Relapse after cessation of weekly tocilizumab for giant cell arteritis: a multicentre service evaluation in England

OBJECTIVES

The National Health Service in England funds 12 months of weekly subcutaneous tocilizumab (qwTCZ) for patients with relapsing or refractory giant cell arteritis (GCA). During the COVID-19 pandemic, some patients were allowed longer treatment. We sought to describe what happened to patients after cessation of qwTCZ.

METHODS

Multicentre service evaluation of relapse after stopping qwTCZ for GCA. The log-rank test was used to identify significant differences in time to relapse.

RESULTS

336 GCA patients were analysed from 40 centres, treated with qwTCZ for a median (interquartile range, IQR) of 12 (12-17) months. At time of stopping qwTCZ, median (IQR) prednisolone dose was 2 (0-5) mg/day. By 6, 12 and 24 months after stopping qwTCZ, 21.4%, 35.4% and 48.6% respectively had relapsed, requiring an increase in prednisolone dose to a median (IQR) of 20 (10-40) mg/day. 33.6% of relapsers had a major relapse as defined by EULAR. Time to relapse was shorter in those that had previously also relapsed during qwTCZ treatment (P = 0.0017); in those not in remission at qwTCZ cessation (P = 0.0036); and in those with large vessel involvement on imaging (P = 0.0296). Age ≥65, gender, GCA-related sight loss, qwTCZ treatment duration, TCZ taper, prednisolone dosing, and conventional synthetic DMARD use were not associated with time to relapse.

CONCLUSION

Up to half our patients with GCA relapsed after stopping qwTCZ, often requiring a substantial increase in prednisolone dose. One third of relapsers had a major relapse. Extended use of TCZ or repeat treatment for relapse should be considered for these patients.

Quality standards for the care of people with giant cell arteritis in secondary care

OBJECTIVE

GCA is the commonest primary systemic vasculitis in adults, with significant health economic costs and societal burden. There is wide variation in access to secondary care GCA services, with 34% of hospitals in England not having any formal clinical pathway. Quality standards provide levers for change to improve services.

METHODS

The multidisciplinary steering committee were asked to anonymously put forward up to five aspects of service essential for best practice. Responses were qualitatively analysed to identify common themes, subsequently condensed into domain headings, and ranked in order of importance. Quality standards and metrics for each domain were drafted, requiring a minimum 75% agreement.

RESULTS

13 themes were identified from the initial suggestions. Nine quality standards with auditable metrics were developed from the top 10 themes. Patient Access, glucocorticoid use, pathways, ultrasonography, temporal artery biopsy, PET scan access, rheumatology/ophthalmology expertise, education, multidisciplinary working have all been covered in these quality standards. Access to care is a strand that has run through each of the developed standards. An audit tool was developed as part of this exercise.

CONCLUSION

These are the first consensus auditable quality standards developed by clinicians from rheumatology and ophthalmology, nursing representatives and involvement of a patient charity. We hope that these standards will be adopted by commissioning bodies to provide levers for change from the improvement of patient care of individuals with GCA.

Non-Positive Experiences Encountered by Pupils During Participation in a Mindfulness-Informed School-Based Intervention

Mindfulness-informed school-based mental health curricula show much promise in cultivating a positive school climate which supports the well-being and mental health of pupils and staff. However, non-positive pupil outcomes and experiences of school-based mental health interventions are often under-recognised and under-reported. This study sought to capture non-positive pupil experiences of a popular mindfulness-informed curriculum. Some pupils across all schools in the study described non-positive experiences, including having troubling thoughts and emotions, and not finding the programme effective. Contexts surrounding these experiences are explored and linked to existing literature, and subsequent recommendations for improvements are made, including the importance of having clear programme structure, definitions and aims, acknowledging and accommodating fidelity issues as best as possible, and better highlighting the potential for non-positive experiences and how they may be reduced.

Deployment of whole genome next-generation sequencing of SARS-CoV-2 in a military maritime setting

BACKGROUND

SARS-CoV-2 can spread rapidly on maritime platforms. Several outbreaks of SARS-CoV-2 have been reported on warships at sea, where transmission is facilitated by living and working in close quarters. Core components of infection control measures such as social distancing, patient isolation and quarantine of exposed persons are extremely difficult to implement. Whole genome sequencing (WGS) of SARS-CoV-2 has facilitated epidemiological investigations of outbreaks, impacting on outbreak management in real time by identifying transmission patterns, clusters of infection and guiding control measures. We suggest such a capability could mitigate against the impact of SARS-CoV-2 in maritime settings.

METHODS

We set out to establish SARS-CoV-2 WGS using miniaturised nanopore sequencing technology aboard the Royal Fleet Auxiliary ARGUS while at sea. Objectives included designing a simplified protocol requiring minimal reagents and processing steps, the use of miniaturised equipment compatible for use in limited space, and a streamlined and standalone data analysis capability to allow rapid in situ data acquisition and interpretation.

RESULTS

Eleven clinical samples with blinded SARS-CoV-2 status were tested at sea. Following viral RNA extraction and ARTIC sequencing library preparation, reverse transcription and ARTIC PCR-tiling were performed. Samples were subsequently barcoded and sequenced using the Oxford Nanopore MinION Mk1B. An offline version of the MinKNOW software was used followed by CLC Genomics Workbench for downstream analysis for variant identification and phylogenetic tree construction. All samples were correctly classified, and relatedness identified.

CONCLUSIONS

It is feasible to establish a small footprint sequencing capability to conduct SARS-CoV-2 WGS in a military maritime environment at sea with limited access to reach-back support. This proof-of-concept study has highlighted the potential of deploying such technology in the future to military environments, both maritime and land-based, to provide meaningful clinical data to aid outbreak investigations.

Brucella suis in three dogs: presentation, diagnosis and clinical management

Brucella suis is an emerging, zoonotic disease predominantly affecting dogs and humans that engage in feral pig hunting in Australia and other countries. Although B. suis infection in dogs shares some clinical similarities to the host-adapted species (B. canis), B. suis remains an incompletely understood pathogen in dogs with limited published data on its pathogenesis and clinical features. This case series describes the presentations, diagnosis, and clinical management of B. suis infection in three dogs: (1) a bitch with dystocia, abortion and mastitis; (2) an entire male dog with septic arthritis and presumptive osteomyelitis; and (3) a castrated male dog with lymphadenitis. Unique features of these cases are reported including the first documented detection of B. suis from milk and isolation from lymph nodes of canine patients, as well as the follow-up of pups born to a B. suis-infected bitch. Consistent with previous reports, all three dogs showed a favourable clinical response to combination antibiotic therapy with rifampicin and doxycycline. Individually tailored drug regimens were required based on the clinical presentation and other factors, including owner expectations and compliance with therapy as well as a zoonotic risk assessment (generally considered low, except around time of whelping). The authors include their recommendations for the clinical management of dogs that are at-risk or seropositive for B. suis with or without clinical signs or laboratory-confirmed infection.

HLA‐DPB1 is associated with ANCA ‐associated vasculitis in children

OBJECTIVE

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare, life-threatening inflammation of blood vessels that can affect both adults and children. Compared to adult-onset disease, AAV is especially rare in children, with an annual prevalence of 0.5-6.4 cases per million children. The etiology of AAV remains largely unknown, and both environmental and genetic factors are likely involved. The present study was undertaken to explore the genetic susceptibility factors recently identified in adult patients, including HLA-DP and HLA-DQ, in pediatric patients.

METHODS

We performed a genome-wide association study of pediatric AAV in patients of European ancestry (n = 63 AAV cases, n = 315 population-matched controls).

RESULTS

We identified a significant genetic association between pediatric AAV and the HLA-DPB1*04:01 allele (P = 1.5 × 10^-8 , odds ratio [OR] 3.5), with a stronger association observed in children with proteinase 3-ANCA positivity than in children with myeloperoxidase-ANCA positivity. Among the HLA alleles, the HLA-DPB1*04:01 allele was the most highly associated with AAV, although not significantly, in a follow-up adult AAV cohort (P = 2.6 × 10^-4 , OR 0.4). T cell receptor and interferon signaling pathways were also shown to be enriched in the pediatric AAV cohort.

CONCLUSION

The HLA-DPB1 locus showed an association with pediatric AAV, as similarly shown previously in adult AAV. Despite the difference in the age of onset, these findings suggest that childhood- and adult-onset vasculitis share a common genetic predisposition. The identification of genetic variants contributing to AAV is an important step to improved classification tools and treatment strategies.

