Translation and initial cross-cultural adaptation of the tool for support-gradual return-to-work for persons with chronic musculoskeletal pain to the Swedish setting

BACKGROUND

A well-defined and clear procedure is a key factor supporting return-to-work and enhancing collaboration and understanding between employers and employees. The adaptation of the Tool for Support-Gradual Return to Work, TS-GRTW, addresses relevant cultural aspects valuable for wider adoption.

OBJECTIVE

develop a Swedish version, the GRTWswe, for implementation and integration into the Swedish labor market's RTW process. This involved translating, culturally adapting, and assessing the appropriateness and utility.

METHODS

In the initial step, a double back translation was performed to create an initial translated version. This version was then utilized in individual consultations, accompanied by an agreement questionnaire. For the subsequent step, group consultations were held to refine and customize the tool to suit the Swedish context. Ten occupational therapists completed the questionnaires, with mean agreement scores surpassing three on a four-point scale. Out of these, nine participated in group consultations.

RESULTS

The findings suggest the requirement for specific modifications to the GRTWswe. These adaptations are essential because of cultural differences in organizational structures and reference frameworks. Moreover, participants unanimously agreed to broaden the scope of target groups, encompassing employees without regard for diagnosis and expanding the range of professions that can utilize this tool. This step aims to enhance the tool's applicability and usefulness.

CONCLUSIONS

The study found strong alignment between questionnaire responses and group consultations outcomes, affirming the adapted tool's suitability for use in a Swedish context. The tool benefits employers and employees by enhancing communication, encouraging collaboration, and structuring processes, promising lasting improvements to work conditions.

Evaluating the Clinical Use and Utility of a Digital Support App for Employees With Chronic Pain Returning to Work (SWEPPE): Observational Study

BACKGROUND

The digital app SWEPPE (sustainable worker, a digital support for persons with chronic pain and their employers) was developed to improve the support of people with chronic pain in their return-to-work process after sick leave and includes functions such as the action plan, daily self-rating, self-monitoring graphs, the coach, the library, and shared information with the employer.

OBJECTIVE

This study aims to describe the use of the smartphone app SWEPPE among people with chronic pain who have participated in an interdisciplinary pain rehabilitation program.

METHODS

This is a case study including 16 people participating in a feasibility study. The analyses were based on user data collected for 3 months. Quantitative data regarding used functions were analyzed with descriptive statistics, and qualitative data of identified needs of support from the employer were grouped into 8 categories.

RESULTS

Self-monitoring was used by all participants (median 26, IQR 8-87 daily registrations). A total of 11 (N=16, 69%) participants set a work-related goal and performed weekly evaluations of goal fulfillment and ratings of their work ability. In total, 9 (56%) participants shared information with their employer and 2 contacted the coach. A total of 15 (94%) participants identified a total of 51 support interventions from their employer. Support to adapt to work assignments and support to adapt to work posture were the 2 biggest categories. The most common type of support identified by 53% (8/15) of the participants was the opportunity to take breaks and short rests.

CONCLUSIONS

Participants used multiple SWEPPE functions, such as daily self-registration, goal setting, self-monitoring, and employer support identification. This shows the flexible nature of SWEPPE, enabling individuals to select functions that align with their needs. Additional research is required to investigate the extended use of SWEPPE and how employers use shared employee information.

Acceptability of the eHealth Intervention Sustainable Worker Digital Support for Persons With Chronic Pain and Their Employers (SWEPPE): Questionnaire and Interview Study

BACKGROUND

Sick leave and decreased ability to work are the consequences of chronic pain. Interdisciplinary pain rehabilitation programs (IPRPs) aim to improve health-related quality of life and participation in work activities, although implementing rehabilitation strategies at work after IPRPs can be difficult. Employers' knowledge about pain and the role of rehabilitation needs to be strengthened. The self-management of chronic pain can be improved through eHealth interventions. However, these interventions do not involve communicating with employers to improve work participation. To address this deficiency, a new eHealth intervention, Sustainable Worker Digital Support for Persons with Chronic Pain and Their Employers (SWEPPE), was developed.

OBJECTIVE

This study aimed to describe the acceptability of SWEPPE after IPRPs from the perspective of patients with chronic pain and their employers.

METHODS

This study included 11 patients and 4 employers who were recruited to test SWEPPE in daily life for 3 months after IPRPs. Data were collected using individual interviews at the end of the 3-month test period and questionnaires, which were completed when SWEPPE was introduced (questionnaire 1) and at a 3-month follow-up (questionnaire 2). Data were also collected on how often SWEPPE was used. Qualitative data were analyzed through a qualitative content analysis using an abductive approach. The framework used for the deductive approach was the theoretical framework of acceptability. Quantitative data were analyzed through descriptive statistics and the differences between the responses to questionnaires 1 and questionnaire 2 using the Wilcoxon signed rank test.

RESULTS

Both patients and employers reported that SWEPPE increased their knowledge and understanding of how to improve work participation and helped them identify goals, barriers, and strategies for return to work. In addition, participants noted that SWEPPE improved employer-employee communication and collaboration. However, experiences and ratings varied among participants and the different SWEPPE modules. The acceptability of SWEPPE was lower in patients who experienced significant pain and fatigue. A high degree of flexibility and choice of ratings in SWEPPE were generally described as helpful.

CONCLUSIONS

This study shows promising results on the user acceptability of SWEPPE from both patient and employer perspectives. However, the variations among patients and modules indicate a need for further testing and research to refine the content and identify the group of patients who will best benefit from SWEPPE.

Rehabilitation following flexor tendon injury in Zone 2: a randomized controlled study

The aim of this study was to compare an early active motion (EAM) regimen to a modified Kleinert passive motion therapy in Zone 2 flexor tendon injuries with regards to range of motion (ROM), grip strength and patient-reported outcome measures (PROMs). Seventy-two patients were included. At 3 months postoperatively, we found no difference in total active motion (TAM) between the EAM and the Kleinert groups (median 195.5°, range 115°-273° versus median 191.5°, range 113°-260°), but a significantly better grip strength (median 76%, range 44%-99% versus median 54%, range 19%-101%; p < 0.0005) in the EAM group. Disabilities of the Arm, Shoulder and Hand (DASH) score as well as patient-reported weakness, cold intolerance and problems in daily activities also favoured the EAM group. At 12 months postoperatively, there was no difference in TAM, grip strength or any of the PROMs used. We conclude that EAM leads to a quicker recovery in terms of grip strength and PROMs, but that both regimens lead to similar results at 12 months.Level of evidence: I.

Patients' experiences of flexor tendon rehabilitation in relation to adherence: a qualitative study

PURPOSE

To explore patients' experiences of early active motion flexor tendon rehabilitation in relation to adherence to restrictions and outcome of rehabilitation.

METHOD

Seventeen patients with a flexor tendon injury in one or several fingers participated in qualitative interviews performed between 74 and 111 days after surgery. Data were analysed using directed content analysis with the Health Belief Model (HBM) as a theoretical framework.

RESULTS

Perceived severity of hand function and susceptibility to loss of hand function affected the participants' behaviour. A higher perceived threat increased motivation to exercise and be cautious in activities. During rehabilitation, the perceived benefits or efficacy of doing exercise and following restrictions were compared to the cost of doing so, leading to adherence or non-adherence behaviour. Perceived self-efficacy was affected by previous knowledge and varied through the rehabilitation period. External factors and interaction with therapists influenced the perception of the severity of the injury and the cost and benefits of adhering to rehabilitation.

CONCLUSION

Patient's perception of the injury, the effectiveness of exercises, context and social support to manage daily life affected adherence to restriction, motivation and commitment to rehabilitation. The HBM as a theoretical framework can be beneficial for understanding factors that influence patients' adherence.Implications for RehabilitationInformation regarding the injury and consequences for the patient should be presented at different time points and in different ways, tailored to the patient.It' is important to aid patients to perceive the small gradual improvements in hand function to create motivation to adhere to exercise.Strategies to reduce the cost of adherence in terms of managing everyday life should be addressed by individually based strategies.Instructions regarding exercise and restrictions should be less complex and consider the patient's individual needs.

Patients' perspectives of collagenase injection or needle fasciotomy and rehabilitation for Dupuytren disease, including hand function and occupational performance

PURPOSE

To describe patients' perspectives of collagenase injection or needle fasciotomy for Dupuytren disease (DD) including hand therapy, and their view of hand function and occupational performance.

MATERIALS AND METHODS

Interviews were performed with twelve patients who had undergone non-surgical treatment and rehabilitation for DD. Data was analysed using a problem-driven content analysis using the model of Patient Evaluation Process as a theoretical framework.

RESULTS

The participants' previous experiences influenced their expectations of the upcoming treatment and they needed information to be prepared for treatment. Treatment and rehabilitation had a positive impact on daily life and were regarded as effective and simple with quick recovery. However, there could be remaining issues with tenderness or stiffness. The participants expressed their belief in rehabilitation and how their own efforts could contribute to an improved result. Despite concerns about future recurrence participants described increased knowledge and sense of control regarding future needs.

CONCLUSION

Undergoing a non-surgical treatment and rehabilitation process for DD was regarded as quick and easy and can meet the need for improved hand function and occupational performance. Taking responsibility for one's own rehabilitation was considered to influence the outcome positively. The theoretical framework optimally supported the exploration of participants' perspective.Implications for rehabilitationTreatment of Dupuytren Disease (DD) with needle/collagenase combined with hand therapy was experienced as giving fast improvement in hand function and occupational performance.An individualized care process which satisfies the need for knowledge about the disease, prognosis, treatment options and rehabilitation can give individuals suffering from DD a sense of security.The need for active participation in the DD care process can vary and it is crucial to listen to individuals' opinions and needs.Individuals can take considerable responsibility for rehabilitation after non-surgical treatment for DD and regard it as important for the outcome.

