NHS England Research Articles

The cost burden of hospitalisation for adrenal insufficiency patients in the NHS in england

The cost burden of hospitalisation for adrenal insufficiency patients in the NHS in england

Abstract PO2-17-11: Management guidelines for epithelial atypia diagnosed in breast screening, based on an analysis of a large prospective cohort study (Sloane Project)

Abstract Background: Epithelial atypia in the breast is most frequently detected through breast screening. Internationally, guidelines differ between advising diagnostic surgical excision of screen-detected atypia versus vacuum-assisted excision (VAE), often with annual follow up surveillance mammography. Prospective data with detailed follow-up and outcomes for subsequent cancer events is lacking. We evaluated a large prospective cohort of screen-detected atypia (Sloane Project) and an expert consensus meeting to develop management recommendations. Methods: We undertook an observational analysis of women with screen-detected epithelial atypia (Atypical Ductal Hyperplasia (ADH), Flat Epithelial Atypia (FEA), Lobular In Situ Neoplasia (LISN), or mixed atypia) reported to the National Health Service (NHS) Breast Screening Programme (BSP) between 01/04/03 and 20/06/18. We estimated cumulative incidence of invasive cancers per 1000 women within 1 and 2 subsequent screening rounds using cumulative incidence functions and repeated these by women’s age, type of atypia and year of diagnosis. Flexible parametric modelling produced hazard ratios (HR). The results were presented at a consensus meeting with clinical experts, patient representation, national decision-makers and commissioners from the NHS in England. A consensus on management recommendations was reached. Results: Among 3238 women (19088 person-years of follow up) with screen-detected atypia, diagnoses increased from 2010 (n=119) to 2015 (n=502). This coincided with the introduction of digital mammography into English screening centres from 2010 and changes in biopsy technique. A total of 141 invasive breast cancers were detected up to December 2018. Cumulative incidence of invasive breast cancer per 1000 women with atypia (ADH, FEA, LISN or mixed) was 14.2 (95% CI 10.3, 19.1) and 45.0 (36.3, 55.1) at 3- and 6-years post atypia based on 40 and 94 cancers, respectively. Women diagnosed with atypia during 2013-2018 had an invasive cancer detected less frequently within 3 years than women with an atypia diagnosis between 2003-2007 or 2008-2012 (6.0 invasive cancers (3.1, 10.9) per 1000 women in 2013-2018 Vs 24.3 (13.7, 40.1) and 24.6 (14.9, 38.3) in 2003-2007 and 2008-2012), suggesting that atypia diagnosis may increasingly contribute to ‘overdiagnosis’. Cancers detected were similar to the general screening population regarding grade, size and nodal involvement. Ipsilateral and contralateral cancers were detected in equal numbers, supporting the concept that atypia represents a risk factor rather than precursor of invasive cancer in the short term. Results by age and type of atypia did not suggest a need for risk-stratified management. Considering subsequent invasive cancer, VAE appeared to be as safe as diagnostic surgical excision of atypia (HR 0.75 (0.45, 1.25)). The expert consensus considered that increased screening of women with screen-detected atypia over and above routine 3-yearly screening was not beneficial, given the overall low numbers of cancers at three years. This applied to all types of atypia and all women who received digital mammography and diagnosis of atypia on core or vacuum-assisted biopsy followed by VAE within a quality assured NHS BSP. Conclusions: Breast atypia represents a risk factor for invasive cancer and does not necessitate surgical excision. Changes to mammography (digital vs plain film) and biopsy techniques (gauge of needle and use of vacuum-assistance) may lead to detection of atypia which is then ‘over-managed’. Current recommendations for annual mammography for 5 years after a diagnosis of epithelial atypia may be overly cautious. We suggest that women with screen detected atypia should be followed up with routine screening appointments. Citation Format: Karoline Freeman, David Jenkinson, Karen Clements, Matthew Wallis, Sarah E Pinder, Elena Provenzano, Hilary Stobart, Nigel Stallard, Olive Kearins, Nisha Sharma, Abeer Shaaban, Cliona Kirwan, Bridget Hilton, Alastair Thompson, Sian Taylor-Phillips. Management guidelines for epithelial atypia diagnosed in breast screening, based on an analysis of a large prospective cohort study (Sloane Project) [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-17-11.

