Rheumatology Care Research Articles

Tele-Rheumatology during the COVID-19 pandemic

IntroductionDuring the Covid-19 pandemic strategies to prevent transmission of the viral infection obliged our hospital to promote virtual consultations. ObjetiveThe objective of this study is to describe the results obtained with the previous strategy of transferring activity to teleconsultation during the period of maximum impact of the pandemic. Material and methodsBetween 16/03 and 10/05/2020 all successive consultations in our unit were performed in virtual rheumatology teleconference (RTC) format. The socio-demographic, geo-functional and clinical characteristics of all patients were collected; a numeric verbal scale (NVS) (where 0 = very dissatisfied to 10 = fully satisfied) was applied to assess the degree of satisfaction of the doctor/patient with the RTC. Results469 TC were included. Most patients seen by RTC were women, mean age: 60,83 years. Only 16% had university education. The mean distance travelled for face-to face consultation is 33 Km with a mean total time of 2 h. Most individuals were diagnosed with osteoarthritis/soft tissue rheumatic diseases and/or osteoporosis; 21% had rheumatoid arthritis. The mean length of the TC was 9.64 min. We find more patient satisfaction with the TC when their level of education is higher (OR = 4.12); doctor satisfaction was higher when the individual was better able to manage the Internet (OR = 3.01). ConclusionIt is possible to transfer rheumatological care activity to TC with a considerable degree of satisfaction for both the patient and the doctor.

Facilitators of and barriers to implementing a traditional Chinese medicine collaborative model of care for axial spondyloarthritis: a qualitative study.

Conventional therapy may be inadequate for many patients with axial spondyloarthritis (axSpA). Traditional Chinese medicine (TCM) may be a viable alternative, but its effectiveness for axSpA is unknown. We are currently conducting a pragmatic randomised controlled trial (RCT) to investigate the effectiveness of a TCM collaborative model of care (TCMCMC), which combines usual rheumatologic care with acupuncture for patients with axSpA. This nested qualitative sub-study aims to identify facilitators of and barriers to the implementation of the TCMCMC. We conducted individual in-depth interviews with participants who had completed the acupuncture regimen to elicit opinions on the facilitators of and barriers to the implementation of the TCMCMC. The interviews were transcribed and analysed using thematic analysis. Twelve participants were included, with data saturation occurring after 10 interviews. The analysis revealed both a number of important 'facilitators' and 'barriers'. Facilitators to the implementation of the TCMCMC included effectiveness of TCM to relieve symptoms, inadequacy of conventional treatment and positive social perceptions of TCM. Barriers included scepticism towards TCM, inability of TCM to provide instant relief, needle-related discomfort, variable effectiveness of TCM influenced by physicians' skills and experience and the high cost of TCM. Recommendations to overcome barriers included further patient education about TCM. Policymakers should take into account the various feasibility factors identified in this study when developing and implementing a TCMCMC. NCT03420404 (ClinicalTrials.gov).

AB0674 RAPID ADOPTION OF TELEMEDICINE IN RHEUMATOLOGY TRAINING: RESULTS FROM THE COVID-19 GLOBAL RHEUMATOLOGY ALLIANCE TRAINEE SURVEY