2022 American College of Rheumatology/EULAR Classification Criteria for Takayasu Arteritis

OBJECTIVE

To develop and validate new classification criteria for Takayasu arteritis (TAK).

METHODS

Patients with vasculitis or comparator diseases were recruited into an international cohort. The study proceeded in 6 phases: 1) identification of candidate criteria items, 2) collection of candidate items present at diagnosis, 3) expert panel review of cases, 4) data-driven reduction of candidate items, 5) derivation of a points-based classification score in a development data set, and 6) validation in an independent data set.

RESULTS

The development data set consisted of 316 cases of TAK and 323 comparators. The validation data set consisted of an additional 146 cases of TAK and 127 comparators. Age ≤60 years at diagnosis and imaging evidence of large-vessel vasculitis were absolute requirements to classify a patient as having TAK. The final criteria items and weights were as follows: female sex (+1), angina (+2), limb claudication (+2), arterial bruit (+2), reduced upper extremity pulse (+2), reduced pulse or tenderness of a carotid artery (+2), blood pressure difference between arms of ≥20 mm Hg (+1), number of affected arterial territories (+1 to +3), paired artery involvement (+1), and abdominal aorta plus renal or mesenteric involvement (+3). A patient could be classified as having TAK with a cumulative score of ≥5 points. When these criteria were tested in the validation data set, the model area under the curve was 0.97 (95% confidence interval [95% CI] 0.94-0.99) with a sensitivity of 93.8% (95% CI 88.6-97.1%) and specificity of 99.2% (95% CI 96.7-100.0%).

CONCLUSION

The 2022 American College of Rheumatology/EULAR classification criteria for TAK are now validated for use in research.

Pharmacist-led multidisciplinary approach in preventing strokes in people with atrial fibrillation

Background/Introduction

Targets set by Public Health England (PHE) state that 90% of patients with atrial fibrillation (AF) are expected to receive anticoagulation by 2029. In 2019/2020, across three London boroughs serving a population of 770,000, the percentage of AF patients at high risk of stroke (CHA2DS2VASc>2) anticoagulated was below the target set by PHE. In addition, optimisation of risk factors can significantly reduce the risk of cardiovascular disease and associated mortality in these patients.

Purpose

To provide specialist input from a cardiovascular pharmacist to prevent AF-related strokes through improvement of anticoagulation rates and optimisation of cardiovascular risk factors in patients with AF across three London boroughs over one year, as well as minimising bleed risk in patients on dual antithrombotic therapy.

Methods

A specialist cardiovascular pharmacist was commissioned to identify high-risk AF patients (CHA2DS2VASc>2) by working with primary care clinicians. Utilising “proactive care frameworks” created by UCLPartners and Clinical Effectiveness Group Queen Mary University of London, patients were stratified and prioritised for review. Patients not on anticoagulation were deemed to be at highest risk, requiring an urgent review to assess suitability for anticoagulation. A virtual multidisciplinary team (MDT) would review any complex patients and agree an action plan. Patients on dual antithrombotic therapy were also assessed to determine if antiplatelet therapy was indicated to minimise risk of major bleeding. All AF patients were reviewed for suitability of statin initiation to optimise cardiovascular risk prevention.

Results

At baseline, 86% (7581/8582) of AF patients with a CHA2DS2VASc>2 across the three boroughs were anticoagulated. 1001 patients were reviewed by a specialist pharmacist, with 84% (841/1001) of patients having a CHA2DS2VASc between 2–5, and 28% (280/1001) on antiplatelet monotherapy. Analysis at 12 months following intervention reported that 95% (7888/8280) of AF patients with a CHA2DS2VASc>2 were suitably anticoagulated, an improvement of 9%. 6% (61/1001) of patients were switched from antiplatelets and 25% (246/1001) were newly initiated on anticoagulation. 13% (130/1001) of patients required specialist MDT input to determine appropriateness for anticoagulation initiation. There was also a reduction in dual anticoagulation and antiplatelet therapy from 429 to 252 patients (41% reduction). Lastly of those reviewed, 2609 patients received a recommendation to start a statin for either primary (n=1981) or secondary prevention (n=628).

Conclusion(s)

Provision of a specialist cardiovascular pharmacist supported a multidisciplinary workforce to significantly improve and optimise cardiovascular risk, and reduce the risk of stroke in this high-risk population for people with AF across all three boroughs. By extrapolating these results nationally, 3600 strokes could be averted over 18 months.

Funding Acknowledgement

Type of funding sources: None.

Impact of cardiovascular events on primary and hospital care costs: findings from UK Biobank study

Background

Need for primary and secondary healthcare increases following cardiovascular disease (CVD) events but there is no data on comparative increases in costs.

Purpose

To estimate annual primary care and hospital inpatient costs associated with key CVD and other adverse events using the UK Biobank (UKB) individual participant data.

Methods

UKB participants with linked primary care data (192,983 participants) or hospital inpatient episodes data (all 501,807 participants) contributed data to this study. The three categories of primary care services (patient consultations, diagnostic and monitoring tests, prescription medications), and hospital episodes were costed (2020 UK£) using the NHS England reference costs. Annual primary care costs and, separately, annual hospital inpatient costs were modelled as functions of participant characteristics at entry (socio-demographic, clinical, prior diseases) and time-updated first occurrences of myocardial infarction, stroke, coronary revascularization, incident cancer, incident diabetes, vascular death and non-vascular death during follow-up (p-value <0.01 in stepwise covariate selection). One-part generalized linear regression model (GLM) with Poisson distribution and identity link function was used for primary care costs, and two-part model was used for inpatient costs (part 1: logistic regression models probability of incurring costs; part 2: GLM with Poisson distribution and identity link function models costs conditional on incurring any). Separate models were fitted among participants with and without previous CVD at entry into UKB.

Results

Most adverse events were associated with excess primary care and hospital inpatient costs. Compared to people without previous CVD, people with previous CVD had on average larger excess primary care and hospital inpatient costs in years with myocardial infarction, stroke and vascular death; but similar excess costs in years with other events. Among both people without and with previous CVD, the excess annual primary care costs were less than 7% of the excess annual hospital inpatient costs for vascular events (Table). However, following diabetes diagnosis the excess annual primary care costs were higher than the excess annual hospital inpatient costs (Table).

Conclusions

These excess primary and hospital care costs associated with CVD events could inform assessments of interventions and policies to reduce CVD risks in UK.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme, UK Medical Research Council (MRC), British Heart Foundation

Cost-effectiveness of statin therapy in categories of patients in the UK

Background

Cardiovascular disease (CVD) mortality has declined steadily over the last few decades across Europe and North America.

Purpose

To provide contemporary estimates of long-term effectiveness and cost-effectiveness of statin therapy in different categories of patients in UK.

Methods

The CTT-UKB micro-simulation model, developed using the Cholesterol Treatment Trialists' Collaboration data (CTT: 118,000 participants; 5 years follow-up), and calibrated in the UK Biobank cohort (UKB: 502,000 participants; 9 years follow-up). The model integrates parametric risk equations for incident myocardial infarction, stroke, coronary revascularization, diabetes, cancer and vascular and nonvascular death, and projects annually these endpoints and survival using patient characteristics at entry. UKB data and linked primary and hospital care data informed healthcare costs in the model (2020 UK£); 2021 UK NHS Drug Tariff informed statin costs (atorvastatin 40mg at £1.22 and 80mg at £1.68 per 28 tablets); and Health Survey for England data informed health-related quality of life in the model. Previous CTT meta-analysis, atorvastatin dose-response randomized trials, and further meta-analyses of statin trials and cohort studies informed effects of 40mg/80mg atorvastatin therapy daily on rates of incident myocardial infarction, stroke, coronary revascularization, vascular death, diabetes, myopathy and rhabdomyolysis.

The model was used to project gains in quality-adjusted life years (QALYs) and additional cost per QALY with lifetime use of atorvastatin 40mg or 80mg daily in categories of UKB participants by sex, age at statin initiation (40–49; 50–59 and 60–70 years), and 10-year CVD risk (QRISK3 risk (%): <5; 5–10, 10–15, 15–20, ≥20). Further scenarios explored effects of 5-year delay of statin initiation in people under 45 years of age or stopping statin therapy at 80 years of age.

