Search

Background/Aims Advice lines services (ALS) are a key aspect of providing coordinated patient care in rheumatology. Demand for rapid access to specialist advice increased during the pandemic due to the disruption of routine outpatient services but it is not clear whether this demand is sustained. We aimed to investigate the changes in demand for ALS, how this varied pre/during COVID-19 and audit the effect upon response times. We also aimed to assess the impact of introducing an email advice service on demand. Methods We audited the number of advice line contacts of a single rheumatology department, serving a population of 500,000 people. The telephone adviceline is provided as an answer machine with an email advice service set up in April 2020. The outcome of each contact is recorded as a) advice only b) action required (e.g., prescription, blood test, GP letter) or c) required appointment (monitor/nurse/medical). We audited response times using the RCN guidelines of a two-day response1 as the gold standard. Results Demand for advice had been increasing pre-COVID with an average of 368 calls/month (1/1/19-1/7/19) to 420/month (1/7/19-31/12/19). Sixty percent were advice only calls but 27% required additional action. Response times met the audit standard in 97% of cases pre-COVID. During the first two months of COVID demand for advice services doubled, however demand continued to rise although outcomes were similar (Table 1). As the number of contacts increased the proportion of telephone contacts responded to within the audit standard fell. Numbers of email contacts were variable, but response times exceeded the audit standard. Conclusion This audit demonstrates the demand of adviceline services has continued to increase throughout the pandemic and beyond, impacting the ability of services to respond within a timely manner. Ongoing QI work is assessing mechanisms to manage increased demand (using healthcare support workers to triage calls) and investigating reasons for accessing ALS to ensure appropriate advice is available. Disclosure S. Hider: None. A. Brownfield: None. R. Doe: None. S. Dutta: None. S. Ryan: None.

Background/Aims Methotrexate (MTX) is recommended as initial disease-modifying anti-rheumatic drug (DMARD) therapy for people with rheumatoid arthritis (RA). Rheumatology nurses provide information about benefits, risks and safety monitoring requirements for methotrexate during DMARD counselling, which may be provided in different formats. This study sought to explore the information needs and experiences of people with RA commencing MTX. Methods Seventy-six adults with RA referred for MTX DMARD counselling attending two rheumatology units in the West Midlands were invited to take part in qualitative semi-structured interviews (either by phone or video) before and after receiving information about MTX. Research partners with RA helped to develop interview topic guides. Interviews were digitally recorded, transcribed and analysed using reflexive thematic analysis. Results Nineteen participants, (11 male, 8 female, White British, age 45-76 years, disease duration 6 weeks - 35 years) took part in telephone (n17) or video (n2) interviews (duration 34-82 minutes). Three main themes were identified: information delivery, necessity of MTX and concerns about MTX. Information delivery: most participants received telephone DMARD counselling which was helpful for people with mobility issues or work commitments. However, most acknowledged a preference for, and the importance of face-to-face communication. Information tended to be provided in a generic manner, using a checklist, and could feel rushed. Written MTX leaflets were received but not used by all participants. Some participants felt well informed whilst others felt overwhelmed with information. Many had difficulty recalling important safety information. Unmet information needs about monitoring, prescribing and follow-up arrangements were frequently reported. Inconsistent information about MTX from different sources could increase concerns. Rheumatology helplines were valued as a direct route to information and care. Necessity of MTX: most participants wanted more information on why they should take MTX, how and when MTX would help them and how long they would be required to take MTX for. Some wanted to know about other drug treatment options. Concerns about MTX: all participants had concerns about the likelihood and severity of side-effects including mouth ulcers, nausea and hair loss. Worries about the use of MTX as a cancer treatment were frequently reported. Whilst concerns remained about MTX most participants accepted the risk of side-effects because of the need to improve their symptoms. Conclusion DMARD counselling was valued by people with RA when starting MTX but was not always responsive to information needs. Addressing individual concerns about the necessity for MTX, concerns about side-effects and prioritising essential safety information is recommended. Practical issues around obtaining supplies of MTX, monitoring, follow-up arrangements and a follow-up telephone call may help address unmet information needs for some. Disclosure S.J. Logan: None. S. Hider: None. J. Green: None. S. Ryan: None.

