British Society For Rheumatology Research Articles

P035 BSR Digital resources- Spotlights and Podcasts The Story So Far

Abstract Background/Aims The British Society for Rheumatology (BSR) has an eLearning site for members. Due to increasing demand for online learning triggered in part by the COVID pandemic, a decision was made to create a BSR digital learning board and produce a broader range of content. Methods The Digital Learning Board (DLB) was formed in February 2021 consisting of trainees, nurses, Consultant Rheumatologists and Allied Healthcare Professionals from all around the 4 nations. After consultation and discussion, a decision was made to produce two main new formats of resources in addition to the online webinar series that was already established. This included Spotlights where a variety of blended learning resources including webinars, podcasts, eLearning cases and links to relevant journal articles are collated on a topic. The Talking Rheumatology Spotlight podcast series was also developed and shared on streaming platforms such as Spotify, iTunes and the eLearning website. This includes overview podcasts on topics as well as bonus case based episodes. Resources for the wider community (not limited to members) include the podcasts and ‘How to’ resources created for doctors and nurses starting work in the specialty for the first time. Numbers of podcast downloads, views on the eLearning website and quantitative and qualitative feedback is collected via eLearning website. Results The DLB have produced 30 spotlights with the most popular topics being axial spondyloarthropathy, psoriatic arthritis and Sjogren’s. The average rating for this series is 4.5/5. Examples of feedback; “all areas of great interest and very educational”“I really enjoyed the course, the fact that BSR included several podcasts allowed me to complete the course while doing my exercise. Great course really useful for my clinical practice” 28 podcasts have also been produced so far. There have been 15,500 downloads with significant international interest particularly in the US, Europe and Oceania. The most popular episodes so far have been Polymyalgia rheumatica and Sjogren's syndrome. The how to resources for trainees resource has been viewed 3,897 times by 1502 unique users, and the how to for nurses resource has been viewed 3159 times by 1360 unique .Examples of feedback from nurses “I have now been in post for 6 months and have learnt so much with this resource”“Great introductory course to Rheumatology” Conclusion Work is underway to promote the resources, seek feedback and suggestions for further topics. Many face to face education programmes including the BSR’s own are running again but research (1) and behaviour suggest blended learning is here to stay and complements in person learning well. We are exploring this area further through the development of pre course learning for our face-to-face courses. Disclosure R. Benson: None. L. Coulson: Other; Louise works for the BSR as Digital Events Manager. W.J. Gregory: Honoraria; W.G. has received honoraria for speaker and advisory board from Abbive, Novartis, Pfizer and UCB.. J. Lemon: None. Y.L. Man: None. K. Maxey: Other; Kate works for the BSR as events and education officer. D. Pilbury: None. M. Serrano: Other; Marina works for the BSR as acting Head of Education. C. Wincup: None. P.A. Watson: Other; I am employed by the British Society for Rheumatology as Digital Learning Editor (2PA per week). S. Ellis: None. E. Chibueze Mbanasor: None. M. Malik: None. B. Lakshmana Murthy: None.

P081 Out-patient management of gout in secondary care: Results from the North West regional audit

Abstract Background/Aims Recommendations for gout management have significantly evolved as outlined by the latest National Institute for Health and Care Excellence (NICE), European League Against Rheumatism (EULAR), British Society for Rheumatology (BSR) and the Medicines and Healthcare products Regulatory Agency (MHRA) guidelines, with increased emphasis being placed on optimising cardiovascular risk. This regional audit aimed to assess concordance with these guidelines within rheumatology outpatient settings in the North West region of England. Methods New or follow-up patients with gout, presenting to a rheumatology outpatient setting within the Greater Manchester and Lancashire area over a five-week period between 1/3/23 and 7/4/23 were included. We collated data on demographics, co-morbidity assessment including cardiovascular risk, prescribing of febuxostat in major cardiovascular disease, diuretic use and advice, setting of treat-to-target levels, use of cardiovascular risk prediction tools and subsequent follow up arrangements. For new patients, collected data also included referral reason, and prescription recommendations for first-line urate-lowering therapy (ULT) and co-prescriptions for flare prophylaxis. Results Ninety-two patients (mean age 60 years, 80% male) were included from 13 rheumatology departments. Twenty-three patients were new referrals. Sixty-seven patients (73%) had ≥ 1 relevant comorbidity; hypertension being the most common (55%). Twenty (22%) patients were on diuretics. Twelve (55%) of these patients had a diagnosis of hypertension without heart failure; none received recommendations to reduce or stop diuretics. In line with current guidelines, no patient with major cardiovascular disease was treated with febuxostat. Treat-to-target levels were agreed in 49 (57%) applicable patients. Cardiovascular prediction tools were only calculated or known in three (3%) patients. However, clinic data collected would have allowed a risk assessment calculation in 13 (14%) patients. Sixteen (17%) patients audited had no planned follow-up. Compared to NICE guidelines, 18 (78%) new patients reviewed in clinic were referred appropriately to rheumatology services. Twenty-two (96%) new patients referred were eligible to start ULT, of which 15 (75%) were started on a NICE/ EULAR recommended first-line ULT treatment (14 patients on allopurinol including 11 patients with no major cardiovascular disease, one patient on febuxostat). Eleven (79%) patients started on allopurinol were initiated on a low dose (50-100mg), as recommended by NICE and the BSR. Ten (67%) patients of those initiated on ULT were also prescribed prophylactic colchicine. Two additional patients were prescribed NSAIDs with PPI cover and one patient was prescribed oral steroids without PPI cover. Conclusion Most new patients were referred and prescribed first-line ULT treatment appropriately, often with colchicine prophylaxis. Uptake of febuxostat as first-line therapy was limited. Cardiovascular risk assessment was rarely done; further work exploring barriers to undertaking these assessments in rheumatology clinics is likely to improve both patient care and guideline compliance. Disclosure L. Gould: Other; L.G. has received conference fees from Eli Lilly. A. Richards: None. L. Gray: Other; L.G. has received travel and conference fees from Eli Lilly. M. Badarulla: Other; M.B. has received conference fees from Eli Lilly. L. Mercer: Other; L.M. has received conference fees from Nordic Pharma and UCB. R. Farid: None. R. Heaton: Consultancies; R.H. has received consultancy fees from Galapagos. Honoraria; R.H. has received speaker honorarium from Abbvie and Nordic. Other; R.H. has received conference fees from UCB. M. Al-Attar: None. M. Whitehead: None. S. Kamath: None. L. Teh: None. A. Odekunle: None. C.A. Sharp: None. A. Babiker: None. S. Hopping: None. A. Oldroyd: None. K. Lazarewicz: None. C. Saleh: None. S. Horton: None. D. Roy: Honoraria; D.R. has an honorary University of Manchester research assistant contract. A. Opeseyitan: None. D. Das: None. S. Varughese: None. D. Yidana: None. S. Wig: None. J. Bluett: Grants/research support; J.B. has received a research grant award from Pfizer. Other; J.B. has received travel/conference fees from UCB, Fresenius Kabi, Pfizer and Eli Lilly.