Results

Across men and women in categories by age and CVD risk, lifetime use of atorvastatin 40mg daily was associated with increases in survival by 0.44–1.69 years (0.28–1.02 QALYs), and atorvastatin 80mg daily with increases in survival of 0.45–1.87 years (0.32–1.13 QALYs; Figure 1) with gains larger among participants at higher CVD risk. Both atorvastatin 40mg and 80mg doses were in the range of cost-effective treatments with incremental cost per QALY gained with atorvastatin 40mg daily versus no statin therapy below £7200/QALY and with atorvastatin 80mg vs 40mg daily below £16000/QALY (Figure 2) across all patient categories studied. Compared to lifetime statin therapy, stopping therapy at 80 years of age substantially reduced benefits and was not cost-effective in any patient category studied. Similarly, compared to immediate initiation, 5-year delay of statin therapy in 40–45 years old patients was not a cost-effective.

Conclusions

In the UK, statin therapy remains highly cost-effective across men and women 40–70 years old, including those at 10-year CVD risk <5%.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme, UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme, UK Medical Research Council (MRC), British Heart Foundation

Benefit accrual with cardiovascular disease prevention and effects of discontinuation: a modelling study

Background

Statin therapy reduces rates of heart attacks and strokes and improves survival in people at increased cardiovascular disease (CVD) risk. However, there is some uncertainty when to start and how long to persist with statin therapy so as to optimise benefits.

Purpose

To project the accrual of benefit with statin therapy in population groups by age at therapy initiation using a newly developed micro-simulation model.

Methods

Participants without previous CVD (N=44,412) and with previous CVD (N=13,061) at entry were randomly selected from the UK Biobank cohort, ensuring sufficient representation in respective categories by age, LDL cholesterol, diabetes and 10-year CVD risk categories (QRISK3 score, for those without previous CVD only). The CTT-UKB model, a CVD micro-simulation model [1], was used to predict subsequent survival and quality-adjusted life years (QALYs) of the participants using their characteristics at entry. Treatment with atorvastatin 40mg daily was used as an example to illustrate the effect of the therapy compared to no such therapy. Scenarios include: (1) lifelong preventive therapy, (2) preventive therapy stopped at 80 years of age, and (3) delayed initiation of preventive therapy by 5 years in participants under 45 years of age.

Results

Statin treatment benefits, measured in QALYs gained, accrue over lifetime. The majority of benefits accrue later in life. Men accumulate larger benefits and earlier than women (Figure 1A). The pattern of benefits accrual is similar for participants with and without previous CVD (data not shown). The higher the participants' CVD risk, the larger and earlier the benefits, with younger participants accruing larger benefits (Figure 1B). Compared with lifelong prevention, stopping treatment at 80 years of age leads to large reductions in overall benefits, especially in women and those at lower CVD risk. For example, compared to lifelong therapy, people without previous CVD who initiate therapy in their 50s, would lose 47% of QALYs benefit (if men), 66% (if women), 73% (if with CVD risk <5%), and 35% (if with CVD risk ≥20%), respectively, if they stop treatment when they reach 80 years of age. Five-year delay of statin therapy initiation in people under 45 years of age reduces their benefits by about 4% on average, though the loss is somewhat larger in people at higher CVD risk (Figure 2).

Conclusion

Benefits from lifelong cardiovascular prevention accrue over peoples' lifespan with large share of benefits accruing at older age. Stopping treatment earlier substantially reduces benefits.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): UK NationalInstitute for Health Research (NIHR) Health Technology Assessment (HTA) Programme, UK Medical Research Council (MRC), and British Heart Foundation

Pharmacist-led multidisciplinary approach in preventing strokes in people with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

In England, 90% of patients with atrial fibrillation (AF) are expected to receive anticoagulation as part of targets set by Public Health England by 2029. In 2019/2020, across three London boroughs serving a population of 770,000, the percentage of AF patients at high risk of stroke (CHA2DS2VASc>2) anticoagulated was 87%, 83% and 84%. This placed two of the three localities in the bottom 10% compared to others in England. In addition, optimising cholesterol and lifestyle choices can significantly reduce the risk of cardiovascular disease and associated mortality in these patients.

Purpose

To prevent AF-related strokes by improving anticoagulation rates and optimising cardiovascular risk factors in patients with AF in all general practices across three London boroughs over one year, and to minimise risk of bleeding in patients on concurrent anticoagulation and antiplatelet therapy.

Methods

A specialist cardiovascular pharmacist was commissioned to systemically identify high-risk AF patients (CHA2DS2VASc>2) by working with primary care clinicians, including up-skilling of primary care pharmacists. Through utilisation of ‘proactive care frameworks’ created by the Clinical Effectiveness Group Queen Mary University of London and UCL Partners, patients were able to be stratified and prioritised for review. AF patients not on anticoagulation or on antiplatelet monotherapy were deemed to be at highest risk, and these patients were reviewed to assess suitability for anticoagulation. Subsequently, patients on concurrent anticoagulation and antiplatelets were assessed to determine if dual antithrombotic prescribing was still indicated to minimise risk of major bleeding. Lastly, to optimise cardiovascular risk prevention, all AF patients were reviewed for suitability of statin initiation for primary or secondary prevention. A virtual multidisciplinary team was convened for complex patients, which included a cardiologist, haematologist, general practitioner and pharmacist to review and agree an action plan.

Results

An interim analysis at 9 months reported that 94% (6745/7145) of patients with a CHA2DS2VASc>2 across the three boroughs were suitably anticoagulated, an improvement of 6% on the initial 88% (6585/7391). There was a reduction in concurrent anticoagulation and antiplatelet therapy from 381 to 262 patients (31.2% reduction) following specialist review. Lastly 2285 patients were reviewed with a recommendation to start a statin for either primary (n=1783) or secondary prevention (n=502).

Conclusion(s)

Provision of a specialist cardiovascular pharmacist supported a multidisciplinary workforce with significant improvement in anticoagulation rates across all three boroughs, reducing the risk of stroke in this high-risk population. In addition, we were able to reduce the risk of bleeding in this cohort of patients by stopping inappropriate antiplatelet therapy, and reduced the risk of cardiovascular disease through statin initiation.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

References

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

Disclosure of Interests

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

Sanofi

Abbvie (2021-)

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

Vifor Pharma GTI Validation 2020

Roche GCA Tocilizumab Registry 2019

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

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

Background

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

Objectives

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

Methods

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

Results

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

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

Figure 1.

Steroid PRO Initial Themes

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

Conclusion

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

Disclosure of Interests

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

P126 GCA Hospital Standards (GHOST) - making a map of specialised services for the care of giant cell arteritis across England

Background/Aims

The objective of this project is to map services essential to delivering high quality care in giant cell arteritis (GCA) across England, identifying gaps in provision and thereby help to remove inequalities. To do this however, there must first be agreement on what these best practice services and standards are.

Methods

A steering committee was formed comprising 18 expert representatives from the 13 clinical regions in England, including rheumatology, ophthalmology, allied health professional and patient representation. A modified Delphi process was commenced with each member initially providing five aspects of service they felt were essential for best practice GCA care. From the 90 answers, common themes were identified by creation of a word cloud and then condensed into domains of practice. These domains were then ranked by each member in order of perceived importance. The top 10 domains taken forward for further review were clinical pathways, patient access, Rheumatology involvement, Ophthalmology involvement, ultrasonography provision, temporal artery biopsy provision, PET-CT scan provision, glucocorticoid treatment, patient education and multi-disciplinary team working. Domains identified as separate areas but not quite making it into the top 10 were Tocilizumab provision, audit and governance and research. With the latter two in particular, it was felt these are overarching principles which should run through all aspects of clinical work. Group consultation was undertaken to discuss the relevant aspects, and from this, three quality metrics and one summary statement were devised for each domain. Rheumatology and Ophthalmology provision were amalgamated, as it was felt these were equally as important, with similar requirements. On the first pass of voting all except ‘patient access’ achieved over 75% agreement amongst the steering committee members. After group consultation and amendment, ‘patient access’ also achieved the minimum 75% agreement cut-off. The final statements can be seen in the table below.

Results:

Conclusion

By devising specific quality metrics in addition to the recommendation statements above, it is envisaged these standards can be easily used as an audit tool to identify gaps and development needs in GCA services.