TEMPORAL TRENDS AND REGIONAL VARIATION OF HIP ARTHROSCOPY AND PELVIC OSTEOTOMY IN ENGLAND FROM 2010 TO 2023

Hip arthroscopy (HA) and pelvic osteotomy (PO) are surgical procedures used to treat a variety of hip pathology affecting young adults, including femoroacetabular impingement and hip dysplasia respectively. This study aimed to investigate the trends and regional variation in the provision of HA and PO across England from 2010 to 2023 to inform healthcare resource allocation.We analysed the National Hospital Episode Statistics database for all HA and PO procedures in NHS England using specific OPCS-4 codes: HA: ‘W83+Z843’ or ‘W84+Z843’; PO: ‘X222+Z75’. We collected patient demographics, age, sex, and region of treatment. We performed descriptive and regression analyses to evaluate temporal trends in PO volume, age, sex and regional variation.22,401 HAs and 1,348 POs were recorded between 2010 and 2023. The annual number of HAs declined by 28.4%, whilst the number of POs increased by 64% (p<0.001). Significantly more females underwent PO vs HA (90% vs 61.3%) and were older than males undergoing the same procedure (PO: 29.0±8.7 vs 25.8±9.2 years; HA: 36.8±12.0 years vs 35.8±11.2 years, p<0.001). For HA, the mean age of both sexes decreased by 3.3 and 2.9 years respectively (p<0.001), whereas the age of PO patients did not change significantly over the study period. There were significant regional variations with a mean incidence of 1.60/100,00 for HA (ranging from 0.70–2.66 per 100,000) and 0.43/100,000 for PO (ranging from 0.08–2.07 per 100,000).We have observed a decline in HA volume in England, likely due to improved patient selection and the impact of COVID-19, whilst PO volume has significantly increased, with regional variation persisting for both procedures. These trends highlight the need for equitable HA and PO access to improve patient outcomes and call for strategic healthcare planning and resource allocation to reduce disparities and improve training opportunities.

THE MEDIUM-TERM RESULTS OF ARTHROSCOPIC HIP SURGERY COMPARED WITH PHYSIOTHERAPY AND ACTIVITY MODIFICATION FOR THE TREATMENT OF FEMOROACETABULAR IMPINGEMENT SYNDROME: A MULTICENTRE RANDOMIZED CONTROLLED TRIAL

The primary treatment goal for patients with femoroacetabular impingement syndrome, a common hip condition in athletes, is to improve pain and function. In selected patients, in the short term following intervention, arthroscopic hip surgery is superior to a pragmatic NHS- type physiotherapy programme. Here, we report the three-year follow-up results from the FemoroAcetabular Impingement Trial (FAIT), comparing arthroscopic hip surgery with physiotherapy in the management of patients with femoroacetabular impingement (FAI) syndrome.Two-group parallel, assessor-blinded, pragmatic randomised controlled study across seven NHS England sites. 222 participants aged 18 to 60 years with FAI syndrome confirmed clinically and radiologically were randomised (1:1) to receive arthroscopic hip surgery (n = 112) or physiotherapy and activity modification (n = 110). We previously reported on the hip outcome score at eight months. The primary outcome measure of this study was minimum Joint Space Width (mJSW) on Anteroposterior Radiograph at 38 months post randomisation. Secondary outcome measures included the Hip Outcome Score and Scoring Hip Osteoarthritis with MRI (SHOMRI) score.Minimum Joint Space Width data were available for 101 participants (45%) at 38 months post randomisation. Hip outcome score and MRI data were available for 77% and 62% of participants respectively. mJSW was higher in the arthroscopy group (mean (SD) 3.34mm (1.01)) compared to the physiotherapy group (2.99mm (1.33)) at 38 months, p=0.017, however this did not exceed the minimally clinically important difference of 0.48mm. SHOMRI score was significantly lower in the arthroscopy group (mean (SD) 9.22 (11.43)) compared to the physiotherapy group (22.76 (15.26)), p-value <0.001. Hip outcome score was higher in the arthroscopy group (mean (SD) 84.2 (17.4)) compared with the physiotherapy group (74.2 (21.9)), p-value < 0.001).Patients with FAI syndrome treated surgically may experience slowing of osteoarthritisprogression and superior pain and function compared with patients treated non- operatively.

SHORT-TERM COMPLICATIONS AND REOPERATION RATES AFTER PELVIC OSTEOTOMY: A REVIEW OF 1,348 CASES IN ENGLAND FROM 2010 TO 2023

Hip dysplasia is a common cause of hip pain in young adults. Pelvic osteotomy (PO) techniques are the gold standard for treating symptomatic patients, albeit technically demanding. This study aimed to (1) evaluate the 90-day complication rate, and (2) investigate the reasons, frequency and timing of reoperations following primary PO procedures.We retrospectively analysed the National Hospital Episode Statistics database, examining all patients aged over 14 who underwent PO in NHS England hospitals from 2010 to 2023. We identified index procedures and reoperations using relevant OPCS-4 codes. We analysed patient demographics, 90-day complications, and readmission rates for ipsilateral metalwork removal, revision PO, hip arthroscopy (HA), and THR conversion, and calculated the mean time to reoperations.This study included 1,348 PO cases (mean age: 28.7±9.1 years, 89.5% female). The mean hospital stay was 5.4±3.9 days, with a 90-day readmission rate of 0.52% at a mean of 51.0±17.2 days. The most common causes were infection (0.22%) and reoperation (0.15%). The 90-day rate of pulmonary embolism and deep vein thrombosis was 0.074%. One patient died within 90 days.Overall, 810 patients (60.1%) were readmitted for a subsequent hip procedure at a mean of 2.12±1.90 years following their primary PO. Metalwork removal was required in 616 patients (45.7%) at a mean of 1.70±1.19 years. Readmission rates for revision PO, HA, and THR, were 4.23% (mean time: 2.89±0.82 years), 4.15% (mean time: 2.91±2.28 years) and 6.01% (mean time: 5.24±3.08 years) respectively.This study highlights a low 90-day complication rate following primary PO, but a high reoperation rate, mainly for metalwork removal. We provide the most up-to-date report of revision PO, HA and THR conversion rates in England. These findings provide valuable insight that can facilitate informed decision-making, expectation-setting, and post-operative planning, also establishing a benchmark for future quality improvement.

