Rheumatology Service Research Articles

P013 A three-year audit of dose tapering biologic medications in a rheumatology service

Abstract Background/Aims Dose tapering of biologic therapies is supported by both ACR and EULAR guidelines. Identification of appropriate patients may deliver cost savings whilst minimising the risk of disease flare. To audit dose tapering activity for patients treated with bDMARD for rheumatoid (RA), psoriatic arthritis (PsA) and ankylosing spondylosis (AS) meeting locally agreed criteria over three years. Methods All patients treated with a bDMARD for RA, PsA or AS fulfilling criteria for dose tapering between 1st October 2019 - 1st October 2021 were identified from electronic health records (EHR). Rituximab patients were excluded due to reactive treatment responding to flare. Patients were required to have been on their bDMARD for = > one year, not prescribed oral steroids / treated with parenteral steroids in the past six months, no swollen joints in the past six months, and not failed dose tapering in the previous year. RA patients were ineligible if DAS ≥3.2 in the previous year; PsA if their biologic was prescribed by dermatology /active psoriasis; AS patients if BASDAI score of > 4 in past year. Records were flagged to prompt a shared decision-making discussion between the treating clinician and patient during routine appointments; additional patients were identified through clinical assessment. Failing dose tapering was defined as a post tapering flare requiring dose increase within one year. Patients were tapered by increasing the interval of a bDMARD. Results The number of patients that dose tapered increased from 24 in 2019 to 51 in 2021, making a total estimated NHS list saving of up to £170,000 per annum. (Table 1). Tapering was unsuccessful for 7/116 (6%) due to post tapering flares. Patients flaring after tapering were reassessed urgently and had their bDMARD dose reviewed. More patients were eligible than identified from EHR search due to missing data in coding; 787 (61%) across all years. Conclusion Dose tapering was well tolerated in eligible patients making this a safe and acceptable initiative. Use of EHR data and behavioural prompts for clinicians supported this in practice. Cost savings were reinvested to increase pharmacy support for homecare prescription management. Disclosure H. Light: None. J. Firth: None. J. Bluett: Grants/research support; JB has received a research grant from Pfizer. Other; JB has received travel/conference fees from UCB, Pfizer and Eli Lilly. K. Kinsey: None.

E049 The Initial Impacts of the UK-Wide Rheumatology Physiotherapy Capabilities Framework

Abstract Background/Aims The Rheumatology Physiotherapy Capabilities Framework, first published September 2021, was developed to describe the physiotherapy-specific skills and knowledge unique to the speciality and to act as a profession standard. Dissemination strategies for the framework included profiling through professional organisations, specialist interest groups and online via Twitter and ResearchGate. This project aims to describe the initial dissemination of the Framework and to provide an evaluation of the areas of impact within rheumatology networks. Methods An appraisal was undertaken in October 2022 on how widely the Rheumatology Physiotherapy Capabilities Framework has been used and embedded in UK clinical practice and service delivery. Evaluation strategies included data on downloads since publication and a brief online survey of a convenience sample of experienced, specialist rheumatology physiotherapists. The open-ended survey question asked for “implementation feedback on your use of the framework” and allowed undirected free-text comments. Responses were analysed using qualitative content and thematic analysis. Results The framework has been downloaded from the British Society for Rheumatology website 154 times and the launch news story on the BSR website has been viewed 4145 times; the Framework has been accessed 354 times from ResearchGate; analysis of impact on the Twitter shows 33 tweets, 238 likes and 95 “re-tweets”. Thematic analysis identified four key areas of use of the framework:(i) Increasing awareness of the physiotherapy role in a Rheumatology service(ii) Personal and team professional development(iii) Recruitment, job matching, re-banding and promotion(iv) Referral pathways and service improvement. Quotes from the survey responses are collated according to these identified themes in Table 1. Conclusion In its first year of publication, this brief survey indicates that the Rheumatology Physiotherapy Capabilities Framework has already started to accomplish many of the aims of its development. The ability for individuals and services to compare their capabilities to an agreed national standard is supporting staff and services in valuable ways. Service improvement projects have been an additional benefit of the framework. It has already become fairly well embedded in UK rheumatology practice; however, further dissemination, awareness-raising strategies and utilisation support are required to fully accomplish its aims. Disclosure W.J. Gregory: Honoraria; W.G. has received honoraria for speaker and advisory board from Abbvie, Novartis and Pfizer. H. Chambers: None. C. McCrum: Honoraria; C.McC. has received speaker honoraria from Novartis. Grants/research support; C.McC. has received a funding grant from Janssen.