Incidence, demographics and rehabilitation after digital nerve injury: A population-based study of 1004 adult patients in Sweden

OBJECTIVE

The main objective of this study was to describe the epidemiology of surgically repaired digital nerve injuries in a Swedish population. Secondary objectives were to describe the demographics of the patient population, injury characteristics, post-operative care and rehabilitation.

METHODS

From 2012 to 2018, 1004 patients with a surgically repaired digital nerve injury resident in the Stockholm region were identified in the Swedish national quality registry for hand surgery and all medical records were thoroughly reviewed.

RESULTS

The incidence rate was 8.3 per 100.000 person-years and these injuries were more common in men than women. The median age at the time of injury was 37 years and a sharp cut was the most common mechanism of injury. Injuries were equally distributed over weekdays and the year, but surgery was most often performed on Mondays. There were no differences in treatment and rehabilitation regimens between sexes, except women were more likely than men to be operated within three days from injury. Timing and content of rehabilitation varied largely between individuals. One third of patients did not receive any sensory relearning and sensory assessment was performed in only 7%.

CONCLUSION

The epidemiology shows no major changes over the last decade. However, we found a large individual variation in follow up visits, rehabilitation content and assessments indicating large differences in consumption of health care resources. Our findings expose the need to further improve and evaluate rehabilitation regimens after digital nerve injury.

Risk factors for reoperation after flexor tendon repair: a registry study

The aim of this study was to identify risk factors for reoperations after Zones 1 and 2 flexor tendon repairs. A multiple logistic regression model was used to identify risk factors from data collected via the Swedish national health care registry for hand surgery (HAKIR). The studied potential risk factors were age and gender, socio-economics and surgical techniques. Included were 1372 patients with injuries to 1585 fingers and follow-up of at least 12 months (median 37 IQR 27-56). Tendon ruptures occurred in 80 fingers and tenolysis was required in 76 fingers. Variables that affected the risk of rupture were age >25 years (p < 0.001), flexor pollicis longus tendon injuries (p < 0.001) and being male (p = 0.004). Injury to both finger flexors had an effect on both rupture (p = 0.005) and tenolysis (p < 0.001). Understanding the risk factors may provide important guidance both to surgeons and therapists when treating patients with flexor tendon injuries.Level of evidence: III.

POS0559 COMPLIANCE WITH RECOMMENDATIONS OF LOW INTAKE OF RED MEAT AND HIGH FIBER INTAKE IS ASSOCIATED WITH A REDUCED RISK OF RHEUMATOID ARTHRITIS

Background

Diet has received much attention as a factor that may contribute to the development of rheumatoid arthritis (RA). Several different nutrients, food components and dietary patterns have been studied in different populations. There is limited information on the importance of compliance with diet recommendations in this context.

Objectives

The aim of this study was to investigate the relation between overall dietary quality, diet components, and the risk of RA.

Methods

Participants in a population-based survey conducted in 1991-1996 who were subsequently diagnosed with RA (from inclusion until December 2004) were identified through register linkage and validated in a structured process. Four controls for each case, matched for sex, year of birth, and year of inclusion, were selected from the study cohort. The controls were alive and RA-free when the index person was diagnosed with RA. At inclusion, diet was assessed using a modified diet history method, consisting of a seven-day food record, a food questionnaire, and a supplementary interview.

The New Diet Score (NDS) reflects the recommendations in the Swedish dietary guidelines (SDG) from 2015, produced developed by the Swedish Food Agency, which in turn are based on the Nordic Nutrition Recommendations from 2012. According to the SDG, it is recommended to eat more fiber, vegetables and fruits and fish, and less red meat and added sugars. The mentioned dietary components are all included in the NDS, with a range 0-5. A score of 1 was assigned to each component where the individual complied with the recommendation. Non-compliance was assigned a score of 0. The cutoff values for the recommendations are based on a previously validated Diet Quality Index, except for red meat (based on SDG) and added sugars (based on World Health Organization guidelines from 2015 for sugar intake).

We used conditional logistic regression analysis to study the relation between NDS, its components, and RA. The NDS was divided into categories, defined as low (0–1), moderate (2–3) and high (4-5), with “low” as reference, and also assessed as a continuous variable. All models were adjusted for reported total energy intake, and potential misreporters of total energy intake were excluded.

We designed multivariable-adjusted models in which we included covariates that had been associated with diet and RA (smoking, alcohol and leisure time physical activity).

Results

In the study population, 172 RA cases were identified. Low red meat intake (<500 g/week) was significantly associated with a decreased risk of RA (Table 1). Compliance with the recommendations for intake of fiber and vegetables and fruit were inversely associated with RA, with a similar trend for the total NDS (Table). In additional multivariable analysis, including both variables and relevant confounders, compliance with recommendations for red meat intake (odds ratio (OR) 0.43; 95% CI 0.22-0.85) and for fiber intake (OR 0.53; 95% CI 0.30-0.94) were both associated with a reduced risk of RA.

Table 1.

Multivariable-adjusted odds ratios (ORs) describing the relation between New Diet Score (NDS) and its components and the risk of developing rheumatoid arthritis

Adjusted for reported energy intake, smoking, alcohol, leisure time physical activityNDS componentsRecommendationOR95% CI Fibre≥2.4 g/MJ0.510.29–0.90 Vegetables and fruits≥400 g/day0.550.32–0.95 Fish≥300 g/week1.250.76–2.05 Added sugar≤10 E%1.100.68–1.78 Red meat<500 g/week0.420.22–0.81NDS 0–11.00(Ref) 2–30.650.38–1.10 4–50.670.30–1.46 Per point increment0.820.67–1.00

Conclusion

These preliminary results indicate that low intake of red meat and higher fiber intake, in line with current recommendations, are independently associated with reduced risk of developing RA, suggesting that components found in meat and fiber-rich foods may affect very early disease mechanisms.

Disclosure of Interests

None declared.

POS0500 LEVELS OF IL-6 AND OTHER INFLAMMATORY PROTEINS IN EARLY RA PREDICT JOINT DAMAGE PROGRESSION OVER 5 YEARS

Background

Joint damage in rheumatoid arthritis (RA) remains a significant problem. Identification of biomarkers associated with joint destruction can improve our understanding of underlying disease processes and future management.

Objectives

To evaluate inflammatory proteins as potential predictors of radiographic progression of joint damage.

Methods

Consecutive early RA patients (symptom duration <12 months), recruited 1995-2005 from a defined area, were followed through 5 years in an observational study. Radiographs of hands and feet were scored in chronological order by a trained reader according to the modified Sharp-van der Heijde score (SHS). Stored plasma samples from the baseline visit were analyzed for levels of 92 inflammatory proteins (Inflammation panel by O-link). Statistical analyses were pre-designated as hypotheses-driven or exploratory. For the latter, principal component analysis was used to identify groups of proteins that explain the variance in the proteome. Within components selected based on Eigenvalues, proteins with a factor loading of >0.50 were investigated as potential predictors of radiographic progression. Logistic and linear regression models were used to assess associations with rapid radiographic progression (RRP; ≥5 SHS/year) and progression of SHS over 5 years.

Results

Data on baseline levels of proteins, and radiographs at baseline and 5 years were available for 114 patients. The median progression of SHS was 11 (interquartile 2-19). For potential biomarkers with an a priori hypothesis, IL-6 significantly predicted both RRP and progression of SHS over 5 years analyzed as a continuous variable [adjusted ß = 0.09 per SD, p=0.032, adjusted for rheumatoid factor (RF) and baseline SHS]. A significant positive association for matrix metalloproteinase 1 (MMP-1) was observed in the unadjusted analysis for SHS progression, but not for RRP (Table 1). In the exploratory analyses, S100 calcium-binding protein A12 (EN-RAGE) was positively, and TNF-related apoptosis-inducing ligand (TRAIL) negatively associated with both outcomes.

Table 1.

Baseline inflammatory protein biomarkers and progression of joint damage over 5 years in rheumatoid arthritis

Rapid radiographic progressionSHS progression (continuous)CrudeAdjusted*CrudeAdjusted*VariablesOR95% CIPP (corr)§OR95% CIPP (corr)§Beta95% CIPP (corr)§Beta95% CIPP (corr)§A priori hypothesis°IL-61.831.11-3.010.0180.141.620.96-2.750.0720.580.140.06-0.230.0020.0160.090.01-0.170.0320.26MMP-11.560.92-2.660.100.551.440.84-2.470.190.960.110.02-0.200.0190.130.08-0.01-0.160.0720.50Exploratory analyses†MCP-31.641.01-2.650.0451.991.14-3.490.0160.03-0.07-0.120.570.04-0.05-0.120.39CDCP11.761.07-2.910.0272.141.22-3.780.0090.06-0.03-0.150.190.08-0.00-0.160.063SLAMF11.641.05-2.570.0311.611.01-2.560.0470.06-0.02-0.150.160.05-0.02-0.130.15TNFSF141.671.08-2.600.0221.530.98-2.370.0600.07-0.02-0.150.120.04-0.04-0.110.30EN-RAGE2.771.56-4.940.0012.441.34-4.430.0040.160.08-0.25<0.0010.100.02-0.190.014LIF1.961.13-3.400.0171.730.95-3.140.0730.110.02-0.200.0190.06-0.03-0.150.18Flt-3L0.600.36-0.980.0400.680.40-1.140.15-0.11-0.20-’-0.030.011-0.07-0.15-0.010.075DNER0.720.42-1.250.250.690.37-1.270.23-0.10-0.19-’-0.000.049-0.08-0.17-0.000.054CD8A0.740.49-1.120.160.850.55-1.310.45-0.09-0.17-’-0.010.031-0.05-0.12-0.030.23TRAIL0.500.30-0.830.0070.510.29-0.880.016-0.12-0.20-’-0.030.007-0.08-0.16-0.000.048

Variables per SD.

* Adjusted for RF and baseline SHS.

§ Holms correction for multiple testing for a priori hypotheses only.

° No significant associations for TNF-alpha, Osteoprotegerin, IL-17A, CCL11, CCL19 or VEGFA.

