[The subanalysis of Rheuma-VOR demonstrates a considerable need for rheumatological care]

BACKGROUND

Early diagnosis and treatment of inflammatory rheumatic diseases can prevent consequential damage such as permanently limited mobility and joint or organ damage. Simultaneously, there is an increasing deficit in medical care owing to the lack of rheumatological capacity. Rural regions are particularly affected.

OBJECTIVES

The available unconfirmed diagnoses of the study Rheuma-VOR were analysed regarding another definitive inflammatory rheumatic disease.

MATERIALS AND METHODS

The returned questionnaires of the rheumatologists participating in Rheuma-VOR were screened for definitive inflammatory rheumatic diseases other than the required diagnosis of rheumatoid arthritis, psoriatic arthritis or spondyloarthritis.

RESULTS

Of 910 unconfirmed diagnoses, in 245 patients another definitive diagnosis could be confirmed. A total of 29.8% of the diagnoses corresponded to degenerative joint changes or chronic pain syndrome, whereas 26.1% involved different forms of inflammatory arthritis. The majority of diagnoses (40.5%) were collagenosis or vasculitis, DISCUSSION: The available data show that a rheumatological presentation was indicated for the majority of patients. Owing to the increasing deficits in medical care a prior selection of the patients is crucial to make optimal use of restricted rheumatological capacities.

Rheuma-VOR study: optimising healthcare of rheumatic diseases by multiprofessional coordinating centres

OBJECTIVES

Early diagnosis of inflammatory arthritis is critical to prevent joint damage and functional incapacities. However, the discrepancy between recommendations of early diagnosis and reality is remarkable. The Rheuma-VOR study aimed to improve the time to diagnosis of patients with early arthritis by coordinating cooperation between primary care physicians, specialists and patients in Germany.

METHODS

This prospective non-randomised multicentre study involved 2340 primary care physicians, 72 rheumatologists, 4 university hospitals and 4 rheumatology centres in 4 German Federal States. The two coprimary endpoints (time to diagnosis and screening performance of primary care physicians) were evaluated for early versus late implementation phase. Additionally, time to diagnosis and secondary endpoints (decrease of disease activity, increase in quality of life and overall well-being, improvement of fatigue, depression, functional ability, and work ability, reduction in drug and medical costs and hospitalisation) were compared with a reference cohort of the German Rheumatism Research Centre (DRFZ) reflecting standard care.

RESULTS

A total of 7049 patients were enrolled in the coordination centres and 1537 patients were diagnosed with a rheumatic disease and consented to further participation. A follow-up consultation after 1 year was realised in 592 patients. The time to diagnosis endpoint and the secondary endpoints were met. In addition, the calculation of cost-effectiveness shows that Rheuma-VOR has a dominant cost-benefit ratio compared with standard care.

DISCUSSION

Rheuma-VOR has shown an improvement in rheumatological care, patient-reported outcome parameters and cost savings by coordinating the cooperation of primary care physicians, rheumatologists and patients, in a nationwide approach.

2023 EULAR recommendations for the management of fatigue in people with inflammatory rheumatic and musculoskeletal diseases

OBJECTIVES

Fatigue is prevalent in people with inflammatory rheumatic and musculoskeletal diseases (I-RMDs) and recognised as one of the most challenging symptoms to manage. The existence of multiple factors associated with driving and maintaining fatigue, and the evidence about what improves fatigue has led to a multifaceted approach to its management. However, there are no recommendations for fatigue management in people with I-RMDs. This lack of guidance is challenging for those living with fatigue and health professionals delivering clinical care. Therefore, our aim was to develop EULAR recommendations for the management of fatigue in people with I-RMDs.

METHODS

A multidisciplinary taskforce comprising 26 members from 14 European countries was convened, and two systematic reviews were conducted. The taskforce developed the recommendations based on the systematic review of evidence supplemented with taskforce members' experience of fatigue in I-RMDs.

RESULTS

Four overarching principles (OAPs) and four recommendations were developed. OAPs include health professionals' awareness that fatigue encompasses multiple biological, psychological and social factors which should inform clinical care. Fatigue should be monitored and assessed, and people with I-RMDs should be offered management options. Recommendations include offering tailored physical activity and/or tailored psychoeducational interventions and/or, if clinically indicated, immunomodulatory treatment initiation or change. Patient-centred fatigue management should consider the individual's needs and preferences, their clinical disease activity, comorbidities and other psychosocial and contextual factors through shared decision-making.

CONCLUSIONS

These 2023 EULAR recommendations provide consensus and up-to-date guidance on fatigue management in people with I-RMDs.

[Nonpharmacological treatment measures, rehabilitation services and membership in patient support groups in axial spondylarthritis (The ATTENTUS axSpA study)]

BACKGROUND

The treatment of axial spondylarthritis (axSpA) includes pharmacological treatment measures (PTM) and nonpharmacological treatment measures (NPTM) as well as supporting resources, such as rehabilitation services (RS) and membership in patient support groups (PSG). Nevertheless, there are significant participation restrictions in patients with axSpA in Germany.

OBJECTIVE

Investigation of functional deficits, participation restrictions and utilization of PTM, NPTM, RS and PSG membership in patients with axSpA.

MATERIAL AND METHODS

Multicentric, observational study of 770 axSpA patients in Germany (ATTENTUS-axSpA).

RESULTS

Substantial functional deficits and participation restrictions were observed in axSpA patients. Of the patients 39% did not receive treatment with biological disease-modifying antirheumatic drugs (bDMARD). In the NPTM 54% received physiotherapy less than once per week and 29% once per week. Physical activities were regularly performed by 86% of patients, mainly in the form of home exercises. Training in a gym (14%) or sports club (7%) was carried out much less frequently. Of the patients 54% received RS, one third had the last rehabilitation more than 5 years ago and 13% of the patients were members in a PSG. A significantly higher utilization of NPTM and rehabilitation was found in this group.

CONCLUSION

Treatment options and resources were often utilized to a small extent and/or in low intensity by axSpA patients, which could be a possible explanation for persisting restrictions of participation. Membership in a PSG was associated with an increased utilization of NPTM and RS.

[Methotrexate treatment before use of biologics in rheumatoid arthritis : Analysis of guideline compliance]

BACKGROUND

With the introduction of biologics the treatment landscape for patients with rheumatoid arthritis (RA) has rapidly expanded; however, according to German and European treatment guidelines the use of biologic disease-modifying antirheumatic drugs (bDMARD) is only indicated after insufficient response under methotrexate (MTX) doses of at least 20 mg/week (first-line treatment). The aim of the study was to analyze the guideline compliance of MTX prescription in the outpatient sector prior to treatment with biologics.

MATERIAL AND METHODS

Claims data from the AOK Lower Saxony from 2013 to 2016 were provided for all insured patients with a diagnosis of RA and bDMARD prescription during the study period. Within a patient-specific observational period of 180 days prior to the first bDMARD prescription, the maximum prescribed MTX dosage was examined.

RESULTS

Data from 90 incident and 315 prevalent RA patients were analyzed. A maximum MTX prescription of < 20 mg/week was observed in 60.0% of incident patients and in 67.0% of prevalent patients. Men had a higher mean MTX maximum dose (17.1 ± 4.8 mg) than women (14.9 ± 5.0 mg; p < 0.0001). Of the study population 29.6% received oral only prescriptions during the observational period. In 12.4% of patients a switch to parenteral administration was made.

DISCUSSION

Targeted use of the full spectrum of therapies provided prior to initiation of bDMARD treatment may contribute to cost-effective RA care. This study showed indications for potential deficits in outpatient MTX prescription practice and can raise awareness for efficient treatment.

[Delegation of medical duties to qualified rheumatology assistants : Effect on depression and anxiety in patients with rheumatoid arthritis]

BACKGROUND

At least 1 comorbidity occurs in 80% of patients with rheumatoid arthritis (RA). In addition to cardiovascular comorbidities psychological comorbid conditions are common. The prevalence of depression and anxiety is higher in patients than in the general population. Screening for comorbidities is crucial. A shortage of outpatient specialist care barely allows resources for this. The implementation of team-based care holds the potential to improve the standard of care while simultaneously working against the shortage of care.

OBJECTIVE

The aim of the study was to examine the effects of care on the course of depression and anxiety in patients with seropositive RA and active disease.

MATERIAL AND METHODS

A multicenter pragmatic randomized controlled trial was conducted over the course of 1 year with 224 patients. After baseline, five more visits followed. In the intervention group (IG), three were initially carried out by qualified rheumatological assistants. Depression, anxiety and patient satisfaction with outpatient care were looked at in detail.

RESULTS

In the IG the anxiety symptoms significantly improved over 12 months (p = 0.036). The proportions of patients with anxiety also significantly changed in the IG (p < 0.001), while there was no change in the control group between baseline and month 12. The values of the depression scale did not differ significantly (p = 0.866). In terms of the information dimension of the satisfaction questionnaire, patients in the IG felt significantly better informed after 6 months (p = 0.013) and 12 months (p = 0.003).