Background:The COVID-19 pandemic led to a rapid increase in remote consultations in rheumatology care. Due to the potential impact of this change on rheumatology clinical training, we investigated trainees’ experiences with telemedicine.Objectives:To assess the impact of telemedicine use during the COVID-19 pandemic on rheumatology training, including supervision.Methods:A voluntary, anonymous web-based survey was administered in English, Spanish, or French from 19/08/2020 to 05/10/2020. Adult and paediatric rheumatology trainees worldwide in training in 2020 were invited to participate via social media and email. Using multiple choice questions, Likert scales, and free text answers, we collected data regarding prior and current telemedicine use, training, and supervision.Results:302 respondents from 33 countries completed the survey, with most (83%, 252/302) in adult rheumatology training. Reported use of telemedicine increased from 13% (39/302) pre-pandemic to 82% (247/302) (Table 1). European trainees predominantly utilised audio-only compared to trainees from the rest of the world (ROW) who predominantly utilised audio-video telemedicine.Most trainees continued to evaluate new patients using telemedicine (65%, 161/247). A larger proportion of trainees were comfortable using telemedicine to evaluate follow-up (69% 170/247) versus new patients (25%, 41/161) (Figure 1).Only 32% (97/302) were trained in telemedicine, with the highest proportion among United States (US) trainees (59%, 69/116); subjects included software, clinical skills, and billing. The majority of trainees found this helpful (92%, 89/97).Supervision was most frequently in the form of verbal discussion after the consultation (Table 1); 24% (59/247) had no telemedicine supervision during the pandemic. In general, trainees found telemedicine negatively impacted their supervision (51%, 123/242) and clinical teaching quality (70%, 171/244); only 9% reported a positive impact on these areas.Conclusion:Adoption of telemedicine during the COVID-19 pandemic has led to areas of concern for rheumatology trainees including inadequate supervision and clinical teaching. Our results suggest a need for education on evaluation of new patients using telemedicine, increasing telemedicine training, and ensuring adequate supervisory arrangements.Table 1.Telemedicine use, supervision, and training by region. Data is presented as n (%). Rest of the world (ROW) data includes Asia (50), Central and South America (23), Canada (12), Australia (8), and Africa (4).Europen = 89USn = 116ROWn = 97Combinedn = 302Telemedicine usePre-pandemic15 (17)9 (8)15 (15)39 (13)During pandemic64 (72)112 (97)71 (73)247 (82)Telemedicine modalitypre-pandemicAudio-only14 (93)3 (33)8 (53)25 (64)Audio-video1 (7)7 (78)7 (47)15 (38)Telemedicine modality during pandemicAudio-only56 (88)47 (42)51 (72)154 (62)Audio-video7 (11)100 (89)29 (41)136 (55)Supervisionpre-pandemicReal-time observation (part of visit)0 (0)4 (44)3 (20)7 (18)Real-time observation (full visit)0 (0)2 (22)2 (13)4 (10)Verbal discussion after8 (53)3 (33)7 (47)18 (46)Written communication after0 (0)0 (0)1 (7)1 (3)None7 (47)2 (22)5 (33)14 (36)Supervision during pandemicReal-time observation (part of visit)2 (3)54 (48)15 (21)71 (29)Real-time observation (full visit)3 (5)32 (29)8 (11)43 (17)Verbal discussion after32 (50)65 (58)28 (39)125 (51)Written communication after7 (11)15 (13)9 (13)31 (13)None28 (44)9 (8)22 (31)59 (24)Figure 1.Rheumatology trainee comfort levels in using telemedicine during the pandemic.Disclosure of Interests:Su-Ann Yeoh: None declared, Kristen Young: None declared, Michael Putman: None declared, Elizabeth Graef: None declared, Francis Berenbaum: None declared, Richard Conway: None declared, Rebecca Grainger Speakers bureau: Speaker fees from Abbvie, Janssen, Novartis, Pfizer, Cornerstones, all not related to this work, Consultant of: Consultancy fees from Abbvie, Janssen, Novartis, Pfizer, Cornerstones, all not related to this work, Grant/research support from: Travel assistance from Pfizer, not related to this work, Adam Kilian: None declared, Maximilian Konig: None declared, Jean Liew Grant/research support from: Research grant from Pfizer unrelated to this manuscript, Pedro M Machado Speakers bureau: Speaker fees from Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this manuscript, Consultant of: Consulting fees from Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this manuscript, Sebastian E. Sattui: None declared, Jeffrey Sparks Consultant of: Consultancy for Bristol-Myers Squibb, Gilead, Inova Diagnostics, Optum, and Pfizer unrelated to this manuscript, Grant/research support from: Research support from Bristol-Myers Squibb unrelated to this manuscript, Paul Sufka: None declared, Manuel Ugarte-Gil Grant/research support from: Research grants from Janssen and Pfizer unrelated to this manuscript, Laura Upton: None declared, Zachary Wallace: None declared, Jinoos Yazdany Consultant of: Consultancy for Astra Zeneca, Eli Lilly, and Pfizer, not related to this work, Grant/research support from: Research grants from Gilead and Pfizer, not related to this work, Arundathi Jayatilleke: None declared

POS1321 MENTAL HEALTH SCREENING IN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS

Background:Mental disorders often begin in the vulnerable phase of adolescence and young adulthood. Young people with chronic diseases are particularly at risk. Early recognition of mental health problems is necessary in order to be able to support those affected in a timely and adequate manner. By implementing a web-based generic screening tool for mental health in routine care, patients with juvenile idiopathic arthritis (JIA) and mental health conditions can be identified and provided with targeted treatment.Objectives:To investigate the prevalence of mental health conditions in young people with JIA in routine rheumatology care.Methods:Mental health screening is implemented as an add-on module to the National Paediatric Rheumatology Database (NPRD). The current data was gathered over a period of 24 months. Patients complete the screening tool which includes the Patient Health Questionnaire1 (PHQ-9, score 0-27) and the Generalized Anxiety Disorder scale2 (GAD-7, score 0-21) via a web-based questionnaire. The cut-off for critical values in PHQ-9 and GAD-7 were defined as values ≥ 10. Simultaneously, other data, such as sociodemographic data, disease activity (cJADAS10, score 0-30), functional status (CHAQ, score 0-3) were collected as well.Results:The analysis included 245 patients (75% female) with a mean age of 15.7 years and a mean disease duration of 8.8 years. 38.8% of the patients had oligoarthritis (18.0% OA, persistent/20.8% OA, extended) and 23.3% RF negative polyarthritis. At the time of documentation 49 patients (30.6%) had an inactive disease (cJADAS10 ≤ 1) and 120 (49.4%) no functional limitations (CHAQ = 0). In total, 53 patients (21.6%) had screening values in either GAD-7 or PHD-9 ≥10. Patients with critical mental health screening values showed higher disease activity and more frequent functional limitations than inconspicuous patients (cJADAS10 (mean ± SD): 9.3 ± 6 vs. 4.9 ± 4.9; CHAQ: 0.66 ± 0.6 vs. 0.21 ± 0.42). When compared to males, females were significantly more likely to report either depression or anxiety symptoms (11.7% vs. 24.9%, p = 0.031).17.6% of all patients with valid items for these data reported to receive psychological support, meaning psychotherapeutic support (14.5%) and/or drug therapy (8.6%). Among those with a critical mental health screening score, 38.7% received psychological support (psychotherapeutic support (35.5%) and/or drug therapy (16.1%)).Conclusion:Every fifth young person with JIA reported mental health problems, however, not even every second of them stated to receive psychological support. The results show that screening for mental health problems during routine adolescent rheumatology care is necessary to provide appropriate and targeted support services to young people with a high burden of illness.