† Only biomarkers with significant associations shown.

Conclusion

Plasma levels of IL-6 at RA diagnosis predict degree of future joint damage. EN-RAGE and TRAIL, both modulators of NF-κB which is known to regulate immune response, are potential biomarkers that need further investigation.

Disclosure of Interests

Emil Rydell: None declared, Kristina Forslind: None declared, Lennart T.H. Jacobsson Consultant of: Novartis, Eli-Lily and Janssen, Carl Turesson Speakers bureau: AbbVie, BMS, Nordic Drugs, Pfizer, Roche, Consultant of: Roche, Grant/research support from: BMS.

POS0617 SYNOVITIS OF THE FIRST METACARPOPHALANGEAL JOINT HAS A MAJOR IMPACT ON GRIP FORCE IN EARLY RHEUMATOID ARTHRITIS

Background

Rheumatoid arthritis (RA) has a major impact on hand function in many patients. Information on the contribution of individual joints to impaired grip strength may be helpful for guiding individualized management.

Objectives

The objective of this study was to investigate the relation between swelling and tenderness of individual finger joints and grip force in patients with early RA.

Methods

An inception cohort of patients with early RA (symptom duration ≤12 months), recruited in 1995-2005, was investigated and followed in a structured program, with follow-up evaluations after 1 and 5 years. All patients were examined by the same rheumatologist according to a structured protocol. Grip force (Newton) was measured using the electronic instrument Grippit (AB Detektor, Gothenburg, Sweden). Average grip force values of each hand were evaluated and compared to the expected, based on age- and sex-specific reference values from the literature (1). Grip force was expressed as % of expected values. Linear regression analyses were used to assess the relation between involvement of individual finger joints and grip force. Synovitis and joint tenderness were assessed in separate models. As wrist involvement, high erythrocyte sedimentation rate (ESR) and severe patient reported pain have been independently associated with reduced grip force in early RA (2), the analyses were adjusted for these covariates.

Results

A total of 215 patients with early RA (71 % women; mean age 60 years) were investigated. The median symptom duration at inclusion was 7 months; interquartile range 5-10. In the right hand, synovitis of the first metacarpophalangeal (MCP) joint was consistently associated with reduced grip force at all evaluations (Table 1). Patients with MCP II and MCP III synovitis also had reduced grip force at inclusion, but not after 1 and 5 years. Proximal interphalangeal (PIP) joint swelling (Table 1), and tenderness of MCP or PIP joints, had a lower impact on grip force. Results were largely similar for the left hand.

Table 1.

Relation between synovitis of individual MCP and PIP joints and grip force of the right hand (% of expected) in patients with early RA; β (95 % CI), adjusted for wrist synovitis, ESR and VAS pain

Inclusion1-year follow-up5-year follow-upMCP I-10.8 (-17.1 to -4.4)-8.0 (-14.8 to -1.2)-8.2 (-16.4 to 0)MCP II-7.5 (-13.9 to -1.1)-0.6 (-7.6 to 6.4)-0.6 (-8.2 to 9.5)MCP III-7.4 (-13.5 to -1.3)-1.3 (-9.4 to 6.8)-4.5 (-13.4 to 4.5)MCP IV-8.9 (-18.5 to 0.7)-8.8 (-25.7 to 8.1)-4.0 (-22.1 to 14.0)MCP V-2.5 (-12.6 to 7.6)-2.6 (-16.5 to 11.2)7.4 (-5.2 to 20.0)IP I2.0 (-6.4 to 10.9)-1.6 (-14.0 to 10.7)-5.1 (-23.3 to 13.2)PIP II-0.8 (-7.7 to 6.2)-3.9 (-13.3 to 5.5)-3.2 (-16.2 to 9.8)PIP III-5.6 (-12.1 to 1.0)2.5 (-6.5 to 11.6)1.9 (-9.0 to 12.9)PIP IV-4.1 (-11.8 to 3.6)-1.9 (-12.8 to 9.0)-0.1 (-14.2 to 14.1)PIP V-7.2 (-16.0 to 1.7)-10.3 (-22.8 to 2.3)-5.6 (-21.2 to 9.9)

Conclusion

MCP I synovitis is a major contributor to reduced grip force in patients with early RA during the first 5 years after diagnosis, independent of wrist synovitis, general pain and systemic inflammation. This underlines the importance of involvement of the thumb for impaired hand function in RA.

References

[1]Nilsen T et al. Scand J Occup Ther 2012; 19: 288-96

[2]Rydholm et al. Rheumatol Int 2019; 39: 2031-41

Disclosure of Interests

None declared

Evidence-based digital support during 1 year after an Interdisciplinary Pain Rehabilitation Programme for persons with chronic musculoskeletal pain to facilitate a sustainable return to work: a study protocol for a registry-based multicentre randomised controlled trial

INTRODUCTION

Chronic musculoskeletal pain (CMSP) severely affects the individual's quality of life, functioning and ability to work, and comes with significant societal costs for sick leave and productivity loss. After rehabilitation, patients with CMSP often experience lack of support when responsibility for the return-to-work process is taken over by the employer. Therefore, we aim to evaluate the effectiveness of a digital support (Sustainable WorkEr digital support for Persons with chronic Pain and their Employers (SWEPPE)) for promoting a sustainable return-to-work for persons with CMSP and to facilitate the employers' supportive role and responsibilities in the process.

METHODS AND ANALYSIS

In this registry-based multicentre randomised controlled trial, 360 patients with CMSP will be randomised to either receive the smartphone application SWEPPE (n=180) or to a control group (n=180). The intervention group will use SWEPPE for 1 year and the control group will not receive any intervention for return to work (RTW). Participants will be recruited from approximately 10 specialist and primary care level units connected to the Swedish National Quality Registry for Pain Rehabilitation providing Interdisciplinary Pain Rehabilitation Programmes (IPRP) for CMSP. Eligibility criteria are age 18-65 years and a need for support in RTW or continued support at work for creating a sustainable work situation. Baseline data will be collected when the participants have completed the IPRP. Final assessment will be performed after 12 months. The primary outcome will be a number of days with sickness cash benefit. Secondary outcomes and explanatory variables including important domains affected by CMSP such as health-related quality of life, functioning and work ability will be collected.

ETHICS AND DISSEMINATION

The Swedish Ethics Review Board approved the study (Dnr 2020-01593, Dnr 2021-01854). The study findings will be disseminated through publication, national and international conferences, and meetings to be available for patients, healthcare providers or stakeholders.

TRIAL REGISTRATION NUMBER

NCT05058547.

Development of a Digital Support Application With Evidence-Based Content for Sustainable Return to Work for Persons With Chronic Pain and Their Employers: User-Centered Agile Design Approach

BACKGROUND

Persons with chronic pain experience a lack of support after completing rehabilitation and the responsibility for the return-to-work (RTW) process is taken over by the employer. In addition, employers describe not knowing how to support their employees. Smartphone apps have been increasingly used for self-management, but there is a lack of available eHealth apps with evidence-based content providing digital support for persons with chronic pain and their employers when they return to work.

OBJECTIVE

This study aims to describe the development of a digital support application with evidence-based content that includes a biopsychosocial perspective on chronic pain for sustainable RTW for persons with chronic pain and their employers (SWEPPE [Sustainable Worker Digital Support for Persons With Chronic Pain and Their Employers]).

METHODS

A user-centered agile design approach was applied. The multidisciplinary project team consisted of health care researchers, a user representative, and a software team. A total of 2 reference groups of 7 persons with chronic pain and 4 employers participated in the development process and usability testing. Mixed methods were used for data collection. The design was revised using feedback from the reference groups. The content of SWEPPE was developed based on existing evidence and input from the reference groups.

RESULTS

The reference groups identified the following as important characteristics to include in SWEPPE: keeping users motivated, tracking health status and work situation, and following progress. SWEPPE was developed as a smartphone app for the persons with chronic pain and as a web application for their employers. SWEPPE consists of six modules: the action plan, daily self-rating, self-monitoring graphs, the coach, the library, and shared information with the employer. The employers found the following functions in SWEPPE to be the most useful: employees' goals related to RTW, barriers to RTW, support wanted from the employer, and the ability to follow employees' progress. The persons with chronic pain found the following functions in SWEPPE to be the most useful: setting a goal related to RTW, identifying barriers and strategies, and self-monitoring. Usability testing revealed that SWEPPE was safe, useful (ie, provided relevant information), logical, and easy to use with an appealing interface.

CONCLUSIONS

This study reports the development of a digital support application for persons with chronic pain and their employers. SWEPPE fulfilled the need of support after an interdisciplinary pain rehabilitation program with useful functions such as setting a goal related to RTW, identification of barriers and strategies for RTW, self-monitoring, and sharing information between the employee and the employer. The user-centered agile design approach contributed to creating SWEPPE as a relevant and easy-to-use eHealth intervention. Further studies are needed to examine the effectiveness of SWEPPE in a clinical setting.

Hand function 5 years after treatment with collagenase Clostridium histolyticum injection for Dupuytren's disease

The aim of this study was to report hand function, disability and satisfaction and patients' perception of functionally troublesome contractures 5 years after injection with collagenase Clostridium histolyticum and hand therapy for Dupuytren's disease. Data from 79 patients were collected before and at 3, 12 and 60 months after treatment. Hand function was significantly improved, and 70% achieved a functional range of motion in the treated hand. QuickDASH scores and range of motion were best at 3 months follow-up. At 60 months, mean total extension deficit was 48°, which was 57% of the deficit before treatment. Thirty-seven patients (47%) had developed recurrent contractures in treated finger(s) meeting the criteria for new treatment. The threshold for functionally troublesome contractures was found to be 30°-60° in the finger joints. Treatment was experienced as painful, but few hand function problems occurred. Most patients would choose this treatment method again.Level of evidence: IV.