Disclosure

F.L. Coath: None. M. Bukhari: None. G. Ducker: None. B. Griffiths: None. S. Hamdulay: None. M. Hingorani: None. C. Horsbrugh: None. C. Jones: None. P. Lanyon: None. S. Mackie: None. S. Mollan: None. J. Mooney: None. J. Nair: None. E. O’Sullivan: None. A. Patil: None. J. Robson: None. V. Saravanan: None. M. Whitlock: None. C. Mukhtyar: None.

A model of lifetime health outcomes in cardiovascular disease based on clinical trials and large cohorts

Background and purpose

Cardiovascular disease (CVD) risk of individuals depends on their socio-demographic characteristics, clinical risk factors, and treatments, and strongly influences their quality of life and survival. Individual-based long-term disease models, which aim to more accurately calculate the lifetime consequences, can help to target treatments, develop disease management programmes, and assess the value of new therapies. We present a new micro-simulation CVD model.

Methods

This micro-simulation model was developed using individual participant data from the Cholesterol Treatment Trialists' collaboration (CTT: 118,000 participants; 15 trials) and calibrated (with added socioeconomic deprivation, ethnicity, physical activity, mental illness, cancer and incident diabetes) in the UK Biobank cohort (UKB: 502,000 participants). Parametric survival models estimated risks of key endpoints (myocardial infarction (MI), stroke, coronary revascularisation (CRV), diabetes, cancer and vascular (VD) and nonvascular death (NVD) using participants' age, sex, ethnicity, physical activity, socioeconomic deprivation, smoking history, lipids, blood pressure, creatinine, previous cardiovascular diseases, diabetes, mental illness and cancer at entry and non-fatal incidents of the key endpoints during follow-up. The model integrates the risk equations and enables annual projection of endpoints and survival over individuals' lifetimes. The model was used to project remaining life expectancy across UK Biobank participants.

Results

Nonfatal cardiovascular events and age were the major determinants of CVD risk and, together with incident diabetes and cancer, of individuals' survival. The cumulative incidence of the key endpoints predicted by the CTT-UKB model corresponded well to their observed incidence in the UK Biobank cohort, overall (Figure 1) and in categories of participants by age, sex, prior CVD and CVD risk. Predicted remaining life expectancy across UK Biobank participants without history of CVD ranged between 22 and 43 years in men and between 24 and 46 years in women, depending on their age and CVD risk (Figure 2). Among UK Biobank participants with history of CVD, depending on their age, predicted remaining life expectancy ranged from 20 to 32 years in men and from 26 to 38 years in women.

Conclusion

This new lifetime CVD model accurately predicts morbidity and mortality in a large UK population cohort. It will be made available to provide individualised projections of expected lifetime health outcomes and benefits of treatments.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme, UK Medical Research Council (MRC), British Heart Foundation Figure 1. Predicted (in black) versus observed (95% CI; in red) incidence of major clinical outcomes in the UK Biobank.Figure 2. Predicted remaining life expectancy of participants in UK Biobank cohort, by age and CVD risk or previous CVD at entry. QRISK, a 10-year CVD risk scoring algorithm for people without previous CVD, recommended for use in the UK National Health Service.

Benefits from optimised antihypertensive and statin treatment in high risk people

Background

Hypertension and hypercholesterolaemia are major modifiable risk factors for cardiovascular diseases (CVD) with available effective and low-cost treatments. However, their suboptimal treatment remains widespread. We characterise treatment gaps in a large urban population and quantify the potential long-term health and economic impact with optimised use.

Methods

We studied 1 million UK urban residents served by 123 primary care practices in 2019. We categorised antihypertensive treatment in adults with diagnosed hypertension, and statin treatment in adults with diagnosed CVD, into optimal, suboptimal and not treated following UK clinical guidelines. A long-term CVD model was used to project cardiovascular events avoided, years of life and quality-adjusted life years (QALYs) gained, and healthcare costs saved with optimised treatments for individual patients accounting for their socio-demographic characteristics and risk factors.

Results

21,954 (24%, mean age 59 years; 49% female) of the 91,828 adults with hypertension were either suboptimally treated (20%) or untreated (4%) and 9,062 (38%, mean age 69 years; 43% female) of the 23,723 adults with CVD were either suboptimally treated (24%) or untreated (14%). Per 1000 patients (95% CI) optimised over lifespan, hypertension treatment would prevent 154 (72–230) major vascular events (MVEs, including heart attack, stroke or arterial revascularisation) and 69 (28–103) vascular deaths, and gain 769 (436–1038) QALYs for those sub-optimally treated, and prevent 138 (68–201) MVEs and 50 (21–76) vascular deaths, and gain 674 (386–920) QALYs for those not treated; statin treatment would prevent 68 (46–88) MVEs and 17 (12–21) vascular deaths, and gain 145 (113–178) QALYs for those sub-optimally treated, and prevent 260 (190–319) MVEs and 55 (40–68) vascular deaths, and gain 535 (412–651) QALYs for those not treated (Figure). Hospital cost savings net of medication costs were about £1100 per person over their remaining lifespan.

Conclusion

Optimising preventive cardiovascular treatments in UK primary care is likely to cost-effectively reduce cardiovascular risk and improve life expectancy, while reducing population inequalities.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Barts Charity, British Heart Foundation, and Health Data Research UK Predicted benefits from optimisation

Improving benefit-harm assessment of glucocorticoid therapy incorporating the patient perspective: The OMERACT glucocorticoid core domain set

OBJECTIVE

Our primary objective was to develop an Outcome Measures in Rheumatology (OMERACT) core domain set to capture the impact of glucocorticoids (GC), both positive and negative, on patients with Rheumatic conditions.

METHODS

The OMERACT Filter 2.1 was used to guide core domain selection. Systematic literature reviews, qualitative studies and quantitative surveys were conducted by the OMERACT GC Impact working group to identify candidate domains for a core domain set. A summary of prior work and Delphi exercise were presented at the OMERACT 2020 virtual GC workshop. A proposed GC Impact core domain set derived from this work was presented for discussion in facilitated breakout groups. Participants voted on the proposed GC Impact core domain set.

RESULTS

113 people, including 23 patient research partners, participated in two virtual workshops conducted at different times on the same day. The proposed mandatory domains to be evaluated in clinical trials involving GCs were: infection, bone fragility, hypertension, diabetes, weight, fatigue, mood disturbance and death. In addition, collection of disease specific outcomes was included in the core domain set as "mandatory in specific circumstances". The proposed core domain set was endorsed by 100% (23/23) of the patient research partners and 92% (83/90) of the remaining participants, including clinicians, researchers and industry stakeholders.

CONCLUSION

A GC Impact core domain set was endorsed at the OMERACT 2020 virtual workshop. The OMERACT GC Impact working group will now progress to identify, develop and validate measurement tools to best address these domains in clinical trials.

POS0158-HPR UNDERSTANDING NURSE-LED CARE IN EARLY RA: INTERVIEW STUDY WITH RHEUMATOLOGY NURSE SPECIALISTS

Background:

Nurse-led care in early RA is not well defined in the literature and the current recommendations.

Objectives:

This study aimed to develop an understanding of what comprises nurse-led care in early RA from the perspective of rheumatology nurse specialists.

Methods:

This was a qualitative study using semi-structured telephone interviews with rheumatology nurse specialists in England (Summer 2020). Interviews were audio-recorded, transcribed verbatim and analysed using inductive thematic analysis.[1]

Results:

Sixteen nurses were recruited and interviews lasted between 30 to 60 minutes. Seven themes were identified.

Early disease management

Care was characterised by evidence-based RA management provided by experienced nurse specialists with a high degree of autonomy, in the context of a rheumatology multidisciplinary team. The aims of care were to: start treatment, keep in treatment, educate and support.

’So treat to target...escalating treatment as necessary, and addressing any concerns that the patients might have’ (CNS14)

Addressing psychosocial needs

Patients with early RA experience shock, fear, anger, grief and denial while feeling unwell with pain and fatigue. Nurses use a holistic, person-centred and empathetic approach to address psychosocial needs, building a working relationship, listening and creating trust.

’Because it all relates, and if they’re stressed because they’re not coping at work, then their arthritis isn’t going to be so good. So everything relates to one another really’ (CNS06)

Monitoring treatment, disease impact and patient outcomes

Nurses monitor disease activity and disease impact using validated outcome measures and by asking questions during the consultation. Good outcomes are disease control, managing disease impact, medication and side effects, wellbeing and keeping in work.