Background/Aims Many people diagnosed with rheumatoid arthritis (RA) receive intramuscular (IM) or oral bridging glucocorticoids whilst methotrexate (MTX) takes effect. Little is known about the information needs and experiences of people with RA receiving glucocorticoids when starting MTX. Methods Seventy-six adults with RA referred for MTX counselling attending two rheumatology units in the West Midlands were invited to take part in qualitative semi-structured interviews (either by phone or video). Research partners with RA helped to develop interview topic guides. Interviews were digitally recorded, transcribed and analysed using reflexive thematic analysis. Results Nineteen participants, (11 male, 8 Female, White British, age 45-76 years, disease duration 6 weeks - 35 years) took part in telephone (n17) and video (n2) interviews (duration 34-82 minutes). Most received IM glucocorticoids (n14) before starting MTX. Three themes were identified; trusting the rheumatologist; provision of information; the benefits of glucocorticoids. Trusting the rheumatologist: Several people accepted the rheumatologist’s decision to have a glucocorticoid injection following diagnosis. Some people did not understand the purpose of the injection, and wanted information about the rationale for the injection, including how long the benefit would last and whether the injection could be repeated. Provision of information: Some people were informed by the nurse that the glucocorticoid injection should help their condition. The majority of people did not receive any written information. This left people wondering whether glucocorticoid injections could be repeated. Whereas most treated with oral glucocorticoids recalled receiving written information. Some people were issued with a steroid card. Few reported concerns about side-effects from IM glucocorticoids and did not seek information on the internet. One declined IM glucocorticoids reporting not receiving enough information to make an informed decision. Benefit of glucocorticoids: Most people reported significant benefit from glucocorticoids, experiencing relief of pain, swelling and stiffness in joints. Many found it easier to manage personal care needs and noted improved sleep and reduced levels of fatigue. This allowed many to resume their roles. Several reported that relief of symptoms gave them hope for treatment with MTX and a better quality of life with RA. Conclusion Treatment with IM glucocorticoids often provides rapid relief of symptoms for people with RA whilst waiting for MTX treatment to be established. Most people recalled receiving little or no information about IM glucocorticoids. Many people wanted to know the likely duration of benefit and how often they could receive IM glucocorticoids. Few people reported concerns about side-effects. Tailored information including the rationale for IM glucocorticoid treatment, duration of IM glucocorticoid treatment and RA treatment plan should be considered. Disclosure S.J. Logan: None. S. Hider: None. J. Green: None. S.J. Ryan: None.

Abstract Objective To assess the longer term impact of the COVID-19 pandemic on the self-reported physical and mental health of people with inflammatory rheumatic diseases (IRDs). Methods Two thousand twenty-four patients with IRDs were randomly selected from electronic health records. Survey invitations were sent (August 2021 coinciding with relaxation of UK COVID-19 restrictions) using SMS and postal approaches. Self-reported data included demographics, shielding status and physical (MSK-HQ) and mental health (PHQ8 and GAD7). Results Six hundred thirty-nine people completed the survey (mean (SD) age 64.5 (13.1) years, 384 (60%) female). Moderate/severe impact of the pandemic on physical and mental health was reported by 250 (41%) and 241 (39%) respectively. One hundred seventy-two (29%) reported moderate/severe depression (PHQ8 ≥ 10) and 135 (22%) moderate/severe anxiety (GAD7 ≥ 10). Females reported greater impacts of the pandemic on physical health (44% vs 34%), mental health (44% vs 34%), arthritis symptoms (49% vs 36%) and lifestyle factors (weight gain and reduced exercise and physical activity) than males. The physical and mental impacts were less in people with RA compared with other IRDs. Physical health impacts did not differ between age groups, but younger patients reported greater impacts on mental health. Conclusion The COVID-19 pandemic has had a significant impact on the physical and mental health of people with IRDs. These effects were greatest in females. Recovery needs to address the negative impact of the pandemic on lifestyle factors to minimise the long-term impacts for people with IRDs. Key Points• The pandemic had a significant impact on long term physical and mental health in almost 40% of people with IRDs.• The impact of the pandemic was greater in women for physical health, mental health and arthritis symptoms.• Many people reported negative pandemic impacts on lifestyle factors including weight and physical activity.

