCT) of a nurse-led, holistic, integrated review in primary care.

Methods

A pilot cluster RCT was delivered across four general practices. Patients with a Read code for an IRC were recruited by postal invitation. In intervention practices (n = 2), eligible patients were invited to attend a nurse-delivered INCLUDE review - an integrated consultation assessing CVD risk (QRisk2), bone health (FRAX) and mood (PHQ2 and GAD2), using a study-specific computerised template. Patients received an individualized patient management plan, including signposting to additional services as appropriate. Medical record review was undertaken (in consenting participants) at 12 months. We compared primary care contacts (which include consultations, letters and test results) and prescribing rates (of antihypertensives, lipid-lowering, osteoporosis and antidepressant/anxiety medication) at baseline and 12 months.

Results

333 patients participated in the study. The mean (SD) age was 68.2 (13.4) years and 200 (60%) were female. Of these 172 (52%) had RA and 88 (26%) had PMR. 154 (46%) reported high blood pressure, 70 (21%) existing anxiety/depression and 37 (11%) osteoporosis. Medical record data was available for 299/333 participants. Participants in intervention practices had more primary care contacts (mean 29 vs 22). Over the 12-month follow-up, there was higher prescribing of all medication classes in participants in intervention practices (see Table), particularly so for osteoporosis medication (baseline 29% vs 12 month 46%).

Conclusion

Nurse-delivered integrated reviews for patients with IRCs identified a significant comorbidity burden. Practices undertaking these reviews had higher prescribing rates at 12 months following treatment of previously un-identified conditions, suggesting that patients with IRCs would benefit from an integrated care review to identify and manage common morbidities.

Disclosures

S. Hider None. A. Machin None. M. Bucknall None. K. Cooke None. C. Jinks None. E. Healey None. A. Finney None. K. Cooke None. S. Wathall None. C. Mallen None. C. Chew-Graham None.

P105 Therapists acceptability of delivering a psychologically informed gait rehabilitation intervention in early rheumatoid arthritis (GREAT): a qualitative interview study

Background

Great Strides is a brief psychologically informed gait rehabilitation intervention (two compulsory face-to-face sessions and up to four optional sessions delivered over 3 months) aimed at improving lower limb function for adults with early rheumatoid arthritis (RA). As part of the Gait Rehabilitation in Early Arthritis Trial (GREAT) feasibility study, physiotherapists and podiatrists received two days of bespoke training delivered by psychologists, physiotherapists and podiatrists on i) the gait rehabilitation exercise programme (six walking exercises) ii) aspects of motivational interviewing (MI) and iii) delivery of key behaviour change techniques (BCTs) to facilitate motivation and adherence to the Great Strides intervention. The training was supported by a bespoke therapist manual and session checklists. The aim of this study was to explore therapists’ acceptability of: (1) the bespoke training received and (2) delivering the intervention within the GREAT feasibility study.

Methods

All 10 therapists who received training were invited to complete semi-structured interviews. The topic guide was informed by the Theoretical Framework of Acceptability (TFA). Interviews were audio recorded, professionally transcribed and a deductive thematic analysis was applied. Data were coded into six TFA constructs (Affective Attitude; Burden; Intervention Coherence; Opportunity Costs; Perceived Effectiveness; Self-efficacy).

Results

Nine out of ten therapists (four physiotherapists, five podiatrists) participated in the semi-structured interviews. Five therapists (four physiotherapists, one podiatrist) delivered the Great Strides intervention. Key barriers and enablers with regards to the acceptability of the bespoke training and intervention delivery were identified. Training: Therapists liked the supportive training environment (affective attitude), understood the purpose of the training sessions (intervention coherence), reported that the role play exercises aided their confidence in applying MI and BCTs (self-efficacy) and found that the training sessions were vital preparation for delivering the intervention (perceived effectiveness). Aspects of training which were considered unacceptable included the lack of time to attend the training sessions (opportunity costs). Delivery: All therapists enjoyed applying MI and BCTs to encourage participants to complete the gait exercises (affective attitude) and valued the opportunity to provide individualised care (intervention coherence). Barriers associated with acceptability included the use of trial-related materials (e.g. checklist) during intervention delivery (burden), interference of intervention delivery with routine clinical workload (opportunity costs) and the time delay between receiving training and initial intervention delivery (perceived effectiveness).