’When you get them stable, when you get them into remission, when they’re happy, when they’re feeling well, I think there’s lots of ways you can measure that’… (CNS13)

Coordinating care, referring and signposting

Nurses coordinate care, refer to other health professionals and signpost patients to relevant services and charities. Lack of access to psychology expertise was highlighted.

‘And whilst most of us have got some degree of understanding of…self management, or psychology…we’re not psychologists’ (CNS02)

Providing a ‘lifeline’

Nurse-led telephone advice services provide a ‘lifeline’ for patients. If patients struggle, they can call and speak with a specialist who knows them and their RA well.

’The advice line has been a lifeline to them, to be able to speak to someone, to be able to get a response quickly to their questions, they feel very well supported, they know that they can always call us’ (CNS16)

Service evaluation and auditing

The individual clinics are reviewed regularly. Patients are asked for feedback on their experience of appointments, if their needs were met and about changes to the service.

...‘It’s really important to ask them initially what they expect to have from the consultation...We’ve always had really good feedback in general’… (CNS02)

COVID-19 challenges and opportunities

The pandemic caused major disruptions to the services, prohibiting most face-to-face consultations which was an essential aspect of clinical assessments. Despite the challenges imposed by the pandemic, the services adapted fast, using telephone, video clinics and digital solutions, which streamlined procedures and improved documentation and communication.

‘I do have to rely on them telling me what’s going on, because I can’t see it at the moment’ (CNS14)

’With Covid we’re doing it over the telephone, and we’re getting them to watch the video [injection tutorial] before we have the appointment with them’ (CNS04)

Conclusion:

Nurse-led care in early arthritis is a specialist service, addressing complex needs of patients, using evidence based and person-centred approaches. Innovation and service improvement are seen as part of the role.

References:

[1]Braun V, Clarke V. Successful Qualitative Research. First edition. London: SAGE 2013.

Disclosure of Interests:

None declared

POS1472-HPR CLINICIANS’ PERSPECTIVES ON PSYCHOLOGICAL DISTRESS AND MEETING PATIENTS’ SUPPORT NEEDS IN RHEUMATOLOGY CARE SETTINGS

Background:

People with inflammatory rheumatic diseases (IRDs) face challenges that include fluctuations in pain, fatigue and flares of disease activity, complex medical regimens, and decisions about when to seek clinical help with symptoms [1,2]. Evidence suggests levels of anxiety and depression are higher in people with IRDs compared to the general population [3]. Rheumatology teams report that psychologically distressed patients can have additional support needs and require more time. Patients’ concerns include health-related anxiety and difficulty accepting the diagnosis. This group can have poor outcomes and poor adherence to treatments. However, little is currently known about optimal ways to meet these patients’ support needs.

Objectives:

To understand rheumatology clinicians’ perspectives on psychological distress in care settings with the long-term aim to develop a proposed model/pathway of support.

Methods:

Telephone interviews were conducted with members of UK rheumatology teams who have clinical experience with patients experiencing distress. The semi-structured interviews explored both ‘what happens now’ (current clinical practice) and ‘what should happen’ (acceptable models of future psychological support provision). The semi-structured format provided flexibility to probe more deeply and develop new lines of enquiry based on participants’ responses.

Results:

Fourteen interviews were conducted with rheumatology clinicians including 2 consultants, 4 nurses, 1 physiotherapist, 4 occupational therapists, 2 clinical psychologists and 1 podiatrist. Inductive thematic analysis was used to analyse the data. Two main themes represent the data (Table 1).

Table 1.Main ThemeSub-themes1. ‘No one shoe fits all’ – the many manifestations of distress in patients.‘I pick up on distress as increased emotion…tearfulness and sadness I suppose, but also frustration, anger...A lot of helplessness comments’1. ‘Distress can be quite emotive and quite obvious, but then it can also hide away’2. ‘They’re [patients] trying to manage their own conditions, but they’re also trying to manage life’2. ‘If Rheumatology could be interwoven with psychological principles’ – the need to attend to the psychological impact of IRDs, alongside the physical impact.‘The physical and mental health side of things are so closely linked because one affects the other…after a while they [patients] don’t really know what’s affecting what’1. ‘Prioritising physical health…sometimes the stress gets not thought about’2. ‘Make best use of everyone in the team to work with patients who are struggling’3. ‘For the psychological side of things we don’t measure anything about that at all’

Conclusion:

Distress can be obvious or hidden and cause issues for both patient and clinician. It can lead to poor engagement with care provision. Clinicians differ in their perceptions of distress and in their thresholds for dealing with distress and have described the inconsistency of support offered for distressed patients. They described the powerful link between physical and mental distress, the vicious cycle that can develop, and the benefits of incorporating a psychological approach to treatment. This study suggests psychological support should be embedded within the team as it is felt there is a need for speciality understanding and for patients’ emotional wellbeing to consistently be given equal priority to their physical wellbeing.

References:

[1]Gettings L. Psychological well-being in rheumatoid arthritis: a review of the literature. Musculoskeletal care 2010;8(2):99-106. doi: 10.1002/msc.171 [published Online First: 2010/03/17]

[2]Homer D. Addressing psychological and social issues of rheumatoid arthritis within the consultation: a case report. Musculoskeletal care 2005;3(1):54-9. doi: 10.1002/msc.26 [published Online First: 2006/10/17]

[3]Isik A, Koca SS, Ozturk A, et al. Anxiety and depression in patients with rheumatoid arthritis. Clinical rheumatology 2007;26(6):872-8. doi: 10.1007/s10067-006-0407-y [published Online First: 2006/08/31]

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Figure 1.

Conclusion:

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

References:

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

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

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

Disclosure of Interests:

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

Pulmonary Involvement in Primary Systemic Vasculitides

OBJECTIVES

This study describes the spectrum and initial impact of pulmonary manifestations in the primary systemic vasculitides.

METHODS

Description and comparison of pulmonary manifestations in adults with Takayasu's arteritis (TAK), giant cell arteritis (GCA), granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (EGPA), polyarteritis nodosa (PAN), and IgA vasculitis (IgAV), using data collected within the Diagnostic and Classification Criteria in Vasculitis (DCVAS) study.

RESULTS

Data from 1952 patients with primary vasculitides were included: 170 TAK, 657 GCA, 555 GPA, 223 MPA, 146 EGPA, 153 IgAV, and 48 PAN. Pulmonary manifestations were observed in patients with TAK (21.8%), GCA (15.8%), GPA (64.5%), MPA (65.9%), EGPA (89.0%), PAN (27.1%) and IgAV (5.9%). Dyspnea occurred in patients with TAK (14.7%), GCA (7.8%), GPA (41.8%), MPA (43.5%), EGPA (65.8%), PAN (18.8%) and IgAV (2.6%). Cough was reported in TAK (7.6%), GCA (9.3%), GPA (34.8%), MPA (37.7%), EGPA (55.5%), PAN (16.7%) and IgAV (3.3%). Hemoptysis occurred mainly in patients with ANCA-associated vasculitis (AAV). Fibrosis on imaging at diagnosis was documented in GPA (1.9%), MPA (24.9%), and EGPA (6.3%). Only patients with AAV (GPA 2.7%, MPA 2.7% and EGPA 3.4%) required mechanical ventilation. At 6 months, the presence of at least one pulmonary item in the Vasculitis Damage Index (VDI) was observed in TAK (4.1%), GCA (3.3%), GPA (15.4%), MPA (28.7%), EGPA (52.7%), PAN (6.2%), and IgAV (1.3%).

CONCLUSIONS

Pulmonary manifestations can occur in all primary systemic vasculitides, but are more frequent and more often associated with permanent damage in AAV.

Patient Reported Outcomes in Large Vessel Vasculitides

Purpose of Review

The goal of this paper is to review current and future uses of patient-reported outcomes in large vessel vasculitis. The large vessel vasculitides comprise Giant Cell Arteritis and Takayasu arteritis; both are types of systemic vasculitis which affect the larger blood vessels. Patient-reported outcomes (PROs) capture the impact of these diseases on health-related quality of life.

Recent Findings

Generic PROs such as the SF-36 are currently used to compare HRQOL of people with GCA and TAK within clinical trials and observational studies and to make comparisons with the general population and HRQoL in other diseases. The development of a disease-specific PRO for GCA is currently underway. Beyond clinical trials, there is much interest in the use of PROs within routine clinical care, particularly E-PROs for remote use.