AB0898-HPR WICH FACTORS ARE RELATED TO PAINFUL EXPERIENCE IN PATIENTS AFFECTED BY CHRONIC INFLAMMATORY RHEUMATIC DISEASE DURING THE COVID-19 PANDEMIC?

Objectives:To evaluate the effect of containment, during the Covid-19 pandemic, on the pain of patients with CIRD, and to analyze the factors associated with the experience of pain.Methods:A cross-sectional study was conducted among patients with rheumatic diseases using a questionnaire providing information on patients and disease characteristics. Impact of COVID-19 on This is a cross-sectional study that consecutively includedPatients were asked to assess the global pain which they had experienced before and during the containment period, using a single Visual Analogue Scale (VAS) ranging from 0 (no pain) to 10 (greatest pain).Statistical Analysis System IBM SPSS Statistics V20.0.0 was used to analyze the study data.We performed univariate then multivariate analysis to search any related factors to pain perception during to quarantines. Qualitative values were analyzed by the chi2 test. Quantitative values were analyzed by the Student test when the measures were normally distributed or by nonparametric test (Mann–Whitney U) when the measures were not normally distributed (Kolmogorov–Smirnov test was used to test normality).Results:Among the 350 patients who answered to the questionnaire online, rheumatoid arthritis represented 62.3%, spondyloarthropathy 34.3% and undifferentiated CIRD 3.4%.Pain experience caused by the CIRD during the containment was reported by 79.1% of patients.The level of pain, using the VAS of Pain increased significantly during the COVID-19 pandemic (4,6 ± 2,8 and 5,4 ± 3 before and during the containment; p<0.001).In multivariate analysis, the factors implicated in pain were the negative impact of Coronavirus on access to rheumatologic care, discontinuation of therapeutic adherence, the disturbed quality of sleep and the negative psychological impact (table 1).Table 1: Summarize multivariable analysis of factors associated with painful experience related to CIRD during containement.Table 1.Multivariable analysis of factors associated with painful experience related to CIRD during containementPImpact on monitoring0.05Impact on therapeutic adherence<0.001Quality of sleep disturbed0.001Negative psychological impact0.02Conclusion:This survey showed the that the COVID-19 pandemic have incresed painful experience in CIRD patients. Factors influencing painful experience should be taken into account to help patients to cope with their chronic rheumatism and this global health crisis.Disclosure of Interests:None declared

POS0261 DIAGNOSTIC PERFORMANCE AND CLINICAL UTILITY OF TWO REFERRAL RULES FOR INFLAMMATORY ARTHRITIS

Background:The Rotterdam Early Arthritis Cohort (REACH) rule [1] and Clinical Arthritis RulE (CARE) [2] are both evidence-based and easy-to-use methods developed to identify the presence of inflammatory arthritis (IA) in patients suspected by their general practitioner (GP). However, the clinical utility of both models in daily clinical practice in an independent primary care setting has not yet been established. While developed for recognizing IA, we believe that it is also important that the broader spectrum of inflammatory rheumatic diseases (IRDs) is correctly classified from primary care, to facilitate appropriate referral towards outpatient rheumatology clinics.Objectives:The primary objective was to determine the diagnostic performance and clinical utility of the REACH and CARE referral rules in identifying IA in an independent population of unselected suspected patients from primary care. Secondly we will assess the diagnostic performance and clinical utility of both models in identifying IRDs.Methods:This prospective observational diagnostic study consisted of adults newly suspected by their GP for the need of referral to the rheumatology outpatient clinic of the Maasstad Hospital in Rotterdam. Primary outcome was IA, consisting of rheumatoid arthritis, axial spondylitis and psoriatic arthritis. Secondary outcome was IRD, defined as IA plus arthritis in systemic disorders such as systemic lupus erythematosus, systemic sclerosis and morbus sjögren. Rheumatologist diagnosis was used as gold standard. To evaluate the clinical performance of the REACH and CARE referral rules in this population, diagnostic accuracy measures were investigated using the Youden index (J) [3]. Moreover, a net benefit approach [4] was used to determine clinical utility of both rules when compared to usual care.Results:This study consisted of 250 patients (22.8% male) with a mean age of 50.8 years (SD 13.9 years). In total 42 (17%) patients were diagnosed with IA and 55 (22%) with an IRD. Figure 1 presents the diagnostic performance in IA (Figure 1A) and in IRD (Figure 1B). For the primary outcome, the REACH model shows an AUC of 0.72 (95% CI 0.64-0.80) and the optimal cut-off point is indicated (J). The CARE model shows an AUC of 0.82 (95% CI 0.75-0.88) and at J there is a somewhat higher sensitivity and specificity. When taking the broader spectrum of IRDs as outcome, the AUC was 0.66 (95% CI 0.58-0.74) for the REACH and 0.76 (95% CI 0.69-0.83) for the CARE model. The net benefit analysis with either IA or IRD as outcome showed that the CARE was of the highest clinical value when compared to usual care.Conclusion:Both the REACH and CARE model showed a good diagnostic performance for detecting IA in an independent population of unselected suspected patients from primary care. Although not specifically developed to recognize the entire spectrum of IRDs, the CARE shows a good performance in doing so. When evaluating clinical utility, we see that both rules have a net benefit in recognizing IA as well as IRDs compared to usual care, however the CARE shows superiority over the REACH. By using the CARE, over half of all suspected patients can be withheld from expensive outpatient rheumatology care, implied by the high specificity of 70%. These results support the idea that incorporating these easy-to-use methods into primary care could lead to providing patients the right care at the right place and improving value based health care.