E073 Attitudes to technology-supported rheumatoid arthritis care, questionnaire study: opportunities for technology to improve RA care

Abstract Background/Aims Rheumatoid arthritis (RA) outcomes have significantly improved with the treat-to-target paradigm, however this necessitates intensive monitoring. Demand outstrips capacity in rheumatology services, making Mobile Health (mHealth) an attractive prospect. However, software developers often design without understanding the needs of ultimate users, solving non-existent problems. EULAR’s ‘Points to Consider’ for remote care specifies that interventions “should be developed in collaboration with all stakeholders including the healthcare team … and people with RMDs” as an overarching principle. This study sought to understand existing challenges for end-users, and how technology might support these. Methods Questionnaires were devised collaboratively between Rheumatologists and Computer scientists, informed by discussions with an RA patient group. People >18 years old with a diagnosis of RA completed paper surveys (utilising likert scales, ranking preferences, and tick-box answers) whilst awaiting appointments at Mile End Hospital (Barts Health NHS Trust). Clinicians were recruited to complete an online survey via mailing lists from multiple centres across London & South-East England, from October 2019-March 2020. The study was registered (CMPS ID [43816]). Ethical approval was obtained through the Bloomsbury Research and Ethics Committee (19/LO/1345). This work forms part of a larger mixed-methods study funded by the PAMBAYESIAN project grant (EP/P009964/1). Results 109 people with RA returned paper questionnaires, 41 clinicians completed the online survey. Pain management, flares, and medications were identified as key challenges by both groups, however patients ranked lifestyle changes much higher than clinicians, who considered disease acceptance and understanding more significant. Considering opportunities; people with RA rated accessing their rheumatologist as the most useful potential feature (72.9%), followed by joint count body maps (59.8%), setting the agenda for appointments (52.3%), information about RA (45.8%) and support with drug monitoring (45.8%). Clinicians rated medication support most useful(96.8%), followed by information about RA (87.1%), agenda setting (87.1%) and flare management (83.9%). Conclusion People with RA and their clinicians identify flares, pain, and medication management as key challenges in the disease, although clinicians may underestimate the impact upon patients’ lifestyles. Medication support, information giving, and agenda setting for appointments. Disclosure A. MacBrayne: None. H. Soyel: None. W. Marsh: None. N. Fenton: None. C. Pitzalis: None. P. Curzon: None. F. Humby: None.

E010 Checkpoint inhibitor-induced rheumatological adverse events: real-world experience from Northeast England

Abstract Background/Aims Immune checkpoint inhibitors (CPIs), in the form of either single agent anti-PD1 or combination therapy with anti-PD1/anti-CTLA4 monoclonal antibodies, are widely used in clinical practice. Whilst CPI-induced rheumatological immune-related adverse events (RirAEs) are relatively infrequent compared to other toxicities (8-12%), increasing CPI use in oncology settings means a growing number of patients are affected. As part of an audit of inter-specialty referrals, we evaluated patients developing new musculoskeletal symptoms on CPI treatment and the breadth of specialist-confirmed RirAEs. Methods Two sources of data were reviewed. First, consecutive consultant-confirmed RirAE cases in our rheumatological service between 2017 and 2022 (referred to as the ‘RirAE cohort’) were evaluated. Second, an observational cohort of 50 consecutive oncology patients treated with CPIs from 2019-2022 in whom symptom questionnaires had been completed (“Oncology cohort”) was reviewed. Local audit registration/safeguarding approvals were obtained. Medical records were reviewed by two medical professionals, and anonymised data analysed in a spreadsheet. Results 24 patients were identified in the RirAE cohort, of whom most presented with arthritis (Table 1). Amongst 50 patients in the Oncology cohort, 20 (40%) reported new-onset/worsening musculoskeletal symptoms on a questionnaire (“MSK-symptomatic Oncology Cohort”). Three of these were referred, diagnosed and counted amongst the RirAE cohort. Of the remaining 17, 6 were identified as having developed musculoskeletal pain by consulting oncologists; the remaining 11 were not objectively identified as having experienced potential musculoskeletal toxicity (Table 1). Conclusion Confirmed RirAEs comprised predominately seronegative, oligoarticular presentations with notable PMR overlap. In the oncology setting, the self-reported joint symptoms of 20/50 (40%) patients were identified by a physician and 3/9 of these (33%) were referred for a specialist opinion. RirAEs may be more common than appreciated amongst CPI recipients, and the extent of low-grade inflammatory arthritis unreported or “hidden” amongst other irAEs is not clear. Early evaluation of new-onset musculoskeletal symptoms in CPI recipients, and close cross-specialty collaboration, could reduce morbidity for patients who already face significant health challenges. Disclosure A. Gault: None. K. Williams: None. C. Stewart: None. A.E. Anderson: None. R. Plummer: None. A.G. Pratt: None.