E019 Management of idiopathic inflammatory myositis - a Northamptonshire audit of British Society for Rheumatology guidelines

Abstract Background/Aims The idiopathic inflammatory myopathies (IIM) are a rare group of multi-system autoimmune conditions characterised by muscle inflammation. They have an incidence of up to 19 per 1,000,000 person years in adults and a UK prevalence of 10,000 people. Last census data estimated the Northamptonshire population at approximately 785,200. The small cohort of patients reflects the limited evidence base for best practice. In March 2022, the first UK evidence guideline on IIM was published from the British Society for Rheumatology (BSR). In view of absence of prior guidance, there is expected variability in patient management within and between centres. To evaluate local practice against these standards an audit was conducted in Northampton General Hospital (NGH). Methods Using local MYOACT registry data and consultant caseload knowledge, a cohort of adult patients with IIM diagnoses consulted within the last 5 years were identified. Retrospective clinical letters were analysed for details of patient care and compared to the 26 recommendations as set out by the myositis guideline. Results A total of 12 patients were sampled as having attended the rheumatology department within the last five years at NGH. All 26 standards will be presented, but for the purposes of this abstract, key results for discussion include: • 100% of corticosteroids were tapered as the patient responded to treatment. • In presence of muscle inflammation 91% were treated with DMARDs. • In presence of active skin disease, 100% received treatment with csDMARD, IVIG or rituximab. • 100% of patients were screened for interstitial lung disease. • In presence of active muscle disease, 56% of patients received an exercise program led and monitored by therapists. • In 45% of patients’ psychological well-being and health was formally considered. Conclusion Initial service evaluation against BSR IIM recommendations reflects typical strengths and weaknesses encountered in delivering rheumatology services. There was strong concordance in diagnostic and pharmacological domains. However greater variability was encountered when considering multidisciplinary psychosocial domains involving access to therapy services and psychological support. Tools such as the 36 Item Short Form Survey, highlighted in BSR recommendations, may offer a validated method for physicians to formally consider and target psychosocial domains in management of idiopathic inflammatory myopathies. Disclosure N. Chauhan: None. S. Abushama: None. R. Jeffery: None.

E008 Review of rheumatology care for women of childbearing age

Abstract Background/Aims Autoimmune rheumatic diseases are frequently diagnosed in women of childbearing age. Managing these conditions during pregnancy is complex because commonly used disease-modifying antirheumatic drugs (DMARDs) can pose risks. Specialized care for this patient group is crucial, necessitating adherence to established rheumatology practice standards and British Society for Rheumatology (BSR) guidelines. Our main objective is to review management of childbearing age females with rheumatic diseases attending Basildon hospital as per BSR guidelines. Methods The data for this retrospective study was collected from the electronic records of female patients attending the rheumatology outpatient clinic at Basildon Hospital between September and December 2022. We reviewed age, the specific rheumatological diagnosis, disease duration, disease activity, current medications, and whether general advice or pregnancy-specific advice was provided. Results Out of the initial cohort of 63 female patients, 48 (76%) aged between 18-55 years were selected as women of childbearing age, The median age was 46 years, with 65% in the age groups of 31-50 years, 25% in group 51-55 years and 10% 18-30 years age group. 58% of patients had inflammatory arthritis, 18.7% had connective tissue disease, 18.7% had other conditions such as hypermobility, osteoarthritis, and regional pain syndrome, 2.3% were diagnosed with vasculitis and 2.3% with polymyalgia rheumatica. Breakdown of inflammatory arthritis patients revealed rheumatoid arthritis in 64%, psoriatic arthritis 15% and ankylosing spondylitis 12%. Axial spondyloarthropathy, palindromic rheumatism, and juvenile idiopathic arthritis, each accounted for 3%. Regarding prescribed medications, 66% of the individuals were on conventional DMARDs, biologics 24%, corticosteroids 6% and 4% were on other treatments. The DMARDs prescribed were methotrexate 27%, hydroxychloroquine 19%, sulfasalazine 13%, mycophenolate 3% and leflunomide 1%. The majority of patients had disease activity in remission or mild, each accounting for 23%. Moderate and severe disease activity were reported in 21% each of the audited sample. Patients received advice specifically related to pregnancy 29%, while 71% did not have documented pregnancy-related guidance. 70% of females of reproductive age received general advice. Conclusion The study highlights a gap in pregnancy-related advice among the childbearing age patients as only 29% received guidance on pregnancy. This underpins the need for proactive counselling and education for female patients in routine practice, work in partnership with obstetric teams, and primary care to reduce potential pregnancy related complications and improve outcomes. Disclosure M. Mohareb: None. S. Ahmed: None. A. Bharadwaj: None. A. Nandagudi: None.

P102 Should Fibromyalgia be Diagnosed in Primary or Secondary Care?