AB0899-HPR THE IMPACT OF CORONAVIRUS (COVID-19) PANDEMIC ON THERAPEUTIC MAINTENANCE IN PATIENTS WITH CHRONIC INFLAMMATORY RHEUMATIC DISEASES

Background:The Coronavirus pandemic caused many consequences on well being, access to care and therapeutic maintenance in patients with chronic diseases.Objectives:To assess the impact of COVID-19 on therapeutic maintenance of patients with Chronic Inflammatory Rheumatic Diseases (CIRD) and to identify related factors to difficulties in access to rheumatologist care during the COVID-19 pandemic.Methods:A cross-sectional study was conducted among patients with rheumatic diseases using a questionnaire providing information on patients and disease characteristics, impact of COVID-19 on access to rheumatologist care and therapeutic maintenance during the confinement. Reasons of therapeutic interruption and of diificulties in access to healthcare were precised.Results:We received answers from 350 patients (female sex of 68%, mean age of 46,1 ± 14,4 years) suffering from Chronic Inflammatory Rheumatic Diseases (CIRD):rheumatic arthritis (RA) (62.3%), spondyloarthropathies (34.3%), and undifferentiated CIRD (3.4%). The global average disease evolution was 12,1 ± 9,7 years.The patients were treated with conventional Disease-modifying anti-rheumatic drugs (cDMARDs) and biologic Disease-modifying anti-rheumatic drugs (bDMARDs) in respectively 67.4% and 30.6% of cases. Corticosteroids and Nonsteroidal Anti-Inflammatories (NSAIDs) intake was noted in 39.1 and 33.7% of patients.Difficulties to access to rheumatologist care appointments were reported in 82.9% of the participants. Reasons of thoses difficulties are summurized in Figure 1.Figure 1.Causes of difficulties of access to Rheumatologist care during COVID-19 pandemic.Half of patients declared that the pandemic had affected their therapeutic compliance. Discontinued drugs were in decreasing order: Synthetic antimalarials (68.4%), NSAIDs (45.8%), Methotrexate (43.8%), bDMARDs (25.2%), Sulfasalazine (18.2%) and Corticosteroids (10,2%).Causes of treatments interruption are summarized in Table I.Table 1.Causes of treatments interuption in patients with CIRDDrugsNot found in pharmaciesThe pharmacy refuses to give me the treatment without a recent prescriptionTo avoid the decrease in immunity and therefore to avoid catching Covid-19I stopped the follow-up, and so I stopped the treatment...Other reasonsNSAIDS027.874.144.427.8Corticosteroids014.392.957.150Methotrexate70.1310.416.422.4Sulfasalazine012.52575100Synthetic antimalarial69.20023.161.5Leflunomide00000bDMARDs07.440.744.451.9Conclusion:The COVID-19 pandemic impacted heavly on therapeutic maintenance in CIRD patients in our country. Patients expressed many difficulties in access to appropiate management. Facing to all thoses consequences, we need to devolopp as soon as possible adequate solutions adapted in such health crisis, especially therapeutic education and telemedecine.Disclosure of Interests:None declared

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

Background:Use of telemedicine in Germany has increased due to the COVID-19 lockdown. Between March and May 2020, government restrictions led to cancellation of routine outpatient appointments to limit viral spread and optimize resources.Objectives:This study assesses patient satisfaction of follow-up telemedicine appointments among patients known to be in disease remission, attending either secondary or tertiary care Rheumatology clinics. Appointments were conducted either by a rheumatologist or a qualified medical assistant for rheumatology (RFA). Additional data regarding perceived concerns arising from the COVID-19 pandemic as well as attitudes to vaccination were collected.Methods:Methods: Patients not requiring adjustment of their DMARDs at the two previous attendances were considered stable. At cancellation of the planned attendance, patients were offered participation in the study and provided verbal informed consent. Participants were randomized to a telemedicine appointment by either a physician or RFA. Telemedicine appointments consisted of a standardized patient interview, including assessment of disease activity (modified CDAI score), attitudes to vaccination as well as current vaccine status and concerns about COVID-19. Following participation, all patients received a pseudonymized postal questionnaire to evaluate appointment satisfaction (FAPI-Score).Results:In total 112/116 (96%) patients that were offered appointments, participated in the study (RA 50%, axSpA 30%, PsA 20%). Of these 88/112 (79%) returned their postal questionnaires. Overall patient satisfaction was excellent (mean 4.3/5 modified FAPI score) and did not differ between care setting or clinical status of the interviewer. RFAs conducted 19/112 (17%) of appointments, 6 (32%) of which required additional physician intervention. Change of DMARDs occurred in 19/112 (17%) appointments. Patients reporting a pain score ≥7 (VAS 1-10) were most dissatisfied with the telemedicine appointment (p=0.036). Concerns about COVID-19 correlated with disease activity: high disease activity (p = 0.031), presence of tender joints (p=0.001), high pain levels (p=0.009) correlated with concern of contracting COVID-19 or experiencing severe disease course. Only 38% of the patients had been vaccinated against pneumococci in the past 5 years and 54% had been vaccinated against influenza in 2019/2020.Conclusion:Telemedicine can contribute to patient care in stable patients. RFAs can also contribute to patient care especially for follow-up appointment when patients are in remission. Vaccination rates and motivation needs to be improved as influenza and pneumococcal vaccination is recommended to all patients with rheumatic diseases without contraindications.Disclosure of Interests:None declared