Learning occupational therapy practice using standardised patients in a practical examination - experiences of students and teachers

BACKGROUND

The use of simulated learning activities in occupational therapy education has emerged in the past decade. Studies describing experiences of using standardised patients in practical examination in occupational therapy is lacking.

OBJECTIVE

To describe teachers' and students' experiences of a newly implemented practical examination in occupational therapy education using standardised patients.

MATERIAL AND METHODS

A qualitative study using data from student questionnaires, a focus-group with five teachers, and teachers' reflective diary notes. Data were analysed with problem-driven content analysis.

RESULTS

Three categories were identified: The practical examination as a learning situation included a structured learning environment and scenarios with standardised patients with the right level of complexity. The teacher's role was influenced by the educational approach applied to create equal conditions for all students, students' thoughts about being assessed and the teachers' emphasis of being well prepared. The examination was an opportunity for developing practical skills. The students valued being prepared for clinical practice and the teachers valued the examination as a bridge between theory and practice.

CONCLUSION AND SIGNIFICANCE

A carefully planned practical examination can contribute to developing professional occupational therapy competences and is a tool for educators to replicate the authentic clinical settings students encounter in fieldwork.

Experiences of men living with Dupuytren's disease-Consequences of the disease for hand function and daily activities

STUDY DESIGN

Qualitative descriptive.

INTRODUCTION

Dupuytren's disease (DD) is a chronic hand condition causing impairment in hand function. Research describing persons' experiences of living with DD is limited. Understanding the subjective experience of illness is valuable for planning and implementing health-care services.

PURPOSE OF THE STUDY

To explore experiences among men living with an impaired hand function due to DD and the consequences of the disease for daily activities.

METHODS

Interviews were conducted with 21 men before surgery. The model of the patient evaluation process guided data collection. Data were analyzed using problem-driven content analysis.

RESULTS

Participants described DD as a chronic disease caused by heredity, previous injury, hard work, or aging. DD was, according to the participants, an uncomfortable and sometimes painful condition, causing a feeling of constant stiffness in the affected hand. DD could cause participants to have fear of hurting the hand, feelings of shame or embarrassment, and a sense of being old. Participants handled the deteriorating hand function by avoiding or refraining from activities, adapting their performance, or performing activities with less quality. The ideal hand function was seen as being able to use the hands without effort.

DISCUSSION

The diverse experiences of DD and if the hand is experienced as something that causes distress can be understood further using body-self dialectic and Gadow's states of embodiment, as well as the process of adapting and learning to live with the functional limitations.

CONCLUSIONS

A clinical implication for hand therapy is to acknowledge patients' individual experiences and support self-modifications and development of new skills.

OP0218 MORTALITY IN PATIENTS WITH PSORIATIC ARTHRITIS IN SWEDEN

Background:

In contrast to the increased mortality reported in other inflammatory diseases such as rheumatoid arthritis and psoriasis, prior mortality studies in psoriatic arthritis (PsA) have shown inconsistent results.

Objectives:

To compare all-cause mortality between PsA patients in Sweden and matched general population controls, and to describe cause of death distributions in the two groups.

Methods:

All individuals in Sweden with ≥1 main diagnosis of PsA (ICD-10: L40.5/M07.0-M07.3) from outpatient visits to rheumatology or internal medicine clinics at age ≥18 years (y) 2001-2017 were identified from the Swedish National Patient Register. Each case was matched to 5 general population controls based on sex, county and age in the year of the first registered arthritis diagnosis for the case. Cases and controls were followed from 1 Jan, 2007, or from first PsA diagnosis thereafter for index cases, until first occurrence of death (data from the Swedish Cause of Death Register), emigration or 31 Dec, 2018. Mortality was assessed overall, as well as stratified by sex (45% males) and disease duration (PsA diagnosis prior to 2007 [38% of cases] vs. 2007-2017), using matched Cox proportional hazard regression, or – in case the Cox assumption regarding proportionality did not hold – matched Breslow test. To account for potential PsA misclassification (in a previous validation study, 86% of 400 cases fulfilled PsA classification criteria), a sensitivity analysis was performed by randomly replacing 20% of cases with one of their own controls. Moreover, incidence rate ratios (IRR) of death were calculated overall and stratified by sex, disease duration and age. Finally, causes of death (from the Cause of Death Register) were described for PsA cases and controls.

Results:

Over the 12y follow-up, 3 121 deaths occurred among 33 036 PsA cases (268 402 person-years at risk) and 12 884 deaths among 161 144 controls (1 302 250 person-years), resulting in an increased mortality among the PsA cases (HR 1.11 [95%CI 1.07-1.16], p<0.001, Figure and Table; sensitivity analysis HR 1.09 [1.05-1.14]). The increased mortality was seen mainly among female PsA cases and among cases with longer disease duration (Figure; Table). IRR:s of death were significantly increased for all ages except <40y, with the numerically highest point-estimates for ages 40-49y and 50-59y (Table). Cause of death frequencies among the PsA cases/controls: cardiovascular disease 29/27%; diabetes mellitus 2.1/2.5%; chronic kidney disease 0.4/0.3%; infection 5.7/4.5%; chronic pulmonary disease 5.1/4.1%; malignancy 29/34%; suicide 2.3/2.0%; other 27/26%.

Table 1.

Mortality rates and incidence rate ratios

PsA casesPopulation controlsNumber of deathsPerson-yearsat riskMortality rate*Number of deathsPerson-yearsat riskMortality rate*Incidence rate ratio (95%CI)Overall3 121268 40211.612 8841 302 2509.91.18 (1.13-1.22)Males1 459120 51712.16 468580 28511.11.09 (1.03-1.15)Females1 662147 88611.26 416721 9668.91.27 (1.20-1.34)Longer disease duration1 943139 37913.97 459670 17411.11.25 (1.19-1.32)Shorter disease duration1 178129 0239.15 425632 0778.61.06 (1.00-1.13)Age intervals (years)<401833 5680.598163 2780.60.89 (0.54-1.48)40-499050 5521.8322246 9551.31.37 (1.08-1.73)50-5928065 8204.31 131321 7303.51.21 (1.06-1.38)60-6972370 22410.33 132341 5879.21.12 (1.04-1.22)70-7996037 23225.84 160178 90923.31.11 (1.03-1.19)≥801 05011 00795.44 04149 79181.21.18 (1.10-1.26)

* Per 1000 person-years.

Conclusion:

In this nationwide 12y assessment, the mortality risk among PsA patients in Sweden was increased by around 10% as compared to the general population, mainly driven by increased risks among females and patients with longer disease duration. Cause of death distributions were numerically similar between PsA cases and controls.

References:

Disclosure of Interests:

Sofia Exarchou Consultant of: AbbVie, Novartis, Daniela Di Giuseppe: None declared, Gerd-Marie Alenius: None declared, Eva Klingberg Speakers bureau: Eli Lilly, Consultant of: Novartis, Grant/research support from: Roche, Valgerdur Sigurdardottir Consultant of: Novartis, Sanofi, Sara Wedrén: None declared, Ulf Lindström: None declared, Carl Turesson Speakers bureau: AbbVie, BMS, Pfizer, Roche, Consultant of: Roche, Grant/research support from: BMS, Lennart T.H. Jacobsson Consultant of: AbbVie, Eli Lilly, Janssen, Novartis, Pfizer, Johan Askling Grant/research support from: For ARTIS: AbbVie, BMS, Eli Lilly, Merck, Pfizer, Roche, Samsung Bioepis, Sanofi, UCB. This study was supported by AbbVie, Amgen, Eli Lilly, Novartis and Pfizer. The sponsors were allowed to comment on the study protocol and were provided with a report of the results, but had no influence on the study design or decision to submit the abstract., Johan K Wallman Consultant of: Celgene, Eli Lilly, Novartis

OP0122 COMPARATIVE EFFECTIVENESS OF JAKI VERSUS BDMARDS; A NATIONWIDE STUDY IN RA

Background:

The Janus kinase inhibitors (JAKi) have been increasingly used for the treatment of rheumatoid arthritis (RA) in Sweden, with baricitinib representing ~80% of prescriptions. Evidence regarding the comparative effectiveness of JAKis versus biologics (bDMARDs), and in particular non- tumour-necrosis-factor inhibitor (TNFi) bDMARDs, in real-life is limited.

Objectives:

To compare RA patients treated with bDMARDs and JAKi in Sweden, in terms of: (1) patient characteristics at treatment start; (2) proportions of patients remaining on therapy, and response rates, at 12 months.

Methods:

RA patients starting treatment in 2017 and 2018 with either a TNFi, rituximab, abatacept, interleukin 6 inhibitors (IL6i) or a JAKi as different lines of treatment were identified in the Swedish Rheumatology Quality Register. One patient could contribute with more than one treatment episode.

Treatment response at 12 months was measured as EULAR good response, HAQ improvement >0.2 units, DAS28 and CDAI remission, and as 0 tender and swollen joint counts (28JC). Patients were classified as non-responders if they stopped treatment before evaluation due to safety or inefficacy. Responses for patients who stopped treatment due to pregnancy or death and patients on treatment but with missing response were imputed using multiple imputation.

Proportions of responders and differences in proportions between treatment groups, adjusted using inverse probability of treatment weighting, were estimated using linear regression with robust standard errors.

Results:

JAKi were often used after bDMARDs, and less frequently prescribed in combination with methotrexate. Measured comorbidities were less frequent among JAKi initiators than among non-TNFi biologic initiators, but RA activity was similar (Table).

Table 1.