Abstract Background/Aims Both the Rheumatology Getting It Right First Time (GIRFT) report, published in February 2021, and the British Society for Rheumatology (BSR) referral guidelines from October 2021 recommend not referring patients with suspected Fibromyalgia to Rheumatology services. In contrast the Royal College of Physicians (RCP) guidelines on Fibromyalgia from 2022 recommend that for unequivocal cases, referral is not necessary, but that referral is appropriate if there is diagnostic uncertainty. We undertook an evaluation of our Rheumatology service to assess whether following either of these guidelines would be appropriate. Methods A prospective analysis of all patients referred to one general Rheumatologist over 18 months to assess the accuracy of suspected fibromyalgia diagnoses from primary care. The included cases were all patients referred with possible fibromyalgia on the referral letter, along with patients with an end diagnosis of fibromyalgia. Results Seventy-two patients were referred to one consultant with possible fibromyalgia on the referral letter. Of these, only 44 (61%) were confirmed as having fibromyalgia. Common other problems felt by the GP to be fibromyalgia included 2+ areas of localised soft tissue rheumatism (seven patients), localised chronic back pain (six patients) and biomechanical lower limb pains due to flat feet (three patients). Another 39 patients were diagnosed as fibromyalgia when not considered by primary care; nine of these patients were referred on the early arthritis pathway and two patients to the axial spondyloarthritis clinic. Overall this workload only constituted approximately 9% of new patients to the service, with patients with an end diagnosis of fibromyalgia making up approximately 7% of the overall new referrals. Conclusion The problems with diagnosing fibromyalgia in primary care are likely multifactorial - general practitioners (GP’s) are very busy and there is an increasing use of allied health professionals (AHP) in primary care, who do not always have the experience or training to diagnose fibromyalgia or other common musculoskeletal conditions. Some GP’s do not feel comfortable diagnosing fibromyalgia and some patients are just not happy with a primary care opinion. Overall, we do not feel that the diagnosis of fibromyalgia can be left solely in the hands of primary care; if the patients in this review had not been referred, then a significant number would have been incorrectly labelled as fibromyalgia, with all the problems that may bring. In view of this, the RCP guidelines would appear more appropriate than the BSR referral guidelines, but even then some of the patients in this review may still have ended up with an incorrect diagnosis, so overall Rheumatology departments should be very cautious about declining referrals for possible fibromyalgia and we continue to see these referrals in our department. Disclosure M.P. Sykes: None.

P188 Frailty and its impact on patient-reported outcomes in polymyalgia rheumatica

Abstract Background/Aims Frailty is an increasingly important construct in the field of rheumatology, aiding the identification of individuals with increased vulnerability to accelerated clinical decline, and overall worse disease outcomes. The aim of this research was to explore the prevalence of frailty and its potential associated impact on patient reported outcomes (PROs) in a cohort of patients with polymyalgia rheumatica (PMR). Methods Patients with a diagnosis of PMR (fulfilling the 2012 EULAR/ACR Provisional Classification Criteria), who were in clinical remission and on active treatment with glucocorticoids were recruited from two centres. Patients were >3 months and <12 months from diagnosis. Frailty was defined by the 5 criteria of the widely validated Fried Phenotypic Frailty Index. Patient-reported outcomes included anxiety, using the Generalised Anxiety Disorder Assessment (GAD-7), mood using the Patient Health Questionnaire (PHQ-9), fatigue using the Functional Assessment of Chronic Illness Therapy-Fatigue Scale (FACIT-F), pain using the visual analogue scale (VAS) and overall health related quality of life using the Health Assessment Questionnaire-Disability Index (HAQ-DI). The associations between categorical variables were compared using the -test or Fishers exact test. The association between continuous variables and categorical variables was assessed using the Kruskal-Wallis test. Correlations were calculated using Pearson’s r. All analyses were conducted using R (R Core Team, 2022). A p-value of < 0.05 was considered as statistically significant. Results 51 consecutive patients were recruited, of which 56.9% (n = 29) were female. Using the Fried Phenotypic Index, 64.7% (n = 33) were classified as robust, 27.5% (n = 14) as pre-frail and 7.8% (n = 4) as frail. All patients classified as frail were female and had a statistically significantly higher BMI (p = 0.040) than those in the robust and pre-frail categories. Compared to robust individuals, those who were frail had statistically significant higher median GAD-7 (p = 0.003), PHQ-9 (p = 0.001), VAS (p = <0.001) and HAQ-DI (p = <0.001) scores. FACIT-F scores were also worse in those who were frail versus robust (p = 0.001). Conclusion Over one third of patients with PMR in this cohort were classified as pre-frail or frail. Increased frailty status was significantly correlated with worse PROs, including mood, pain, fatigue and overall quality of life. As frailty is a potentially reversible state, accurately identifying frailty, and implementing appropriate interventions is of utmost importance to ensure improved clinical outcomes in those with PMR. Disclosure P. Harkins: Grants/research support; British Society for Rheumatology. S. Cowley: None. R. Harrington: None. D. Kane: None. R. Conway: None.

OA32 A national survey of rheumatology telephone adviceline support in the United Kingdom: frontline perspectives