Quality in acute inpatient rheumatology 2021 : Current aspects of the KOBRA quality label of the Association of Rheumatological Acute Care Clinics

Mit einer umfassenden gesundheitspolitischen Qualitätsoffensive ab 2021 sollen die Qualität und Transparenz in der Versorgung von Menschen mit Krankheiten in Krankenhäusern in Deutschland verbessert werden. Gesetzliche Vorgaben zu Mindestmengen und die Ausweitung von Qualitätsverträgen zwischen Kostenträgern und Krankenhäusern sowie die Verwendung von planungsrelevanten Qualitätsindikatoren für eine bedarfs- und qualitätsorientierte Weiterentwicklung der stationären Versorgung werden den Wettbewerb in der Versorgungsqualität zwischen den Krankenhäusern verstärken. Dem Thema „Entwicklung und Definition von Qualität in der Medizin“ hat sich auch der Verband der Rheumatologischen Akutkliniken e. V. (VRA) schon früh nach der Gründung im Jahr 1998 umfassend angenommen. Im Zentrum der akutstationären Qualitätssicherung stehen verbindlich festgelegte Strukturkriterien in Verknüpfung mit dem 2003 in der Rheumatologie gestarteten und bis heute kontinuierlich durchgeführten KOBRA-Projekt (Kontinuierliches Outcome Benchmarking in der Rheumatologischen Akutversorgung) mit der Messung von Prozess- und Ergebnisqualität. Auf der Basis dieses Rahmenkonzeptes (Erfüllung der Strukturkriterien und Durchführung des KOBRA-Projektes) können erfolgreich teilnehmende rheumatologische Einrichtungen für jeweils 2 Jahre das KOBRA-Label erwerben, welches von der Projektleitung – dem aQua-Institut – vergeben wird. Die herausragende Stellung des KOBRA-Projektes wird beispielhaft anhand von Datenauswertungen des Projektzyklus 2018 gezeigt mit Auswertungen zum Therapiestrategiewechsel bei aktiver rheumatoider Arthritis, Diagnosesicherung von Kollagenosen und Vaskulitiden während des stationären Aufenthaltes sowie zur partizipativen Entscheidungsfindung bei rheumatoider Arthritis. Auf den gesundheitspolitisch geforderten „Paradigmenwechsel – weg vom Bett, hin zu einer leistungs-, bedarfs- und qualitätsorientierten Planung“ – ist die akutstationäre Rheumatologie mit der Verankerung von Projekten zur Struktur‑, Prozess- und Ergebnisqualität sehr gut vorbereitet. Für die in der vom Gemeinsamen Bundesausschuss (G-BA) erstellten Richtlinie zu „Rheumatologischen Zentren“ geforderten Qualitätssicherung ist das KOBRA-Projekt ebenfalls eine sehr gute Voraussetzung.

Supporting Equity in Rheumatoid Arthritis Outcomes in Canada: Population-specific Factors in Patient-centered Care.

Health equity considerations have not been incorporated into prior Canadian Rheumatology Association guidelines. Our objective was to identify the challenges and possible solutions to mitigate threats to health equity in rheumatoid arthritis (RA) care in Canada. A consultation process informed selection of priority populations, determined to be rural and remote, Indigenous, elderly with frailty, first-generation immigrant and refugee, low income and vulnerably housed, and diverse gender and sex populations. Semistructured interviews were completed with patients with lived experience, healthcare providers, and equity-oriented researchers. These interviews probed on population factors, initial and ongoing healthcare access issues, and therapeutic considerations influencing RA care. Known or proposed solutions to mitigate inequities during implementation of service models for the population group were requested. The research team used a phenomenological thematic analysis model and mapped the data into a logic model. Solutions applicable to several population groups were proposed. Thirty-five interviews were completed to identify realities for each population in accessing RA care. Five themes emerged as primary solutions to population-based inequities, including actively improving the patient-practitioner relationship, increasing accessibility and coordination of care through alternative models of care, upholding autonomy in treatment selection while actively addressing logistical barriers and individualized therapy needs, collaborating with health supports valued by the patient, and being advocates for policy change and health system restructuring to ensure appropriate resource redistribution. The challenges for populations facing inequities in rheumatology care and promising solutions should inform guideline development and implementation, policy change, and health system restructuring.