Summary

Further work will be needed to complete the development of disease-specific PROs for people with large vessel vasculitis and to establish feasibility, acceptability, and utility of E-PROs.

Clinicopathologic Associations in a Large International Cohort of Patients with Giant Cell Arteritis

OBJECTIVE

In addition to aiding in diagnosis, histopathologic findings from temporal artery biopsy (TAB) specimens in giant cell arteritis (GCA) may be valuable for their associations with clinical features of the disease. This study compared histopathologic findings on TAB with biopsy interpretation and demographic, clinical, and imaging features at time of diagnosis.

METHODS

Patients with a clinical diagnosis of GCA who had a TAB were selected from an international, multicenter observational cohort of vasculitis. Associations between demographic, clinical, radiographic, and histopathologic features were identified using bivariate testing and multivariate regression modeling.

RESULTS

Out of 705 patients with GCA who underwent TAB, 69% had histopathological evidence of definite vasculitis. Specific histopathological findings included the presence of giant cells (51%), fragmentation of the internal elastic lamina (41%), intimal thickening (33%), and predominantly mononuclear leukocyte infiltration (32%). Histopathologic interpretation of definite vasculitis was independently associated with giant cells (odds ratios (OR) 151.8, 95% confidence interval (CI): 60.2-551.6), predominantly mononuclear leukocyte infiltration (OR 11.8, CI 5.9-24.9), and fragmentation of the internal elastic lamina (OR 3.7, CI 1.9-7.4). A halo sign on temporal artery ultrasound and luminal damage of large arteries on angiography were significantly associated with presence of giant cells (OR 2.6, CI 1.1-6.5 and OR 2.4, CI 1.1-5.2, respectively). Specific histopathologic findings were associated with older age but no associations were identified with vision loss or other clinical features.

CONCLUSION

Histopathologic findings in GCA are strongly associated with the clinical diagnosis of GCA but have a limited role in identifying patterns of disease.

Comparative analysis of three laboratory based serological assays for SARS-CoV-2 in an Australian cohort

Many unanswered questions remain regarding the role of SARS-CoV-2 serological assays in this unfolding COVID-19 pandemic. These include their utility for the diagnosis of acute SARS-CoV-2 infection, past infection or exposure, correlation with immunity and the effective duration of immunity. This study examined the performance of three laboratory based serological assays, EUROIMMUN Anti-SARS-CoV-2 IgA/IgG, MAGLUMI 2000 Plus 2019-nCov IgM/IgG and EDI Novel Coronavirus (COVID-19) IgM/IgG immunoassays. We evaluated 138 samples from a reference non-infected population and 71 samples from a cohort of 37 patients with SARS-CoV-2 confirmed positive by RT-PCR. The samples were collected at various intervals of 0-45 days post symptoms onset (PSO). Specificity and sensitivity of these assays was 60.9%/71.4% (IgA) and 94.2%/63.3% (IgG) for EUROIMMUN; 98.5%/18.4% (IgM) and 97.8%/53.1% (IgG) for MAGLUMI; and 94.9%/22.5% (IgM) and 93.5%/57.1% (IgG) for EDI, respectively. When samples collected ≥14 days PSO were considered, the sensitivities were 100.0 and 100.0%; 31.0 and 82.8%; 34.5 and 57.1%, respectively. Using estimated population prevalence of 0.1, 1, and 10%, the positive predictive value of all assays remained low. The EUROIMMUN Anti-SARS-CoV-2 IgA lacked specificity for acute diagnosis and all IgM assays offered poor diagnostic utility. Seroconversion can be delayed although all patients had seroconverted at 28 days in our cohort with the EUROIMMUN Anti-SARS-CoV-2 IgG. Despite this, with specificity of only 94% this assay would not be satisfactory for seroprevalence studies in the general Australian population given this is likely to be currently <1%.

Nationwide health check program by patients with severe mental illness or long-term antidepressants

Background

The English NHS Health Check is a unique national risk assessment, awareness and management programme for preventing cardiovascular disease (CVD), diabetes and chronic kidney disease (CKD). We aimed to assess their uptake and association with new diagnoses (CVD, hypertension, type-2 diabetes and CKD) in patients with severe mental illness (SMI) compared to patients without this condition and for patients on long-term antidepressant treatment (LTAD) (≥6 prescriptions vs &lt; 6).

Methods

Cohort study (2013-2017) using the QResearch database. 1,319 general practices across England contributed of over nine million patients aged 40-74 years. 3,492,186 patients were eligible for NHS Health Checks of which 590,218 attended. Outcomes: hazard ratios (HR) with 95% confidence intervals (CI) for uptake of NHS Health Checks and for new diagnoses within 1 year in attendees. Models were adjusted for sex, age, ethnicity, deprivation and region.

Results

65,490 people with SMI and 46,437 people on LTAD (20% of the total eligible with SMI/LTAD, respectively) attended an NHS Health Check. People with SMI or on LTAD were more likely to attend compared to people without those conditions, adjusted HRs 1.05 (95% CI 1.02-1.08) and 1.10 (95% CI 1.08-1.13), respectively. Among attendees, people with SMI and on LTAD were 23% and 55% more likely to be diagnosed with CKD (95% CI 1.12-1.34 and 1.42-1.70, respectively) than people without these conditions. Attendees on LTAD were 66% more likely to have a major CVD event within 1 year than those without LTAD (95% CI 1.41-1.94) or a new diagnosis of hypertension and type 2 diabetes, HRs 1.12 (95% CI 1.05-1.20) and 1.45 (95% CI 1.31-1.60), respectively.

Conclusions

People with SMI or on LTAD were more likely to attend NHS Health Checks than people without these conditions. Higher rates of CKD in patients with SMI/LTAD and CVD, hypertension and type 2 diabetes in the latter might indicate increased risks and unmet need in these patient groups

Key messages

People with SMI/LTAD were more likely to attend NHS Health Checks. People on LTAD were more likely to be diagnosed with CVD, CKD, hypertension and type-2 diabetes than people without these conditions. SMI attendees were more likely to be diagnosed with CKD.

Feasibility and Face Validity of Outcome Measures for Use in Future Studies of Polymyalgia Rheumatica: An OMERACT Study

OBJECTIVE

To survey participants with polymyalgia rheumatica (PMR) to evaluate the face validity, acceptability, and domain match of proposed candidate outcome measures.

METHODS

A structured, online, anonymous survey was disseminated by patient support groups through their networks and online forums. The candidate outcome measures comprised (1) visual analog scale (VAS) and numerical rating score (NRS) to assess pain; (2) VAS, NRS, and duration to assess stiffness; (3) the modified Health Assessment Questionnaire and Health Assessment Questionnaire Disability Index to assess physical function; and (4) C-reactive protein and erythrocyte sedimentation rate to assess inflammation. Free-text answers were analyzed using descriptive thematic analysis to determine respondents' views of the candidate instruments.

RESULTS

Seventy-eight people with PMR from 6 countries (UK, France, USA, Canada, Australia, and New Zealand) participated in the survey. Most respondents agreed candidate instruments were acceptable or "good to go." Free-text analysis identified 5 themes that participants considered inadequately covered by the proposed instruments. These related to (1) the variability, context, and location of pain; (2) the variability of stiffness; (3) fatigue; (4) disability; and (5) the correlation of inflammatory marker levels and severity of symptoms, sometimes reflecting disease activity and other times not.

CONCLUSION

Participants reported additional aspects of their experience that are not covered by the proposed instruments, particularly for the experience of stiffness and effect of fatigue. New patient-reported outcome measures are required to increase the relevance of results from clinical trials to patients with PMR.