P113 Attitudes to Technology supported Rheumatoid Arthritis care Questionnaire study: Barriers to People with RA & their clinicians using Technology in the care pathway

Abstract Background/Aims Rheumatoid arthritis (RA) outcomes have significantly improved with the treat-to-target paradigm, however, this necessitates intensive monitoring. Demand outstrips capacity in rheumatology services, making Mobile Health (mHealth) an attractive prospect. However, software developers often design without understanding the needs of ultimate users, solving non-existent problems. EULAR’s ‘Points to Consider’ for remote care specifies that interventions “should be developed in collaboration with all stakeholders including the healthcare team … and people with RMDs” as an overarching principle. This study sought to understand the barriers to end-users utilising technology within RA care. Methods Questionnaires were devised collaboratively between Rheumatologists and Computer scientists, informed by discussions with an RA patient group. Patients >18 with a diagnosis of RA completed paper surveys (utilising likert scales, ranking preferences, and tick-box answers) whilst awaiting appointments at Mile End Hospital (Barts Health NHS Trust). Clinicians were recruited to complete an online survey via mailing lists from multiple centres across London & South-East England, from October 2019-March 2020. The study was registered (CMPS ID [43816]). Ethical approval was obtained through the Bloomsbury Research and Ethics Committee (19/LO/1345). This work forms part of a larger mixed-methods study funded by the PAMBAYESIAN project grant. Results 109 people with RA returned paper questionnaires, 41 clinicians completed the online survey. Most used technology daily (87.2% patients; 100% clinicians), but few used RA apps (75.3% patients never used). Whilst clinician use was higher (54.8%), only 2/31 (6.4%) recommended Rheumatology apps to patients. People with RA were willing to share & record monitoring data, with only 8.3% unwilling to share via technology, 53.8% preferring monthly submissions. Clinical data, e.g. pain scores & joint counts, was preferred to sharing personal data. Sharing with clinicians was preferred to self-monitoring. 83.9% clinicians responded positively to using technology, but cited NHS technical capabilities, cost, need for clinical trials, and concerns for data saturation as the most significant barriers. Conclusion In spite of reasonable tech-literacy, willing to use, and many existing apps, people with RA and their clinicians do not utilise technology in RA care. Clinicians identified data saturation and insufficient evidence as barriers, in addition to systemic healthcare system barriers. Disclosure A. MacBrayne: None. H. Soyel: None. W. Marsh: None. N. Fenton: None. C. Pitzalis: None. P. Curzon: None. F. Humby: None.

E058 The effects of a pain management programme for patients with an inflammatory arthritis

Abstract Background/Aims This study examines the benefits of Pain Management Programmes (PMPs) for patients with inflammatory arthritis who still report pain and fatigue despite optimal medical management. PMPs are widely recommended (e.g. NICE 2021) for people living with persistent pain, using cognitive behavioural therapy and acceptance and commitment therapy. Programmes aim to enable participants to develop self-management ways of living with their pain, so that pain interferes less in their lives and people feel more confident, and positive about the future. We developed a PMP for patients with an inflammatory rheumatological condition with the additional aim of helping participants to identify when they could self-manage their pain and when they needed healthcare to treat their condition and manage acute pain crises. Methods Patients were offered the programme in an information session, followed by assessment with a psychologist and physiotherapist where treatments options were discussed, among them the PMP. Selection criteria were: any type of inflammatory rheumatological condition and persistent pain diagnosed at least 18 months earlier and relatively stable in terms of current treatment; over the age of 18; and able to speak English. The programme ran for eight weekly, 5-hour sessions, with reviews at one and 9 months afterwards. Groups of between 3-11 patients were run in person by a multidisciplinary team of specialists from both outpatient pain management and rheumatology services. Between April 2016 and September 2020, 45 patients (8 men, 37 women) attended 6 programmes and 33 completed outcome measures on pain, disability and distress on the first and last day and at reviews. Results Post-treatment results showed significant improvement in confidence in managing pain, less interference of pain with everyday life, less fear, greater acceptance and a more positive outlook. Mood, pain intensity and relief from the pain did not change. Improvements gained post-treatment were sustained at one month and nine-months. The effect size of the improvements was medium or large. Conclusion This study shows that attending a PMP can improve quality of life for people with inflammatory arthritis even without reducing pain intensity. Across the programme, patients grew in confidence to engage in life alongside their pain; with significant changes sustained at nine months. However, follow-up outcomes were not returned by two thirds of those who completed the programme, in part due to the pandemic, making it hard to generalise to the wider population of patients. Disclosure K. Corcoran: None. I. Hung: None. R. Stovell: None. J. Manson: None. S. Moore: None. A. Soni: None. A. Williams: None.

E074 Self-care for rheumatoid arthritis during the COVID-19 pandemic: transferability of Canadian and UK experiences