Conclusion

Both GREAT intervention training and delivery were considered acceptable to most therapists. The results have guided key refinements for training and intervention delivery for the GREAT internal pilot and full trial (e.g. remote access to training, timing of training in relation to intervention delivery). These refinements have the potential to improve the bespoke training and enhance the delivery of the Great Strides intervention maximising efficiency and potential for effectiveness.

Disclosures

M. Sekhon None. E. Godfrey None. G. Hendry None. N.E. Foster None. S. Hider None. M. van der Leeden None. H. Mason None. A. McConnachie None. I. McInnes None. A. Patience None. C. Sackley None. M. Steultjens None. A. Williams None. J. Woodburn None. L. Bearne None.

Risk of fragility fracture among patients with gout and the effect of urate-lowering therapy

BACKGROUND

Previous studies that quantified the risk of fracture among patients with gout and assessed the potential effect of urate-lowering therapy have provided conflicting results. Our study aims to provide better estimates of risk by minimizing the effect of selection bias and confounding on the observed association.

METHODS

We used data from the Clinical Practice Research Datalink, which records primary care consultations of patients from across the United Kingdom. We identified patients with incident gout from 1990 to 2004 and followed them up until 2015. Each patient with gout was individually matched to 4 controls on age, sex and general practice. We calculated absolute rate of fracture and hazard ratios (HRs) using Cox regression models. Among patients with gout, we assessed the impact of urate-lowering therapy on fracture, and used landmark analysis and propensity score matching to account for immortal time bias and confounding by indication.

RESULTS

We identified 31 781 patients with incident gout matched to 122 961 controls. The absolute rate of fracture was similar in both cases and controls (absolute rate = 53 and 55 per 10 000 person-years, respectively) corresponding to an HR of 0.97 (95% confidence interval 0.92-1.02). Our finding remained unchanged when we stratified our analysis by age and sex. We did not observe statistically significant differences in the risk of fracture among those prescribed urate-lowering therapy within 1 and 3 years after gout diagnosis.

INTERPRETATION

Overall, gout was not associated with an increased risk of fracture. Urate-lowering drugs prescribed early during the course of disease had neither adverse nor beneficial effect on the long-term risk of fracture.

Antibiotic use and the risk of rheumatoid arthritis: a population-based case-control study

BACKGROUND

Antibiotic-induced disturbances of the human microbiota have been implicated in the development of chronic autoimmune conditions. This study aimed to assess whether antibiotic use is associated with the onset of rheumatoid arthritis (RA).

METHODS

A nested case-control study was conducted utilising data from the primary care Clinical Practice Research Datalink (CPRD). Patients with an incident diagnosis of RA were identified (1995-2017). Each case was matched on age, gender, and general practice to ≥ 5 controls without RA. Conditional logistic regression was used to examine previous antibiotic prescriptions and RA onset after controlling for confounding factors.

RESULTS

We identified 22,677 cases of RA, matched to 90,013 controls, with a median follow-up of 10 years before RA diagnosis. The odds of developing RA were 60% higher in those exposed to antibiotics than in those not exposed (OR 1.60; 95% CI 1.51-1.68). A dose- or frequency-dependent association was observed between the number of previous antibiotic prescriptions and RA. All classes of antibiotics were associated with higher odds of RA, with bactericidal antibiotics carrying higher risk than bacteriostatic (45% vs. 31%). Those with antibiotic-treated upper respiratory tract (URT) infections were more likely to be RA cases. However, this was not observed for URT infections not treated with antibiotics. Antifungal (OR = 1.27; 95% CI 1.20-1.35) and antiviral (OR = 1.19; 95% CI 1.14-1.24) prescriptions were also associated with increased odds of RA.

CONCLUSION

Antibiotic prescriptions are associated with a higher risk of RA. This may be due to microbiota disturbances or underlying infections driving risk. Further research is needed to explore these mechanisms.

Searching for a prodrome for rheumatoid arthritis in the primary care record: A case-control study in the clinical practice research datalink

BACKGROUND

Rheumatoid arthritis (RA) has articular and non-articular manifestations. Early, intensive treatment has substantial benefit for both. This requires patients be identified as soon as symptoms develop.

OBJECTIVES

To determine whether selected signs and symptoms can be identified in the primary care records of patients prior to a formal diagnosis of RA being made and, if so, how early they can be identified.

METHODS

A case-control study was constructed within the UK Clinical Practice Research Datalink (CPRD). 3577 individuals with 'definite' RA, were matched to 14,287 individuals without inflammatory arthritis. An index date was established (i.e., date general practitioner (GP) first appeared to suspect RA). Rates of consultation and consultations for suspected early RA symptoms were compared in cases and controls in the two years prior to the index date using conditional logistic regression, adjusted for number of consultations.