An NHS Trust comparison of reporting radiographers and consultant radiologists ability to identify cancer on chest radiographs with confirmation through a Fast track CT thorax referral system

IntroductionThe National Institute for Health and Care Excellence (NICE) recommends that GPs initially refer patients with suspected lung cancer for a chest X-ray (CXR). The Radiology department has a ‘fast track system’ to identify those patients who may have lung cancer on CXR and are referred for a CT thorax with contrast to help determine a cancer diagnosis. This fast track system was put in place to ensure the NICE guidelines and NHS England's standards on a faster cancer diagnosis are being met. This audit studied the ability of radiologists and reporting radiographers to identify lung cancer on CXRs and the accuracy of the fast-track system. Methods846 cases with lung alerts were analysed and 545 CXRs were audited. The CXRs were split into images reported by radiologists (168) and those reported by reporting radiographers (377). CT thorax results were collected through PACS and Cerner computer systems to identify if the ‘fast track’ system had yielded a “positive”, “negative”, or “other findings” result for lung cancer. Results32.8% (179) of CXRs flagged for lung cancer were positive, 40.6% (221) were negative, and 26.6% (145) had other findings. Chi square statistical test showed no significant difference (p = 0.14) between the two reporting groups in their ability to identify lung cancer on CXRs. 27% (38) of CXRs flagged by radiologists and 35% (125) by reporting radiographers were positive for lung cancer. ConclusionThis clinical audit indicates, reporting radiographers and radiologists are not statistically significantly different regarding their ability to identify lung cancer on CXRs, when supported by the fast track system. The fast-track system had a 59.4 % accuracy rate, detected by the number of imaging of reports that identified a serious pathology. This concludes that the system is performing well, yet could still be improved. Implications for practiceThis audit provides further evidence for the value of developing and deploying reporting radiographers for projection radiography reporting.

Diversity amongst Decision Makers?: Workplace Inequality, Black Underrepresentation, and the Afterlife of Colonialism in NHS Governance

Whereas senior management within NHS England was once so monocultural that it was dubbed the ‘snowy white peaks of the NHS’, recent data suggests that things have begun to change. However, Black staff in particular are still underrepresented. Interviews with Black and White NHS managers from four London trusts found that though the acronyms ‘BME’/‘BAME’ lack subtlety, management considered quantitative data important. The #BlackLivesMatter movement impacted NHS staff as a potential catalyst for change, though momentum fizzled out. Barriers to diversity and promotion have been seen to include microaggressions and negative stereotyping of Black staff. This article interrogates such underrepresentation, and uses the concept of ‘the afterlife of colonialism’ to suggest that NHS management hierarchies follow colonially-introduced hierarchies of ethnicity and discrimination, creating structural issues that are difficult to address. Taking a feminist framework of analysis, I will argue that diversity race work, including that of #BlackLivesMatter, is anti-hierarchical at its core, suggesting that it is difficult to assimilate within the hierarchically minded world of management. I will conclude that for ethnic diversity amongst staff to be realised, all staff must be committed to supporting this agenda, regardless of their race.

Exploring the role of the pharmacist within the Hospital@Home team at a tertiary centre in England