CONCLUSION

A positive effect of team-based care on the course of depression and anxiety in patients with seropositive RA and active disease could be shown.

Work participation in patients with axial spondyloarthritis: high prevalence of negative workplace experiences and long-term work impairment

INTRODUCTION

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that typically affects people in their second and third decades of life, which are important years for establishing a professional career. We aim to study outcomes of work participation (WP) and their associations with demographic and clinical confounders, in addition to prevalence of negative workplace experiences in axSpA.

METHODS

In total, 770 patients with axSpA participated in the multicentre, observational ATTENTUS-axSpA survey in Germany. Demographic information, clinical parameters and patient-related outcomes (including disease activity and function) with a focus on WP were prospectively recorded.

RESULTS

A high prevalence of negative workplace experiences was reported among the 770 patients analysed. Overall, 23.4% of patients were not employed and 6.5% received disability pensions. Current work cessation was prevalent in 120 patients, and 28 of those were out of work for 10 years or longer. Of the 590 currently employed patients, 31.9% reported absenteeism and 35.9% reported presenteeism for >1 month within the past year. Multivariate logistic regression identified low disease activity (Bath Ankylosing Spondylitis Disease Activity Index), better physical function (Bath Ankylosing Spondylitis Functional Index) and better global functioning (Assessment of SpondylAarthritis International Society-Health Index) as the main predictors for unimpaired WP (n=242). Importantly, biological treatment, disease duration, age, sex, education level and body mass index were not reliable predictors.

DISCUSSION

Despite improvements in pharmacological treatment options, we still observed substantially impaired WP in patients with axSpA. These data emphasise the high unmet need for targeted strategies to provide improved medical and social care.

[Health workforce development in rheumatology : A mapping exercise and wake-up call for health policy]

BACKGROUND AND OBJECTIVE

Health workforce shortage in German rheumatology has been identified as a healthcare service and delivery problem. Health policy has increased staffing targets, yet effective intervention strategies are lacking. This research aimed to systematically map the rheumatology workforce to improve the evidence for interventions and explore possibilities for more effective health workforce management.

METHODS

The WHO National Health Workforce Accounts provided a conceptual framework for the mapping exercise. Four major sets of indicators were selected, comprising staffing levels, health labor market flows, composition and education/training. A comparison of age groups and time series was applied to explore trends. Public statistics and other secondary sources served our analysis using descriptive methodology.

RESULTS

In Germany there are 1076 physicians specialized in internal medical rheumatology. Absolute numbers have nearly doubled (91%) since 2000 but with a strong demographic bias. Between 2000 and 2019 numbers markedly increased in the group aged 50 years and older but only by 9% in the younger group under 50 years; since 2010 the group aged 40-50 years even faces a decrease. In 2019, the absolute numbers of rheumatologists in retirement age exceeded those aged 40 years and under. Since 2015 an expanding workforce trend has overall flattened but this was strongest in the hospital sector; the numbers in resident training did not show any relevant growth.

CONCLUSION

Health workforce trends reveal that an available number of rheumatologists cannot meet new health policy planning targets. There is a need for effective health workforce management, focusing on innovation in resident training, improved task delegation and gender equality.

Health workforce needs of small medical specialties: findings from rheumatology in Germany

Background

Small medical specialties may be more vulnerable to workforce shortage and the COVID-19 pandemic and this may directly impact in the provision of care for chronically-ill patients. This study aims to explore health workforce development and new needs, using rheumatology in Germany as a case study.

Methods

An explorative multi-methods approach was applied, combining health labour market assessment of rheumatology physicians (public statistics 2000-2019) and a questionnaire-based online survey conducted in early 2021 (n = 101 respondents; rheumatology physicians and residents). Main selected topics: work hours, workload, mental health issues, discrimination and sexual harassment experiences, impact of COVID-19. Descriptive statistical analysis was performed and qualitative content analysis for free-text information.

Results

Health labour market analysis showed that the numbers of rheumatologists increased markedly between 2000 and 2019 in the groups aged +50 years, but only 9% in younger groups under 50 years; since 2010 the group 40-50 years showed decreases. In 2019, the absolute number of rheumatologists working in healthcare after retirement-age exceeded those aged 40 and under. Survey data revealed a strong mismatch between actual and desired work hours for women and men. 81% rated their workload as high or very high; every sixth rheumatologist has suffered from stress or burnout syndromes at least once in the past. Experiences of gender discrimination and sexual harassment/violence were frequently reported, mostly by women. COVID-19 was an amplifier of stress with major stressors being digitalisation and increased demand for communication and patient education.

Conclusions

Decreasing health workforce capacities in German rheumatology combine with negative perceptions of work and workplace conditions, threatening both retention and service delivery.

Key messages

• Small medical specialties, like rheumatology, face severe shortage that threaten healthcare for chronically-ill patients and need greater attention.

• COVID-19 has reinforced rheumatologists’ workload and stressors, thus worsing mental health and retention.

Assessing acceptability and identifying barriers and facilitators to implementation of the EULAR recommendations for patient education in inflammatory arthritis: a mixed-methods study with rheumatology professionals in 23 European and Asian countries

OBJECTIVES

To disseminate and assess the level of acceptability and applicability of the European Alliance of Associations for Rheumatology (EULAR) recommendations for patient education among professionals in rheumatology across Europe and three Asian countries and identify potential barriers and facilitators to their application.

METHODS

A parallel convergent mixed-methods design with an inductive approach was used. A web-based survey, available in 20 different languages, was distributed to health professionals by non-probability sampling. The level of agreement and applicability of each recommendation was assessed by (0-10) rating scales. Barriers and facilitators to implementation were assessed using free-text responses. Quantitative data were analysed descriptively and qualitative data by content analysis and presented in 16 categories supported by quotes.

RESULTS

A total of 1159 completed the survey; 852 (73.5%) were women. Most of the professionals were nurses (n=487), rheumatologists (n=320), physiotherapists (n=158). For all recommendations, the level of agreement was high but applicability was lower. The four most common barriers to application were lack of time, lack of training in how to provide patient education, not having enough staff to perform this task and lack of evaluation tools. The most common facilitators were tailoring patient education to individual patients, using group education, linking patient education with diagnosis and treatment and inviting patients to provide feedback on patient education delivery.

CONCLUSIONS

This project has disseminated the EULAR recommendations for patient education to health professionals across 23 countries. Potential barriers to their application were identified and some are amenable to change, namely training patient education providers and developing evaluation tools.

AB0785 Role of Patient Organizations in Implementation of Recommended Non-pharmacological Treatment Modalities in Spondyloarthritis: Evidence for the Effectiveness of Self-management Strategies

Background

EULAR recommends participation in patient (pt) organizations to improve pt self-management of axial spondyloarthritis (axSpA)1. Non-pharmacological treatment modalities (NPTM)2 are recommended in axSpA treatment guidelines.3

Objectives

To characterize the impact of pt advocacy group membership and its association with NPTM frequency and clinical parameters in axSpA.

Methods

Pts with a confirmed axSpA diagnosis were enrolled in the multicenter, observational ATTENTUS-axSpA survey conducted across Germany (11/2019–07/2020). Demographics, clinical and pt-related data were collected electronically.

Results

Of the 787 enrolled axSpA pts, this analysis was conducted on the working population (n=695)4. Overall, 12.2% (n=85) pts were members of a pt advocacy group and 87.8% (n=610) were not. Pt advocacy group members had higher Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores, increased functional impairment (BASFI, Bath Ankylosing Spondylitis Functional Index) and higher impact of axSpA on health (ASAS-HI, Assessment of SpondyloArthritis International Society-Health Index; Table 1). Despite worse prognostic factors, there was no significant difference in Work Productivity and Activity Impairment (WPAI) score [40.6 (27.0) for pt advocacy group members vs 36.8 (29.9) for non-members; p=0.380]. Membership in a pt advocacy group was associated with increased prescribed, supervised NPTM (57.6% [n=49] vs 34.4% [n=210]). Pts reported to have ever received 2.6 rehabilitation measures, and ≥3.0 different rehabilitation NPTM measures. Cumulatively, 25.0% (N=654) of rehabilitation measures were physiotherapy (Figure 1).

Table 1.