Abstract Background/Aims The COVID-19 pandemic posed unique challenges for people worldwide in self-caring for their rheumatoid arthritis (RA). COVID-19 also prompted global changes in public health (e.g., vaccination programs and mask wearing) and rheumatology services (e.g., integrating telehealth with in-person healthcare). To facilitate cross-country learning of how to support people with RA to self-care during and post-pandemic, better understanding of individuals’ experiences of self-care in the context of changes in public health and ‘integrated’ healthcare is needed. Our study aimed to explore transferability in experiences of public health measures and telehealth during COVID-19 among individuals with RA in Canada and the UK. Methods Between July and October 2022, online focus groups (90 mins) took place with participants living with RA in the UK. Participants were recruited via social media and professional networks (including Versus Arthritis). Each participant received a report ∼7days before each focus group, with a request to review in advance. The report contained preliminary findings identified through reflexive thematic analysis of interviews (30-70 mins) with thirty-nine participants with RA in British Columbia, Canada (26-86 years; 36 females) between December 2020 and 2021. Nine preliminary themes were identified across three topics: accessing telehealth and in-person healthcare; decision-making around COVID-19 vaccinations and public health measures; and renegotiating ‘the self’. The themes guided the focus groups, wherein UK participants shared their perspectives on each theme arising in the Canadian context. Audio-visual recordings were transcribed verbatim, and transcripts were de-identified. Ongoing directed content analysis of focus group data involves a collaborative approach with patient partners. Results Four focus groups involving thirteen participants (44-81 years;11 females) living across the UK were conducted. Participants had lived with RA for between 3-36 years. Canadian experiences typically resonated with UK participants, with some feeling a sense of unity and sadness that challenges were also experienced by others living with RA beyond their national context. Many UK participants supported preferences expressed by Canadian participants for a ‘hybrid’ healthcare approach to maximise benefits and minimise downsides of telehealth, and in-person consultations post-pandemic. Benefits (e.g., avoiding risk of COVID-19 transmission with telehealth) and disadvantages (e.g., lacking sensitivity/accuracy of in-person assessments) described by Canadian participants also resonated with UK-based participants. Many described how their decision-making on adopting public health measures to maintain their self-care was supported and/or undermined in their local context/community. Conclusion Our findings offer novel insights into the challenges and opportunities experienced by people with RA in their decision-making around public health measures and telehealth during a global pandemic. They also demonstrate some transferability of experiences between the UK and Canada. Insights may serve to inform decision-making for policy and programmes to support self-care (e.g., by integrating telehealth into routine rheumatology practice) across countries during and post-pandemic. Disclosure J. Gavin: None. J. Leese: None. S.O. Ramachandran: None. S. Therrien: None. C. Backman: None. J. Ma: None. E. Davidson: None. S. McQuitty: None. A.M. Hoens: None. C.L. Koehn: None. J. Adams: None. L. Li: None.

P089 A pilot study to consider implementing a validated tool to improve the objective assessment method of methotrexate intolerance for a paediatric rheumatology department

Abstract Background/Aims This report identifies if the adoption of the Methotrexate Intolerance Severity Score improves the documentation and objective evaluation of the experiences of patients with Juvenile Idiopathic Arthritis, currently treated with methotrexate within in a local paediatric rheumatology service. In doing so, it will evidence any treatment failure resulting in a change of therapy, including the advocated escalation to more expensive and invasive biological therapies. Methods Literature was retrieved from electronic databases and published guidelines. Stakeholders were identified and approached via a variety of methods. Using the claims, concerns and issues framework to document their findings, a pilot study implementing the validated methotrexate intolerance severity score was conducted. The parents of the first ten patients accessing the local paediatric rheumatology advice line within a twelve-week period, who wished to discuss their child’s methotrexate therapy, were interviewed by the clinical nurse specialist team according to the methotrexate intolerance severity score. Analysis of the ten telephone assessments included the patient pharmacological and haematological evidence already established for each child, previous documentation of any methotrexate intolerance, and previous awareness of potential side effects of this drug therapy Results Designed without key stakeholder input, the methotrexate intolerance severity score improved documentation but focused on the gastrointestinal symptoms of intolerance only. The results of this pilot project indicated that although nausea and vomiting remained the two most common problems identified by all three key stakeholder groups (the parents, the CNS team and the original MISS article), it failed to objectively record a number of other commonly experienced signs and symptoms attributed to methotrexate treatment, assessing intolerance using only four of the nine most commonly reported side effects. Crucially it also failed to consider the pharmacokinetic and toxicity profile of methotrexate, nor did it have capacity to document a range of other parent reported symptoms. Although published in 2011, it has yet to be adopted for regular use within the UK paediatric rheumatology services. Conclusion Further work is required; inclusion of the objective findings that contribute to and mimic methotrexate intolerance e.g., hepatotoxicity should be considered in addition to further research regarding the patient experience of methotrexate intolerance. Incorporating the experiences of the patients and families would contribute to the relevance of the methotrexate intolerance severity score to key stakeholders. Resulting in a more objective assessment tool, this would improve measurement of methotrexate intolerance, ultimately quantifying intolerance and access to biologic therapies and improve the clinical comprehension of the patient experience of this ‘gold standard’ disease modifying anti-rheumatic drug therapy. Disclosure C. Tranter: None.