Patient characteristics at treatment initiation

CharacteristicMedian (IQR) or N (%)AbataceptIL6iRituximabTNFiJAKiTreatment Starts6945346923497905Age63 (53-71)59 (48-70)65 (54-73)59 (47-68)60 (51-70)Female543 (78)441 (83)519 (75)2739 (78)759 (84)RA duration (years)13 (5-21)10 (5-18)12 (6-22)9 (3-17)13 (7-22)Rheum. factor535 (79)385 (73)588 (87)2405 (70)686 (77)DAS284.8 (3.9-5.6)4.9 (4.0-5.7)4.7 (3.8-5.5)4.4 (3.4-5.3)4.7 (3.9-5.7)HAQ1.3 (0.8-1.6)1.3 (0.8-1.8)1.3 (0.8-1.8)1.0 (0.5-1.4)1.3 (0.8-1.8)Tender joints5 (2-9)6 (3-10)5 (2-9)4 (2-8)6 (2-10)Swollen joints4 (2-6)4 (2-7)4 (2-7)3 (1-6)4 (2-7)ts/bDMARD line3 (2-4)3 (2-4)2 (1-4)1 (1-2)4 (2-6)At least one prev. TNFi539 (78)442 (83)457 (66)1448 (41)770 (85)At least one prev. non-TNFi271 (39)220 (41)243 (35)441 (13)584 (65)Methotrexate co-treatment264 (50)172 (40)286 (53)1708 (62)296 (40)Glucocorticoids co-treatment247 (47)186 (43)275 (51)1126 (41)389 (53)Cancer*90 (2.8)64 (2.3)363 (7.7)410 (1.8)20 (2.2)Cardio-vascular dis.*245 (7.5)123 (4.4)322 (6.8)749 (3.4)41 (4.4)Chronic respiratory dis.*303 (9.3)140 (5.0)473 (10.0)721 (3.2)50 (5.4)Diabetes*324 (9.9)216 (7.7)456 (9.7)1479 (6.7)69 (7.5)

* any diagnosis within 5 years before start Adjusted differences in proportion with each response outcome

In a crude comparison, 65% (61%-68%) of JAKi, 62% (59%-66%) of abatacept, 58% (53%-62%) of IL6i, 80% (77%-83%) of rituximab and 68% (67%-70%) of TNFi initiators remained on treatment at 12 months after start. Also, JAKi showed lower overall responder proportions than TNFi, rituximab and IL6i.

After adjustment for demographic and socio-economic factors, RA disease activity, previous use of ts/bDMARDs, co-medication with glucocorticoids and methotrexate and comorbidities at baseline, no significant differences in responder proportions between JAKi and bDMARDs remained (Figure). Furthermore, the adjusted proportions of patients on treatment were higher for JAKi and rituximab than for the other bDMARDs.

Conclusion:

This preliminary analysis of patients treated in clinical practice found no statistically significant difference in effectiveness between JAKi and bDMARDs.

Disclosure of Interests:

Andrei Barbulescu: None declared, Johan Askling Grant/research support from: Abbvie, Astra-Zeneca, BMS, Eli Lilly, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB. These entities have entered into agreements with Karolinska Institutet with JA as principal investigator, mainly in the context of safety monitoring of biologics via the ARTIS national safety monitoring system, Katerina Chatzidionysiou Speakers bureau: Eli Lilly, Abbvie and Pfizer, Consultant of: Eli Lilly, Abbvie and Pfizer, Helena Forsblad-d’Elia: None declared, Alf Kastbom Employee of: Sanofi, Ulf Lindström: None declared, Carl Turesson Speakers bureau: Abbvie, Bristol-Myers Squibb, Medac, Pfizer, Roche, Consultant of: Roche, Grant/research support from: Bristol-Myers Squibb, Thomas Frisell: None declared

OP0114 SHORT- AND LONGER-TERM RISKS FOR ACUTE CORONARY SYNDROME IN PATIENTS WITH RHEUMATOID ARTHRITIS STARTING TREATMENT WITH DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS. A COLLABORATIVE OBSERVATIONAL HEAD-TO-HEAD STUDY ACROSS FIVE NORDIC RHEUMATOLOGY REGISTERS

Background:

Rheumatoid Arthritis (RA) is associated with increased cardiovascular co-morbidity including acute coronary syndrome (ACS), partly due to effects of systemic inflammation. Disease-modifying anti-rheumatic drugs (DMARDs) may reduce RA disease activity, but act through several pathways and may themselves have an impact on cardiovascular risks. Whether the risks of ACS associated with biologic (b) and targeted synthetic (ts) DMARDs differ is still unknown.

Objectives:

To assess and compare incidences of ACS during treatment of RA with etanercept (ETA), adalimumab (ADA), infliximab (INF), certolizumab pegol (CTZ), golimumab (GOL), rituximab (RIT), abatacept (ABA), tocilizumab (TCZ), baricitinib (BAR) or tofacitinib (TOF).

Methods:

We defined and pooled treatment cohorts of patients starting any of the above treatments between 2008 and 2017 from clinical rheumatology registers in Denmark (DK), Finland (FI), Norway (NO), and Sweden (SE). One patient could contribute several treatment episodes. Age, sex, co-medication (methotrexate, prednisolone), number of previous b/tsDMARDs, CRP, comorbidities (cardiovascular (including ACS (defined as ICD-10: I20.0, I21.0-4, I21.9) and cerebrovascular disease, thromboembolic events, diabetes, hospitalized infection, cancer, kidney failure, COPD) and associated drugs were extracted and used as adjustment in Cox regression analyses comparing the incidence of ACS between treatments. We used several follow-up lengths (1, 2, and up to 5 years) and two different risk windows (ACS on drug [ending follow-up on treatment discontinuation] and ACS ever since treatment start [disregarding any treatment discontinuation]). We also stratified by age and number of previous b/tsDMARDs.

Results:

We included 40850 treatment courses in 24083 patients (DK 7271, FI 3732, NO 1540, and SE 11540; around 75% women). ETA was the most common treatment (27%) whereas BAR and TOF comprised <1%, and the other DMARDs 6-14% each. The proportions with a history of ACS at treatment start ranged from 1.2% (NO) to 1.8% (DK).

We found 780 incident ACS events during 141 326 person-years (pyrs) in the 5-year follow-up time and “ACS ever since treatment start” risk window, resulting in a crude incidence rate of 5.5 events per 1000 pyrs. No event was recorded for BAR nor TOF, which also had the shortest follow-up. Adjusted hazard ratios (HR) increased slightly with longer follow-up times, but the two risk windows provided similar HRs. For the 5-year follow-up, RIT was associated with an increased risk of ACS compared to ETA (Table), while no association was observed for shorter follow-up times. Stratifying on age did not modify the associations. Separate analyses by number of previous b/tsDMARDs suggested that ABA (HR=1.8, 95% CI 1.0-3.3), INF (HR=2.2, 95% CI 1.0-4.6) and RIT (HR=1.9, 95% CI 1.1-3.4) were associated with increased risks of ACS compared to ETA in the subgroup of patients with two or more previous bDMARDs (Figure), whereas no differences were found among patients starting either drug as 1st/2nd bDMARD.

Table 1.

Comparisons of risks for ACS during a 5-year follow-up since start of bDMARD treatment.

DrugN eventspyrsCrude incidence rate/ 1000 pyrsHR (95% CI)1ETA175359174.9ref.ADA115240934.81.0 (0.8-1.3)CTZ54141583.80.9 (0.6-1.2)GOL4090064.41.1 (0.8-1.5)INF106178036.01.2 (0.9-1.5)ABA70107956.51.1 (0.8-1.4)RIT158166229.51.3 (1.0-1.6)TCZ62128664.80.9 (0.5-1.2)BAR036TOF030

Pyrs: person-years; HR: hazards ratio

1 adjustment: see text.

Conclusion:

In this cohort including ≥ 24,000 patients followed for up to 5 years, the ACS incidence rate was 5.5/1000 pyrs, with RIT showing an increased risk compared to ETA. In clinical practice, the choice of bDMARD does not seem to influence ACS risk in the short term. In the longer term, differences in ACS risk between bDMARDs may reflect channeling to these, or truly differential effects in subpopulations of patients.

Acknowledgements:

Partly funded by Nordforsk and Foreum

Disclosure of Interests:

Bénédicte Delcoigne: None declared, Lotta Ljung: None declared, Sella Aa. Provan Speakers bureau: Novartis, Consultant of: Novartis, Grant/research support from: Boehringer- Ingelheim, Bente Glintborg Grant/research support from: Pfizer, BMS, AbbVie, Kathrine Lederballe Gron Grant/research support from: BMS, Merete L. Hetland Consultant of: Abbvie, Biogen, BMS, Celltrion, Eli Lilly, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopies, Sandoz, Novartis, Grant/research support from: Abbvie, Biogen, BMS, Celltrion, Eli Lilly, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopies, Sandoz, Novartis, Niels Steen Krogh: None declared, Nina Trokovic: None declared, Heikki Relas Speakers bureau: Abbvie, Celgene, Pfizer, Grant/research support from: Abbvie, Celgene, Pfizer, Carl Turesson Speakers bureau: Abbvie, Bristol-Myers Squibb, Medac, Pfizer, Roche, Consultant of: Roche, Brigitte Michelsen Consultant of: Novartis (paid to employer), Grant/research support from: Novartis (paid to employer), Johan Askling Consultant of: Abbvie, Astra-Zeneca, BMS, Eli Lilly, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB. These entities have entered into agreements with Karolinska Institutet with JA as principal investigator, mainly in the context of safety monitoring of biologics via the ARTIS national safety monitoring system.

POS0629 PREDICTORS OF CHANGE IN DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS AFTER START OF TREATMENT WITH ABATACEPT

Background:

Abatacept is a biologic disease-modifying anti-rheumatic drug (bDMARD) used to treat rheumatoid arthritis (RA) since 2006, acting by inhibition of T-cell co-stimulation. There are limited data on factors predicting clinical outcomes in RA after start of treatment with abatacept.

Objectives:

The primary aim was to identify predictors of change in disease activity in RA-patients after start of treatment with abatacept.