Descriptive characteristics and impact of membership in pt advocacy group

CharacteristicPatient advocacy group member (n=85)Not patient advocacy group member (n=610)Total (n=695)p-valueAge (yrs), mean (SD)50.2 (7.7)44.6 (11.1)45.3 (10.9)<0.001BMI (kg/m2) mean (SD)27.5 (5.0)28.0 (12.7)28.0 (12.0)0.713Male, n (%)45 (52.9)378 (62.0)423 (60.9)0.128Disease duration (yrs) mean (SD)13.7 (10.3)12.5 (11.1)12.6 (11.0)0.303ASAS-HI, 0-177.3 (3.4)6.4 (3.9)6.5 (3.8)0.045BASDAI, 0-104.3 (1.9)3.8 (2.2)3.9 (2.2)0.044BASDAI ≥4, n (%)49 (57.6)275 (45.1)324 (46.6)0.025BASFI, 0-103.9 (2.3)3.2 (2.5)3.3 (2.4)0.015Biologic treatment, n (%)52 (61.2)312 (51.1)364 (52.4)0.072Full time employment, n (%)48 (56.5)410 (67.2)458 (65.9)0.06Absenteeism*, mean (SD)8.4 (21.2)10.9 (26.8)10.6 (26.2)-Presenteeism*, mean (SD)38.4 (24.6)31.8 (25.7)32.6 (25.6)-Overall work impairment score*, mean (SD)40.6 (27.0)36.8 (29.9)37.2 (29.6)0.380Activity impairment, mean (SD)46.7 (21.7)40.5 (26.8)41.3 (26.4)0.058Pts having ever received medicinal rehabilitation measures, mean (SD)67 (78.8)328 (53.8)395 (56.8)<0.001Prescribed supervised group NPTM#, mean (SD)49 (57.6)210 (34.4)259 (37.3)<0.001Regular physical training†, mean (SD)76 (89.4)515 (84.4)591 (85.0)0.231

*Work-related questions of WPAI-score have been calculated for pts in employment (N=340); †regular physical training in the context of axSpA; #rehabilitation sport and/or functional training. ASAS-HI, Assessment of SpondyloArthritis International Society-Health Index; BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; BASFI, Bath Ankylosing Spondylitis Functional Index; BMI, Body Mass Index; n, number of pts; pts, patients; SD, Standard Deviation; WPAI, Work Productivity and Activity Impairment; yrs, years.

Conclusion

Pt advocacy group membership was associated with increased prescribed NPTM in axSpA. Pt organizations may support the implementation of guidelines and improvement of self-management strategies in pts with axSpA, which may influence work participation.

References

[1]Nikiphorou E, et al. Ann Rheum Dis 2021;0:1–8

[2]Rausch Osthoff A-K, et al. Ann Rheum Dis 2018;77:1251–1260

[3]van der Heijde D, et al. Ann Rheum Dis 2017;76:978–991

[4]Kiltz et al. 2021. EULAR eposter; POS0983

Disclosure of Interests

Dirk Meyer-Olson Speakers bureau: Speakers bureau: Abbvie, Amgen,Berlin Chemie, Bristol Myers Squibb, Cellgene, Chugai, Fresenius Kabi, GSK, Jansen Cilag, Lilly, Medac, Merck Sharp & Dome, Mylan, Novartis, Pfizer, Sandoz Hexal, Sanofi and UCB, Consultant of:Abbvie, Amgen, Berlin Chemie, Bristol Myers Squibb, Cellgene, Chugai, Fresenius Kabi, GSK, Jansen Cilag, Lilly, Medac, Merck Sharp & Dome, Mylan, Novartis, Pfizer, Sandoz Hexal, Sanofi and UCB, Kirsten Hoeper Speakers bureau: Speakers bureau: Abbvie, Chugai, Gilead, Lilly, Novartis, Sandoz Hexal and Sanofi., Consultant of: Abbvie, Chugai, Gilead, Lilly, Novartis, Sandoz Hexal and Sanofi., Ludwig Hammel: None declared, Sebastian Lieb Employee of: Employee of Novartis, Andreas Haehle Employee of: Employee of Novartis, Uta Kiltz Speakers bureau: Speakers bureau: AbbVie, Biocad, Chugai, Eli Lilly, Grünenthal, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Consultant of: AbbVie, Biocad, Chugai, Eli Lilly, Grünenthal, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Grant/research support from: Abbvie, Amgen, Biogen, Fresenius, GSK, Novartis and Pfizer

POS1483-HPR DYSFUNCTIONAL COPING CORRELATES WITH DEPRESSION AND ANXIETY AND PREDICTS WORSE OUTCOME IN PATIENTS WITH A HIGH DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS

Background

Disease flares of rheumatoid arthritis (RA) are important stressors for patients (pts) who may use coping for disease management. Some coping styles are thought to be beneficial and may help to improve disease outcome whereas others are thought to be harmful.

Objectives

We investigate the frequency and intensity of different coping styles in pts with an acute flare of seropositive RA and its impact on disease outcomes after 12 month of therapy.

Methods

Coping was analysed with the Brief-COPE (1) using a 4 point Likert scale in 222 pts participating in the ERFASS study (2). Coping styles were analysed by confirmatory and exploratory factor analysis (CFA, EFA). Disease activity was measured via DAS28 (CRP), depression and/or anxiety using Hospital Anxiety and Depression Scale (HADS) and Patient Health Questionnaire 9 (PHQ-9). Repeated measures ANOVA was used to identify the effect of different coping strategies on disease activity and Spearman-Rho to identify correlations.

Results

Factor analysis revealed five dominant coping styles (problem oriented, emotion oriented, dysfunctional, religion, alcohol/drugs) which were consistent during 6 and 12 months follow up. When analysing the relative intensity of each coping strategy over time there was no significant change during treatment (Table 1). The usage of only a single coping style at baseline (“I am doing this a medium amount” or “a lot”) was reported by 70 pts (31,5%). 65 pts (29,3%) reported the use of 2 coping styles simultaneously, 25 pts (11,3%) 3 coping styles and 4 pts (1,8%) four coping styles. Problem oriented coping was used by 125 pts (56,3%), emotional coping by 97 pts (43,7%), dysfunctional coping by 41 pts (18,5%), religion by 24 pts (10,8%) and alcohol/drugs by only 4 pts (1,8%). 58 pts (26,1%) reported not to use any of the coping styles (“I am doing this not at all” or “only a little bit”) and these pts had a lower DAS28 during the course of the study (p=0.036) as compared to pts who use one or more coping strategies. When analysing the group with high disease activity (DAS28 >5.1) at baseline (n=60), pts with medium or high dysfunctional coping had a significantly higher disease activity after 12 months as compared to those with no or little dysfunctional coping (U = 187,00, Z = -2.025, p = 0.043) (Figure 1). The other coping styles did not significantly predict the outcome of disease activity. We observed a strong correlation between dysfunctional coping and depression (PHQ9 r = 0.590; HADS depression r = 0.569) as well as anxiety (HADS anxiety r = 0.639) but not for the other coping strategies at baseline.

Figure 1.Table 1.

Development of disease activity (DAS28) and coping strategies over time

TimeBaseline mean (SD)Month 6 mean (SD)Month 12 mean (SD)DAS284.32 (1.14)2.79 (1.23)2.47 (1.05)Problem oriented53.10 (14.93)49.69 (14.10)47.43 (14.00)Emotion oriented49.94 (13.00)50.73 (12.76)50.46 (13.45)Dysfunctional40.25 (14.59)36.44 (11.76)36.00 (12.26)Religion36.15 (18.30)35.53 (17.02)34.68 (16.64)Alcohol / Drugs27.03 (7.81)27.15 (8.75)26.53 (6.07)

Conclusion

Different ways of coping may be used simultaneously during an acute flare of seropositive RA. In pts with high disease activity dysfunctional coping is the only coping strategy predicting a worse disease outcome after 12 months and dysfunctional coping correlates with depression and anxiety.

References

[1]Carver CS (1997) You want to measure coping but your protocol’s too long: consider the brief COPE. Int J Behav Med 4(1):92–100.

[2]Hoeper JR, Zeidler J, Meyer SE, et al. Effect of nurse-led care on outcomes in patients with ACPA/RF-positive rheumatoid arthritis with active disease undergoing treat-to-target: a multicentre randomised controlled trial. RMD Open 2021

Disclosure of Interests

Juliana Rachel Hoeper: None declared, Ioana Iliadis: None declared, Marianne Richter: None declared, Sara Eileen Meyer: None declared, Kai Kahl: None declared, Torsten Witte: None declared, Kirsten Hoeper Speakers bureau: Abbvie, Novartis, Galapagos, Sandoz Hexal, Chugai, Lilly, Consultant of: Abbvie, Novartis, Galapagos, Sandoz Hexal, Dirk Meyer-Olson Speakers bureau: Bristol Myers Squibb, Celltrion, Chugai, Fresenius Kabi, Galapagos, Lilly, Sandoz Hexal

, Consultant of: Abbvie, Amgen, Astra Zeneca, Biogen, Novartis, Viatris

[Care of rheumatology patients during the lockdown in early 2020 : Telemedicine, delegation, patient satisfaction and vaccination behavior]

BACKGROUND

Telemedicine was implemented in outpatient care during the lockdown between March and May 2020. The aim of the study was to assess patients from a private practice and the university outpatient department with respect to patient satisfaction with telemedicine, COVID-19 worries and vaccination behavior and to compare the teleconsultation by a medical assistant for rheumatology (RFA) and a physician.