Abstract Background/Aims Telephone advicelines (TALs) are a core feature of rheumatology services and highly valued by patients for providing clinical advice and support. The demand for TALs has increased since the pandemic, placing pressure on current capacity. This study aimed to assess how TALs are currently provided and the impact on rheumatology nurses who routinely deliver this service. Methods An online questionnaire was developed and piloted with input from patients and stakeholders and advertised through the Royal College of Nursing Rheumatology Forum and the British Society for Rheumatology. The survey included health professional demographics, how TALs operate, reasons for contacting TALs, documentation recorded and the impact on provider wellbeing using closed and free text questions. The survey was available from March to September 2023 and had university ethics approval. Results 123 people completed the survey. The majority were rheumatology nurses (n = 118), over 45yrs (n = 96,81%), band 7 or above (n = 88;74%) with over 10 years experience (n = 77,65%), with a first degree or higher (n = 106, 90%). 45 (38%) nurses had a prescribing qualification. The majority of TALs provided a voicemail response (n = 90, 76%),with a triaging system (n = 75, 64%) conducted by clinical support workers (n = 44, 37%) and nurses (n = 29,25%). The number of calls received over a month ranged from 100 to over 800 with 68 (58%) respondents reporting between 500-700 calls. TALs were provided over 5 days (n = 93,79%) for 8 hours (n = 61, 52%), by rheumatology nurses (n = 118), with calls returned within 1-2 days (n = 96,81%) by 1-2 nurses (n = 72,61%), although some calls took over 7 days to respond to (n = 19). The three main reasons for contacting TALs included increased disease activity, managing pain, and concerns relating to DMARDs. There was often no standard operating procedure (n = 72, 61%) or provision for people whose first language is not English (n = 99,84%). Data were collected on the nature of the call (n = 74, 63%) and the response given (n = 47, 40%). Providing TALs negatively impacted on provider wellbeing; 89 (75%) felt anxious ‘sometimes to mostly’ and 79 (67%) found it ‘mostly-always’ stressful. 85 (72%) had not received any training to conduct TALs and 79 (67%) reported that cover was often not available for leave or sickness. The qualitative findings also confirmed that expert providers found delivering TALs stressful and felt underprepared. One respondent commented that “The adviceline is the most stressful aspect of the role but has the least support.” Many felt the adviceline had developed without adequate planning, contributing to the service being under resourced and under recognised. Conclusion TALs support patients with concerns about their symptoms and treatments on a daily basis, yet the increased demand for delivering TALs is impacting on nurse wellbeing. Consequently, national guidelines are required on optimal service requirements including resource allocation, training and health professional support. Disclosure S. Ryan: None. S. Hider: None. A. Hassell: None.

P183 Cognitive function in polymyalgia rheumatica

Abstract Background/Aims Over the past decade our understanding of the prevalence, and indeed impact, of cognitive impairment in rheumatic diseases has increased. An aging population coupled with systemic inflammation have been postulated as key drivers of increased cognitive decline in these conditions. Intact cognitive function is imperative not only for quality of life and maintenance of one’s functional capacity, but also for the successful therapeutic management of disease, namely the adherence to treatment regimens. The prevalence of cognitive impairment in community dwelling adults above the age of 65 in Ireland has been estimated at 13%.1 To date, the prevalence of cognitive impairment in PMR has not been studied. The aim of this research is therefore to explore the prevalence and potential associated factors of cognitive impairment in those with PMR. Methods Patients with a diagnosis of PMR (fulfilling the 2012 EULAR/ACR Provisional Classification Criteria) who were in clinical remission and on active treatment with glucocorticoids were recruited from two centres. Patients were >3 months and <12 months from diagnosis. Cognitive function was evaluated using the Montreal Cognitive Assessment (MoCA) test which was conducted by trained interviewers. Cognitive impairment was defined by the previously validated MoCA cut-off score of < 26. Demographics, clinical and laboratory data, in addition to patient reported outcomes (PROs) were collected. PROs included anxiety using the Generalised Anxiety Disorder Assessment (GAD-7), mood using the Patient Health Questionnaire (PHQ-9), fatigue using the Functional Assessment of Chronic Illness Therapy-Fatigue Scale (FACIT-F), pain using the visual analogue scale (VAS) and overall health-related quality of life using the Health Assessment Questionnaire-Disability Index (HAQ-DI). The associations between categorical variables were compared using the -test or Fishers exact test. The association between continuous variables and categorical variables were assessed using the Kruskal-Wallis test. Correlations were calculated using Pearson’s r. All analyses were conducted using R (R Core Team, 2022). A p-value of < 0.05 was considered as statistically significant. Results 51 consecutive patients with PMR were recruited, of which 56.9% (n = 29) were female. 70.6% (n = 36) of patients were cognitively impaired, with visuo-spatial, delayed recall and abstraction the most commonly affected cognitive domains. Interestingly, those with cognitive impairment had a younger age, versus those without (p = 0.514). Although not statistically significant, median BMI, anxiety, depression and pain scores were all higher in those who were cognitively impaired. Moreover, median fatigue scores were also worse in the cognitively impaired group. No statistically significant difference in serum markers was observed. Conclusion This study demonstrates that the burden of cognitive impairment in PMR is significant, and is markedly higher than that observed usually at population level. Future studies exploring specific etiologic contributors are needed. Disclosure P. Harkins: Grants/research support; British Society for Rheumatology. S. Cowley: None. R. Harrington: None. D. Kane: None. R. Conway: None.

Treatment of polymyalgia rheumatica: British Society for Rheumatology guideline scope.

The last British Society for Rheumatology (BSR) guideline on PMR was published in 2009. The guideline needs to be updated to provide a summary of the current evidence for pharmacological and non-pharmacological management of adults with PMR. This guideline is aimed at healthcare professionals in the UK who directly care for people with PMR, including general practitioners, rheumatologists, nurses, physiotherapists, occupational therapists, pharmacists, psychologists and other health professionals. It will also be relevant to people living with PMR and organisations that support them in the public and third sector, including charities and informal patient support groups. This guideline will be developed using the methods and processes outlined in the BSR Guidelines Protocol. Here we provide a brief summary of the scope of the guideline update in development.