P105 Mode of hospital rheumatology appointments in people with rheumatoid arthritis: the impact of the pandemic in England

Abstract Background/Aims During the COVID-19 pandemic rheumatology services were advised to limit face to face contact, with remote telemedicine used instead. Although suitable for some people, issues have been highlighted with telemedicine. The frequency and proportion of remote appointments during the pandemic has not been described, or the socio-demographic characteristics of those accessing remote or in-person rheumatology care. This study aims to describe rheumatology healthcare utilisation and mode of appointment (remote/in-person) in people with rheumatoid arthritis (RA), prior to, and during the pandemic in England. Methods A retrospective prevalent cohort study of people with RA, identified using a validated algorithm, as of 1st April 2019 using electronic health record data (OpenSAFELY). Outpatient rheumatology appointments between 1st April 2019 and 31st March 2022 were identified. For each year, the number of outpatient appointments, mode of appointment (remote/in-person) and patient socio-demographic characteristics were described. Results 130,884 people with RA were identified. Since the start of the pandemic, the proportion of people without any appointments in a 12-month period increased from 28.5% in 2019/20 to 33.3% in 2020/21 and has not recovered. Older people were most frequently not seen (51% of people >80 years in 2020/21 and 2021/22). Of appointments where mode was known, 54.4% of people with appointments in the year from April 2020 were only seen remotely, reducing to 35.1% in the year from April 2021 (Table 1). The proportion with all remote appointments increased with increasing age, comprising 62% of people >80 years in 2020. This age gradient persisted in 2021, though proportions of those >80 years with all-remote appointments was lower (44%). Compared to urban dwellers, a higher proportion of those living in rural areas had all remote appointments in 2020 (58% vs 53%) and 2021 (38% vs 34%). Conclusion During the pandemic, one third of people with RA were not seen at all over a 12-month period and these were more frequently older people. Over half of people were only seen remotely in 2020, decreasing to one-third in 2021. Given the limitations of remote appointments it is unknown whether this increased frequency of remote appointments will impact long-term outcomes. Disclosure R.E. Costello: Shareholder/stock ownership; AstraZeneca. R.J. Hollick: None. M. Parker: None. J. Kennedy: None. B. Mackenna: None. S. Brophy: None. L. Tomlinson: None. J.H. Humphreys: None.

E064 A rare hereditary haemochromatosis type three (3) related arthritis

Abstract Background/Aims Arthritis is a common manifestation in hereditary haemochromatosis (HHC). Haemochromatosis arthropathy frequently involves small joint of hands especially the metacarpo-phalangeal joints (MCPJs) and hence is one of the differentials when assessing for rheumatoid arthritis, psoriatic arthritis along with osteoarthritis but requires a high index of suspicion. We report a case of Haemochromatosis arthropathy where the arthropathy was due to type 3 hereditary haemochromatosis (HHC) which is a much rarer form and requires specialist genetic testing. Methods A 38-year-old lady was referred with abnormal iron profile and ten-month history of small joint arthralgia mainly affecting the index and middle finger in right hand with occasional swelling. She had a normal body mass index with minimal alcohol intake. Clinical examination showed low grade synovitis in index finger metacarpo-phalangeal joint (MCPJ). Blood investigations for Rheumatoid arthritis and connective tissue diseases were negative with normal CRP & ESR, Ferritin was slightly raised at 236 and transferrin saturation was 100% on two successive occasions, LFTs were normal. Xray of hands showed slight narrowing of 2nd MCPJ and US hands showed thickened synovium but no erosions or Doppler activity in 2nd MCPJ. Results Based on these, possible hereditary haemochromatosis (HHC) arthropathy was considered. By that time, she had been seen by the hepatology service where no evidence of iron deposition in other organs was found. Surprisingly her genetic testing for hereditary haemochromatosis (HHC) (Cys282Y/H63D in HFE gene) was negative resulting in most common HFE-related HHC excluded. Iron studies were repeated which were still raised, hence after discussion with hepatologist and biochemist the plan was made to investigate for rarer form of hereditary haemochromatosis (HHC), genetic tests showed that she had TFR2 variant mutation which would be consistent with type 3 hereditary haemochromatosis (HHC), which is inherited in autosomal recessive pattern. Venesections were started with ferritin levels improving to less than 50 with plans to monitor arthralgia to see if there is any improvement over time. Conclusion Metacarpo-phalangeal joints (MCPJs) involvement is common in various arthropathies. This case highlights the importance of considering other, much rarer forms of hereditary haemochromatosis (HHC) as treatment will help in preventing iron deposition in other organs like liver, heart, pancreas etc. These conditions are very rare and there is need to create awareness of genetic testing as hereditary haemochromatosis (HHC) arthropathy does present not uncommonly to rheumatology services and requires dedicated non-HFE molecular panel. Disclosure H. Umair: None. M. Kazmi: 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.