Abstract Introduction Hospital@Home (H@H) is an emerging healthcare model providing hospital-level care within patients’ homes (1). Despite its global presence for three decades, H@H adoption remains limited in the United Kingdom. The COVID-19 pandemic prompted National Health Service (NHS) England to promote virtual wards, including H@H, as an innovative care alternative (2). Among the pivotal functions in H@H are prescribing, administering, or stopping medications, where pharmacists play a critical role, undertaking these tasks along with the multidisciplinary team (MDT). However, there has been little research that investigates pharmacists’ scope of practice in H@H. Aim To explore the role of the pharmacist within the H@H team at a tertiary centre in England. Methods A qualitive study was conducted using 1) online (via Microsoft Teams) or in-person audio-recorded semi-structured interviews with pharmacists working in the tertiary centre’s H@H team, and 2) non-participant observations of purposively sampled MDT H@H team meetings; heart failure, general care and antibiotic. Pharmacists’ collaboration with MDT members, tasks they performed and how the MDT made decisions were the focus of the observations. Interview transcripts and observation field notes were concurrently analysed inductively to generate key themes. All three H@H pharmacists were approached to take part in the study. All members of the respective MDTs were recruited to take part in the observations. All participants gave informed consent. Results All three H@H pharmacists participated in interviews. Six MDT meetings were observed, attended by doctors (n=7), nurses (n=8) and pharmacists (n=3). Interviews lasted approximately 45 minutes each and MDT meetings lasted 30-120 minutes. Four main themes were generated from the analysis: 1. Scope of practice extends beyond a “traditional” pharmacist. 2. Being open-minded to a changing scope of practice. 3. Active collaboration with MDT members underpins and expands role. 4. Is intentional about, and advocates for the provision of patient-centered care. Pharmacists’ varied scope of practice (e.g. participating/co-leading MDT meetings and conducting home visits) placed them in pivotal roles in patient care coordination, treatment planning, and decision-making. Pharmacists were open-minded and proactive in expanding the scope of H@H care, and their role. They continuously acquired new skills as they encounter and provide diverse care scenarios. Their specialised knowledge and skillsets were viewed by the MDT as an asset. Pharmacists were reflective practitioners, saw patients as complex individuals with specific needs to care for and advocated for their needs. Conclusion To our knowledge, this is the first study exploring the role of the H@H pharmacist in England, adding to the knowledge base in this emerging service delivery; pharmacists undertake non-traditional clinical roles in the team, work collaboratively with others to expand the service and their own skillset, to advocate for the need of patients. Although only three pharmacists were interviewed, this was the entire available sample. The study did not include home visit observations, which could provide insights into pharmacists’ interactions with patients in their homes. Future research can focus on complementing the findings of this study with in-depth exploration of the pharmacist’s role in H@H settings.

Community pharmacy discharge medicines service activity as recorded in PharmOutcomes: a retrospective exploration and analysis.

Transition of care when a patient moves between healthcare locations is a risk factor for medication errors and medicines-related preventable harm. The aims of this retrospective service evaluation were to understand, by classifying and quantifying, the nature of interventions made by community pharmacy when receiving a discharge medicines service referral from a secondary care hospital, with a focus on two groups of high-risk medicines supplied at discharge-oral anticoagulants and weak opioids following hip or knee surgery. Records made on the PharmOutcomes™ platform by community pharmacists in response to referral for the NHS England discharge medicines service were analysed and summarized. This analysis was exploratory and interpretative in nature and used a convenience sample of patients who had consented for the service over 12 months from May 2022 to April 2023. During 12 months, 6811 referrals occurred, of which 71% were recorded as having different stages of the service completed on PharmOutcomes™. Medicines reconciliation, first-prescription review, and consultation stages decreased as patients progressed through the service. Slightly greater rates of completion were observed for patients receiving oral anticoagulants and for codeine or dihydrocodeine following hip and knee surgery, although overall referrals were low for this latter cohort. Through this service, community pharmacists are well placed to support the safe and effective use of medicines including oral anticoagulants and weak opioids posthospital discharge and potentially reduce incidents of avoidable harm. The variations in recorded completion rates across the three stages of the service and the apparent greater finalization rates for the high-risk medicines studied require further investigation.

Sustainability in endourology: Greening the stone theatre and beyond

Objective: Climate change has been described as the ‘biggest global health threat of the 21st century’ and NHS England has set out its plans to develop a ‘net zero’ NHS by 2040. This is a target of completely negating the amount of greenhouse gases produced by healthcare in the United Kingdom, currently estimated at 4% of the UK total carbon emissions. We need to consider as a community of endourologists how we can make sustainable choices. Methods: Recommendations for sustainable surgery in the United Kingdom have been considered and applied to the field of Endourology. There is a relatively little published evidence on this evolving area. Results: Areas for making sustainable choices in Endourology can broadly be divided into ‘Prevention and Education’, ‘Pre-operative’, ‘Planning’, ‘Operative’ and ‘After Care’. While reducing waste in theatre is clearly important, there are many other decisions we can make with our patients to create a lower carbon journey. Conclusion: Sustainability in Endourology strongly parallels GIRFT recommendations and the concept of realistic medicine. We should all make personal and professional choices to reduce our carbon footprint with the shared goal of Net zero in 2040. Level of evidence: 4

Impact of the Proposed Closure of the NHS Practitioner Mental Health Programme for Doctors and Managers in Secondary Care

To reduce its financial deficit, NHS England decided to cull the funding of the Practitioner Health Programme (PHP), which has been providing confidential mental health services to 110,000 NHS doctors/ senior managers since 2011. This decision was announced when NHS doctors were in a dispute over pay and conditions, AND coincided with increasing prevalence of mental illness, stress and burnout. This decision raised concerns among doctors' unions, medical royal colleges, and doctors through social media. An open letter asked the Health Secretary to reconsider this decision. Access to primary care doctors was maintained. What appears not to have been considered is that around 50,000 junior doctors, including locally employed doctors and international medical graduates who are in short-term contracts or rotational attachments, are unlikely to meet the waiting time for such ‘secondary care OH services’. In addition, the elephant in the room of a massive challenge of the professional stigma that prevents doctors from accessing mental health support early seems to have been missed. This editorial briefly explores the causes of a high prevalence of stress and work-related mental illness amongst HCPs, the consequences on their overall health, employing organisations and their patients.