METHODS

Patients with rheumatoid arthritis, psoriatric arthropathy or spondylarthritis without treatment modifications since the previous presentation were offered a telemedical replacement appointment within the framework of this study in the case of appointment cancellation by the treating center. Participants were randomized to a telemedicine appointment by a physician or an RFA (RFA university only). The patient history was carried out by telephone and standardized using a questionnaire. The disease activity was determined using the modified clinical disease activity score (CDAI) and the BASDAI. Subsequently, all patients received a pseudonymized evaluation questionnaire.

RESULTS

In total 112/116 (96%) patients participated. Of these 88/112 (79%) returned the questionnaire. The RFAs conducted 19/112 (17%) of the telephone calls. The treatment was modified in 19/112 (17%) patients. Concerns about contracting COVID-19 correlated with high disease activity (p = 0.031) including the presence of painful joints (p = 0.001) and high pain levels (VAS ≥7, p = 0.009). These patients would have also cancelled their appointment themselves (p = 0.015). Patient satisfaction with the consultation was good (mean 4.3/5.0 modified FAPI) independent of the institution, the duration of the consultation and the consultation partner. Patients with a high pain intensity were the least satisfied (p = 0.036). Only 42/100 (38.2%) of the patients had been vaccinated against pneumococci and 59/100 (53.6%) against influenza.

CONCLUSION

Telemedical care within the framework of a telephone consultation is well-suited for selected patients. With respect to patient satisfaction the delegation of a telemedical consultation to an RFA is possible. There is a need for improvement with respect to the vaccination behavior.

Increasing planning targets is not enough: health workforce management in rheumatology in Germany

Background

Health workforce shortage in German rheumatology and its negative impact in healthcare are increasingly recognised. Health policy has increased staffing targets, but effective intervention strategies are lacking. This paper aims to systematically map the rheumatology workforce and to explore opportunities for intervention, thus contributing to better health workforce management.

Methods

The WHO National Health Workforce Accounts (NHWA) provided a conceptual framework for the mapping exercise. Four major sets of indicators were selected, comprising staffing levels, health labour market flows, skill-mix and education/training. Comparison of age-groups and time series was applied to explore trends. Public statistics and other secondary sources served the analysis, using descriptive methodology.

Results

Rheumatologists nearly doubled in absolute numbers since 2000, but this trend shows a problematic demographic bias. Between 2000 and 2019 numbers increased markedly in the groups aged +50 years, but only about 9% in younger groups under 50 years. Most alarming, since 2010 the group 40 to 50 years showed a reverse trend and strong decreases. In 2019, absolute numbers of rheumatologists working in healthcare after retirement-age exceeded those aged 40 and under. Since 2015 an expanding workforce trend overall flattened, but strongest in the hospital sector; annual inflows do not show relevant growths.

Conclusions

Health workforce assessment reveals negative demographic trends and decreasing appeal of the specialty especially to men, thus highlighting a need for more effective health workforce management. Intervention strategies should target innovation in resident training and task shifting and improve gender equality.

Key messages

Health workforce trends indicate that new health policy planning targets cannot be met with an available stock of rheumatologist. The WHO NHWA provide a useful toolbox to map health workforce trends and identify weaknesses and gaps.

[Rehabilitation in Rheumatoid Arthritis]

Die rheumatoide Arthritis stellt unter den Erkrankungen des Bewegungssystems eine besondere Herausforderung für die Rehabilitationsmedizin dar 1. Eine genaue Kenntnis der Erkrankung, inklusive der medikamentösen und der nicht medikamentösen Behandlungsoptionen, ist die wesentliche Voraussetzung für einen nachhaltigen Rehabilitationserfolg und um den berechtigen Anspruch der Erkrankten auf berufliche und soziale Partizipation umzusetzen.

Work situation of rheumatologists and residents in times of COVID-19 : Findings from a survey in Germany

Background and objective

The work situation is an important dimension of professional life and wellbeing, and a policy lever to strengthen recruitment and retention. This study aims to explore the work situation of physicians and residents in internal medical rheumatology, considering the impact of the coronavirus pandemic COVID-19.

Methods

A questionnaire-based online survey was conducted in early 2021 at the Hannover Medical School, supported by the German Society of Rheumatology. Target groups were all rheumatology physicians and residents in Germany. The main areas of investigation included work hours, task delegation, and collaboration; workload and mental health issues; discrimination and sexual harassment experiences; and the impact of COVID-19. Descriptive statistical analysis was performed for the standardized items and qualitative content analysis for the free-text information.

Results

The respondents (n = 101) expressed positive attitudes towards cooperation and task delegation to medical assistants, especially those specialized in rheumatology, while attitudes towards cooperation with GPs pointed to blockades. There was a strong mismatch between actual and desired work hours both in the group of women and in the group of men. 81% rated their workload as high or very high; every sixth rheumatologist has suffered from stress or burnout syndromes at least once in the past. Experiences of gender discrimination and sexual harassment/violence were frequently reported, mostly by women. COVID-19 was an amplifier of stress, with major stressors being digitalization and increased demand for communication and patient education.

Conclusion

There is an urgent need to improve the work situation of rheumatologists and reduce stress and mental health risks.

Supplementary Information

The online version of this article (10.1007/s00393-021-01081-5) includes the survey questionnaire in German.

Effect of nurse-led care on outcomes in patients with ACPA/RF-positive rheumatoid arthritis with active disease undergoing treat-to-target: a multicentre randomised controlled trial

Objective

To determine the non-inferiority of nurse-led care (NLC) in patients with anticitrullinated protein antibody (ACPA)-positive and/or rheumatoid factor (RF)-positive rheumatoid arthritis (RA) with active disease who are starting disease-modifying antirheumatic drug therapy, following treat-to-target (T2T) recommendations.

Methods

A multicentre, pragmatic randomised controlled trial was conducted to assess clinical effectiveness, anxiety, depression and patient satisfaction following a non-inferiority design. The participants were 224 adults with ACPA/RF-positive RA who were randomly assigned to either NLC or rheumatologist-led care (RLC). The primary outcome was the Disease Activity Score in 28 Joints measured with C reactive protein (DAS28-CRP) assessed at baseline and after 3, 6, 9 and 12 months. A DAS28-CRP difference of 0.6 was set as the non-inferiority margin. Mean differences between the groups were assessed following per-protocol and intention-to-treat strategies.

Results

Demographic data and baseline characteristics of patients in the NLC group (n=111) were comparable to those of patients in the RLC group (n=113). The improvement in disease activity (change in DAS28-CRP, primary outcome) over the course of 12 months was significant in both groups (p<0.001). No significant differences were observed between the NLC and RLC groups (p=0.317). Non-inferiority of NLC was shown for the primary outcome and all secondary outcomes.

Conclusion

This study supported the non-inferiority of NLC in managing T2T and follow-up care of patients with RA with moderate to high disease activity and poor prognostic factors in addition to RLC.

Trial registration number

DRKS00013055.

A rare disease patient-reported outcome measure: revision and validation of the German version of the Systemic Sclerosis Quality of Life Questionnaire (SScQoL) using the Rasch model

Background

Rare disease patient-reported outcome measures (PROMs) require linguistic adaptation to overcome the challenge of geographically dispersed patient populations. Importantly, PROMs such as health-related quality of life (HRQoL) should accurately capture responses to patient-identified concerns. The Systemic Sclerosis Quality of Life Questionnaire (SScQoL) is a 29-item tool validated in six languages. Previous evaluation of the German version revealed problems with dichotomous responses. This study aimed to revise the German SScQoL, extend the response structure, and evaluate content and construct validity, reliability and unidimensionality.

Methods

The instrument validation study involved revising the German SScQoL response structure, cognitive debriefing with patients and validation using Rasch analysis. The revised SScQoL was completed by Swiss-German-speaking patients with SSc within the Swiss MANagement Of Systemic Sclerosis (MANOSS) study. Rasch analysis was employed to test the validity, reliability and unidimensionality of the revised instrument.

Results

Based on cognitive debriefing with patients (n = 6) dichotomous items were extended to a polytomous 4-point response structure. A total of 78 patients completed the revised SScQoL. Initial analysis of the 29 items suggested the scale lacked fit to the model (χ² = 51.224, df = 29, p = 0.007). Grouping items into five domains resulted in an adequate fit to the Rasch model (χ² = 5.343, df = 5, p = 0.376) and unidimensionality (proportion of significant independent t tests: 0.045, 95% CI 0.016–0.114). Overall, the scale was well targeted, had high internal consistency (Person Separation Index, PSI = 0.931) and worked consistently in patients with different demographic and clinical characteristics.

Conclusions

The revised German SScQoL has a 4-point response structure and is a valid, reliable measure. Rasch analysis is useful for validating continuous response structure of quality of life measures. Further evaluation of measurement equivalence with other German-speaking cultures is required for multinational comparisons and data pooling.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-01944-9.