Methods:

This cohort study was based on data from the Swedish Rheumatology Quality register (SRQ). All patients with RA who started treatment with abatacept between 2006 and 2017 were included. Clinical data from the SRQ included demographics, disease characteristics and antirheumatic treatment. Disease activity was measured according to DAS28-ESR (Disease Activity Score of 28 joints based on erythrocyte sedimentation rate) at inclusion and at follow-up visits at 6 and 12 months from start of treatment with abatacept. Baseline predictors of change in disease activity were investigated using linear regression models bivariately and adjusted for baseline values of DAS28. Covariates with a p-value of <0.1 were retained for the final multivariate model. In case of covariates with major collinearity, the one with the stronger association with change of DAS28 was selected.

Results:

In a total of 2716 patients, 872 had data on change in DAS28 at 12 months. Among these, most patients were women (79.6%) and the mean age at start of abatacept was 58.4 years (SD 13.6). The majority of patients had established RA, with a mean disease duration of 13.5 years (SD 11.1). Most patients had severe, active disease, with substantial pain and disability, despite extensive treatment. The mean number of bDMARDs that a patient had been exposed to was 1.90 (SD 1.32). DAS28 decreased significantly over the first year (mean 1.22: 95 % CI 1.12, 1.32). The greatest decrease in DAS28 (mean 1.09) occurred during the first 6 months from start of abatacept. The multivariate regression model identified male sex and limited previous bDMARD exposure as independent predictors of change in DAS28 at 12 months from start of abatacept – adjusted for baseline DAS28, RA duration and current treatment with methotrexate or prednisolone (Table 1).

Table 1.

Determinants for retransitioning

BivariateAdjusted for baseline DAS28MultivariateVariablesB95% CIP-valueB95% CIP-valueB95% CIP-valueMale sex0.39[0.13, 0.64]0.0030.43[0.20, 0.66]<0.0010.42[0.19, 0.64]<0.001Age (per SD)0.10[-0.004, 0.21]0.0580.044[-0.051, 0.14]0.37N/ARA duration (per SD)-0.14[-0.25, -0.037]0.008-0.11[-0.21, -0.016]0.022-0.030[-0.13, 0.065]0.54HAQ (per SD)0.12[0.007, 0.23]0.037-0.24[-0.35, -0.13]<0.001N/AVAS pain (per SD)0.26[0.15, 0.37]<0.001-0.058[-0.17, 0.054]0.31MTX10.20[-0.013, 0.41]0.0660.17[-0.018, 0.36]0.0760.11[-0.076, 0.29]0.25Prednisolone1-0.19[-0.41, 0.017]0.072-0.17[-0.36, 0.024]0.087-0.14[-0.33, 0.043]0.13bDMARDs2 (per SD)-0.30[-0.40, -0.20]<0.001-0.32[-0.41, -0.23]<0.001-0.31[-0.40, -0.21]<0.001

B=beta coefficient; N/A=not applicable; SD=standard deviation; CI=confidence interval. Bold text indicates significant associations.

DAS28, Disease activity Score of 28 joints; RA, rheumatoid arthritis; HAQ, Health Assessment Questionnaire; VAS, visual analogue scale; MTX, methotrexate; bDMARD, biologic disease-modifying antirheumatic drug.

1Current treatment

2Number of previous bDMARDs

Conclusion:

In this national register study, male sex and limited previous exposure to bDMARDs were independent predictors of reduction of disease activity one year after start of treatment with abatacept for RA, possibly reflecting a better prognosis overall in such patients.

Disclosure of Interests:

Julia Liukkonen: None declared, Giovanni Cagnotto: None declared, Jan-Åke Nilsson: None declared, Saedis Saevarsdottir: None declared, Carl Turesson Speakers bureau: Abbvie, Bristol Myers-Squibb, Medac, Pfizer, Roche., Consultant of: Roche, Grant/research support from: This study was supported by an unrestricted grant from Bristol-Myers Squibb

POS0557 THE RELATION BETWEEN INVOLVEMENT OF INDIVIDUAL JOINTS OF THE UPPER EXTREMITY AND GRIP FORCE IN EARLY RHEUMATOID ARTHRITIS

Background:

Rheumatoid arthritis (RA) has a major impact on hand function in many patients.

Objectives:

The objective of this study was to investigate the relation between swelling and tenderness of individual joints in the upper extremities and grip force in patients with early RA.

Methods:

An inception cohort of patients with early RA (symptom duration ≤12 months), recruited in 1995-2005, was investigated and followed in a structured program. All patients were examined by the same rheumatologist according to a structured protocol, and swelling and tenderness of individual joints was recorded. Grip force (Newton, N) was measured using the electronic instrument Grippit (AB Detektor, Gothenburg, Sweden). Average grip force values of each hand were evaluated and compared to the expected, based on age- and sex-specific reference values from the literature (1). Grip force was expressed as % of expected values. Linear regression analyses were used to assess the relation between upper extremity joint involvement in individual joints and grip force, using the presence/absence of synovitis/tenderness in each joint as covariates. For the multivariate analysis, covariates with p<0.10 in the univariate analyses were selected. In cases with major collinearity (Spearman’s r>0.3), the covariate with the stronger association in the univariate analysis was included.

Results:

A total of 215 patients with early RA (71 % women; mean age 60 years) were investigated. The median symptom duration at inclusion was 7 months; interquartile range 5-10. The median 28 joint counts for swollen joints was 7 (interquartile range, IQR 5-11) and for tender joints 4 (IQR 1-9). In univariate analyses, swelling of the wrist, each metacarpophalangeal (MCP) joint and proximal interphalangeal (PIP) joints III and V, as well as tenderness of the elbow, wrist and each MCP and PIP joint were associated with significantly reduced grip force in the right hand. In the left extremity, corresponding associations were observed for swelling of the wrist, each MCP joint and PIP joints I and V, and for tenderness of the wrist and each MCP and PIP joint. In multivariate analysis, wrist synovitis was associated with reduced grip force (β -11.0 and -14.3 % of expected, respectively). There were also independent significant associations for tenderness of MCP IV and the elbow with reduced grip force in the right hand, and for swelling of MCP I and MCP V with reduced grip force in the left hand (Table 1).

Table 1.

Joint involvement associated with average grip force (% of expected value), multivariate linear regression

Unstandardized β95 % CIRight handSwollen Wrist-11.0-17.5 to -4.5Tender MCP IV-15.6-25.2 to -6.0Tender PIP V-2.3-12.0 to 7.3Tender Elbow-11.7-22.1 to -1.3Left handSwollen Wrist-14.3-20.4 to -7.6Swollen MCP I-7.6-14.6 to -0.6Swollen MCP V-11.7-21.9 to -1.5Swollen PIP I-0.8-9.2 to 7.5

MCP: Metacarpo phalangeal joint

PIP: Proximal interphalangeal joint

Conclusion:

Involvement of several different joints in the upper extremity contributes to impaired hand function. Clinical synovitis of the wrist was associated with reduced grip force in both hands. In the left hand, arthritis of the thumb had a major impact on grip force. In general, MCP involvement was found to be more important for the grip than PIP involvement.

References:

[1]Nilsen T et al. Scand J Occup Ther 2012; 19: 288-96

Disclosure of Interests:

None declared

POS1169 IMPACT OF THE COVID-19 PANDEMIC ON MORBIDITY AND MORTALITY AMONG SWEDISH PATIENTS WITH INFLAMMATORY JOINT DISEASES VERSUS THE GENERAL POPULATION

Background:

Studies from COVID-19 case-repositories among patients with rheumatic diseases have assessed associations (relative risks) between characteristics of the disease and adverse COVID-19 outcomes. Such designs are susceptible to bias from selection of cases reported. Few studies have assessed absolute and relative risks for COVID-19 outcomes in population-based cohorts of patients with inflammatory joint diseases, nor compared these risks to those in the general population.

Objectives:

To estimate all-cause mortality, absolute and relative risks for severe COVID-19 in patients with chronic inflammatory joint diseases, compared over time and to the general population.

Methods:

We updated a multi-register nationwide linkage (“ARTIS”) on adults with RA, PsA, AS, SpA or JIA and population referents (matched on sex, age, and region), with data on hospitalizations, admission to intensive care (ICU), and deaths due to COVID-19. We calculated all-cause mortality March-September 2015-2020, and absolute and relative risks for COVID-19 outcomes March-September 2020. Patients were compared to population referents using hazard ratios (HR) from Cox models adjusted for comorbidities and socio-economy.

Results:

We identified 110567 individuals with inflammatory joint disease (53455 with RA) in Sweden on March 1st 2020, and 484277 matched general population subjects. In all cohorts, the absolute risk of death from any cause in 2020 was higher than 2015-2019 (Figure 1), with a peak in mid-April, but the relative risks of death (vs. the general population) 2020 remained similar to HRs for 2015-2019 (HR for 2020 in Table 1).

Among all individuals with inflammatory joint disease in 2020, the risk for hospitalization, admission to ICU, and death due to COVID-19 was 0.5%, 0.04% and 0.1%, respectively (Table 1). HRs (vs. the general population) were elevated for almost all outcomes. HRs for COVID-19 related outcomes (Table 1) were higher than for non-COVID-19 outcomes; adjustment for co-morbidities and socio-economy explained much of these increases, somewhat less so for the former.

Figure 1.

All-cause mortality in Swedish individuals with inflammatory joint disease and general population, March-September 2020 and the average 2015-2019

Table 1.