North Atlantic climate far more predictable than models imply

Quantifying signals and uncertainties in climate models is essential for the detection, attribution, prediction and projection of climate change^1-3. Although inter-model agreement is high for large-scale temperature signals, dynamical changes in atmospheric circulation are very uncertain⁴. This leads to low confidence in regional projections, especially for precipitation, over the coming decades^5,6. The chaotic nature of the climate system^7-9 may also mean that signal uncertainties are largely irreducible. However, climate projections are difficult to verify until further observations become available. Here we assess retrospective climate model predictions of the past six decades and show that decadal variations in North Atlantic winter climate are highly predictable, despite a lack of agreement between individual model simulations and the poor predictive ability of raw model outputs. Crucially, current models underestimate the predictable signal (the predictable fraction of the total variability) of the North Atlantic Oscillation (the leading mode of variability in North Atlantic atmospheric circulation) by an order of magnitude. Consequently, compared to perfect models, 100 times as many ensemble members are needed in current models to extract this signal, and its effects on the climate are underestimated relative to other factors. To address these limitations, we implement a two-stage post-processing technique. We first adjust the variance of the ensemble-mean North Atlantic Oscillation forecast to match the observed variance of the predictable signal. We then select and use only the ensemble members with a North Atlantic Oscillation sufficiently close to the variance-adjusted ensemble-mean forecast North Atlantic Oscillation. This approach greatly improves decadal predictions of winter climate for Europe and eastern North America. Predictions of Atlantic multidecadal variability are also improved, suggesting that the North Atlantic Oscillation is not driven solely by Atlantic multidecadal variability. Our results highlight the need to understand why the signal-to-noise ratio is too small in current climate models¹⁰, and the extent to which correcting this model error would reduce uncertainties in regional climate change projections on timescales beyond a decade.

SAT0643-HPR NURSE-LED CARE FROM THE PERSPECTIVE OF PEOPLE WITH EARLY RHEUMATOID ARTHRITIS: A QUALITATIVE SYSTEMATIC REVIEW

Background:

Nurse-led care has been shown to be clinically effective and cost effective in rheumatoid arthritis (RA) but the role of the nurse in early RA is not well defined. Evidence for processes of care in RA is limited and it is not known how well rheumatology nurse-led clinics meet care needs of people with early RA.

Objectives:

The aim of this study was to develop an understanding of rheumatology nurse-led care from the perspective of people with early RA.

Methods:

A qualitative systematic review was conducted. The review protocol is published in the International prospective register of systematic reviews.

In March 2019, the following databases were searched: MEDLINE, EMBASE, CINAHL, PsycINFO and OpenGrey. Due to lack of studies in early RA this review included adults with early and established inflammatory arthritis, qualitative studies with data on patients’ perspectives of nurse-led care, published in peer-reviewed journals in English between 2010 and 2019. Two reviewers screened titles, abstracts and full texts. Data were extracted and managed in tables. Joanna Briggs Institute Critical Appraisal Checklist was used for quality assessment of the included studies. A thematic synthesis was undertaken using the framework of Thomas and Harden.1

Results:

The search identified 1034 records. After screening and assessing for eligibility, 8 qualitative studies were included in the review (133 patients), 2 studies included people with early RA. Three main themes were identified (Figure 1).

Figure 1.

Themes of nurse-led care from the perspective of people with RA

Providing knowledge and skill. This theme delineated rheumatology nursing as providing professional expertise in the planning and delivery of care. The rheumatology nurse-led service included easy access via telephone helpline, consultations with the clinical nurse specialist for assessment of disease activity and care needs, planning of care, disease information and education, supporting self-management, and referral to rheumatologist and the multi-disciplinary team. People with RA highly valued the nurse expertise and specialist knowledge provided at nurse-led clinics.‘She was very good at informing me, so I have only praise for this ... because I have never had it like this before’. (Person with early RA).

Using a person-centred approach.This theme showed nurse-led care using a person-centred approach combined with empathy and good communication skills, which created a good therapeutic environment. People with RA appreciated the person-centeredness, empathy and involvement of the nurse. ‘She is very sensitive. She can see if I am feeling bad and comes straight to me and asks: “How are you today?” ...You are treated and taken seriously’. (Person with early RA).

Meeting patients‘ care needs. This theme presented nurse-led care as creating a sense of being empowered and psychologically supported in the management of RA and its impact. Nurse-led care made people with RA feel cared for, secure and confident. It added value to rheumatology care and made care complete.‘The thought of sticking a needle into my own stomach... it felt a bit like I would never manage to do that. However, they have been absolutely wonderful here ... and now I can do it myself’. (Person with early RA).

Conclusion:

Nurse-led care for people with RA is characterised by provision of rheumatology expertise using a person-centred approach, and patients‘ holistic care needs are being met. This study found a dearth of literature on perceptions of nurse-led care in people with early RA, which highlights the need for further research in this population.

References:

[1]Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews.BMC Med Res Methodol2008; 8: 45.

Disclosure of Interests:

Anne-Marie Tetsche Sweeney: None declared, Candy McCabe: None declared, Caroline Flurey: None declared, Joanna Robson: None declared, Alice Berry: None declared, Pamela Richards: None declared, Mwidimi Ndosi Grant/research support from: Bristol Myers Squibb, Consultant of: Janssen, Pfizer

Mixed methods study of clinicians' perspectives on barriers to implementation of treat to target in psoriatic arthritis

OBJECTIVES

In treat to target (T2T), the patient is treated to reach and maintain specified and sequentially measured goals, such as remission or low disease activity. T2T in psoriatic arthritis (PsA) has demonstrated improved clinical and patient-reported outcomes and is recommended in European guidelines. However, most clinicians do not use T2T in PsA. This study examined the barriers and enablers to implementation in practice.

METHODS

Sequential mixed methods comprising a qualitative design (interviews and focus group) to inform a quantitative design (survey). Qualitative data were analysed thematically, and quantitative statistics were analysed descriptively.

RESULTS

Nineteen rheumatology clinicians participated in telephone interviews or a face-to-face focus group. An overarching theme 'Complexity' (including 'PsA vs Rheumatoid Arthritis', 'Measurement' and 'Resources') and an underpinning theme 'Changes to current practice' (including 'Reluctance due to organisational factors' and 'Individual determination to make changes') were identified. 153 rheumatology clinicians responded to an online survey. Barriers included limited clinical appointment time to collect outcome data (54.5%) and lack of training in assessing skin disease (35%). Enablers included provision of a protocol (86.4%), a local implementation lead (80.9%), support in clinic to measure outcomes (83.3%) and training in T2T (69.8%). The importance of regular audit with feedback, specialist PsA clinics and a web-based electronic database linked to hospital/national information technology (IT) systems were also identified as enablers.

CONCLUSIONS

Implementation of T2T in PsA requires an integrated approach to address the support, training and resource needs of individual clinicians, rheumatology teams, local IT systems and service providers to maximise success.

P185 Patient perceptions of physical activity following a diagnosis of giant cell arteritis: a multinational qualitative study

Background

Giant cell arteritis (GCA) is the most common vasculitis in the UK, with an incidence of 220 cases per million in adults over 50 years of age. The physical symptoms as well as the side effects of glucocorticoids may impact patients’ ability to exercise. Maintaining physical activity (PA) has been shown to be beneficial to disease activity in other inflammatory conditions and is also a specific priority for GCA patients. The aim of this project was to explore patient perceptions of physical activity in GCA.

Methods

Multinational qualitative study, using interviews with 36 patients from the UK (25) and Australia (11), all of whom had a definitive diagnosis from imaging or biopsy. Interviews were recorded, transcribed, and analysed using inductive thematic analysis. This is secondary analysis of data collected to explore health-related quality of life in people with GCA.

Results

107 individual themes were reported by patients, which divided broadly into two overarching themes: barriers to (59) and facilitators of (48) physical activity. Four sub-themes were identified within each overarching theme. For barriers, these were: negative physical symptoms (including effects of disease flares, visual loss, fatigue, weakness, pain and stiffness), lack of physical capability (including poor stamina, confidence and mobility), negative perceptions around PA, and negative reinforcement (i.e. new physical symptoms following PA). Facilitators of physical activity were also grouped into four sub-themes: external facilitators (including motivation from healthcare professionals), access to appropriate facilities, personal strategies (including pacing and goal-setting) and personal facilitators (including internal motivation to improve symptoms, and positive reinforcement from noticing physical and psychological benefits of PA).

Conclusion

There are a variety of barriers to physical activity in GCA patients, including patients being fearful of exercise. In other inflammatory conditions, patients report improved symptoms following physical activity as well as wider benefits to general wellbeing and cardiovascular health. Education, motivational interviewing, and personalised strategies may be beneficial components of an intervention to support physical activity in patients with GCA.

Disclosures

K. Austin None. E. Dures Grants/research support; Has previously received an independent learning grant from Pfizer, however the work has been completed and the grant has been closed. C. Almeida None. F. Cramp None. K. Gilbert None. C. Guly None. C. Hill None. S. Mackie None. A. O'Brien None. R. Watts None. J. Robson None.