Designing a Strategy Trial for the Management of Gout: The Use of a Modified Delphi Panel.

ObjectiveDisagreement exists between rheumatology and primary care societies regarding gout management. This paper describes a formal process for gathering input from stakeholders in the planning of a trial to compare gout management strategies.MethodsWe recruited patients, nurses, physician assistants, primary care clinicians, and rheumatologists to participate in a modified Delphi panel (mDP) to provide input on design of a trial focused on optimal management for primary care patients with gout. The 16 panelists received a plain‐language briefing document that discussed the rationale for the trial, key clinical issues in gout, and aspects of trial design. The panelists also received information and considerations on nine voting questions (VQs), judged to be the key design questions. Cognitive interviews with panelists ensured that the VQs were understood by the range of panelists involved in the mDP. Panelists were asked to score all VQs from 1 (definitely no) to 9 (definitely yes). Two voting rounds were conducted—round 1 by email and round 2 by video conference.ResultsThe VQs were modified through the cognitive interviews. The round 1 voting resulted in consensus on eight items, with consensus defined as median voting score in the same tercile (1‐3, 4‐6 or 7‐9). Re‐voting at the meeting (round 2) reached consensus on the remaining item.ConclusionAn mDP with various stakeholders facilitated consensus on the design of a trial of different management strategies for chronic gout. This method may be useful for designing trials of clinical questions with substantial disagreement across stakeholders.

Predictors of Smoking Cessation in Patients With Rheumatoid Arthritis in Two Cohorts: Most Predictive Health Care Factors.

Recognizing smoking as a risk factor for rheumatoid arthritis (RA) severity, the present study was undertaken to evaluate patient- and health care-level predictors of smoking cessation in patients with RA to guide implementation of smoking cessation interventions. Electronic health record data from 2 health systems were abstracted for patients with at least 2 International Classification of Disease diagnosis codes for RA between 2005 and 2016. Patients missing smoking statuses or with <6 months of follow-up were excluded. Multivariable logistic regression was used to determine predictors of smoking cessation. Among 3,577 patients with RA, 507 smoked at baseline, and 29% quit over a median of 4.75 years. Black male patients, ages 40-59 years and enrolled in Medicaid, were significantly more likely to be baseline smokers; however, none of these factors predicted cessation. Instead, patients new to rheumatology care were 60% more likely to quit (adjusted odds ratio [ORadj ] 1.60 [95% confidence interval (95% CI) 1.02-2.50]), and patients in the rural community health system were 66% more likely to quit (ORadj 1.66 [95% CI 1.03-2.69]). Seropositive patients were 43% less likely to quit smoking (ORadj 0.57 [95% CI 0.35-0.91]). Health care factors, including health system and being new to rheumatology care, were more predictive of smoking cessation in patients with RA than patient sociodemographic factors, suggesting an important role for health system cessation efforts for patients with RA. Seropositive patients were less likely to quit and may particularly benefit from cessation support. Emphasizing smoking cessation with new or seropositive RA patients and leveraging health system interventions could improve smoking cessation and outcomes in RA.

A Population-Based Approach to Reporting System-Level Performance Measures for Rheumatoid Arthritis Care.

To operationalize and report on nationally endorsed rheumatoid arthritis (RA) performance measures (PMs) using health administrative data for British Columbia (BC), Canada. All patients with RA in BC ages ≥18 years were identified between January 1, 1997 and December 31, 2009 using health administrative data and followed until December 2014. PMs tested include: the percentage of incident patients with ≥1 rheumatologist visit within 365 days; the percentage of prevalent patients with ≥1 rheumatologist visit per year; the percentage of prevalent patients dispensed disease-modifying antirheumatic drug (DMARD) therapy; and time from RA diagnosis to DMARD therapy. Measures were reported on patients seen by rheumatologists, and in the total population. The cohort included 38,673 incident and 57,922 prevalent RA cases. The percentage of patients seen by a rheumatologist within 365 days increased over time (35% in 2000 to 65% in 2009), while the percentage of RA patients under the care of a rheumatologist seen yearly declined (79% in 2001 to 39% in 2014). The decline was due to decreasing visit rates with increasing follow-up time rather than calendar effect. The percentage of RA patients dispensed a DMARD was suboptimal over follow-up (37% in 2014) in the total population but higher (87%) in those under current rheumatologist care. The median time to DMARD in those seen by a rheumatologist improved from 49 days in 2000 to 23 days in 2009, with 34% receiving treatment within the 14-day benchmark. This study describes the operationalization and reporting of national PMs using administrative data and identifies gaps in care to further examine and address.

The impact of COVID-19 and healthcare system changes on the well-being of rheumatic patients.