OP0260-HPR PREDICTORS OF WORK PARTICIPATION IN PATIENTS WITH ACTIVE RHEUMATOID ARTHRITIS AFTER 12 MONTHS OF T2T THERAPY INTERVENTION

Background:

Rheumatoid arthritis (RA) is associated with restrictions on work participation (WP) caused mainly by periods of sick leave (absenteeism), reduced productivity at work due to disease (presenteeism) and occupational disability, which account for a significant proportion of indirect costs.

Objectives:

We investigate the predictors of WP after 12 months of Treat-to-Target (T2T) intervention.

Methods:

Data were analyzed from the multi-center ERFASS study, which included patients with rheumatoid factor and/or APCA positive RA after initiation or escalation of disease modifying anti rheumatic drug (DMARD) therapy following a T2T regimen prospectively over 12 months from 01/2018 to 12/2019. A total of 157 patients of working age (18 to 65 years) were included in this evaluation. Socio-demographic and occupational characteristics (WPAI, self-conducted work questionnaire), clinical parameters including disease activity (DAS28, RADAI), impact of disease (RAID), functional capacity (FFbH), depression (PHQ-9) and fatigue (VAS) were analyzed and logistic regression analysis to detect baseline predictors for unimpaired WP after 12 months was performed.

Results:

The mean age of the patients was 52.9 years (standard deviation (SD): 8.19) and 117 (74.5%) were female. 51 patients (32.5%) started first line DMARDs and in 106 patients (67.5%) treatment was escalated. T2T resulted in a significant decrease in mean DAS28 from 4.2 (SD 1.10) at baseline to 2.5 (SD 1.11; p<0.001) after 12 months, 64.3% of the patients were in remission (DAS28<2.6) and 12.1% had low disease activity (DAS28 2.6-3.2). The proportion of patients with no impairment of WP increased significantly and presenteeism and absenteeism became significantly less prevalent, but the proportion of patients with reduced WP at month 12 remained high (74.1%; graph 1). We observed a moderate positive significant correlation between presenteeism and absenteeism (rMo12=0.446; p<0.001). Patients with no restrictions on WP showed a significantly greater decrease in mean DAS28 from 3.7 (SD 1.15) at baseline to 1.9 (SD 0.61) at month 12 as compared to patients with restrictions (mean DAS28: 4.4 (SD 1.04) at baseline to 2.7 (SD 1.15) at month 12; p<0.001). Results from univariate and logistic regression analyses revealed high functional capacity and low depression score at baseline as major contributing factors for unimpaired WP (Table 1).

Table 1.

Baseline predictors of work participation1 at month 12

Predictors (independent variables)Univariate analysis2:p-valuesMultivariate analysis3: Odds Ratios, p-valuesgender0.117+OR: 0.412; p=0.113age0.010*+OR:0.951; p=0.071school graduation0.150+professional degree0.739duration of complaints0.127+therapy group (starters vs. escalation/ change)0.004*+DAS-28(CRP)0.001*CRP0.906tender joints0.004*swollen joints0.021*disease activity (VAS)0.003*+OR: 0.827; p=0.086subjective disease activity (RADAI)<0.001*disease burden (RAID)<0.001*functional capacity (FFbH)<0.001*+OR: 1.477; p=0.031*fatigue (VAS)<0.001*+depression (PHQ-9)<0.001*+OR: 0.876; p=0.035*working time model (full vs. part-time)0.498physical work load0.427

1 dependant variable: 0=reduced WP (not working/ absenteeism/ presenteeism (≥2)); 1=full WP (working without absenteeism/ presenteeism (≥2))

2 according to applicability chi-square test, t-test for independent variables, Mann-Whitney-U test

3 binary logistic regression analysis, stepwise-backward procedure

+ included into logistic regression model

* significance level: p<0.05

Conclusion:

Despite T2T and high DAS28 remission, we observed persistent limitations in WP. Impaired WP was associated with increased disease activity but logistic regression revealed a significant influence of depression and functional capacity. Our data underscore the multifactorial causes of impaired WP, which should be targeted by vocational rehabilitation.

Disclosure of Interests:

Sara Eileen Meyer: None declared, Juliana Rachel Hoeper: None declared, Torsten Witte: None declared, Kirsten Hoeper Speakers bureau: She has received consultancy and speaker honoraria from Abbvie, Chugai, Gilead, Lilly, Novartis, Sandoz Hexal and Sanofi., Dirk Meyer-Olson Speakers bureau: He has received consultancy and speaker honoraria from Abbvie, Amgen, Berlin Chemie, Bristol Myers Squibb, Cellgene, Chugai, Fresenius Kabi, GSK, Jansen Cilag, Lilly, Medac, Merck Sharp & Dome, Mylan, Novartis, Pfizer, Sandoz Hexal, Sanofi and UCB.

POS0983 WORK PARTICIPATION IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS IN GERMANY: RESULTS FROM A MULTICENTER, OBSERVATIONAL SURVEY (ATTENTUS-axSpA)

Background:

Axial spondyloarthritis (axSpA) is a chronic inflammatory condition often associated with impaired working participation1 not only translating to devastating outcomes for patients (pts) but also increased economic and social burden due to a significant amount of indirect costs. Data on the different work participation domains in axSpA pts with access to biologic therapies are limited.

Objectives:

To characterise the different domains of work participation [presenteeism, absenteeism, sick leave, unemployment, disability pensions] in axSpA pts and their associations with demographic and clinical confounders.

Methods:

Pts with confirmed clinical diagnosis of axSpA were enrolled in a multicenter, observational ATTENTUS survey conducted across Germany (Nov-2019 to Jul-2020). To ensure high data quality, inclusion criteria was verified by external monitoring, followed by evaluation of the domains of impaired work participation, including absenteeism and presenteeism (WPAI). Demographics, clinical parameters and patient related outcomes (PROs) were collected via tablet. This analysis included working age (18–65 years) pts; and excluded students and retired pts. Pts without absenteeism (value=0) and presenteeism ≤20% were defined as no impairment at work.

Results:

A total of 787 axSpA pts were enrolled in the survey. Seven students, 68 retired pts and 17 pts not fulfilling the inclusion criteria were excluded from this analysis, leaving 695 pts with complete data sets. Baseline data are outlined in Table 1. 50 pts received disability pensions, 29 pts received unemployment benefits, 590 (84.9%) pts reported paid work [part-time: n=132 (22.4%); full-time: n=458 (65.9%)], with 242 (41.0%) pts having no impairments at work. 379 (64.2%) employed pts took sick leave within the previous 12 months (mo) (<3 mo: n=351; 3–6 mo: n=17; >6 mo: n=11). Absenteeism and presenteeism occurred in 140 (23.7%) and 496 (84.1%) pts, respectively. Pts without impairments were mostly of young age, male sex, well-educated, with low disease activity, less fatigue and shorter duration of morning stiffness, and preserved global and physical functioning. No apparent differences between pts with and without impairment of work participation were observed in terms of biologic treatment, disease duration and BMI.

Table 1.

Descriptive characteristics of the study population

Mean (SD), unless specifiedImpaired WP (n=453)Full WP(n=242)p-valueTotal(n=695)Age (yrs)46.7 (11.1)42.8 (10.1)<0.00145.3 (10.9)BMI28.5 (14.0)27.0 (6.8)0.14628.0 (12.0)Male, n(%)246 (54)177 (73)<0.001423 (61)Disease duration (yrs)12.7 (11.3)12.4 (10.2)0.81312.6 (11.0)University-Education, n(%)104 (23.0)82 (33.9)0.001186 (26.8)In a committed relation, n(%)310 (68.4)159 (65.7)0.464469 (6.6)ASAS-HI8.0 (3.3)3.7 (3.0)<0.0016.5 (3.8)BASDAI4.8 (1.9)2.1 (1.6)<0.0013.9 (2.2)BASDAI > 4, n(%)286 (63.1)28 (11.6)<0.001314 (45.2)Fatigue [BASDAI #1]5.8 (2.1)2.8 (2.1)<0.0014.7 (2.5)Duration morning stiffness [BASDAI #6]3.5 (2.4)1.6 (1.8)<0.0012.8 (2.4)BASFI4.2 (2.3)1.5 (1.5)<0.0013.3 (2.4)Biologic treatment, n(%)230 (50.8)134 (55.4)0.390364 (52.4)Full time employment, n(%)256 (56.5)202 (83.5)<0.001458 (65.9)Absenteeism17.9 (32.1)0-10.6 (26.2)Presenteeism48.6 (21.00)9.6 (8.3)-32.6 (25.6)

ASAS-HI, Assessment of SpondyloArthritis International Society-Health Index; BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; BASFI, Bath Ankylosing Spondylitis Functional Index; BMI, basal metabolic index; n, number of pts; SD, standard deviation; WP, work productivity; years, yrs

Conclusion:

There was a substantial impact on work participation for axSpA pts, despite numerous available therapeutic options. Pts with impaired work participation compared to pts with no impairment, reported increased fatigue, longer duration of morning stiffness, decreased functional capacity, female sex and a lower level of education.