RESULTS

The mean (standard deviation) age of participants was 58.8 (14.5) years and 66.8% were female. Rates of any consultation were significantly higher in RA cases than in controls for at least two years prior to the index date. Cases were more likely to have a pre-diagnosis coded consultation for joint, and particularly hand symptoms (aOR 11.44 (9.60, 13.63)), morning stiffness (8.10 (3.54, 18.5)), carpal tunnel syndrome (4.57 (3.54, 5.88)) and other non-articular features.

CONCLUSIONS

In patients who develop RA, GP consultation rates are higher for at least two years prior to the first recorded suspicion of RA. This study highlights symptoms that should raise a GP's index of suspicion for RA.

Comorbidity clusters in people with gout: an observational cohort study with linked medical record review

Objective

To investigate how comorbid conditions cluster in patients with gout in a UK primary care population.

Methods

A cross-sectional study was performed using baseline data from a primary-care-based prospective observational cohort of people aged ⩾18 years with gout. Participants with gout were identified through primary care medical records. Factor analysis was performed to obtain distinct clusters of comorbidity variables including obesity, hypertension, diabetes mellitus, hyperlipidaemia, coronary heart disease, heart failure, chronic kidney disease (CKD) and cancer. Hierarchical cluster analysis of patient observations was also performed to identify homogenous subgroups of patients based on combinations of their comorbidities.

Results

Four distinct comorbidity clusters (C1-C4) were identified in 1079 participants [mean (s.d.) age 65.5 years (12.5); 909 (84%) male]. Cluster C1 (n = 197, 18%) was the oldest group and had the most frequent attacks of gout; 97% had CKD. Participants in C2 (n = 393, 36%) had isolated gout with few comorbidities but drank alcohol more frequently. In cluster C3 (n = 296, 27%), hypertension, diabetes mellitus, hyperlipidaemia, coronary heart disease and/or CKD were prevalent, and urate-lowering therapy was prescribed more frequently than in other clusters. All patients in C4 (193, 18%) had hypertension and were more likely to be obese than other clusters.

Conclusion

Four distinct comorbidity clusters were identified. People with multiple comorbidities were more likely to receive allopurinol. Tailoring of treatments depending on cluster and comorbidities should be considered.

The real evidence for polymyalgia rheumatic as a paraneoplastic syndrome

Not available.

Risk of fragility fracture among patients with late-onset psoriasis: a UK population-based study

This study aimed to examine fracture risk in patients with late-onset psoriasis. A cohort study was conducted using primary care records from the Clinical Practice Research Datalink. Psoriasis patients had a 10% increased risk of fracture compared to matched controls (hazard ratio (HR) = 1.10; 95% confidence interval (CI) 1.04, 1.16).

INTRODUCTION

This study aimed to examine fracture risk in patients with late-onset psoriasis and investigate the effect of methotrexate on fracture risk.

METHODS

A cohort study was conducted using primary care records from the UK-based Clinical Practice Research Datalink. Individuals aged 40 years and over, with incident (new onset) diagnoses of psoriasis, were identified from 1990 to 2004 and followed up until 2015. For each exposed individual, up to four age-, gender-, and practice-matched controls were randomly selected. Incidence rates of fragility fracture (hip, vertebral, spine, radius or unspecified site) per 10,000 person-years were calculated and hazard rates were compared to the unexposed using Cox regression models. The risk of fracture was also estimated, within the exposed group for patients receiving/not receiving methotrexate.

RESULTS

Twenty-four thousand two hundred nineteen patients with psoriasis and 94,820 controls were identified. The absolute rate of fracture in psoriasis patients was 58 per 10,000 person-years (95% CI 55, 61) and 53 per 10,000 person-years in the matched controls (CI 52, 54). Psoriasis patients had a 10% increased risk of fracture compared to their matched controls (HR = 1.10; 95% CI 1.04, 1.16). Methotrexate use was not associated with increased risk (HR = 0.91; 95% CI 0.72, 1.15).

CONCLUSIONS

Identifying additional clinical factors associated with increased fracture risk is important in improving fracture risk stratification. Further work is needed to determine the relationship between age of onset of psoriasis and fracture risk, explore causative explanations, and identify if existing fracture risk stratification tools underestimate fracture risk in patients with psoriasis.