ObjectivesThe COVID-19 pandemic has significantly impacted the healthcare systems. Many Polish outpatient clinics have been implementing telemedical consultations as a tool to ensure the continuity of care for patients with chronic diseases. The aim of the study was to evaluate patients’ satisfaction with telemedical appointments, as well as availability of the various medical services and patients’ well-being during the pandemic.Material and methodsAn online-based questionnaire on the experience with telemedical consultations, availability of medical services and current state of health was conducted among Polish rheumatology patients approximately 6 months after the outbreak of the COVID-19 pandemic.ResultsThe survey was completed by 107 respondents with a mean age of 41.52 ±14.33 years. The overall level of satisfaction from telemedical consultations, evaluated with a VAS 1–10 scale, was assessed as 6.23 ±3.04 for teleconsultations in primary healthcare units and 6.00 ±2.80 for rheumatology outpatient units. 42.99% of the respondents were in favour of maintaining telemedical appointments even after the pandemic. Incidences of reduced access to medical services during the COVID-19 pandemic were reported by 77.57% of the patients. Almost half of the respondents reported reduced accessibility to rheumatological care. An alarming decline in health self-esteem, evaluated with a VAS 1–10 scale, was noted from the average 6.37 ±1.92 before COVID-19 to the current rating of 5.78 ±1.91 (p = 0.0087).ConclusionsPolish rheumatology patients are moderately satisfied with the medical teleconsultations in primary health care units and rheumatology outpatient clinics. A substantial number of patients experienced deterioration of well-being as well as limited access to traditional healthcare services, including rheumatology care.

O22 Evaluating the impact of COVID-19 on patient access to rheumatology services, medication and future care: a nationwide study of more than 2,000 patients

Background/Aims COVID-19 has had significant impacts upon the delivery of rheumatology care in the UK. To date, there is little data specifically addressing how care has been disrupted and the impact upon patient attitudes and beliefs. Herein, we describe the results of a national study investigating how COVID-19 has; (1) reduced access to services; (2) altered treatment and drug monitoring; (3) impacted on clinic follow-up; (4) changed patient beliefs regarding ongoing/future care. Methods We conducted an online survey of patients attending rheumatology clinics in the UK. Questions were developed by clinicians with input from patient charities and four expert patients. The survey was hosted online between 8 September and 8 October 2020. Results In total, 2,054 patients completed the survey and the average number of rheumatic conditions each patient reported was 1.98±1.38 with the most common being; rheumatoid arthritis (48%), lupus (20%), Sjogren’s syndrome (19%), fibromyalgia (15%) and vasculitis (8%). More than half (57%) were told to shield, whilst 10% decided to shield of their own accord. Compared with before the pandemic, 57% felt it was difficult/very difficult to contact their rheumatologist. Regarding treatment, 15% reported difficulty obtaining their usual medication. Less than half (45%) of patients continued medication as previously and had no problem accessing it, although 21% said their usual drug monitoring had been discontinued. Overall, 3% stopped their treatment of their own accord. In all, 26% said their appointments in rheumatology clinics had been cancelled and they did not know when they would be seen again (4% reported no change in their outpatient follow-up). Prior to the pandemic, 13% of patients had received a telephone consultation, however, since the pandemic 60% had received one. Just 19% felt it was easy to be honest with their clinician via telephone. Only 33% were satisfied with the current level of care, 43% reported their rheumatology care was worse than pre-pandemic and 38% of patients felt they needed to see their rheumatologist but could not get an appointment. Over half (57%) of patients expressed worries about their future care. If offered an appointment in the next few months 66% said they would prefer it be face-to-face. Conclusion To our knowledge, this study is the largest survey of patient experiences of the COVID-19 pandemic under rheumatological care anywhere in the world. We found more than half of patients were told to shield and one-in-ten decided to shield without being directly told to do so. Less than half of patients maintained relatively good access to their usual medication without necessary monitoring in many cases. In particular, patients express high levels of concern about their future care. These high levels of disruption indicate the importance of maintaining routine rheumatology services during the ongoing pandemic. Disclosure C. Wincup: Grants/research support; CW has received research funding from Versus Arthritis, LUPUS UK and the British Society for Rheumatology. R. Amarnani: None. I. Giles: None.

P135 Delivering a rheumatoid arthritis remote monitoring service during the COVID-19 pandemic: the patient's perspective

Background/Aims Rheumatoid arthritis (RA) is a chronic inflammatory condition fluctuating between unpredictable episodes of joint pain, stiffness and disability and low disease state or remission. The traditional outpatient model can lead to patients in disease remission being seen more frequently than necessary and with missed opportunity to capture disease flares. A remote monitoring service (RMS) was co-designed with RA patients which uses SMS communication to deliver the Rheumatoid Arthritis Impact of Disease (RAID) tool on a monthly basis whilst offering patients 2-way text message contact outside of hospital-based care. Methods Access to hospital-based rheumatology care was dramatically restricted during the COVID-19 pandemic. 126 patients engaged with the remote monitoring service between January 2019 to September 2020 were sent a satisfaction survey in October 2020. The survey used a combination of 5-point Likert scales and open questions to rate confidence in statements focused on four aspects of the RMS during the COVID-19 pandemic: 1. managing data 2. managing flares 3. managing me 4. managing appointments. Results 48.4% (61/126) patients responded to the survey. Managing data: 93.4% of patients who responded to the question strongly agreed/agreed data was safe and used for the purpose of care. 91.8% strongly agreed/agreed RAID responses were reviewed by the RMS monthly. 90.1% strongly agreed/agreed the RMS would contact them to review care if needed. Managing flares: 85.9% strongly agreed/agreed they could text into the RMS if having a flare of their condition. 75.4% strongly agreed/agreed they received the care needed using the RMS. 61.41% patient strongly agreed/agreed using the RMS helped manage flares better than before using the service. Managing me: 74.0% strongly agreed/agreed the RMS had made access to care easier. 82.0% strongly agreed/agreed the RMS helped them to feel looked after outside of hospital care. 72.0% strongly agreed/agreed the RMS looked after emotional well-being as well as physical health. 80.0% strongly agreed/agreed the RMS helped them to feel cared for during the COVID-19 lockdown period. Managing appointments: 43.8% strongly agreed/agreed rheumatology appointments were not always when needed. 39.6% strongly agreed/agreed they would consider deferring an appointment if well as an appointment approached. 79.2% strongly agreed/agreed they would be offered an appointment when needed. 72.9% strongly agreed/agreed a telephone or video consultation is an acceptable alternative to attending a hospital appointment. Conclusion RA patients using a remote monitoring service during the COVID-19 pandemic rated it highly for supporting flare management and emotional well-being, providing remote care and ensuring data security. Regular, remote capture of asynchronous patient data has the potential to facilitate flexible and responsive appointment scheduling to support the self-management of patients with rheumatoid arthritis and in delivering care when it is needed the most. Disclosure M.J. Martin: None. T. Garrood: None.