P026 Chronic chilblain like lesions associated with the COVID-19 pandemic

Abstract Background/Aims We report the features of chronic chilblain-like digital lesions newly presenting since the start of the covid-19 pandemic. Comparison with primary perniosis and acrocyanosis, reveals a unique phenotype which appears to be a long-covid phenomenon. Methods The case records of 26 patients with new onset persistent chilblain-like lesions presenting to the Rheumatology service of St George’s University Hospital, London between Autumn 2020 and Spring 2022 were reviewed. Demographic and clinical features, serology, imaging, treatment response and outcome up to Summer 2022 were collated retrospectively. Results Chilblain-like lesions first occurred between September and March; 2019/2020 6 cases, 2020/2021 18 cases and 2021/2022 2 cases. Mean age 35.4 (17-60) years, 88% female, 85% white, all non-smokers. Median body mass index (BMI) 20.2, range 17.0 - 33.2. BMI underweight (<18.5) in 27%. All cases reported new red-purple-blue colour changes of the fingers, some with pain, swelling and pruritis, affecting both hands in 12, one hand in 6, and both hands and feet in 8 cases. There was a past history of cold sensitivity or primary Raynaud’s in 54%. Covid was confirmed in 3 cases, 2 - 8 months prior to onset of chilblain-like symptoms. Possible covid, unconfirmed, was suspected in 5 cases, 1 - 11 months earlier. Affected digits appeared diffusely erythro-cyanotic in 81%, with blotchy discrete maculo-papular erythematous lesions in 42%, some with both features. Involvement was asymmetric in 54%, thumbs spared in 69%. Complement was low in 50% (8/16), ANA positive in 26% (6/23). MRI of hands showed phalangeal bone marrow oedema in keeping with osteitis in 4 of 7 cases. More severe signs and symptoms were associated with low BMI, low C3/4 and a past history of cold sensitivity or Raynauds. Cold avoidance strategies were sufficient for 58%. Pain prompted a trial of NSAIDs, aspirin, nitrates, calcium channel blockers, hydroxychloroquine, oral or topical corticosteroid or topical tacrolimus in 42%. In general, these were minimally effective or not tolerated. 4 severe cases received sildenafil or tadalafil, effective in 2. In 27% complete remission occurred during the first summer season after symptoms commenced, median duration 6 (range 2 - 10) months. In the remaining 19 cases, chilblain-like symptoms returned or worsened in the subsequent second winter period, with 6 of 19 entering remission the following summer. For the remaining 13 persistent cases the total duration of symptoms spans more than a year, and in four cases more than 2 years. Conclusion This series illustrates a distinct chronic chilblain-like condition. Features similar to primary perniosis include female predominance, middle age, pruritic painful blotchy lesions, asymmetry and low BMI. Features in keeping with acrocyanosis include chronicity, extensive diffuse erythro-cyanotic discoloration, relative improvement in warm weather and lack of association with smoking. Disclosure J.A. Nathan: None. P. Kiely: None.

P093 Clinical outcomes and care quality standards in young adult patients with early inflammatory arthritis: Results from a national cohort

Abstract Background/Aims Emerging adulthood is a unique developmental period between late adolescence and establishment of personal and social identity associated with adulthood. Emerging adult populations may have distinctive experiences of adult healthcare and their needs may differ from those of older healthcare users. Little is known about the patterns of presentation, experiences of care or disease outcomes of emerging adults in adult rheumatology settings. We used the National Early Inflammatory Arthritis Audit (NEIAA) to describe differences between emerging and older adult patients diagnosed with early inflammatory arthritis (EIA). Methods NEIAA is an observational cohort design study assessing care against National Institute for Health and Clinical Excellence quality metrics. Adults in England and Wales with a confirmed new diagnosis of inflammatory arthritis between May 2018 and April 2022 were grouped into two categories: emerging adults (16-24 years) and older patients (≥25 years). Patient characteristics, disease phenotype (including oligo- or polyarticular presentation) and initial treatment strategy were described. Results A total of 20,472 patients were included. 571 (2.8%) diagnosed with EIA were emerging adults (EA); this group had higher proportions of females (71.8%). Compared to older patients, EA patients were less likely to ever smoke (44.1% vs 69.5%) and had fewer comorbidities. EA patients were more likely to have oligoarticular symptoms (<5 tender and swollen joints; 53% vs 37%). Symptom duration prior to diagnosis was longer for EA patients (46% describing symptom duration >6 months vs 37%). Median Disease Activity Score/DAS28 at presentation was lower (4.2 vs 4.7). There were no differences in symptom burden as measured by the mean musculoskeletal health questionnaire (25 vs 24). EA patients completed fewer patient reported outcomes (33% vs 39%), but were more likely to complete all forms (20% vs 17%). Disease modifying anti-rheumatic drugs treatment strategies appeared similar, although more EA patients did not start medications by three months (26% vs 19%). Fewer EA patients received steroids (56% vs 71%).There were no significant differences between groups in patient numbers referred within three days of symptom onset from primary care or reviewed within three weeks with treatment initiation within six weeks in rheumatology care. More of the EA group were in employment at diagnosis. The EA population reported higher impairment at work (Work Productivity and Activity Index overall score 38% vs 30%, driven by difference in presenteeism). Conclusion Low proportion of EA patients in this EIA population raises concern that the study is not capturing a representative sample of this younger and developmentally distinct population. Available data suggest important differences in time to presentation, disease pattern and pathways of care between EA and older patients. EA population deserves further detailed investigation, exploring frequency and patterns of EIA and identifying particular issues faced when using adult rheumatology services. Disclosure M. Adas: None. N. Arumalla: None. D. Mclaughlin: None. J. Galloway: Honoraria; from AbbVie, Celgene, Chugai, Galapagos, Gilead, Janssen, Lilly, Pfizer, Roche and UCB. J. Ledingham: Other; is a BSR trustee. F. Mcerlane: None.