Objectives COVID-19 led to rapid uptake of digital health care. We sought to examine digital access, health and digital literacy, and impact on confidence and satisfaction with remote consultations in people with inflammatory rheumatic diseases (IRDs). Methods People with IRDs (n = 2024) were identified from their electronic health record and invited to participate in a cross-sectional survey, using short message service (SMS) and postal approaches. Data were collected on demographics, self-reported diagnosis, access to and use of internet-enabled devices, health and digital literacy, together with confidence and satisfaction with remote consultations. Ethical approval was obtained (Ref 21/PR/0867). Results Six hundred and thirty-nine (639) people completed the survey [mean (s.d.) age 64.5 (13.1) years, 384 (60.1%) female]. Two hundred and eighty-seven (44.9%) completed it online. One hundred and twenty-six (19.7%) people reported not having access to an internet-enabled device. Ninety-three (14.6%) reported never accessing the internet; this proportion was highest (23%) in people with RA. One hundred and seventeen (18%) reported limited health literacy. Even in those reporting internet use, digital literacy was only moderate. People with limited health or digital literacy or without internet access were less likely to report confidence or satisfaction with remote consultations. Conclusion Limited health and digital literacy, lack of digital access and low reported internet use were common, especially in older people with RA. People with limited health literacy or limited digital access reported lower confidence and satisfaction with remote consultations. Digital implementation roll-out needs to take account of people requiring extra support to enable them to access care digitally or risks exacerbating health inequalities.

Objective To describe factors associated with change in health-related quality of life (HRQOL) in people living with gout in primary care. Methods In a UK prospective cohort study, adults with a diagnosis of gout registered with 20 general practices completed the Gout Impact Scale (GIS; scale 0–100), 36-item Short Form Physical Function subscale (PF-10; 0–100) and HAQ Disability Index (HAQ-DI; 0–3) via postal questionnaires at baseline and 6, 12, 24 and 36 months. Linear mixed modelling was used to investigate factors associated with changes in HRQOL over 3 years. Results A total of 1184 participants responded at baseline (adjusted response 65.6%); 990 (83.6%) were male, with a mean age of 65.6 years (s.d. 12.5). A total of 818, 721, 696 and 605 responded at 6, 12, 24 and 36 months, respectively. Factors associated with worse disease-specific and generic HRQOL over 3 years were flare frequency (five or more flares; GIS subscales, PF-10), oligo/polyarticular flares (GIS subscales, PF-10, HAQ-DI), worse pain (GIS subscales, PF-10, HAQ-DI), body pain (GIS subscales, PF-10, HAQ-DI) and more severe depression (GIS subscales, PF-10, HAQ-DI) (P ≤ 0.05). More severe anxiety was associated with worse disease-specific HRQOL only (GIS subscales). Older age (PF-10), being female (PF-10, HAQ-DI) and BMI (HAQ-DI) were associated with worse generic HRQOL (P ≤ 0.05). Conclusion Gout-specific, comorbid and sociodemographic factors were associated with change in HRQOL over a 3-year period, highlighting people at risk of worse outcomes who could be targeted for interventions.