The real evidence for polymyalgia rheumatica as a paraneoplastic syndrome

The aim of this study was to systematically consider the evidence for polymyalgia rheumatica (PMR) as a paraneoplastic disease. A systematic review of Medline and Embase was conducted from their inception to February 2017. Risk of bias was assessed using the Newcastle-Ottawa tool. Data were extracted regarding the PMR-cancer association, the types of cancer associated with PMR and the presentation of PMR patients subsequently diagnosed with cancer. Twenty-three full text articles were reviewed from the 1174 unique references identified in the search. Nine articles were included in the final review. There was some evidence of an association between PMR and cancer in the short-term (first 6 to 12 months after diagnosis), but no evidence of an association after this time. Limited evidence suggests that lymphoma, prostate and haematological cancers may be those cancers more commonly diagnosed in those with PMR. There was little evidence to suggest what presenting features may be associated with the development of cancer. There is little evidence of PMR as a true paraneoplastic disease. However, there is reason to be cautious when making the diagnosis of PMR. Clinicians should be aware of this potential association both prior to making a diagnosis and throughout the course of the condition.

Risk of fracture among patients with polymyalgia rheumatica and giant cell arteritis: a population-based study

BACKGROUND

Glucocorticoids are associated with increased fracture risk and are the mainstay of treatment in polymyalgia rheumatica (PMR) and giant cell arteritis (GCA). However, fracture risk in these conditions has not been previously quantified. The aim of this study was to quantify the risk of fracture among patients with PMR and GCA.

METHODS

A retrospective cohort study was conducted using primary care records from the UK-based Clinical Practice Research Datalink. Individuals aged 40 years and over, with incident diagnoses of PMR or GCA were separately identified from 1990-2004 and followed up until 2015. For each exposed individual, four age-, sex- and practice-matched controls were randomly selected. Incidence rates of fracture per 10,000 person-years were calculated for each disease group and hazard rates were compared to the unexposed using Cox regression models.

RESULTS

Overall, 12,136 and 2673 cases of PMR and GCA, respectively, were identified. The incidence rate of fracture was 148.05 (95% CI 141.16-155.28) in PMR and 147.15 (132.91-162.91) in GCA per 10,000 person-years. Risk of fracture was increased by 63% in PMR (adjusted hazard ratio 1.63, 95% CI 1.54-1.73) and 67% in GCA (1.67, 1.49-1.88) compared to the control populations. Fewer than 13% of glucocorticoid-treated cases were prescribed bisphosphonates.

CONCLUSIONS

This study reports, for the first time, a similar increase in fracture risk for patients with PMR and GCA. More needs to be done to improve adherence to guidelines to co-prescribe bisphosphonates. Further research needs to identify whether lower glucocorticoid starting doses and/or aggressive dose reduction reduces fracture risk.

Evaluating on-line health information for patients with polymyalgia rheumatica: a descriptive study

BACKGROUND

The Internet is increasingly used to access health information, although the quality of information varies. The aim of this study was to evaluate the readability, and quality of websites about polymyalgia rheumatica (PMR).

METHODS

Three UK search engines (Google, Yahoo and Bing) were searched for the term 'polymyalgia rheumatica'. After deleting duplicates, the first 50 eligible websites from each were evaluated. Readability was assessed using the Flesch Reading Ease and 'Simple Measure of Gobbledygook (SMOG) Readability' indicators. Credibility was assessed using a previously published Credibility Indicator.

RESULTS

Of the 52 unique websites identified, the mean (standard deviation) Flesch Reading Ease and SMOG Readability scores were 48 (15) and 10 (2), respectively. The mean (SD) Credibility Indicator was 2 (1). Fifty (96%) of websites were accurate. Website design and content was good, with an average of 68 and 64% respectively, of the assessed criteria being met.

CONCLUSIONS

Most websites about PMR require a higher readability age than is recommended. Thus whilst websites are often well designed and accurate this study suggests that their content could be refined and simplified to maximise patient benefit.

A joint effort over a period of time: factors affecting use of urate-lowering therapy for long-term treatment of gout

Background

Although international guidelines encourage urate lowering therapy (ULT) for people who have more than two attacks of gout, only 30 % of patients are prescribed it and only 40 % of those adhere to the treatment. The aim was to explore reasons for this through an exploration of patient experience and understanding of ULT treatment for gout.

Methods

A qualitative study was conducted throughout the United Kingdom. Narrative and semi-structured video-recorded interviews and thematic analysis were used.