E016 An audit on patient initiated follow up in rheumatology in Manchester Royal Infirmary

Abstract Background/Aims PIFU is not a new concept in rheumatology. Instead of arranging regular routine appointments for patients with stable diseases, PIFU empowers patients to seek help when needed, enabling them to take control of their care and reduce pressure on rheumatology services. NHS England recommends PIFU for rheumatology patients with stable inflammatory arthritis. They should also have a good understanding of their disease management and be able to contact the service promptly. If patients on PIFU contact the service and require face-to face appointments, they should be seen within 2-4 weeks. Despite existing recommendations, there appears to be wide variation between clinicians and managers on the understanding of PIFU. The aim of this audit is to compare diagnoses of rheumatology patients for PIFU in a single rheumatology department, and the waiting time for review once patients placed on PIFU have made contact, to NHS England standards. Methods A list of rheumatology patients placed on PIFU between October 2022 and July 2023 at Manchester Royal Infirmary was obtained. Data were collected from electronic patient records. Results A total of 130 (1.5%) patients were listed on PIFU by 18 clinicians. The table outlines the demographics and detailed breakdown of diagnoses1. 1 (1%) was put on PIFU after patient declined biologic treatment for active inflammatory arthritis. 3 patients contacted the department whilst on PIFU, 2 of them required face-face review. Median time from start of PIFU to patient-initiated contact was 60 days (IQR 47.5-107.5). One with palindromic rheumatism was seen at 6 weeks and one with osteoarthritis had no appointment date yet 8 weeks after initial contact. Conclusion The audit confirmed that only 22 (17%) patients followed NHS England guidelines and 0% was seen as recommended once the patient contacted the department. Currently, 1.5% of patients in the rheumatology department are placed on PIFU, which is below 5% as per NHS England guidelines. This audit highlights the urgency to educate clinicians and managers on the cohort of patients listed on PIFU and to ensure all these patients are seen within the recommended time. Work is being done in the department to address these issues. Disclosure A. Cheung: None. G. Nowell: None. S. Ling: None. Y. Chiu: None. P. Ho: None.

Long-term assessment of the NHS hybrid closed-loop real-world study on glycaemic outcomes, time-in-range, and quality of life in children and young people with type 1 diabetes

Hybrid closed-loop (HCL) systems seamlessly interface continuous glucose monitoring (CGM) with insulin pumps, employing specialised algorithms and user-initiated automated insulin delivery. This study aimed to assess the efficacy of HCLs at 12 months post-initiation on glycated haemoglobin (HbA1c), time-in-range (TIR), hypoglycaemia frequency, and quality of life measures among children and young people (CYP) with type 1 diabetes mellitus (T1DM) and their caregivers in a real-world setting. Conducted between August 1, 2021, and December 10, 2022, the prospective recruitment took place in eight paediatric diabetes centres across England under the National Health Service England’s (NHSE) HCL pilot real-world study. A cohort of 251 CYP (58% males, mean age 12.3 years) with T1DM participated (89% white, 3% Asian, 4% black, 3% mixed ethnicity, and 1% other). The study utilised three HCL systems: (1) Tandem Control-IQ AP system, which uses the Tandem t:slim X2 insulin pump (Tandem Diabetes Care, San Diego, CA, USA) with the Dexcom G6® CGM (Dexcom, San Diego, CA, USA) sensor; (2) Medtronic MiniMed™ 780G with the Guardian 4 sensor (Medtronic, Northridge, CA, USA); and (3) the CamAPS FX (CamDiab, Cambridge, UK) with the Ypsomed insulin pump (Ypsomed Ltd, Escrick, UK) and Dexcom G6® CGM.All systems were fully funded by the NHS. Results demonstrated significant improvements in HbA1c (average reduction at 12 months 7 mmol/mol; P < 0.001), time-in-range (TIR) (average increase 13.4%; P < 0.001), hypoglycaemia frequency (50% reduction), hypoglycaemia fear, and quality of sleep (P < 0.001) among CYP over a 12-month period of HCL usage. Additionally, parents and carers experienced improvements in hypoglycaemia fear and quality of sleep after 6 and 12 months of use. In addition to the improvements in glycaemic management, these findings underscore the positive impact of HCL systems on both the well-being of CYP with T1DM and the individuals caring for them.