P032 Starting work as a rheumatology doctor: how to do it well

Abstract Background/Aims Starting work in a specialty for the first time can be extremely challenging. This has implications for patient care, junior and supervising doctor enjoyment and future career choices. A focus group was established to explore what resources junior doctors would want when starting Rheumatology. This determined that a blended learning package with podcasts, webinars and eLearning with topics including history and examination skills, understanding investigations and prescribing disease modifying drugs (DMARDs) would be ideal. Furthermore, it would be well placed to include resources to help junior doctors consider a career in Rheumatology. Methods The focus group results were used to design online ‘how to’ resources guiding doctors through tasks that they might be expected to do as a Rheumatology doctor. These were created by teams of junior doctors alongside Consultant Rheumatologists with creative support from the British Society for Rheumatology (BSR) education team. Content was pitched at an introductory level to help doctors when they first start working in Rheumatology. The most appropriate delivery modalities were selected for each topic e.g. a podcast for ‘how to talk to patients about DMARDs’ and eLearning including a video for ‘how to do disease activity scoring’. The resources are hosted on the BSR eLearning site and are free for anyone to use (no membership required) https://www.rheumatology.org.uk click eLearning. BSR communications and twitter were used to advertise the launch of the ‘how to’ series prior to junior doctor rotations in August. Results Since the ‘how to’ eLearning site was launched there have been 258 users. All content has been accessed. To date the most popular topics have been ‘how to’ - Interpret antibodies-Use DMARDs safely-Interpret x-rays-Score disease activity Feedback has been extremely positive with an overall satisfaction of 4/5. An example of written feedback from a user “ … it was a good overview, I would recommend to new IMT doctors starting in departments, or those considering Rheumatology as a career, I like how you have incorporated different modalities for learning e.g. mixture of lectures, podcasts, reading.” Conclusion The response to the resources created so far have been extremely positive. 258 users is a good start but increasing awareness of the resources should allow many more doctors to benefit from these resources. The authors plan to develop and improve content and welcome any feedback or suggestions for future topics. Disclosure R. Benson: None. E. Appleby: None. C. Gledhill-Flynn: None. K. Maxey: Other; Kate is a member of the Education team at the British Society for Rheumatology. D. Southam: Other; Daisy is employed by the British Society for Rheumatology as Head of Education. J. Little: None. P.A. Watson: Other; I am employed by the British Society for Rheumatology as eLernaing Editor.

P051 Development and evaluation of a text-analytics algorithm for automated application of the BSR COVID-19 shielding criteria in rheumatology patients

Abstract Background/Aims In April 2020 the British Society for Rheumatology (BSR) issued a risk stratification guide to identify patients at the highest risk of COVID-19 requiring shielding. This guidance was based on patients’ age, comorbidities, and immunosuppressive therapies - including biologics that are not captured in primary care records. This meant rheumatologists needed to manually review outpatient letters to score patients’ risk. The process required considerable clinician time, with shielding decisions not always transparently communicated. Our aim was to develop an automated shielding algorithm by text-mining outpatient letter diagnoses and medications, reducing the need for future manual review. Methods Rheumatology outpatient letters from Salford Royal Hospital, a large UK tertiary hospital, were retrieved between 2013-2020. The two most recent letters for each patient were extracted, created before 01.04.2020 when BSR guidance was published. Free-text diagnoses were processed using Intelligent Medical Objects® software1 (Concept Tagger), which utilised interface terminology for each condition mapped to a SNOMED-CT code. We developed the Medication Concept Recognition tool (MedCore Named Entity Recognition) to retrieve medications type, dose, duration and status (active/past) at the time of the letter. The medication status was established based on the heading where they appeared (e.g. past medications, current medications), but incorporated additional information such as medication stop dates. The age, diagnosis and medication variables were then combined to output the BSR shielding score. The algorithm’s performance was calculated using clinical review as the gold standard. Results To allow for the comparison with manual decisions, we focused on all 895 patients who were reviewed clinically. 64 patients (7.1%) had not consented for their data to be used for research as part of the national opt-out scheme. After removing duplicates, 803 patients were used to run the algorithm. 11,558 free-text diagnoses were extracted and mapped to SNOMED CT, with 15,003 free-text medications (that included past, present and any planned treatment). The automated shielding algorithm demonstrated a sensitivity of 80.3% (95% CI: 74.7, 85.2%) and specificity of 92.2% (95% CI: 89.7, 94.2%). Positive likelihood ratio was 10.3 (95% CI: 7.7, 13.7), negative likelihood ratio was 0.21 (95% CI: 0.16, 0.28), F1 score was 0.81. False positive rate was 7.9%, whilst false negative rate was 19.7%. Further evaluation of false positives/negatives revealed clinician interpretation of BSR guidance and misclassification of medications status were important contributing factors. Conclusion An automated algorithm for risk stratification has several advantages including reducing clinician time for manual review to allow more time for direct care, improving efficiency and transparently communicating decisions based on individual risk. With further development, it has the potential to be adapted for future public health initiatives that requires prompt automated review of hospital outpatient letters. Disclosure M. Jani: None. G. Alfattni: None. M. Belousov: None. Y. Zhang: None. M. Cheng: None. K. Webb: None. A. Kanter: None. W. Dixon: Consultancies; Google (unrelated to this work). G. Nenadic: None.

E048 A review of published data on reported staffing ratios for rheumatology specialist physiotherapists in rheumatology departments

Abstract Background/Aims The NHS England Getting It Right First Time (GIRFT) Rheumatology Report published in 2021 identified that Rheumatology departments in England were not getting best use of the multidisciplinary skills mix of their teams and that this expertise could be harnessed to address capacity challenges, optimise services and increase service resilience and sustainability. The British Society for Rheumatology (BSR) Workforce Report, published the same year, suggests that services require approximately one Rheumatology Consultant per 60,000-80,000 population and a one-to-one ratio of Rheumatology Specialist Nurses to Consultants. There were no suggestions in either report for Allied Health Professionals' staffing levels. Data presented in the BSR Report show that 50% of UK departments do not have a physiotherapist embedded in their multi-disciplinary team, and 7% of Trusts reported not having access to physiotherapy services. The aim of this project was to review published data on ratios of Rheumatology Specialist Physiotherapists per 100,000 population and to estimate current ratios of Rheumatology Specialist Physiotherapists per Consultant Rheumatologist in UK rheumatology services. Methods A literature review was undertaken, date range 2012-2022, on UK rheumatology staffing ratios for physiotherapists including full papers and abstracts. In addition, the BSR Workforce Report data on the average UK rheumatology department Whole Time Equivalent (WTE) staffing was used to calculate current average ratio of rheumatology physiotherapists to 100,000 population. Results Review of published literature identified one full paper and two conference abstracts. A cross-sectional study in 2017 found an average adjusted mean WTE of 0.3 per 100,000 population. The raw data from published conference abstracts on a repeated survey, in 2017 and 2021, of north-west England Rheumatology Specialist Physiotherapists was reviewed and calculated to show 0.34 and 0.32 WTE respectively for rheumatology physiotherapy per 100,000 population. Analysis of the BSR Workforce Report shows that the current UK average is 0.27 Rheumatology Specialist Physiotherapists per 100,000 population. These BSR data equate to 1 WTE Rheumatology Specialist Physiotherapist for every 5.25 WTE Rheumatology Consultants. Or for every full-time Rheumatologist, a requirement of approximately 1 day per week of rheumatology physiotherapy provision. The data from the three sets of survey data found on literature review, with an average of 0.32 WTE per 100,000 population, equate to 1 WTE rheumatology physiotherapist for every 4.5WTE rheumatology consultants. Conclusion Despite the established wide variation in staffing ratios with regard to multi-disciplinary teams in Rheumatology and a dearth of published information, the data that are available show a remarkable consistency in reported current Rheumatology Specialist Physiotherapist staffing ratios. These data are from surveys of current provision and do not replace evidence-based recommendations, which are still very much required as well as a standard for commissioning as part of an essential package in high-quality service provision. Disclosure W.J. Gregory: None.