References:

[1]Ramoda R et al. Arthritis Res Ther. 2016;78

Disclosure of Interests:

Uta Kiltz Speakers bureau: AbbVie, Biocad, Chugai, Eli Lilly, Grünenthal, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Consultant of: AbbVie, Biocad, Chugai, Eli Lilly, Grünenthal, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Grant/research support from: Abbvie, Amgen, Biogen, Fresenius, GSK, Novartis and Pfizer, Kirsten Hoeper Speakers bureau: Abbvie, Chugai, Gilead, Lilly, Novartis, Sandoz Hexal and Sanofi. Consultant of: Abbvie, Chugai, Gilead, Lilly, Novartis, Sandoz Hexal and Sanofi. Ludwig Hammel: None declared, Sebastian Lieb Employee of: Employee of Novartis, Andreas Haehle Employee of: Employee of Novartis, Dirk Meyer-Olson Speakers bureau: Abbvie, Amgen, Berlin Chemie, Bristol Myers Squibb, Cellgene, Chugai, Fresenius Kabi, GSK, Jansen Cilag, Lilly, Medac, Merck Sharp & Dome, Mylan, Novartis, Pfizer, Sandoz Hexal, Sanofi and UCB, Consultant of: Abbvie, Amgen, Berlin Chemie, Bristol Myers Squibb, Cellgene, Chugai, Fresenius Kabi, GSK, Jansen Cilag, Lilly, Medac, Merck Sharp & Dome, Mylan, Novartis, Pfizer, Sandoz Hexal, Sanofi and UCB.

AB0707 RHEUMATOLOGY PATIENT CARE IN THE COVID-19 PANDEMIC: TELEMEDICINE, DELEGATION, PATIENT SATISFACTION AND VACCINATION BEHAVIOUR

Background:

Use of telemedicine in Germany has increased due to the COVID-19 lockdown. Between March and May 2020, government restrictions led to cancellation of routine outpatient appointments to limit viral spread and optimize resources.

Objectives:

This study assesses patient satisfaction of follow-up telemedicine appointments among patients known to be in disease remission, attending either secondary or tertiary care Rheumatology clinics. Appointments were conducted either by a rheumatologist or a qualified medical assistant for rheumatology (RFA). Additional data regarding perceived concerns arising from the COVID-19 pandemic as well as attitudes to vaccination were collected.

Methods:

Methods: Patients not requiring adjustment of their DMARDs at the two previous attendances were considered stable. At cancellation of the planned attendance, patients were offered participation in the study and provided verbal informed consent. Participants were randomized to a telemedicine appointment by either a physician or RFA. Telemedicine appointments consisted of a standardized patient interview, including assessment of disease activity (modified CDAI score), attitudes to vaccination as well as current vaccine status and concerns about COVID-19. Following participation, all patients received a pseudonymized postal questionnaire to evaluate appointment satisfaction (FAPI-Score).

Results:

In total 112/116 (96%) patients that were offered appointments, participated in the study (RA 50%, axSpA 30%, PsA 20%). Of these 88/112 (79%) returned their postal questionnaires. Overall patient satisfaction was excellent (mean 4.3/5 modified FAPI score) and did not differ between care setting or clinical status of the interviewer. RFAs conducted 19/112 (17%) of appointments, 6 (32%) of which required additional physician intervention. Change of DMARDs occurred in 19/112 (17%) appointments. Patients reporting a pain score ≥7 (VAS 1-10) were most dissatisfied with the telemedicine appointment (p=0.036). Concerns about COVID-19 correlated with disease activity: high disease activity (p = 0.031), presence of tender joints (p=0.001), high pain levels (p=0.009) correlated with concern of contracting COVID-19 or experiencing severe disease course. Only 38% of the patients had been vaccinated against pneumococci in the past 5 years and 54% had been vaccinated against influenza in 2019/2020.

Conclusion:

Telemedicine can contribute to patient care in stable patients. RFAs can also contribute to patient care especially for follow-up appointment when patients are in remission. Vaccination rates and motivation needs to be improved as influenza and pneumococcal vaccination is recommended to all patients with rheumatic diseases without contraindications.

Disclosure of Interests:

None declared

[Delegation of medical tasks in rheumatology]

Modern rheumatology enables better and earlier diagnosis and therapy of inflammatory rheumatic system diseases. At the same time, the requirements for the care of rheumatologic patients have risen considerably for non-medical assistant professions and specialists for nursing professions. Since 2006 there has been established an education curriculum "Rheumatological Specialist Assistant DGRh-BDRh" (RFA) with the training to become a "Rheumatological Specialist Assistant (DGRh-BDRh)". In Europe and in parallel in Germany, assistant professions are increasingly involved in the early detection and care of patients with rheumatic diseases and entrusted with tasks.In this work, the overarching principles for delegation of medical tasks to RFA and recommendations for the delegation are published by the Commission for Delegation of the German Society for Rheumatology (DGRh). These recommendations are based on the requirements of the German Medical Association and have been legally evaluated. With the extension of the training of the RFA board certification is aimed for "MFA for Rheumatology". These recommendations enable more transparency and security for delegating doctors and the delegated RFA's.

OP0154-HPR EFFECT OF NURSE-LED-CARE ON PATIENT OUTCOMES IN RHEUMATOID ARTHRITIS IN GERMANY: A MULTICENTRE RANDOMISED CONTROLLED TRIAL

Background:

Inflammatory rheumatic disorders are very complex and require high medical resources. However, there is a shortage of care for these patients, which results in suboptimal reach of therapy objectives. Nevertheless, these very objectives need to be pursued quickly to prevent permanent joint damage. In order to ensure adequate care, multidisciplinary teams which include clinical nurse specialists are required. These clinical nurse specialists play an important role in improving standard-of-care in addition to the rheumatologist. The current standard of care ensures that essential medical provision remains intact, however, psychological, social, rehabilitative and educational needs are often skipped due to time constraints. While studies from e.g. the UK and Denmark have already supported the non-inferiority of nurse-led care (NLC)1, no such studies have yet been published in Germany.

Objectives:

To demonstrate the non-inferiority of NLC to the current standard-of-care, rheumatologist-led care (RLC), for patients with seropositive rheumatoid arthritis (RA) with induction, escalation or change of therapy regarding disease activity as well as different patient reported outcomes (PROs).

Methods:

This trial was conducted as a prospective multi-centered RCT with a non-inferiority design over the course of 12 months. Based on power calculations, 236 adults with RA were included in the study and randomized to either NLC or RLC. The primary outcome measure is disease activity (DAS28), assessed at baseline (T0), 6 weeks (T1), 3,6, 9, and 12 months (T3, T6, T9, T12). Secondary measures are health related quality of life (RAID), functionality (FFbH) and depression (PHQ9).

Results:

There are no significant differences between intervention group (IG) (n=117) and control group (CG) (n=119) at baseline. The mean age of the IG is 58.80 years (SD=12.09) and of the CG 58.34 years (SD=11.72). 72.4% of the IG and 78.1% of the CG are female. The mean duration of symptoms was 147 months (SD=144.63) for the IG and 116 months (108.89) for the CG. The mean DAS28 for the IG is 4.36 (SD=1.24) and 4.51 (SD=1.24) for the CG.

A mixed one-way repeated measures ANOVA showed that the DAS28 improves significantly over time, Huyn-FeldtF(4.42, 751.72) = 105.701,p< .001, partialη2= 0.383, but the interaction of the DAS28 and the randomization is not significant, Huyn-FeldtF(4.42, 751.72) = 1.464,p= 0.260, partialη2= 0.009. No main effect for randomization was found, meaning that the IG and CG did not differ significantly,F(1, 170) = 1.005,p= 0.317, partialη2= 0.006.

The Mann-Whitney-Test showed that the change of the secondary outcomes does not depend on the randomization FFbHU= 4978.50,Z= -.755,p=.450. RAIDU= 5121.00,Z= -.539,p=.590. PHQ9U= 4800.50,Z= -1.281,p=.200. The secondary outcomes improve significantly over time, as shown by a Wilcoxon Signed Rank test for the FFbHZ= -5.589,p< .001, the RAIdZ= -9.884,p< .001 and the PHQ9Z= -7.960,p< .001.

Conclusion:

The results support the non-inferiority of NLC in the management of RA regarding the primary and secondary outcome measures and provide first evidence that NLC could improve care and help carry the doctors’ workflow.

Figure 1.Figure 2.

References:

[1]de Thurah A, Esbensen BA, Roelsgaard IK, et al. Efficacy of embedded nurse-led versus conventional physician-led follow-up in rheumatoid arthritis: a systematic review and meta-analysis. RMD Open 2017;3:e000481.