The relationship of hand osteoarthritis symptom onset with menopause and menopausal hormonal therapy-results of a retrospective secondary care study

Purpose: Hand osteoarthritis (OA) is more common in women and previous studies have noted its incidence increases around the time of the menopause. More recently, there has been a report in a large primary care dataset of increased incidence of hand OA following cessation of menopausal hormonal therapy (MHT). We set out to describe the temporal relationship between menopause, use of MHT and the onset of hand symptoms in a population of women with hand OA in a secondary care (rheumatology) setting.

Development of an Implementation Strategy for Patient Decision Aids in Rheumatoid Arthritis Through Application of the Behavior Change Wheel

ObjectiveDecision aids are being developed to support guideline‐based rheumatology care in Canada. The study objective was to identify barriers to decision aid use in rheumatoid arthritis (RA) within a behavior change model to inform an implementation strategy.MethodsPerspectives from Canadian health care providers (HCPs) and patients living with RA were obtained on an early RA decision aid and on perceived facilitators and barriers to decision aid implementation. Data were collected through semistructured interviews, transcribed, and then analyzed by inductive thematic analysis. The lessons learned were then mapped to the behavior change wheel COM‐B system (C = capability, O = opportunity, and M = motivation interact to influence B = behavior) to inform key elements of a national implementation strategy.ResultsFifteen HCPs and fifteen patients participated. The analysis resulted in five lessons learned: 1) paternalistic decision‐making is a dominant practice in early RA, 2) patients need emotional support and access to educational tools to facilitate participation in shared decision‐making (SDM), 3) there are many logistical barriers to decision aid implementation in current care models, 4) flexibility is necessary for successful implementation, and 5) HCPs have limited interest in further training opportunities about decision aids. Implementation recommendations included the following: 1) making the decision aids directly available to patients (O) and providing SDM education (C/M), 2) creating an SDM rheumatology curriculum (C/O/M), 3) using “decision coaches” or patient partners as peer support (C/O/M), 4) linking decision aids to “living” rheumatology guidelines (M), and 5) designing trials of patient decision aid/SDM interventions to evaluate patient‐important outcomes (O/M).ConclusionA multifaceted strategy is suggested to improve uptake of decision aids.

COVID catalyst: telemedicine in rheumatology protects patient care beyond just the pandemic

During January 2021, rheumatologic care in Washington DC was affected by both the peak of the COVID-19 pandemic in the United States as well as a deadly insurrection and attack on the US Capitol. As rheumatologists practicing a few blocks from the White House, the authors discuss the crucial role that telemedicine served in delivering healthcare to patients with rheumatic diseases during and after the attack on the US Capitol as threats of violence, physical barriers, military vehicles, and armed troops challenged traditional means of caring for patients. The authors also discuss the role for telemedicine in safely providing future healthcare delivery.

The utility of a local multidisciplinary working group to oversee the establishment of rapidly evolving standards of care and to support trial recruitment during the COVID-19 pandemic

Coronavirus disease 2019 (COVID-19) was first identified in December 2019 in Wuhan, China. The first analyses of cases described high numbers of critically ill patients requiring intensive care admission with significant late inflammatory features. By the time the first cases of SARS-CoV-2 infection were diagnosed in the UK, a wide range of drugs were under consideration and it became clear that the input of clinicians covering all organ systems (in particular, infectious diseases, haematology, rheumatology, renal medicine and intensive care) and of expert specialist pharmacists was necessary at the local level. Thus, an expert multidisciplinary (MDT) group within our organisation was convened to offer a standardised approach and robust clinical governance for the treatment of COVID-19 patients admitted to our hospitals and rapidly develop standards of care as evidence evolved. This commentary explores the methods and mechanisms for creating an MDT COVID-19 treatment working group which are applicable to any hospital likely to admit and care for high numbers of COVID-19 patients and demonstrates how the structure and governance of the group allowed for rapid adoption of both dexamethasone and tocilizumab into standard of care as data became available.