Background Immunosuppressive treatments inhibit vaccine-induced immunity against SARS-CoV-2. We evaluated whether a 2-week interruption of methotrexate treatment immediately after the COVID-19 vaccine booster improved antibody responses against the S1 receptor-binding domain (S1-RBD) of the SARS-CoV-2 spike protein compared with uninterrupted treatment in patients with immune-mediated inflammatory diseases. Methods We did an open-label, prospective, two-arm, parallel-group, multicentre, randomised, controlled, superiority trial in 26 hospitals in the UK. We recruited adults from rheumatology and dermatology clinics who had been diagnosed with an immune-mediated inflammatory disease (eg, rheumatoid arthritis, psoriasis with or without arthritis, axial spondyloarthritis, atopic dermatitis, polymyalgia rheumatica, and systemic lupus erythematosus) and who were taking low-dose weekly methotrexate (≤25 mg per week) for at least 3 months. Participants also had to have received two primary vaccine doses from the UK COVID-19 vaccination programme. We randomly assigned the participants (1:1), using a centralised validated computer randomisation program, to suspend methotrexate treatment for 2 weeks immediately after their COVID-19 booster (suspend methotrexate group) or to continue treatment as usual (continue methotrexate group). Participants, investigators, clinical research staff, and data analysts were unmasked, while researchers doing the laboratory analyses were masked to group assignment. The primary outcome was S1-RBD antibody titres 4 weeks after receiving the COVID-19 booster vaccine dose, assessed in the intention-to-treat population. This trial is registered with ISRCT, ISRCTN11442263; following the pre-planned interim analysis, recruitment was stopped early. Findings Between Sept 30, 2021 and March 3, 2022, we recruited 340 participants, of whom 254 were included in the interim analysis and had been randomly assigned to one of the two groups: 127 in the continue methotrexate group and 127 in the suspend methotrexate group. Their mean age was 59·1 years, 155 (61%) were female, 130 (51%) had rheumatoid arthritis, and 86 (34%) had psoriasis with or without arthritis. After 4 weeks, the geometric mean S1-RBD antibody titre was 22 750 U/mL (95% CI 19 314–26 796) in the suspend methotrexate group and 10 798 U/mL (8970–12 997) in the continue methotrexate group, with a geometric mean ratio (GMR) of 2·19 (95% CI 1·57–3·04; p Interpretation A 2-week interruption of methotrexate treatment for people with immune-mediated inflammatory diseases resulted in enhanced boosting of antibody responses after COVID-19 vaccination. This intervention is simple, low-cost, and easy to implement, and could potentially translate to increased vaccine efficacy and duration of protection for susceptible groups. Funding National Institute for Health and Care Research.

Background/Aims The COVID-19 pandemic led to an overnight shift in healthcare delivery and rapid uptake of digital technology. Such approaches risk digital exclusion for people without access to or not confident in their use of technology. We sought to examine digital access and e-health literacy in people with inflammatory conditions. Methods People (n = 2,024) were identified from their electronic health record and invited to participate in a survey, using SMS and postal approaches. Data were collected on age, gender, self-reported arthritis diagnosis (RA, PsA, AS, SLE and other), access to an internet-enabled device and frequency of internet access, health literacy (single-item literacy screener) and self-perceived e-health literacy (eHEALs). Ethical approval was obtained (Ref 21/PR/0867). Results 639 people completed the survey, of whom 287 (44.9%) completed it online. Mean (sd) age was 64.5 (13.1) years and 384 (64.7%) were female. 98.3% were white. Approximately 20% of people did not have access to an internet enabled device (Table). 93 (15.3%) of patients reported never accessing the internet, this proportion was higher in people with RA. Approximately 19% had low health literacy. In those reporting internet use, eHealth literacy was moderate. The most popular options for accessing arthritis advice were telephone helplines or appointments. Conclusion Low health literacy, lack of digital access and low reported internet use was common, especially in people with RA, leading to high use of telephone advice and rheumatology appointments. Digital roll-out needs to take account of people requiring extra support to enable them to access care or risks excluding many patients with inflammatory conditions. Disclosure S. Hider: None. S. Muller: None. L. Gray: None. F. Manning: None. M. Brooks: None. D. Heining: None. A. Menon: None. J. Packham: None. S. Raghuvanshi: None. E. Roddy: None. S. Ryan: None. I. Scott: None. Z. Paskins: None.