P046 The influence of deprivation in the outcomes of Psoriatic Arthritis within the UK - utilising Outcomes of Treatment in Psoriatic Arthritis Study Syndicate data

Abstract Background/Aims Psoriatic arthritis (PsA) is a chronic inflammatory arthropathy, which affects approximately 30% of patients with psoriasis and is associated with a high degree of morbidity. The introduction of biological disease-modifying antirheumatic drugs (bDMARDs) revolutionised treatment strategies for patients with PsA, however response is not universal. Deprivation and its associated risk factors may impact the initiation of and response to treatment with bDMARDs. There is limited data exploring the effect of deprivation on disease response to biologics in PsA. Psoriasis patients with a higher socioeconomic status have been shown to be more likely to respond to biologics, to our knowledge this has not been investigated in PsA. This study aimed to assess the impact of deprivation on initiation of and clinical response to biologic DMARDs. Methods Patients commencing a bDMARD were recruited to the UK prospective observational study Outcome of Treatment in Psoriatic Arthritis Studies Syndicate (OUTPASS REC ref:13/NW/0068). Index of Multiple Deprivation (IMD), the official measure of relative deprivation in England, was the exposure of interest. Subjects were ranked based on their IMD and split into the 20% most deprived (deciles 1-2), middle 40% (deciles 3-6) and 40% least deprived (deciles 7-10). This was done to aid analysis as IMD weightings provide greater differentiation among the least advantaged areas with fewer distinctions for less deprived areas. Treatment response was measured using changes in DAS28/PsARC, analysed using multivariate linear regression and multivariate logistic regression, respectively. Response was measured at three months as NICE guidance advises review of biological therapies at this time. Results There was no difference in the distribution of patients between the three groups (most deprived=138, middle deprived=207, least deprived=193). There were no statistically significant differences in the time from diagnosis to starting biologics in the most deprived group compared to the middle (p = 0.62) or least deprived p = 0.42) groups. There was no statistically significant difference in treatment responses between the groups. DAS28 change and PsARC improvement at three months remained similar between the most deprived, the middle deprived (p = 0.71, p = 0.08) and least deprived groups (p = 0.81, p = 0.22). Conclusion There was no difference in the distribution of IMD in patients recruited to OUTPASS, suggesting that the study is inclusive in recruiting across IMD subgroups. There was no difference in time from diagnosis to starting bDMARD therapy or response to treatment across the deprivation spectrum. These findings suggest that the NHS in England is performing its role of providing care according to need and regardless of circumstance. The study assesses deprivation in the context of free healthcare and may not be applicable to fee-paying healthcare systems. Further research is required to determine the relationship between deprivation and other outcomes, including work instability, in PsA. Disclosure M. Lyon: None. S. Zhao: None. A. Barton: Member of speakers’ bureau; speaker fees from Chugai-Roche and Galapagos. Grants/research support; grant funding from BMS, Pfizer, all unrelated to the work presented. H. Chinoy: Corporate appointments; Advisory Board member for Astra Zeneca, Pfizer, Argenx, Galapagos; Data and Science Monitoring Board chair for Horizon Therapeutics.. Consultancies; Consulting for PTC Therapeutics. Member of speakers’ bureau; fees as a speaker for GSK, UCB. M. Jani: None. J. Bluett: Grants/research support; research grant award from Pfizer and travel/conference fees from UCB, Fresenius Kabi, Pfizer and Eli Lilly.

P086 Trends in the Incidence and Management of Gout in England: A Nationwide Study using the OpenSAFELY Platform

Abstract Background/Aims Gout is the most common inflammatory arthritis worldwide, yet one of the worst managed. Few population-level studies have evaluated how the COVID-19 pandemic impacted on incidence, prevalence, management and hospitalisations for people with gout. We investigated this in England using the OpenSAFELY platform. Methods With the approval of NHS England, we conducted a population-level cohort study using primary care and hospital data via the OpenSAFELY platform for 17.9 million adults (40% of England’s population). We analysed the following outcomes between 1 March 2015 and 28 February 2023: 1) incidence and prevalence of recorded gout diagnoses; 2) incidence of hospitalisations with primary admission diagnoses of gout; 3) initiation of urate-lowering therapy (ULT); and 4) serum urate target attainment. Results From 17.9 million adults, there were 246,695 incident gout diagnoses between March 2015 and February 2023. The mean age of diagnosed patients was 61.3 years; 66,265 (26.9%) were female; and 189,035 (90.9%) of 208,050 with available ethnicity data were White. On a background trend of decreasing gout incidence since 2015, new gout diagnoses fell by 31.0% in the first year of the pandemic (from 1.78 to 1.23 diagnoses per 1,000 adults), relative to pre-pandemic. A partial recovery in gout incidence was seen in the years commencing March 2021 and March 2022, but this remained below pre-pandemic levels. Gout prevalence was 3.07% in 2015/16 and 3.21% in 2022/23. Gout hospitalisations decreased by 30.1% in the year commencing March 2020, relative to the preceding year (9.58 vs. 13.7 admissions per 100,000 adults). People presenting with gout during the pandemic did not have more severe disease than those presenting pre-pandemic, but did have proportionately fewer comorbidities. Of 228,095 people with incident gout and available follow-up, 66,560 (29.2%) were prescribed ULT within six months of diagnosis. Of 65,305 ULT initiators with available follow-up, 16,790 (25.7%) attained a urate ≤360 micromol/L within six months of ULT initiation. In interrupted time-series analyses, ULT prescribing improved modestly during the pandemic, relative to pre-pandemic, while urate target attainment was similar. Conclusion The incidence of recorded gout diagnoses in England decreased markedly during the pandemic. No rebound increase in incidence has been observed as of early 2023, suggesting many people remain undiagnosed as a consequence of the pandemic. For patients who were diagnosed during the pandemic, ULT initiation improved modestly relative to before the pandemic; however, absolute levels of ULT initiation and target attainment remain far below an acceptable standard. Importantly, we showed how country-wide, routinely-collected data can be used to map disease epidemiology and monitor care quality for rheumatological diseases. Disclosure M.D. Russell: Honoraria; AbbVie, Biogen, Eli Lilly, Galapagos, Menarini. Grants/research support; from Eli Lilly, Pfizer, Janssen and UCB. J. Massey: None. E. Roddy: None. B. MacKenna: None. S. Bacon: None. B. Goldacre: Grants/research support; Laura and John Arnold Foundation, NIHR, NHS England, Mohn-Westlake Foundation, Wellcome Trust, Good Thinking Foundation, HDRUK, Health Foundation, WHO, MRC, Asthma UK, BLF, National Core Studies. C.D. Andrews: None. G. Hickman: None. A. Mehrkar: Other; former employee and interim Chief Medical Officer of NHS Digital, RCGP representative on GP Data Professional Advisory Group to NHS Digital. A. Mahto: Honoraria; AbbVie, Galapagos. Grants/research support; Educational support from Eli Lilly. A.I. Rutherford: Grants/research support; Educational support from Eli Lilly. S. Patel: None. M.A. Adas: None. E. Alveyn: None. D. Nagra: None. K. Bechman: Grants/research support; Educational support from UCB, and Grants from Versus Arthritis/Pfizer. J.M. Ledingham: Other; BSR President, secretary for The Federation of Joint Royal Colleges of Physicians Specialist Certificate Exam Board, and a trustee of BSR. J. Hudson: None. S. Norton: None. A. Cope: Honoraria; BMS, AbbVie, GSK/Galvini. Grants/research support; BMS. J. Galloway: Honoraria; Abbvie, Biovitrum, BMS, Celgene, Chugai, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Sanofi, Sobi, and UCB.