P154 Real-world audit of patients with idiopathic inflammatory myositis-related interstitial lung disease in a European population

Abstract Background/Aims The British Society for Rheumatology (BSR) has released guidelines for managing idiopathic inflammatory myositis (IIM). Our centre operates specialist clinics for scleroderma and lupus, but to date, IIM patients are seen in a general CTD clinic. As part of work to establish a dedicated myositis clinic, we collated data on 71 patients under active follow-up with myositis spectrum disease deemed appropriate for follow-up within a specialist clinic. We aimed to review patients diagnosed with IIM-ILD and review serological immune profile, screening practices for pulmonary involvement, findings on CT/pulmonary function tests (PFTs) and pharmacological management. Methods We performed a detailed retrospective review of the notes of suitable patients, identified using diagnostic codes attached to clinic letters. Results 71 patients were identified: 14 with anti-synthetase syndrome (ARS), 21 with dermatomyositis (DM), 13 with polymyositis (PM), 3 with immune-mediated necrotising myopathy (IMNM) and 17 with overlap syndrome. 65% (46/70) of adult IIM patients were screened for pulmonary involvement. Screening practices of patients based on antibody profile and myositis subtype are further described in the table. 31% of patients (22/70) had IIM-ILD, of which 12 had ARS, 4 had PM, 1 had DM and 5 had overlap disease (2 PM/scleroderma, 1 DM/ARS, 1 DM/scleroderma and 1 scleroderma/ARS). 21/22 underwent PFTs; 53% of patients had active ILD over an average of 51.8 months. On imaging, 76.2% (16/22) had changes consistent with ILD. Ground glass change and reticulation were demonstrated in 50% of scans. In comparison, honeycombing and traction bronchiectasis was found in 22% and 44% of scans, respectively. A non-specific interstitial pneumonia (NSIP) pattern was described in 44% of scans, organising pneumonia (OP) pattern in 22%, and 17% had a mixed OP and NSIP pattern. 20/22 patients were prescribed high-dose steroids, csDMARD therapy or aggressive immunosuppression (cyclophosphamide or rituximab). Conclusion Our review demonstrates that 65% of patients with adult IIM were screened for ILD. NSIP and OP were the most common radiological appearances. Half of our cohort required aggressive immunosuppression, cyclophosphamide being the most commonly prescribed agent and mycophenolate being preferred for maintenance therapy. No patients were prescribed tacrolimus or ciclosporin. Despite treatment, 52% of patients had evidence of progressive disease on serial PFTs. Disclosure A. Loganathan: Grants/research support; Arthritis Australia. S. Sturney: None. N. Foley: None. T. Hartley: None. S. Tansley: None.

E050 Developing multidisciplinary models of care in rheumatology at University College London Hospital: 18 months of learning from conception to delivery and beyond

Abstract Background/Aims The COVID-19 pandemic has placed unprecedented pressures on NHS departments, with demand rapidly outstripping capacity. The British Society for Rheumatology ‘Rheumatology Workforce: a crisis in numbers (2021)’ highlighted the need to provide innovative ways of delivering rheumatology specialist care. At University College London Hospitals (UCLH) we created a rheumatology multidisciplinary team (MDT) clinic to meet rising demands on our service. The aims of the Rheumatology MDT clinic were to: reduce new appointment/follow-up waiting times, increase clinic capacity, incorporate musculoskeletal (MSK) point of care ultrasound, reduce number of hospital visits and add value to each clinic encounter. Methods We ran a 6-month pilot, supported by our outpatient transformation team, incorporating a Rheumatology Advanced Practice Physiotherapist (APP), Clinical Nurse Specialist (CNS) and MSK ultrasound within a Consultant clinic. The success of the pilot helped secure funding for a further 12 months. Over 18 months we have implemented: APP/Consultant enhanced triage - up to 40% of referrals were appropriate for APP assessment, including regional MSK problems and back pain. This increased capacity for consultant-led appointments. Standardisation of time-lapse between CNS and consultant follow-up appointments to ensure appropriate spacing between patient encounters. Facilitated overbooking of urgent cases afforded by additional capacity provided by the APP. MSK ultrasound embedded in the clinic template. ‘Zoom’ patient education webinars facilitated by MDT members and wider disciplines e.g. dietetics, to empower self-management and reduce the administrative burden of patient emails/phone calls occurring outside the clinic. Patient participation sessions and feedback to help shape the service. Results During the 6-month pilot we reduced our waiting time for follow-up appointments from 9 months to 2. We now have capacity to book 1-2 urgent cases each week. Pre-MDT the average wait from consultant referral to physiotherapist appointment was 55 days. The MDT allows for same day assessment (reducing 2-3 patient journeys a clinic) and where suitable, facilitates discharge or onwards referral to the appropriate service. A dedicated MDT CNS has shortened treatment times, reduced email traffic between CNS and consultant and allows for same day, joint decision-making resulting in fewer appointments. Zoom webinar feedback has been positive. Patients value the broad expertise of allied health professionals which supports self-management. Embedding ultrasound allows for same day diagnostics, decreased referrals to radiology and reduced hospital visits. Conclusion Our MDT model has reduced waiting lists, decreased treatment delays and cut hospital attendances. Point of care ultrasound allows for same day decision making and abolishes the cost and diagnostic delay associated with referrals to radiology or outsourced providers. Shared decision-making adds value to outpatient attendances, which is reflected in patients’ positive feedback. The MDT model maximises the existing workforce skill set by enhancing the APP and CNS role, allowing patients immediate access to their expertise. Disclosure F. Higgs: None. D. Ludwig: None. N. Allotey: None. S. Begum: None. J. Burton: None.