Early development of new cardiovascular risk factors in the systemic vasculitides

OBJECTIVES

To analyse the frequency and predictors of new-onset cardiovascular (CV) risk factors in patients with anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) and giant cell arteritis (GCA).

METHODS

We analysed the frequency and predictors of new-onset hypertension and/or diabetes mellitus (HTN/DM) amongst patients with AAV or GCA recruited in the Diagnostic and Classification of Vasculitis (DCVAS) study. Patients with pre-existing HTN/DM were excluded.

RESULTS

We included 873 patients with AAV (506 GPA, 183 MPA, 184 EGPA), and 443 with GCA. Patients with GCA were more likely female (68% vs. 52%; p<0.001) and older (71.33±8.65 vs. 52.80±16.48; p<0.001) compared to patients with AAV. HTN/DM developed within 6 months of diagnosis in 9% of patients with AAV (6% in GPA, 21% in MPA, 3% in EGPA) and 6% of patients with GCA, p=0.15. Rise in creatinine/reduced glomerular filtration rate and/or anaemia (OR 3.98, 95% CI 2.09-7.59, p<0.001) and diagnosis (MPA: OR 2.42, 95%CI 1.52-3.83, p<0.001 and GCA: OR 2.12, 95%CI 1.34-3.38, p=0.001 vs. GPA) were significantly associated with the occurrence of HTN/DM after adjusting for age, sex, ethnicity, and smoking status. We developed and validated a predictive score to discriminate patients according to the risk of developing HTN/DM within 6 months from diagnosis.

CONCLUSIONS

Despite different epidemiological and clinical characteristics, new CV risk factors occur equally in the early stages of AAV and GCA. Renal function and type of diagnosis are associated with the occurrence of HTN/DM. We developed a simple predictive score for the risk-stratification of patients.

Eosinophil granule major basic protein 1 deposition in eosinophilic esophagitis correlates with symptoms independent of eosinophil counts

In patients with eosinophilic esophagitis (EoE), symptoms often do not correlate with peak eosinophil counts (PEC) determined on histopathological examination of biopsy specimens. This may be because eosinophils degranulate during active disease and lose their morphological identity as intact cells and, therefore, are not enumerated on microscopic examination. Eosinophil granule proteins that are released into tissues with degranulation, including major basic protein 1 (eMBP1), likely contribute to disease pathogenesis and, therefore, may correlate with symptoms better than PEC. We sought to determine whether symptoms in patients with EoE more closely relate to eosinophil granule protein deposition than to eosinophil enumeration, especially in patients with fewer than 15 eosinophils per high power field (HPF). Esophageal biopsy specimens from 34 patients diagnosed with EoE were obtained for histopathological examination and for evaluation of eMBP1 staining by indirect immunofluorescence. PEC by histopathology were compared to extracellular eMBP1 grades by immunostaining. PEC and eMBP1 grades also were analyzed for their relationship to symptoms and clinical course. Biopsy specimens from 19 of the 34 patients had fewer than 15 PEC on histopathological examination, and the other 15 patients had 15 or greater PEC. Positive eMBP1 immunostaining was found in all symptomatic patients. EoE symptoms were related to eMBP1 immunostaining grades (p = 0.0001), but not PEC (P = 0.14). Eosinophil granule protein deposition, specifically eMBP1, is increased in esophageal biopsy specimens from symptomatic patients with EoE and may be a marker of disease activity, including patients with EoE who have 'resolved' disease.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Ethnic variations in the risk of hypoglycaemia among people with Type 2 diabetes prescribed insulins and/or sulfonylureas: a historical cohort study using general practice-recorded data

AIM

To identify ethnic differences in hypoglycaemic risk among people with Type 2 diabetes prescribed insulins and/or sulfonylureas in community settings.

METHODS

Using routine general practice-recorded data, two cohorts of adults with Type 2 diabetes from east London were studied between January 2013 and December 2015: (1) adults prescribed insulins ± other antidiabetes medications (n=7269) and (2) adults prescribed sulfonylureas ± other antidiabetes medications excluding insulins (n=12 502). Incidence rate ratios of hypoglycaemia by ethnicity, adjusting for age, sex, socio-economic status and clustering within Clinical Commissioning Groups, were estimated using random effects Poisson regression.

RESULTS

Compared with white British people prescribed insulins, those of black Caribbean ethnicity were at increased hypoglycaemic risk [adjusted incidence rate ratio 1.56 (95% CI 1.21,2.01)], while Bangladeshi people had a lower risk [adjusted incidence rate ratio 0.49 (95% CI, 0.38,0.64)]. In the sulfonylurea cohort, black Caribbean, black African and Indian people all had increased risks of hypoglycaemia compared with white British people [adjusted incidence rate ratios 1.63 (95% CI 1.15,2.29), 1.90 (95% CI 1.32,2.75) and 1.93 (95% CI 1.39,2.69), respectively].

CONCLUSION

The differences in hypoglycaemic risk among people with Type 2 diabetes prescribed insulin and/or sulfonylureas warrant further investigation of any differing biological responses and/or cultural attitudes to antidiabetes therapy among ethnic groups, and should be considered by clinicians evaluating the treatment goals of people with Type 2 diabetes using insulins or sulfonylureas.

Multinational Qualitative Research Study Exploring the Patient Experience of Raynaud's Phenomenon in Systemic Sclerosis

OBJECTIVE

Raynaud's phenomenon (RP) is the most common manifestation of systemic sclerosis (SSc). RP is an episodic phenomenon, not easily assessed in the clinic, leading to reliance on self-report. A thorough understanding of the patient experience of SSc-RP is essential to ensuring that patient-reported outcome (PRO) instruments capture domains important to the target patient population. We report the findings of an international qualitative research study investigating the patient experience of SSc-RP.

METHODS

Focus groups of SSc patients were conducted across 3 scleroderma centers in the US and UK, using a topic guide and a priori purposive sampling framework devised by qualitative researchers, SSc patients, and SSc experts. Focus groups were audio recorded, transcribed, anonymized, and analyzed using inductive thematic analysis. Focus groups were conducted until thematic saturation was achieved.

RESULTS

Forty SSc patients participated in 6 focus groups conducted in Bath (UK), New Orleans (Louisiana), and Pittsburgh (Pennsylvania). Seven major themes were identified that encapsulate the patient experience of SSc-RP: physical symptoms, emotional impact, triggers and exacerbating factors, constant vigilance and self-management, impact on daily life, uncertainty, and adaptation. The interrelationship of the 7 constituent themes can be arranged within a conceptual map of SSc-RP.

CONCLUSION

We have explored the patient experience of SSc-RP in a diverse and representative SSc cohort and identified a complex interplay of experiences that result in significant impact. Work to develop a novel PRO instrument for assessing the severity and impact of SSc-RP, comprising domains/items grounded in the patient experiences of SSc-RP identified in this study, is underway.

Health-related outcomes of importance to patients with Takayasu's arteritis

OBJECTIVES

The need to include patients' perspectives as key outcomes in clinical trials is widely accepted. No disease-specific patient-reported outcomes have been developed in Takayasu's arteritis. This project was designed to identify outcomes of importance to patients with Takayasu's arteritis during active disease and remission across 2 different cultures.

METHODS

Patients with Takayasu's arteritis from the US and Turkey were recruited to participate in semi-structured, one-on-one interviews or focus groups. The interviews and group sessions were recorded, transcribed, and entered into an Nvivo database. A line-by-line review of narrative data was used to develop themes describing the impact of Takayasu's arteritis on patients' life. US Patients were invited to freelist terms that they associated with disease states (active disease and remission). The Smith's Salience Index (SSI) was used to identify the most salient terms.

RESULTS

Results. A total of 31 patients with Takayasu's arteritis participated in this study. Interviews and focus groups identified pain, fatigue, and emotional impact as common themes. Outcomes did not differ between the 2 countries. The most salient terms identified through freelisting were pain/discomfort and fatigue/low energy levels (SSI=0.56 and 0.33, respectively) during active disease and pain/discomfort and emotional impact (SSI=0.51 and 0.37, respectively) during remission.

CONCLUSIONS

Patients with Takayasu's arteritis report a range of disease-specific symptoms across different cultures and disease states that are generally not specifically captured by generic patient-reported outcome tools currently used in research. Identifying disease-specific outcomes would advance clinical trials methodology to best capture the full spectrum of disease activity in Takayasu's arteritis.