Absolute and relative risks for COVID-19 outcomes in Swedish individuals with inflammatory joint disease compared to general population comparators March-September 2020

OutcomeEvents(risk, %)Events (risk, %), general populationHR1*HR2**AllHospitalization, all causes8971 (8.1%)24273 (5.0%)1.65(1.61, 1.69)1.18 (1.15, 1.21)Hospitalization, COVID-19581 (0.5%)1443 (0.3%)1.77 (1.61, 1.95)1.32 (1.19, 1.46)ICU, COVID-1945 (0.04%)162 (0.03%)1.22 (0.88, 1.70)1.17 (0.82, 1.66)Death, all causes1310 (1.2%)3036 (0.6%)1.90 (1.78, 2.02)1.13 (1.05, 1.21)Death, COVID-19161 (0.1%)338 (0.07%)2.09 (1.73, 2.52)1.18 (0.97, 1.44)RAHospitalization, all causes5275 (9.9%)13072 (5.9%)1.71 (1.66, 1.77)1.21 (1.17, 1.25)Hospitalization, COVID-19379 (0.7%)784 (0.4%)2.02 (1.78, 2.28)1.40 (1.23, 1.60)ICU, COVID-1931 (0.06%)79 (0.04%)1.63 (1.08, 2.48)1.53 (0.98, 2.40)Death, all causes968 (1.8%)2026 (0.9%)1.99 (1.85, 2.15)1.18 (1.09, 1.28)Death, COVID-19134 (0.3%)245 (0.11%)2.28 (1.85, 2.81)1.27 (1.02, 1.59)PsA AS SpA JIAHospitalization, all causes3696 (6.5%)11201 (4.3%)1.54 (1.48, 1.59)1.16 (1.11, 1.20)Hospitalization, COVID-19202 (0.4%)659 (0.3%)1.41 (1.20, 1.65)1.20 (1.02, 1.41)ICU, COVID-1914 (0.02%)83 (0.03%)0.78 (0.44, 1.37)0.76 (0.43, 1.37)Death, all causes342 (0.6%)1010 (0.4%)1.56 (1.38, 1.76)0.98 (0.86, 1.12)Death, COVID-1927 (0.05%)93 (0.04%)1.34 (0.87, 2.05)0.83 (0.54, 1.28)

*HR1 unadjusted, matched (age, sex, and region)

**HR2, as HR1 but adjusted for comorbidities and socio-economy

Conclusion:

Risks of severe COVID-19 were increased among patients with inflammatory joint diseases, but similar increases were seen for non-COVID-19 morbidity. Co-morbidities and socio-economy explain much of this increase.

Disclosure of Interests:

Hannah Bower: None declared, Thomas Frisell: None declared, Daniela Di Giuseppe: None declared, Bénédicte Delcoigne: None declared, Gerd-Marie Alenius: None declared, Eva Baecklund: None declared, Katerina Chatzidionysiou Speakers bureau: Eli Lilly, AbbVie and Pfizer, Consultant of: Eli Lilly, AbbVie and Pfizer, Nils Feltelius Employee of: Nils Feltelius is employed by the Medical Products Agency (MPA), which is a governmental body. The views in this abstract may not represent the views of the MPA, Helena Forsblad-d’Elia: None declared, Alf Kastbom Employee of: Former employee of Sanofi, Lars Klareskog: None declared, Elisabet Lindqvist: None declared, Ulf Lindström: None declared, Carl Turesson Speakers bureau: Roche, AbbVie and Pfizer, Consultant of: Roche, Grant/research support from: Research grant from Bristol-Myers Squibb, Christopher Sjowall: None declared, Johan Askling Grant/research support from: PI for agreements between Karolinska Institutet and Abbvie, BMS, Eli Lilly, Pfizer, Roche, Samsung Bioepis, and Sanofi for safety monitoring of anti-rheumatic therapies (ARTIS).

A smartphone application to facilitate adherence to home-based exercise after flexor tendon repair: A randomised controlled trial

OBJECTIVE

Evaluate the effect of a smartphone application on exercise adherence, range of motion and self-efficacy compared to standard rehabilitation after repair of the flexor digitorum profundus tendon.

DESIGN

Prospective multi-centre randomised controlled trial.

SETTING

Four hand surgery departments in Sweden.

SUBJECTS

A total of 101 patients (35 women) (mean age 37.5 ± 12.8) were randomised to control (n = 49) or intervention group (n = 52).

INTERVENTION

A smartphone application to facilitate rehabilitation.

MAIN OUTCOME MEASURES

Adherence assessed with the Sport Injury Rehabilitation Adherence Scale at two and six weeks (primary outcome). Secondary outcomes were self-reported adherence in three domains assessed at two and six weeks, self-efficacy assessed with Athlete Injury Self-Efficacy Questionnaire at baseline, two and six weeks. Range of motion and perceived satisfaction with rehabilitation and information were assessed at 12 weeks.

RESULTS

Twenty-five patients were lost to follow-up. There was no significant between group difference in Sport Injury Rehabilitation Adherence Scale at two or six weeks, mean scores (confidence interval, CI 95%) 12.5 (CI 11.8-13.3), 11.8 (CI 11.0-12.8) for the intervention group, and 13.3 (CI 12.6-14.0), 12.8 (CI 12.0-13.7) for the control group. Self-reported adherence for exercise frequency at six weeks was significantly better for the intervention group, 93.2 (CI 86.9-99.5) compared to the controls 82.9 (CI 76.9-88.8) (P = 0.02). There were no differences in range of motion, self-efficacy or satisfaction.

CONCLUSION

The smartphone application used in this study did not improve adherence, self-efficacy or range of motion compared to standard rehabilitation for flexor tendon injuries. Further research regarding smartphone applications is needed.

LEVEL OF EVIDENCE

I. Randomised controlled trial.

SAT0058 AGE DEPENDENT EFFECTS OF BODY MASS INDEX AND SMOKING ON THE RISK OF RHEUMATOID ARTHRITIS IN MEN – RESULTS FROM A NESTED CASE CONTROL STUDY

Background:

As rheumatoid arthritis (RA) is more common in women compared to men, most studies of disease predictors have mainly included women, and data on risk factors in men are limited. Smoking is an established predictor of RA. A negative association between body mass index (BMI) and the risk of RA in men has been reported from several studies of Scandinavian populations.

Objectives:

To investigate whether the impact of smoking and BMI on the risk of subsequent development of RA in men differs by age.

Methods:

A total of 22 444 men from a defined catchment area were included in a Preventive Medicine Program (PMP). Height and weight were measured as part of the health survey, and BMI was calculated as weight (in kg)/height (in m2). Information on smoking was obtained using a structured self-administered questionnaire. Normal BMI, overweight and obesity was defined according to the WHO criteria. From this population, we identified individuals who developed RA after inclusion by linking the PMP register to the local community based RA register and to local and national patient administrative databases. In a structured review of the medical records, patients were classified according to the 1987 ACR criteria for RA. Four controls for each validated case, matched for sex, year of birth and year of screening, who were alive and free of RA when the index person was diagnosed with RA, were selected from the PMP register. The impact of BMI category and smoking on the risk of RA was examined in multivariable conditional logistic regression models, stratified by age at inclusion in the health survey (above vs below the median).

Results:

A total of 151 men were diagnosed with RA and fulfilled the ACR criteria after inclusion in the PMP (median time to diagnosis 13 years, interquartile range 9-19; 76 % rheumatoid factor positive at diagnosis). These pre-RA cases were compared to 604 matched controls. Among men aged >46 years, overweight/obesity was associated with a significantly reduced risk of subsequent RA (odds ratio (OR) 0.40; 95 % confidence interval (CI) 0.21-0.76, adjusted for smoking), whereas there was no such association in younger men (adjusted OR 0.75 (95% CI 0.42-1.36). Smoking was a significant predictor of RA in men aged >46 years (Table 1). There was a similar trend in those aged ≤46 years, but it did not reach statistical significance (Table 1).

Conclusion:

Overweight/obesity was associated with a reduced risk of subsequent RA in men aged >46 years. The relative importance of life style factors for the risk of RA may be greater in older men compared to younger.

Disclosure of Interests:

Carl Turesson Grant/research support from: Unrestricted grant from Bristol-Myers Squibb, Consultant of: Roche, Speakers bureau: Abbvie, Bristol Myers-Squibb, Pfizer, Roche, Ulf Bergström: None declared, Mitra Linnerud Keshavarz: None declared, Jan-Åke Nilsson: None declared, Lennart T.H. Jacobsson Consultant of: AbbVie, Eli Lilly, Janssen, Novartis and Pfizer

THU0303 TREATMENT OF GIANT CELL ARTERITIS WITH TOCILIZUMAB IN CLINICAL PRACTICE IN SWEDEN

Background:

Giant cell arteritis (GCA) is the most common form of systemic vasculitis in adults. GCA is often associated with comorbidities related to the disease itself or caused by its treatment, here: mainly glucocorticosteroids. Since 2017, tocilizumab (TCZ) is approved for the treatment of GCA, but its uptake and treatment outcomes in clinical practice remain to be characterized.

Objectives:

To describe characteristics of GCA patients treated with tocilizumab (TCZ) in clinical practice, to evaluate the use of prednisolone up until and following TCZ treatment start, and to describe the TCZ treatment duration.

Methods:

We linked together the Swedish Rheumatology Quality Register (SRQ), the national Prescribed Drug register, and national Patient register, covering data from July 2009 until July 2019. Through these linkages, we identified GCA patients treated with TCZ including start and discontinuation, their comorbidities and use of other medications. TCZ treatment durations were evaluated through survival probability curves.

Results:

We identified 468 patients with GCA treated with TCZ, before and after its formal approval for GCA, Table 1. Over calendar time, the proportion who started TCZ as first ever bDMARD increased, as did the mean age at start of TCZ. The pattern of co-morbidities and health care utilisation demonstrated substantial burden from, e.g., diabetes and infections (Table). Patients starting treatment with TCZ were characterized by an increasing average dose of prednisolone during the last 1.5 years before TCZ start. Thereafter, prednisolone use declined substantially, from a mean of 15 mg/day in the six months before the start of TCZ to 6 mg/day 1 year after its start (Figure 1). Analysis of the duration of TCZ treatment (from start until discontinuation) suggested that at one year, two thirds of patients were still on treatment (Figure 2).

Table.

Swedish GCA patients starting treatment with tocilizumab July 2009 - Nov 2019.