P108 Exploring the Treatment Burden of Disease Modifying Anti-Rheumatic Drug Monitoring in People with Rheumatoid Arthritis: A Qualitative Study with Recommendations for Practice

Abstract Background/Aims People with rheumatoid arthritis (RA) taking disease-modifying anti-rheumatic drugs (DMARDs) require safety monitoring to identify potential side-effects. This study explored patients’ and family members’ perspectives on DMARD monitoring, and how associated treatment burden could be minimised to optimise concordance and safety. Methods Adults with RA on DMARDs and family members were recruited from 2 rheumatology departments in the West Midlands to take part in semi-structured telephone interviews between July 2021 and January 2022. Public contributors with RA helped to develop the topic guide and interpret the results. Interviews were digitally recorded and data analysed using a framework method. Findings were discussed with a group of stakeholders to develop implications for practice. Results Thirteen people with RA (10 females, age range 40-79yrs, seven retired, disease duration 1 month-21 years) and 3 family members (male, retired, aged 70 to 79 years) participated in an interview. Three main themes were identified: 1) DMARD monitoring took precedence over the work involved. 2) Inflexibility with appointment times and travel requirements increased the work for patients and families. 3) Drug Monitoring was more than safety surveillance. DMARDs were considered a necessity to treat active disease and maintain wellbeing. Consequently, the work associated with DMARDs monitoring was often accepted in return for control of symptoms. Treatment burden was not always recognised, as early appointment times increased the work for patients with physical care needs and those with co-morbidities, who required extra time for preparation. Inflexibility in drug monitor locations impacted on the personal, practical and financial costs associated with travelling and parking, with family members having to take time off work. Monitoring encompassed more that drug safety addressing symptom management, functional ability and emotional wellbeing. Three core recommendations for addressing treatment burden to optimize concordance and safety were co-designed by the stakeholders (3 rheumatology nurses, 3 clinical academics, 2 rheumatologists, 1 GP and 1 person with RA) and the research team: 1) Conceptualising monitoring: changing the emphasis of care from ‘drug’ monitoring to ‘person’ monitoring to facilitate a holistic assessment of the person and their condition. 2) Identifying treatment burden: being clear who within the healthcare team is identifying treatment burden and when. Proactively, assessing treatment burden when a DMARD is commenced, rather than waiting for burden to exceed capacity, resulting in non-concordance. 3) Minimising treatment burden: by negotiating how treatment burden can be managed including offering flexible and responsive options, in terms of appointment times and monitoring locations. Conclusion The work involved for people with RA in drug monitoring is significant and often unrecognised. Our findings have led to clear recommendations to promote a more person-centred approach, increase recognition of, and minimise the treatment burden associated with DMARD monitoring. Disclosure S.J. Ryan: Royalties; book royalties oxford handbook clinical rehabilitation 5600006372. Grants/research support; General Nursing Council Trust. Other; unpaid committee role with the haywood foundation. L. Bullock: None. F. Manning: Grants/research support; NIHR Applied Research Collaboration South West Peninsula. Other; Honorary lectureship in bone health Keele University. Z. Paskins: Consultancies; non paid consultancy for UCB. Grants/research support; versus arthritis, royal osteoporosis society, general nursing council trust, charted society for physiotherapy, british society for rheumatology. Other; unpaid committee roles with royal osteoporosis society, versus arthritis and haywood foundation. C. Chew-Graham: Royalties; for a book primary care mental health 9781911623021. Grants/research support; NIHR and other funding bodies for research.

Management of antineutrophil cytoplasmic antibody-associated vasculitis: a review of recent guidelines.

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is an autoimmune rheumatic disease consisting of three discrete diagnoses of microscopic polyangiitis, granulomatosis with polyangiitis, and eosinophilic granulomatosis with polyangiitis. Among diseases treated in a rheumatology department, AAV has poor clinical outcomes, with high rates of mortality and progression to end-stage renal disease and frequent disease relapse. Due to the frequent negative patient outcomes, optimal therapeutic strategies are essential in the management of AAV. In the present review, four guidelines for management of AAV are summarized: British Society for Rheumatology (BSR) and British Health Professionals in Rheumatology (BHPR) guideline for the management of adults with AAV; European League Against Rheumatism (EULAR)/European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) recommendation for the management of AAV; 2021 American College of Rheumatology (ACR)/Vasculitis Foundation Guideline for the Management of AAV; Kidney Disease: Improving Global Outcome (KDIGO) 2021 Clinical Practice Guideline for the Management of Glomerular Diseases, which will aid in clinicians' medical decisions. Finally, the summary of the 2022 Update of the EULAR Recommendations on the Management of AAV, presented in the EULAR Congress 2022 is also introduced.

Specialist nurse training in ultrasonography for the diagnosis of giant cell arteritis.

Dear Editor, Ultrasonography is a diagnostic modality that has been tested to OMERACT standards for the diagnosis of GCA [1]. It is a bedside tool with ubiquitously available technology. It can lead to earlier diagnosis or exclusion of GCA, potentially improving outcomes and minimizing glucocorticoid toxicity. Ultrasonography is more cost effective than temporal artery biopsy (TAB) with fewer resources needed to run the ultrasound service [2]. These attributes led it to be the recommended first line investigation for the diagnosis of GCA [3]. However, it is restricted by the availability of trained sonographers. Our centre has a validated GCA fast track pathway [4]. But, it is reliant on the skills of one expert sonographer (C.B.M.), which is a clinical risk. To mitigate this risk a vasculitis specialist nurse (G.D.) has been trained in ultrasonography for the diagnosis of GCA. There is a precedent for a nurse-led temporal artery biopsy service [5]. Temporal arterial biopsy has many limitations including the sampling of a single artery. Ultrasonography has the benefit of examining arteries more extensively, looking for cranial and extra-cranial involvement as recommended by the British Society for Rheumatology [6].