Patient Survey Exploring the Burden of Inflammatory Back Pain in Patients With Uveitis.

Background In the UK, diagnostic delays remaina challenge in axial spondyloarthritis (axSpA). Studies have shown that acute anterior uveitis is the most common extra-articular manifestation associated with axSpA. As part of a National Axial Spondyloarthritis Society (NASS) Aspiring to Excellence quality improvement project, this study aimed to ascertain the burden of inflammatory back pain (IBP) in patients attending a uveitis clinic and to establish the number of these patients who had not been referred to a rheumatologist, thereby contributing to the diagnostic delay. The secondary aims were to explore the factors contributing to the diagnostic delay. Methods A 22-question patient survey was created to identify the burden of back pain in patients attending a specialist uveitis clinic at a London NHS Trust. Participants were recruited when attending their clinic appointments. Survey content included patient demographics and whether they had experienced back pain for longer than three months. The Berlin Criteria was used to identify the presence of inflammatory back pain, and it was also ascertained whether participants had a previous diagnosis of axSpA. Participants were asked if they had seen any healthcare professionals regarding their back pain and the total number of consultations they had had with each profession. Results A cohort of 50 patients who attended the uveitis clinic at the Royal Free London NHS Trust completed the survey between February and July 2022. The mean age of the respondents was 52 years with a mean length of time with uveitis of 6.57 years. Of them, 64% were female and 36% were male. Forty per cent (40%) of participants (20 respondents) reported experiencing back pain for more than three months and 12% (six respondents) had a diagnosis of axSpA. Of those who reported back pain for more than three months, the mean age of onset of back pain was 28.6 years. Of the 14 participants (28%) who had back pain and were not diagnosed with axSpA, nine (18%) fulfilled the Berlin criteria for IBP. All participants had seen a GP or allied health professional specifically for their back pain. On average, respondents had seen two allied healthcare professionals, but only 40% (eight) of respondents with back pain had been seen by a rheumatologist. Conclusions In this study, thedata highlights that inflammatory back pain is common in patients with uveitis and themajority of patients with inflammatory back pain had not been referred to a rheumatology service and potentially haveundiagnosed axSpA. Contributing factors to this potential delay in diagnosis include a lack of awareness of axSpA and its presenting features and associated conditions and a lack of onward referral for a specialist rheumatology opinion. This highlights the need for public, patient and healthcare professional education and the development of timely referral pathways to reduce delays in diagnosis.

Impact of single multidisciplinary triage system and straight to test process evaluation at surrey integrated musculoskeletal services

PurposeOrthopaedics, rheumatology, pain management, specialist radiology and therapy services were brought under one umbrella to form Northwest Surrey integrated musculoskeletal (IMSK) services and introduced advance clinical practice, a multi-disciplinary team triage with a formalised straight to test (STT) process defined in 2018. Historically, prior to these services' integration, there were a primary and second care triage systems within individual specialities. The aim of this service evaluation is to assess the impact of a single IMSK multidisciplinary triage (MDT) system and the efficacy of STT from triage, which allows patients to be sent for diagnostics based on the cluster of symptoms and past medical history in order to achieve early identification of serious pathologies. This is a complex adaptive system with pathways spanning into the core areas of orthopaedics, rheumatology, therapies, pain management services, radiology and some less frequent specialities such as neurology, oncology, vascular and gynaecology. One of the objectives of this study was to identify how many referrals were triaged to consultants, Advance practice and therapies. In addition, the authors wanted to highlight the proportion of referrals that were sent straight to test from triage and the percentage of these that had sinister pathology identified. This information would then be compared against existing red flag literature to identify common themes. This study aims to discuss the aforementioned objectives.Design/methodology/approachData were extracted retrospectively from a hospital database from January to December 2019 for all the adult musculoskeletal service referrals. The data collected were analysed on a Microsoft Excel sheet with information including date of triage, hospital number, ordering clinician, body part, type of diagnostic, indications for scanning, outcome for STT, serious pathology findings (named code 5 within our trust) and outcome of appointment.FindingsA total of 47,039 referrals were received into the IMSK service. Of these referrals 19,967 were directly referred to therapies, with 27,072 referrals received into the IMSK service MDT process. Within triage, 718 patients were directed to STT to rule out serious pathology. A total of 28 patients (3.9%) had sinister pathology identified on their investigation. A total of 46% of patients were discharged from their first consultation following STT. Overall, 50% of the total number of referrals into the IMSK service was seen by advanced practitioners with 16% of patients directed to consultants with pre-consultation diagnostic work up.Originality/valueThis service evaluation highlights that STT allows early access to diagnostics, resulting in quicker access to identification of sinister pathology. A one stop MDT system has been shown to be effective in guiding the referral to the right place with increased referrals into allied health advance practice clinics and access to therapies directly. It has resulted in a reduction of unwarranted referrals to consultant care, duplication of investigations and identified patients on multiple pathways.