Background/Aims The substantial personal and socioeconomic costs associated with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and axial spondyloarthritis (SpA) make understanding their epidemiology crucial. The Clinical Practice Research Datalink (Aurum) is an electronic healthcare record (EHR) database, containing primary care records from ∼20% of English practices (>13 million patients currently registered). To determine RA/PsA/axial SpA epidemiology using EHR data, validated methods need to be applied to ascertain patients with these diagnoses. To address this, we updated and applied approaches validated in other primary care EHR databases in Aurum and described the annual incidence/point-prevalence of RA/PsA/axial SpA alongside patient characteristics (providing indirect evidence of coding accuracy). Methods Diagnosis and synthetic disease-modifying anti-rheumatic drug (DMARD) prescription code lists were constructed, and pre-defined approaches for ascertaining patients with RA/axial SpA/PsA applied. The annual incidence and point-prevalence of RA/PsA/axial SpA were calculated from 2004-2020. Samples were stratified by age/gender, and mean age and gender/ethnic-group relative frequencies described. The study was approved by the CPRD Independent Scientific Advisory Committee (reference 20_000244). Results From 2004-2019 the point-prevalence of RA/PsA increased annually, peaking in 2019 (RA 7.79/1,000; PsA 2.87/1,000) then falling slightly. From 2004-2020 the point-prevalence of axial SpA increased annually (except in 2018/2019), peaking in 2020 (1.13/1,000). Annual RA incidence was higher between 2013-2019 (when included in the Quality Outcomes Framework, ranging 0.491 to 0.521/1,000 person-years) than 2004-2012 (ranging 0.345 to 0.400/1,000 person-years). The annual incidence of PsA and axial SpA increased from 2006 (0.108 to a peak of 0.172/1,000 person-years) and 2010 (0.025 to a peak of 0.045/1,000 person-years), respectively. These years were when new disease classification criteria were introduced. Marked falls in the annual incidence of RA, PsA and axial SpA between 2019 and 2020 were seen, reducing by 40.1%, 67.4% and 38.1%, respectively, reflecting the impact of the COVID-19 pandemic on arthritis diagnoses. Stratifying incidence/prevalence by age/gender broadly showed expected patterns (although the incidence of axial SpA/PsA in women increased over time), and the mean age and gender proportions followed those previously reported. Conclusion The approaches we used to determine patients with RA, PsA, and axial SpA in Aurum led to incidence/prevalence estimates broadly consistent with published studies, and patient characteristics as would be expected. These data support the potential of the Aurum-updated ascertainment approaches for use in further studies of RA, PsA and axial SpA. Disclosure I. Scott: None. R. Whittle: None. J. Bailey: None. H. Twohig: None. S. Hider: None. C. Mallen: None. S. Muller: None. K. Jordan: None.

Background/Aims The COVID-19 pandemic placed patients with rheumatoid arthritis (RA) at increased risk of poor outcomes as a result of their condition, compounded by use of immunosuppressant medication, and higher prevalence of comorbidities. As a consequence, some patients were instructed within the UK to follow strict guidelines to “shield”, severely restricting routine social interactions. This study explored patients’ longitudinal experiences of living with RA during the COVID-19 pandemic. Methods Patients with rheumatoid arthritis, from a community hospital-based rheumatology service, participated in two semi-structured telephone interviews at baseline in autumn 2020 and 2-4 months later. Interviews were recorded and transcribed verbatim. Interpretative phenomenological analysis was undertaken by two members of the research team with input from two patient partners (KR and MB). Results 15 participants (9 females, 10 retired, age range 45-79 years) were interviewed twice. Five themes were identified: i) fear, ii) social wellbeing, iii) physical health, iv) pre-existing self-management of RA as a coping mechanism, and v) vulnerability. The overriding emotion was one of fear of contracting COVID-19, which remained high throughout both interviews. Fear was influenced by patients’ existing knowledge of their RA and medications and the presence of other significant co-morbidities. Further influences on fear included mainstream media reports (increasing reporting of deaths and new variants) and personal knowledge (family and friends who had contracted COVID-19). The impact on social wellbeing became more pronounced as remote communications could not replicate the benefits of physical interaction. Participants reported no impact on their physical health, with increased rest resulting from restricted social interaction perceived to be beneficial. Many participants utilised the resilience they had learned as a result of having RA to cope, including stress management, pacing, and exercise. Being categorised as “clinically extremely vulnerable” led to a reassessment of self-identity, with participants not wanting to be perceived as being weak or helpless. Finally, many participants used lockdown to reflect on and reassess their personal priorities. Conclusion This longitudinal interview study with 15 people with RA highlights that the main impact of the pandemic appeared to be on emotional wellbeing brought about by fear of COVID-19, later compounded by lack of social interaction. In this small study, participants’ physical health was reported to be stable and participants were able to use self-management skills to cope. The realisation of the seriousness of contracting COVID-19 led to feelings of vulnerability and a reassessment of self-identity. The study raises important issues for those providing healthcare to people with RA, including effective communication with awareness of its likely impact, using pre-existing self-management strategies to enhance wellbeing, and recognition of the potential for social isolation and the implications thereof. Disclosure P. Campbell: None. Z. Paskins: None. S. Hider: None. A. Hassell: None. F. Crawford-Manning: None. K. Rule: None. M. Brooks: None. S. Ryan: None.