P72 Research experience across the paediatric rheumatology multi-disciplinary team

P72 Research experience across the paediatric rheumatology multi-disciplinary team

P262 The occurrence and characteristics of severe pain in patients with axial spondyloarthritis

Abstract Background/Aims Pharmacological management of axial spondylarthritis (axSpA) seeks to control inflammation. Even if successful, available evidence suggests that many patients continue to experience pain. The aim of the current study was to determine the prevalence and characteristics of severe pain among persons with axSpA. Methods The Scotland Registry for Ankylosing Spondylitis (SIRAS) collected clinical and patient-reported data from adults seen in secondary care in Scotland with a clinical diagnosis of ankylosing spondylitis. Questionnaires asked about severe pain (high pain intensity; high pain interference; and extreme/unbearable pain), lifestyle, and various aspects of health. The relationship between severe pain and clinical/patient-reported factors was assessed using logistic regression. Results 929 participants had pain data available (73% male; median symptom duration 20yrs). High pain intensity and pain interference were more common (57% and 42%) than extreme/unbearable pain (11%). Prevalence did not differ with age, although women were less likely to report severe pain than men (Odds Ratios (ORs) 0.56-0.61) as were those with longer duration of education, and those from more affluent areas. The odds of severe pain increased with every 1 unit increase in BASFI (ORs 1.44-1.56). Strong associations were also seen with disease activity, spinal mobility, fatigue, poor sleep, and worse quality of life. Conclusion In axSpA, severe pain is common, with a clear socio-economic gradient and major impact on quality of life. Rheumatologists need to be aware of the large unmet need in terms of pain management in this patient group with around 1 in 9 patients reporting extreme/unbearable pain. Disclosure G.T. Jones: Grants/research support; Research grant income for biologics registers in axSpA and PsA from the British Society for Rheumatology. The Society receives income from AbbVie, Pfizer, UCB and Amgen to support these registers, current analysis funded by GlaxoSmithKline who were provided with a copy of the results prior to submission. O. Rotariu: None. L.E. Dean: None. A.G. MacDonald: None. G.J. Macfarlane: Grants/research support; Research grant income for biologics registers in axSpA and PsA from the British Society for Rheumatology. The Society receives income from AbbVie, Pfizer, UCB and Amgen to support these registers, current analysis was funded by GlaxoSmithKline who were provided with a copy of the manuscript prior to submission.

P243 Anti-rituximab antibodies demonstrate neutralising capacity, associate with lower circulating drug levels and early relapse in patients undergoing treatment for systemic lupus erythematosus

Abstract Background/Aims A major limitation of biologic therapy is formation of anti-drug antibodies (ADA). We previously demonstrated that ADA to rituximab are more prevalent in patients undergoing treatment for systemic lupus erythematosus (SLE) than rheumatoid arthritis and vasculitis, and predict subsequent infusion reactions. However, little is known regarding the long-term dynamics of ADA to rituximab. In this study we evaluated the longitudinal impact of ADA positivity in terms of drug kinetics, treatment response and neutralising capacity in SLE. Methods Patients with SLE undergoing treatment with rituximab were recruited to this study (n = 35). Serum samples were collected at the following intervals post-treatment; 1-3 months, 6 months, 12 months, 36 months (n = 114). Clinical and laboratory data was collected pre-treatment and at each time point. ADA were detected using an electrochemiluminescent immunoassay. Serum rituximab levels were measured via ELISA. A complement dependent cytotoxic assay was used to determine neutralising capability of ADA in a subgroup of positive samples (n = 38). Results ADA were found to be persistently positive over the 36-month follow-up period in 64.3% of patients. There was no significant difference in baseline disease activity (BILAG / SLEDAI-2K) between those who were subsequently ADA positive vs negative. ADA positive patients were younger at diagnosis compared with ADA negative (mean 22.50 ± 9.10 vs 37.29 ± 11.31 years, p = 0.002). Multivariate logistic regression found older age at diagnosis was associated with reduced incidence of persistent ADA with a 22% decrease in risk for each addition year after diagnosis (p = 0.03). ADA positive patients had a significantly lower C3 level at baseline (mean 0.61 ± 0.23 vs 0.87 ± 0.30, p = 0.026), which remained lower at each subsequent time point post-treatment up to 12 months. ADA titres peaked earlier and remained higher in those who had been treated with rituximab previously compared with those who were rituximab naive (median 132 AU/ml vs 7 AU/ml at 1-3 months). At 6 months post-treatment, patients with detectable ADA had a significantly lower circulating drug level than ADA negative (p = 0.0018). In terms of clinical response, ADA positive patients had an initial significant improvement in disease activity (SLEDAI-2K) by 3 months (p < 0.001). However, response was not maintained at 12 months. In comparison, ADA-negative patients showed a significant improvement in SLEDAI-2K at 6 months and this was maintained across the 36-month follow-up period. BILAG defined relapse within 12 months of treatment was only seen in ADA positive patients. Finally, all ADA positive samples were found to neutralise rituximab in vitro. Conclusion ADA to rituximab were common and persisted over the 36 month period of this study. ADA associated with earlier drug elimination, increased relapse rates and demonstrated neutralising capacity suggesting that ADA could be a significant limitation to sustained response to treatment. Disclosure C. Wincup: Grants/research support; Lupus UK, Versus Arthritis, British Society for Rheumatology. N. Dunn: None. C. Ruetsch-Chelli: None. A. Manouchehrinia: None. N. Kharlamova: None. M. Naja: None. B. Seitz-Polski: None. D. Isenberg: None. A. Fogdell-Hahn: None. C. Ciurtin: None. E. Jury: None.