Disclosure of Interests:

Juliana R Hoeper: None declared, Georg Gauler Consultant of: Abbvie, Lilly, MSD, Speakers bureau: Abbvie, Celgene, Novartis, Sanofi,, Dirk Meyer-Olson Grant/research support from: Novartis, Sandoz Hexal, Consultant of: Abbvie, Amgen, Bristol Myers Squibb, Chugai, Lilly, Mylan, Novartis, Sandoz Hexal, Sanofi, Speakers bureau: Abbvie, Bristol Myers Squibb, Chugai, Lilly, Novartis, Pfizer, Sandoz Hexal, Sanofi, Karin Rockwitz Consultant of: Janssen Cilag, Speakers bureau: Janssen Cilag, Patricia Steffens-Korbanka Consultant of: Abbvie, Chugai, Novartis, Sanofi, Mylan, Lilly, Speakers bureau: Abbvie, Chugai, Novartis, Sanofi, Lilly, Carsten Stille: None declared, Jochen Walter Consultant of: Pfizer, Speakers bureau: AbbVie, Frauenhofer Institut, Gilead, Janssen-Cilag, Medac, Novartis, Pfizer, Martin Welcker Grant/research support from: Abbvie, Novartis, UCB, Hexal, BMS, Lilly, Roche, Celgene, Sanofi, Consultant of: Abbvie, Actelion, Aescu, Amgen, Celgene, Hexal, Janssen, Medac, Novartis, Pfizer, Sanofi, UCB, Speakers bureau: Abbvie, Aescu, Amgen, Biogen, Berlin Chemie, Celgene, GSK, Hexal, Mylan, Novartis, Pfizer, UCB, Joerg Wendler Consultant of: Janssen, AbbVie, Sanofi, Speakers bureau: Roche, Chugai, Janssen, AbbVie, Novartis, Jan Zeidler: None declared, Kirsten Hoeper Consultant of: AbbVie, Celgene,, Speakers bureau: Abbvie, Chugai, Novartis, Lilly, Celgene, Sandoz Hexal

THU0623-HPR REVISION AND VALIDATION OF THE GERMAN VERSION OF THE SYSTEMIC SCLEROSIS QUALITY OF LIFE QUESTIONNAIRE (SSCQOL) WITH MOKKEN SCALE ANALYSIS

Background:

The Systemic Sclerosis Quality of Life Questionnaire (SScQoL) has been validated in six European languages.1Previous adaptation into German revealed issues with the dichotomous response structure in 10 items necessitating a review of the tool and further psychometric testing with patients in German speaking countries.

Objectives:

The aim of this study was to assess the German version of the SScQoL, extend the response structure and test its construct validity using Mokken scale analysis.

Methods:

This was a mixed methods study involving cognitive debriefing and survey methods. The expert committee extended the response structure of the 10 items from dichotomous to polytomous (4-point) responses: ‘always’, ‘usually’, ‘sometimes’ and ‘never’. In cognitive debriefing, a small convenience sample of patients with SSc completed the new version while ‘thinking aloud’ and commented on relevance of the items and the response structure.

Results:

In cognitive debriefing, six patients with SSc completed the new German SScQoL and reported problems with the remaining dichotomous items. These were subsequently converted into polytomous 4-point response structure by the expert committee.

Conclusion:

The German SScQoL has been revised into polytomous item structure and shown to be a valid and reliable measure of health-related quality of life in SSc. Further cross-cultural validity tests are required to assess its measurement equivalence with other SScQoL versions and thus enable multinational comparisons.

References:

[1]Ndosi M, Alcacer-Pitarch B, Allanore Y et al. Common measure of quality of life for people with systemic sclerosis across seven European countries: a cross-sectional study. Ann Rheum Dis, 2018; 77: 1032-1038

Table 1.

Mokken scale analysis of the revised German SScQoL

Subscale (items)Scalability (H)Standard errorFunction (6)0.6640.048Emotional (13)0.6520.060Sleep (2)0.7980.061Social (6)0.6920.053Pain (2)0.9600.029Global scale (29)0.6230.062

Table legend: scalabilityH≥ 0.50 = strong, 0.49 to 0.40 = moderate, 0.39 to 0.30 = weak, while values of < 0.30 are not considered as unidimensional.

Disclosure of Interests:

Agnes Kocher Grant/research support from: Sandoz to support the development of an eLearning module for patients with rheumatic diseases., Mwidimi Ndosi Grant/research support from: Bristol Myers Squibb, Consultant of: Janssen, Pfizer, Kirsten Hoeper Consultant of: AbbVie, Celgene,, Speakers bureau: Abbvie, Chugai, Novartis, Lilly, Celgene, Sandoz Hexal, Michael Simon: None declared, Dunja Nicca: None declared

AB1298-HPR RHEUMA-VOR: A PROOF-OF-CONCEPT NETWORK STUDY FOR THE IMPROVEMENT OF RHEUMATOLOGICAL HEALTH CARE THROUGH COORDINATED COOPERATION

Background:

Rheumatoid arthritis (RA), psoriasis arthritis (PsA) and spondyloarthritis (SpA) are the most common chronic inflammatory rheumatic diseases. For all three diseases, the so-called “window of opportunity” [1,2,4] has been identified as the decisive factor affecting the outcome.

Objectives:

The aim of the prospective study is to improve the early diagnosis of RA, PsA and SpA and thus positively impact the quality of care for patients with the support of coordinating centers.

Methods:

Primary care providers are given access to screening questionnaires to document potential early cases of RA, PsA, and SpA, based on characteristic symptoms. These are evaluated by multidisciplinary teams at the regional coordinating centers. If they fulfill the criteria for referral, patients get an appointment at a cooperating rheumatology specialist within weeks. If a rheumatic disease is diagnosed, physicians and patients receive questionnaires about sociodemographic, physilogical and psychological parameters.

In order to increase the quality of referrals, a 15-minute rheumatological consultation at the ACURA Rheumatology Center was implemented for all patients from Rhineland-Palatinate whose suspected diagnosis was confirmed by the coordination centre. In course of this, the Rheuma-VOR Screening-App will also be developed and optimized. The cooperating partners and additional information are already published [5].

Results:

Preliminary data (31 Dec 2019) are presented. In Rhineland-Palatinate, Saarland and Lower Saxony, 4942 suspected diagnoses of 1526 different referring physicians have now been reported. A total of 2578 patients were referred by the three coordination centres to one of the 49 participating rheumatological specialists. 1004 patients were diagnosed with one of the three diseases. About 306 patients have already taken the follow-up appointment after one year.

In course of a screening consultation 736 patients have been screened to date. The patients have to wait in average about 42 days from the suspected diagnosis to the rejected or confirmed rheumatological diagnosis.

Conclusion:

Although the average waiting time for all three diseases is currently almost twice as long as the 23.9 days in the Rhineland-Palatinate predecessor project ADAPTHERA which just focuses on RA, the current results are very positive compared to the national average [3]. The aim is to further increase the screening quality and screening numbers, especially in the 1-year follow-up.

Current data will be presented at the conference.

References:

[1]Boehncke WH, Menter A (2013) Burden of disease: psoriasis and psoriatic arthritis. Am J Clin Dermatol 14:377-388

[2]Claudepierre P (2014) Spondyloarthritis: a window of opportunity? Joint Bone Spine 81:197-199

[3]Lauter A, Triantafyllias K, Leiß R et al. (2019) ADAPTHERA—Statewide cross-sectoral care network for patients with early rheumatoid arthritis shows sustained remission in standard care. ZRheumatol. 78 (7): 660–669

[4]O’dell JR (2002) Treating rheumatoid arthritis early: a window of opportunity? Arthritis Rheum 46:283-285

[5]Schwarting A (2018) From ADAPTHERA to Rheuma-VOR: Concept of Coordinated Cooperation to Improve the Quality of Rheumatology Care Akt Rheumatol 43 (05): 406-409

Acknowledgments:

The authors thank all partners and participants of Rheuma-VOR

Disclosure of Interests:

Matthias Dreher: None declared, Reinhold E. Schmidt: None declared, Torsten Witte: None declared, Gunter Assmann: None declared, Kirsten Hoeper Consultant of: AbbVie, Celgene,, Speakers bureau: Abbvie, Chugai, Novartis, Lilly, Celgene, Sandoz Hexal, Konstantinos Triantafyllias: None declared, Jan Zeidler: None declared, Harald Binder: None declared, Andreas Schwarting: None declared

Rehabilitation von Patienten mit entzündlich-rheumatischen Erkrankungen

Die rheumatologische Rehabilitation dient der Wiederherstellung einer eingeschränkten sozialen oder beruflichen Teilhabe bei Patienten mit entzündlich rheumatologischen Erkrankungen. Trotz deutlicher Fortschritte bei der medikamentösen Versorgung von Patienten mit entzündlich-rheumatischen Erkrankungen, insbesondere bei der rheumatoiden Arthritis und der Spondyloarthritis, finden sich trotz Verbesserungen weiterhin noch deutliche Einschränkungen der beruflichen Teilhabe bei Patienten mit diesen Krankheitsbildern. Dieser Übersichtartikel vermittelt den aktuellen Stand der rheumatologischen Rehabilitation in Deutschland und beschreibt aktuelle Problemfelder der rehabilitationsmedizinischen Versorgung sowie mögliche Lösungsansätze.