Objectives People with inflammatory arthritis (IA) have an increased incidence of serious illness and mortality, placing them at risk from poor outcomes from COVID-19. This study explored patients’ perceptions of risk from COVID-19 over a longitudinal period of the pandemic. Methods Fifteen adults with inflammatory arthritis attending a NHS rheumatology service, each took part in 3 semi-structured telephone interviews conducted between 16th September 2020 - 29th July 2021. Interpretive phenomenological analysis was undertaken by two researchers and two public contributors. Results Four main themes relating to perceptions of risk from COVID-19 were identified: i) Inflammatory arthritis, medications and co-morbidities, ii) Immediate social environment iii) Health policy communication, and iv) Media influence. Participants recognised that having IA increased their individual risk. Perceptions of risk and associated fear increased during the pandemic, influenced by family/friends who had had COVID-19 and health policy communications. The perceived constant use of negative messages led to many participants disengaging with the media. At the final interviews when the vaccination programme was well established, participants continued to assess the risk and benefits of engaging in activities. Conclusions This study demonstrates the breadth of factors that influenced perceptions of risk in people with an inflammatory arthritis. As health professionals we only have a small sphere of influence over some of these factors, namely health care communications. People with inflammatory arthritis appropriately knew their condition increased their infection risk, but more could be done to consider how and to what extent we involve patients in explaining risk at times of crisis. LAY SUMMARY What does this mean for patients? People with inflammatory arthritis (IA) have an increased risk of serious infection. We interviewed 15 adults with IA, three times, over 7 months during the pandemic to explore how patients interpreted their own risk to COVID-19. We found that people were fearful that COVID-19 could be fatal due to having IA. This fear was heightened by media reports of new variants, seeing family and friends with COVID-19, and receiving letters from the hospital and government confirming their increased risk. Awareness of risk remained high throughout the three interviews which may reflect the lack of evidence, at that time, regarding the exact risk to people with an IA. Our work adds to previous research that individual risk needs to be communicated in such a way that it contains information as to how risk can be reduced without inducing further distress. Patient involvement in how risk can be communicated effectively is required.

Gout is the most prevalent inflammatory arthritis in men. Data from epidemiological studies conducted in several countries suggest that the prevalence and incidence of gout have risen over the last few decades, although incidence may have stabilized recently. Dietary factors (animal purines, alcohol, and fructose), co-morbid medical conditions (obesity, metabolic syndrome, hypertension, and chronic kidney disease), and medications (diuretics, aspirin, beta blockers, angiotensin converting-enzyme inhibitors, and non-losartan angiotensin II receptor blockers) have been confirmed to be risk factors for both hyperuricaemia and gout. In contrast, low-fat dairy products, coffee, vitamin C, calcium channel antagonists, and losartan appear to reduce the risk of developing gout. People with gout are themselves at increased risk of developing cardiovascular disease and chronic kidney disease, independent of traditional risk factors for these conditions.