July 2009 -July 2015July 2016 - July 2017July 2017 -July 2018July 2018 - Nov 2019Patients8914014099Female64%77%73%71%Age, mean (sd)67 (7.9)68 (8.8)69 (8)70 (7.8)Previous use of bDMARDs27%21%11%11%Hospitalisations most recent 5 years, mean (sd)3.9 (4.2)3.2 (2.6)2.9 (2.5)3.3 (3)Co-morbidities, most recent 5 years:Chronic obstructive pulmonary disease6%2%4%3%Ischemic heart disease12%7%14%11%Diabetes mellitus, type 1&234%26%26%26%Fractures (any location)15%14%11%10%Knee/hip replacement7%10%7%8%Myocardial infarction2%1%4%3%Stroke2%4%2%5%Hospitalisation listing infection39%40%39%37%Figure 1.

Average daily dose of prednisolone before and after* start of tocilizumab, based on cumulative dose every 6 months. *The average daily dose of prednisolone after the start of TCZ is calculated only among patients who were still on treatment at the end of each period (351 patients in the first 6 months, 251 in 6m-1y, 161 in 1 – 1.5 y, 95 in 1.5 – 2y).

Figure 2.

Kaplan-Meier curve for tocilizumab in GCA by time since treatment start.

Conclusion:

Patients treated with TCZ for GCA in clinical practice are characterized by a significant burden of co-morbidities, many of which may be related to prolonged use of glucocorticosteroids. This study confirms a marked reduction in the use of oral prednisolone following treatment with TCZ, and demonstrates that in a majority of patients in clinical practice, treatment with TCZ for GCA is extended beyond one year. Future analyses will evaluate the association of these observed treatment patterns with the level of GCA disease control, co-morbidities and quality of life, over time.

Acknowledgments:

These analyses was partly funded through an agreement between Roche and Karolinska Institutet.

Disclosure of Interests:

Daniela Di Giuseppe: None declared, Ann Knight: None declared, Aladdin J Mohammad Speakers bureau: lecture fees from Roche and Elli Lilly Sweden, PI (GiACTA study), Carl Turesson Grant/research support from: Unrestricted grant from Bristol-Myers Squibb, Consultant of: Roche, Speakers bureau: Abbvie, Bristol Myers-Squibb, Pfizer, Roche, Johan Askling Grant/research support from: JA acts or has acted as PI for agreements between Karolinska Institutet and the following entities, mainly in the context of the ARTIS national safety monitoring programme of immunomodulators in rheumatology: Abbvie, BMS, Eli Lilly, Merck, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB Pharma

The Role of Hand Therapy in Dupuytren Disease

The role of hand therapy in the treatment of Dupuytren disease varies depending on the patient and the procedure. There is limited evidence for hand therapy as a preventive treatment of Dupuytren disease. Before corrective treatment, the hand therapist can contribute with assessments to promote evaluation of outcome. After corrective treatment, hand therapy is tailored to each patient's needs and consists of orthoses, exercise, edema control, and pain or scar management. Orthoses are usually part of the hand therapy protocol after corrective procedures despite lack of strong supporting evidence and should be provided based on individual patient needs.

Brief Report: Association of Rheumatoid Factor and Anti-Citrullinated Protein Antibody Positivity With Better Effectiveness of Abatacept: Results From the Pan-European Registry Analysis

OBJECTIVE

To investigate the role of rheumatoid factor (RF) status and anti-citrullinated peptide antibody (ACPA) status as predictors of abatacept (ABA) effectiveness in patients with rheumatoid arthritis (RA).

METHODS

We conducted a pooled analysis of data from 9 observational RA registries in Europe (ARTIS [Sweden], ATTRA [Czech Republic], BIOBADASER [Spain], DANBIO [Denmark], GISEA [Italy], NOR-DMARD [Norway], ORA [France], Reuma.pt [Portugal], and SCQM-RA [Switzerland]). Inclusion criteria were a diagnosis of RA, initiation of ABA treatment, and available information on RF and/or ACPA status. The primary end point was continuation of ABA treatment. Secondary end points were ABA discontinuation for ineffectiveness or adverse events and response rates at 1 year (good or moderate response according to the European League Against Rheumatism criteria with LUNDEX adjustment for treatment continuation). Hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the study end points in relation to RF and ACPA status were calculated.

RESULTS

We identified 2,942 patients with available data on RA-associated autoantibodies; data on RF status were available for 2,787 patients (77.0% of whom were RF positive), and data on ACPA status were available for 1,903 patients (71.3% of whom were ACPA positive). Even after adjustment for sociodemographic and disease- and treatment-related confounders, RF and ACPA positivity were each associated with a lower risk of ABA discontinuation for any reason (HR 0.79 [95% CI 0.69-0.90], P < 0.001 and HR 0.78 [95% CI 0.68-0.90], P < 0.001, respectively), compared to RF-negative and ACPA-negative patients. Similar associations with RF and ACPA were observed for discontinuation of ABA treatment due to ineffectiveness, with HRs of 0.72 (95% CI 0.61-0.84) and 0.74 (95% CI 0.62-0.88), respectively (both P < 0.001).

CONCLUSION

Our results strongly suggest that positivity for RF or ACPA is associated with better effectiveness of ABA therapy.

Rheumatoid Arthritis Patients after Initiation of a New Biologic Agent: Trajectories of Disease Activity in a Large Multinational Cohort Study

Background

Response to disease modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (RA) is often heterogeneous. We aimed to identify types of disease activity trajectories following the initiation of a new biologic DMARD (bDMARD).

Methods

Pooled analysis of nine national registries of patients with diagnosis of RA, who initiated Abatacept and had at least two measures of disease activity (DAS28). We used growth mixture models to identify groups of patients with similar courses of treatment response, and examined these patients' characteristics and effectiveness outcomes.

Findings

We identified three types of treatment response trajectories: ‘gradual responders’ (GR; 3576 patients, 91·7%) had a baseline mean DAS28 of 4·1 and progressive improvement over time; ‘rapid responders’ (RR; 219 patients, 5·6%) had higher baseline DAS28 and rapid improvement in disease activity; ‘inadequate responders’ (IR; 103 patients, 2·6%) had high DAS28 at baseline (5·1) and progressive worsening in disease activity. They were similar in baseline characteristics. Drug discontinuation for ineffectiveness was shorter among inadequate responders (p = 0.03), and EULAR good or moderate responses at 1 year was much higher among ‘rapid responders’ (p < 0.001).

Interpretation

Clinical information and baseline clinical characteristics do not allow a reliable prediction of which trajectory the patients will follow after bDMARD initiation.

•

This study examined disease activity trajectories in a multinational cohort of 3898 rheumatoid arthritis patients.

•

Growth mixture models identified three groups: gradual, rapid, and inadequate responders (GR: 91·7%, RR: 5·6%, IR: 2·6%).

•

At baseline, groups were similar in demographic and clinical characteristics, and moderately different in function and disease activity.

•

The groups had large difference in drug retention and in good or moderate response rate.

Using nine national registries, this study of 3898 established RA patients initiating a new bDMARD identified distinct types of responders: gradual, rapid and inadequate responders. Neither socio-demographic nor clinical characteristics at baseline allowed the prediction of the type of response trajectory after treatment initiation, but effectiveness outcomes strongly differed, suggesting that these empirically derived subgroups have clinical relevance.

As a major aim of precision medicine is to make anti-rheumatic therapy more personalized, the detection of responder types following initiation of a specific bDMARD underscores the need to find reliable predictors of trajectories to identify patients needing a distinct treatment strategy.

Women's Social Support and Social Network after Their First Myocardial Infarction; A 4-Year Follow-Up with Focus on Cardiac Rehabilitation

Background: Knowledge about women's recovery following a myocardial infarction (MI) with focus on how their social support and network change over time as a result of participation in a cardiac rehabilitation programme (CRP) is not well established.

Aim: The aim of this study was to describe and compare social support and network changes over a 4-year period in women with a first MI, based on socio-demographic and situational data.

Method: A longitudinal, comparative study with a non-randomised design including pre- and post-tests (1 and 4 years after MI) was carried out in 18 hospitals in Sweden. Consecutively chosen women ( N = 240) answered a questionnaire on the subject of social support and network.

Results: The women who participated in a CRP were mainly dependent upon professional support during the first year after MI ( p < 0.0001), while those who declined to participate in a CRP needed professional support throughout the whole 4-year period ( p = 0.001). Participation in CRP was dependent on the women's age, those under 60 years ( p = 0.050).

Conclusion: There is a need to develop CRPs that are specifically designed for women based on their age and family relationships. Nurses' training programmes should place greater emphasis on cardiac rehabilitation from the perspective of women with focus on professional support.

The impact of patient heterogeneity and socioeconomic factors on abatacept retention in rheumatoid arthritis across nine European countries

Background

There are substantial differences in accessibility to biological disease modifying antirheumatic drugs (bDMARDs) across countries. The objective of this study was to analyse the impact of patient demographics, disease characteristics and gross domestic product (GDP) on abatacept (ABA) retention in patients with rheumatoid arthritis (RA) treated in clinical practice.

Methods

Data from nine European observational RA cohorts of patients treated with ABA were pooled. Kaplan-Meier analysis was used to compare drug retention across registries. Specific causes of drug retention were investigated using competing risks multivariate Cox regression.

Results

A total of 3961 patients treated with ABA, with 6188 patient-years of follow-up, were included. Patients in the different national registries had similar demographic features, but varied in baseline disease characteristics. ABA drug retention differed between countries, with median drug retention rates ranging from 1.2 to more than 6 years. The differences in drug retention were marginally explained by disparities in disease characteristics, while the national GDP per capita was strongly associated with drug retention (correlation coefficient −0.74; p=0.02).

Conclusions

Patient characteristics at ABA initiation vary across Europe, probably reflecting differences in eligibility criteria and prescription patterns. However, the difference in ABA drug retention between countries was not primarily explained by disparities in patient characteristics. Lower ABA retention was observed in countries with a more liberal access to bDMARDs and higher GDP. National differences need to be accounted for when pooling data on treatment with bDMARDs from various countries.