[Early recognition and screening consultation: a necessary way to improve early detection and treatment in rheumatology? : Overview of the early recognition and screening consultation models for rheumatic and musculoskeletal diseases in Germany]

In order to reduce the prognostically relevant time interval between the initial manifestation of a rheumatic and musculoskeletal disease and diagnosis as well as the consecutive initiation of an appropriate treatment, several rheumatological centers in Germany have improved the access to initial rheumatologic evaluation by establishing early recognition/screening clinics at their respective sites. Corresponding models located at Altoetting·Burghausen, Bad Pyrmont, Berlin Buch, Duesseldorf, Heidelberg, Herne, Mannheim as well as supraregional/multicenter initiatives Rheuma Rapid, RhePort and Rheuma-VOR are presented in this overview along with the respective characteristics, potential advantages and disadvantages, but also first evaluation results of several models. The aim of this publication is to promote early detection of rheumatic and musculoskeletal diseases as one of the most important challenges in current rheumatology by encouraging further rheumatologic centers and practices to launch their own early recognition/screening consultation model on the basis of aspects presented herein.

[Experiences and results from Rheuma-VOR]

Rheumatoid arthritis, psoriatic arthritis and axial spondylarthritis are the most common chronic autoimmune rheumatic diseases. For all three diseases an early diagnosis and initiation of treatment is crucial. The proof of concept network study "Rheuma-VOR" is a further developed version of the predecessor project ADAPTHERA and was extended to several federal states. The aim of this prospective study is to improve the early diagnosis of rheumatoid arthritis, psoriatic arthritis and axial spondylarthritis and thus positively impact the quality of care for patients with the help of multidisciplinary coordinating centers. To date 3710 disease-specific questionnaires from patients with the suspected diagnosis of rheumatoid arthritis, psoriatic arthritis or axial spondylarthritis from 1298 different primary care providers were registered in the multidisciplinary coordination centers. A total of 1958 appointments were made with 1 of the 53 participating rheumatology specialists. In 876 patients, 1 of the 3 rheumatic diseases was diagnosed in an early stage. The waiting period was on average 42.5 days depending on the federal state, which is well below the nationwide average. It should also be noted that the coordinated cooperation and risk stratification of the Rheuma-VOR coordination centers relieved the capacity of rheumatology specialists by 1281 appointments (34.5%). In addition, the 2‑week Rheuma Bus Tour and the accompanying initiatives in Rhineland-Palatinate (Rheuma-VOR screening app and the triage consultation) are showing first promising positive results.

2018 update of the EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis

To update the European League Against Rheumatism (EULAR) recommendations for the role of the nurse in the management of chronic inflammatory arthritis (CIA) using the most up to date evidence. The EULAR standardised operating procedures were followed. A task force of rheumatologists, health professionals and patients, representing 17 European countries updated the recommendations, based on a systematic literature review and expert consensus. Higher level of evidence and new insights into nursing care for patients with CIA were added to the recommendation. Level of agreement was obtained by email voting. The search identified 2609 records, of which 51 (41 papers, 10 abstracts), mostly on rheumatoid arthritis, were included. Based on consensus, the task force formulated three overarching principles and eight recommendations. One recommendation remained unchanged, six were reworded, two were merged and one was reformulated as an overarching principle. Two additional overarching principles were formulated. The overarching principles emphasise the nurse’s role as part of a healthcare team, describe the importance of providing evidence-based care and endorse shared decision-making in the nursing consultation with the patient. The recommendations cover the contribution of rheumatology nursing in needs-based patient education, satisfaction with care, timely access to care, disease management, efficiency of care, psychosocial support and the promotion of self-management. The level of agreement among task force members was high (mean 9.7, range 9.6-10.0). The updated recommendations encompass three overarching principles and eight evidence-based and expert opinion-based recommendations for the role of the nurse in the management of CIA.

[Infectious complications of biologic therapy in patients with rheumatoid arthritis]

The introduction of biological disease-modifying drugs (DMARDs) has substantially improved the treatment options for patients with rheumatoid arthritis. However, infectious complications represent the most common side effects of these drugs, including severe infections as well as rare opportunistic infections. Treating patients on biological DMARDs is therefore one of the biggest challenges in rheumatology care. The present review describes the current state of knowledge regarding frequency and type of infectious complications associated with biological DMARDs. The article focuses mainly on risk management, in particular on diagnosis and recurrence prevention of tuberculosis and reactivation of hepatitis B virus infection. Furthermore, we discuss the importance of vaccinations in primary disease prevention in patients with rheumatoid arthritis.

Comparative effects of AT1-antagonism and angiotensin-converting enzyme inhibition on markers of inflammation and platelet aggregation in patients with coronary artery disease

OBJECTIVES

We evaluated whether renin-angiotensin system (RAS) blockade attenuates cardiovascular events.

BACKGROUND

Because inflammation and enhanced thrombogenesis are hallmarks of atherosclerosis, we assessed whether RAS inhibition elicits anti-inflammatory and anti-aggregatory effects.

METHODS

Interleukin 6 (IL-6), high-sensitivity C-reactive protein (hsCRP), metalloprotease 9 (MMP-9), and interleukin 10 (IL-10) were determined in patients with coronary artery disease (CAD) and arterial hypertension six to eight weeks after coronary angioplasty (low-density lipoprotein serum levels <150 mg/dl). Patients were randomized double-blind to either 20 mg enalapril (ENAL, n = 27) or 300 mg irbesartan (IRB, n = 21) for 3 months. Blood samples were drawn at baseline and at three months. Thromboxane A2-induced platelet aggregation was determined turbidimetrically; urine bicyclo-prostaglandin E2 (PGE(2)) and inflammatory markers were measured by enzyme-linked immunosorbent assay technique.

RESULTS

Both treatment regimens enhanced serum IL-10 levels (IRB p < 0.001, ENAL p < 0.03) and reduced serum MMP-9 protein (IRB p < 0.001, ENAL p < 0.05) and MMP-9 activity (IRB p < 0.005, ENAL p < 0.05). Only IRB reduced serum IL-6 and hsCRP levels significantly compared with baseline (p < 0.01), whereas ENAL did not (hsCRP p < 0.02 IRB vs. ENAL, p < 0.01 IRB vs. ENAL). Platelet aggregation was only reduced by IRB (p < 0.001, ENAL p < 0.06, IRB vs. ENAL p < 0.001) while urine PGE(2) levels remained unchanged.

CONCLUSIONS

Angiotensin-converting enzyme (ACE) inhibition and angiotensin II type 1 receptor (AT1) blockade reduced serum MMP-9 protein/activity to a similar extent, and only AT1 blockade reduced hsCRP, IL-6, and platelet aggregation in patients with CAD. Thus, AT1-blockade appears to exert stronger systemic anti-inflammatory and anti-aggregatory effects compared with ACE inhibition.

[Usefulness of a VDD defibrillation electrode in recording atrial electrograms during atrial flutter and atrial fibrillation]

BACKGROUND

Monitoring of atrial signals improves the accuracy in identifying supraventricular tachyarrhythmias to prevent inappropriate therapies in patients with implantable cardioverter-defibrillators (ICD). Since complications due to the additional atrial lead were found in dual chamber ICD systems with 2 leads, we designed a single-pass VDD-lead for use with dual chamber ICDs.

PATIENTS AND METHODS

After promising animal experiments in a German multicenter study a prototype VDD lead (single-coil defibrillation electrode with 2 additional fractally coated rings for bipolar sensing in the atrium) was temporarily used in 20 patients. Atrial and ventricular signals were recorded during sinus rhythm, atrial flutter, atrial fibrillation and ventricular tachycardia or ventricular fibrillation. Terminations of ventricular arrhythmias were performed by internal DC shock.

RESULTS

The implantation of the electrode was successful in 18 of 20 patients. Mean atrial pacing threshold was 2.45 +/- 0.9 V/0.5 ms, mean atrial impedance was 215 +/- 31 Ohm. Atrial amplitudes were greater during sinus rhythm (2.7 +/- 1.6 mV) than during atrial flutter (1.36 +/- 0.28 mV, p < 0.05) or atrial fibrillation (0.92 +/- 0.29 mV, p < 0.01). During ventricular fibrillation atrial "sinus"-signals had significantly (p < 0.01) lower amplitudes than during sinus rhythm. Mean ventricular sensing was 13.3 +/- 7.9 mV, mean ventricular impedance was 577 +/- 64 Ohm. Defibrillation was successful with 20 J shock. 99.6% of P waves could be detected in sinus rhythm and 85 +/- 9.9% of flutter waves during atrial flutter. During atrial fibrillation 55% of atrial signals could be detected without modification of the signal amplifier.

CONCLUSIONS

A new designed VDD dual chamber electrode provides stable detection of atrial and ventricular signals during sinus rhythm and atrial flutter. For reliable detection of atrial fibrillation modifications of the signal amplifier are necessary.