E011 Magnetic resonance imaging in axial spondyloarthritis: usage, reporting times and scanning times - a service evaluation in a large tertiary centre

Abstract Background/Aims Rapid access to magnetic resonance imaging (MRI) of the spine and sacroiliac joints is essential for the timely diagnosis of axial spondyloarthritis (axSpA). A recent NASS/BRITSpA national FOI survey highlighted deteriorating waiting times to access MRI for the assessment of inflammatory back pain in the UK, with only 73% of Trusts reporting access within 8 weeks, compared to 90% in 2017. In addition, NHS England and the Royal College of Radiologists have recently published a target of 28 days for turn-around time (TAT) for a verified report to be provided after image acquisition in any circumstance. Aims: To evaluate the usage of MRI performed under the “inflammatory back pain protocol” at a large tertiary centre, including the time from MRI request to scan being performed, TAT for reporting and whether this has changed over time. Methods A service evaluation audit was conducted at Leeds Teaching Hospitals Trust (LTHT). MRIs of the spine and sacroiliac joints requested between December 2021 and May 2023 under the local “inflammatory back pain protocol” were identified by the radiology department. Data extracted from medical records included: indication for MRI request, time elapsed from request to scan, and from scan to verified report. Results A total of 668 MRI requests were identified. The commonest reason for MRI request was to aid the diagnosis of axSpA 75% (n = 501); followed by disease activity monitoring in established axSpA (16.7%, n = 111) and assessment of axial involvement in peripheral psoriatic arthritis, i.e. diagnosis of axPsA (8.5% n = 57 scans). The majority (92%) had a request to scan time of 8 weeks, with a TAT to report of 4 weeks (77%). However, a greater delay in TAT to verified report was seen from December 2022 to May 2023 with &amp;lt;45% of reports issued within 28 days, despite no change in scanning time. Causes identified were related to local workforce issues including delays in appointing new radiographers and radiology consultants. Conclusion The main reason for request of an MRI under the inflammatory back pain protocol at LTHT is to support making a diagnosis of axSpA. A significant number of patients were scanned for treatment monitoring and to diagnose axial psoriatic arthritis, although data on the utility of MRI for these indications are limited. Whilst nearly all patients were scanned within 2 months at all time periods, the TAT to report has significantly deteriorated since December 2022 in our region, due to workforce issues. Further understanding of the impact of workforce factors on service delivery in rheumatology is required. Disclosure J. Weddell: None. R. Shah: None. P. Robinson: None. A. Barr: None. C. Vandevelde: None. J. Freeston: None. D. McGonagle: None. H. Marzo-Ortega: None.