Results

Participants talked about their views and experiences of treatment, and the factors that affected their use of ULT. The analysis revealed five main themes: 1) knowledge and understanding of gout and its treatment; 2) resistance to taking medication; 3) uncertainty about when to start ULT; 4) experiences of using ULT; and 5) desire for information and monitoring.

Conclusion

Patients’ understanding and experiences of gout and ULT are complex and it is important for clinicians to be aware of these when working with patients. It is also important for clinicians to know that patients’ perceptions and behaviour are not fixed, but can change over time, with changes to their condition, with dialogue and increased understanding. Patients want this interaction with their clinicians, through “a joint effort over a period of time”.

"Why me? I don't fit the mould … I am a freak of nature": a qualitative study of women's experience of gout

Background

Gout is more common in men, and is often perceived by both patients and health practitioners to be a disorder of men, but its prevalence in women is increasing. Little is known about women’s experience of gout and the impact it has on their lives. It is important for practitioners to be aware of these areas, given the increasing numbers of women with gout they are likely to see in the future. This study aimed to explore women’s experiences of gout.

Methods

A qualitative research design was used. Semi-structured interviews were conducted with 43 people, of whom 14 were women. Interviews were video and/or tape recorded and transcribed verbatim. Data from the interviews was first grouped into broad categories, followed by a more detailed thematic analysis and interpretation.

Results

Participants’ ages ranged from 32 to 82. Nine participants were retired and five were in fulltime work. Four themes emerged: (1) experience of onset, help seeking and diagnosis (2) understanding and finding information about gout, (3) impact on identity, and (4) impact on roles and relationships.

Conclusions

The diagnostic process for women with gout can be uncertain due to lack of awareness of gout in women (by health care professionals and women themselves). Women do not have a good understanding of the condition and find it difficult to find information that feels relevant to them. Gout has a major impact on women’s identity and on their roles and relationships. These findings are of importance to health care professionals dealing with women with potential gout and those with an existing diagnosis.

Prospective observational cohort study of Health Related Quality of Life (HRQOL), chronic foot problems and their determinants in gout: a research protocol

Background

Gout is the commonest inflammatory arthritis affecting around 1.4% of adults in Europe. It is predominantly managed in primary care and classically affects the joints of the foot, particularly the first metatarsophalangeal joint. Gout related factors (including disease characteristics and treatment) as well as comorbid chronic disease are associated with poor Health Related Quality of Life (HRQOL) yet to date there is limited evidence concerning gout in a community setting. Existing epidemiological studies are limited by their cross-sectional design, selection of secondary care patients with atypical disease and the use of generic tools to measure HRQOL. This 3 year primary care-based prospective observational cohort study will describe the spectrum of HRQOL in community dwelling patients with gout, associated factors, predictors of poor outcome, and prevalence and incidence of foot problems in gout patients.

Methods

Adults aged ≥ 18 years diagnosed with gout or prescribed colchicine or allopurinol in the preceding 2 years will be identified through Read codes and mailed a series of self-completion postal questionnaires over a 3-year period. Consenting participants will have their general practice medical records reviewed.

Discussion

This is the first prospective cohort study of HRQOL in patients with gout in primary care in the UK. The combination of survey data and medical record review will allow an in-depth understanding of factors that are associated with and lead to poor HRQOL and foot problems in gout. Identification of these factors will improve the management of this prevalent, yet under-treated, condition in primary care.

The epidemiology of polymyalgia rheumatica in primary care: a research protocol

BACKGROUND

Polymyalgia Rheumatica (PMR) is the commonest inflammatory condition seen in older patients in primary care. To date, however, research has been focused on secondary care cohorts rather than primary care where many patients are exclusively managed. This two year prospective inception cohort study of PMR patients will enable us to understand the full spectrum of this condition.

METHODS

Patients diagnosed with PMR in primary care will be identified via Read codes and mailed a series of postal questionnaires over a two-year period to assess their levels of pain, stiffness and functioning, as well as medication usage and other health-related and socio-demographic characteristics. In addition, participants will be asked for permission to link their survey data to their general practice electronic medical record and to national mortality and cancer registers.

DISCUSSION

This will be the first large-scale, prospective, observational cohort of PMR patients in primary care. The combination of survey data with medical records and national registers will allow for a full investigation of the natural history and prognosis of this condition in the primary care setting, in which the majority of patients are treated, but where little research on the treatment and outcome of consultation has been undertaken. This will provide information that may lead to improved primary care management of PMR.