OA36 Systemic juvenile idiopathic arthritis: the Great Ormond Street Hospital experience (2005-2021)

Abstract Background/Aims sJIA is a complex, systemic-inflammatory disorder. The proposed biphasic model of disease suggests that unchecked early auto-inflammation driven by increased innate immune activation, including dysregulation of IL-1 and IL-6, may lead to a state of chronic T-lymphocyte activation. This leads to an unfavourable balance of T-effector and regulatory cells that can drive chronic arthritis over time. It is therefore unsurprising that there is growing evidence to support instigation of IL-1 or IL-6 blockade as first-line treatment in sJIA. Early cytokine antagonist therapy could abrogate development of a population of these arthritis-causing T-cells to avert chronic systemic inflammation and arthritis. Aims: 1) describe clinical presentations, therapeutic interventions, complications, and remission rates at different time-points over disease course in sJIA; 2) identify potential therapeutic signals in patients with sJIA who received biologic treatment early in disease course compared to those who did not. Methods Retrospective review of all patients with sJIA at GOSH (02/10/05-21/10/21, inclusive). Data collected: patient demographics; clinical and laboratory data; treatment history; adverse events. Time-points for data collection: at diagnosis; 3-months; 1-year; last follow-up. Descriptive statistics reported as median and range or IQR for continuous variables, and as absolute frequencies and percentages for categorical variables. Comparisons of quantitative variables were made by Mann-Whitney U-test. Categorical data were compared using Fisher’s exact test (p-values&amp;lt;0.05 were considered significant). Results A total of 76 children (female n = 40, 53%) were diagnosed with sJIA; median age was 4.5 years (range 0.6-14.1). A biologic disease modifying anti-rheumatic drug (bDMARD) alone was commenced as first-line treatment in 28% (n = 21/76) of the cohort; however, at last review, 84% (n = 64/76) had received treatment with a bDMARD. Clinically inactive disease (CID) was achieved by 88% (n = 67/76) of the cohort at last review; however, only 32% (24/76) achieved treatment-free CID. At 1-year follow-up, CID was achieved in a significantly greater proportion of children who received treatment with a bDMARD within 3-months of diagnosis compared to those who did not (90% versus 53%, p = 0.002). Conclusion We propose a UK treatment-algorithm for children diagnosed with sJIA (see figure). We recommend reappraisal of the current NHS England commissioning policy. Disclosure C. Foley: None. D. McKenna: None. K. Gallagher: None. K. McLellan: None. H. Alkhdher: None. S. Lacassagne: None. E. Moraitis: None. C. Papadopoulou: None. C. Pilkington: None. M. Al Obaidi: None. D. Eleftheriou: None. P. Brogan: None.

P007 Successful use of patient initiated follow-up in a tertiary paediatric rheumatology service

Abstract Background/Aims Patient initiated follow-up (PIFU) is a national strategy enabling patients or carers to initiate contact with a service rather than a traditional model of routine scheduled appointments. PIFU enables patient empowerment and elective recovery after the Covid-19 pandemic. NHSE identified Paediatrics as appropriate for PIFU, but specific measures are needed to ensure safeguarding of paediatric patients is maintained. Methods With NHSE &amp; I support and extrapolating guidance implementing PIFU in adult rheumatology services, we developed a clinical pathway that included safeguarding/governance structures within Paediatric Rheumatology at Alder Hey Children’s Hospital. Two strategies were developed - PIFU culminating with either a timed return (PEND) or discharge (DISCHARGE) model. A PIFU feasibility study in paediatric rheumatology initially targeted three index conditions (arthritis, mechanical pain and primary Raynaud’s) in March 2022. This was extended within a Plan-Do-Study-Act model of Quality Improvement. Results We placed 536 patients within PIFU pathways (PEND = 297, DISCHARGE = 239). The monthly usage of PIFU increased from &amp;lt;10 patients per month in March 2022 to &amp;gt; 40 patients per month in August 2023 with expansion of PIFU conditions. Within this time frame the number of patients put through the DISCHARGE model increased steadily to 60% of the monthly proportion as clinician confidence in PIFU increased. We demonstrate an 11% (total Rheumatology patients) PIFU rate over the study time frame, with a 2.7% (15/536) reactivation rate. Where calculable, timescale for review following activation was &amp;lt;48 hours. In our experience, patients/families are comfortable with PIFU and feel reassured by the safety-net provided. Decision for PIFU PEND/DISCHARGE is made in partnership with patients/families. As well as increased use within Rheumatology, PIFU use has extended to 80% of clinical teams across Alder Hey. The Trust-wide PIFU rate of 10% in September 2023 is double the original NHS England guidance target of 5%. Conclusion We advocate safety of PIFU in the correct population and its ability to empower patients. Table 1 shows the significant impact that correct use of PIFU can have on increasing capacity for seeing new patients, decreasing time to review and matching the number of patient reviews to referrals. Disclosure W. Calvert: None. J. Spinty: None. L.J. McCann: None. G. Cleary: None.

NHS England looks to cut back on doctors’ statutory and mandatory training

NHS England looks to cut back on doctors’ statutory and mandatory training

Mixed Methods EvAluation of the high-volume low-complexity Surgical hUb pRogrammE (MEASURE): a mixed methods study protocol

IntroductionThe waiting list for elective surgery in England recently reached over 7.8 million people and waiting time targets have been missed since 2010. The high-volume low complexity (HVLC) surgical hubs...