To the 95th anniversary of the Russian rheumatological service

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Improving access to care for rheumatology services in Canada.

Rheumatic diseases are becoming increasingly prevalent in Canada, and its associated strain on the healthcare system is expected to increase over the next decades. Furthermore, there is an increasing body of evidence to suggest that access to rheumatology care is currently not meeting established quality of care benchmarks. To frame issues affecting access to care for rheumatology services in Canada, a proposed chronological framework from a rheumatology patient's perspective is proposed. Illustrating principles from a health policy lens including drawing from the stages heuristic framework and multiple streams theory, issues surrounding access to rheumatology assessment, to rheumatological investigations and lastly to appropriate treatment are explored. In particular, the current supply and demand mismatch within the rheumatology workforce presents challenges for patients in accessing rheumatic diseases providers. Potential policy solutions including increasing the pool of rheumatic diseases care providers, enhancing the clinical capacity with extended role providers and increasing uptake of virtual care are discussed. To ameliorate access to rheumatology investigations, the concept of provider education surrounding the appropriateness of investigations and merit-based funding are explored. Lastly, access to rheumatological treatment is framed using biologic therapies as an example, highlighting the policy challenges in biosimilar uptake and associated ethical and political considerations. By using a health policy lens to explore deficiencies within Canada's current system, the overarching goal of this analysis is to set the stage for reasoned and timely solutions in the future.

Patient participation in defining best-practice rheumatology service provision in Aotearoa New Zealand: a qualitative study with service consumers

BackgroundAotearoa New Zealand (AoNZ) has no agreed models for rheumatology service provision in government-funded health care. We aimed to describe what people with inflammatory rheumatic diseases who have used rheumatology services view as being important in those services, and map these views to previously collated statements describing best practice components of rheumatology services from international recommendations. If these statements did not capture all service aspects that people with inflammatory rheumatic diseases considered important, we aimed to co-create new statements with our patient-participants.MethodsWe conducted one focus group and an interview with people with inflammatory rheumatic disease who had used a government-funded rheumatology service in the previous 5 years (patient-participants) and analysed data using thematic analysis. The research team mapped subthemes to previously collated best practice recommendations that had been included in a Delphi consensus exercise with rheumatologists in AoNZ and proposed new statements, based on patient-participant data. Patient-participant feedback on thematic analysis and the new statements led to a refining of statements. A patient-partner in the research team informed research design and data analysis.ResultsPatient-participants viewed it as highly valuable for rheumatology services to respect and value their experiences as people and patients, and those of their whānau (Māori word for family). They expected rheumatology services to provide the right care, at the right time. Many of the subthemes mapped to the best-practice statements. However, three new principles and three new statements were developed and refined by patient-participants. The three principles addressed valuing individuals, and their whānau (family) and their experiences, and providing a patient-focused health system that supports patient participation in decision-making and self-management, and patient education. New statements related to having a specific rheumatologist and other staff for comprehensive care, having adequate nurse staffing, and active provision of outside services and support.ConclusionIt was important to patients that rheumatology services demonstrated that patients and their whānau (family) were valued. The inclusion of people with rheumatic diseases who are users of rheumatology services in service development can provide valuable insights to inform how services should be delivered.

Correlates of rheumatoid arthritis among women in Albania

Aim: Our aim was to assess the association of rheumatoid arthritis with socio-demographic characteristics and lifestyle factors among women in transitional Albania. Methods: A cross-sectional study was carried out in 2012-2013 including a sample of 2198 women aged 30 years and above who attended the Rheumatology services at primary health care clinics in Tirana municipality (mean age: 60.2±9.7 years; overall response rate: 95%). The diagnosis of rheumatoid arthritis was based on the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) 2010 criteria. In addition, a structured questionnaire was administered to all study participants including information on demographic and socioeconomic characteristics and behavioral factors. Binary logistic regression was used to assess the association of rheumatoid arthritis with covariates. Results: Overall, 437 (19.9%) women were diagnosed with rheumatoid arthritis (both incident and prevalent cases). In multivariable-adjusted models, rheumatoid arthritis was positively and significantly related to older age (OR=1.8, 95%CI=1.3-2.6), a lower educational attainment (OR=1.4, 95%CI=1.1-1.9), smoking (OR=1.5, 95%CI=1.1-2.0), alcohol intake (OR=1.9, 95%CI=1.2-3.1) and overweight and obesity (OR=1.5, 95%CI=1.2-2.0 and OR=1.6, 95%CI=1.2-2.0, respectively). Conclusion: This study provides useful evidence about selected correlates of rheumatoid arthritis among women attending specialized primary health care services in Albania. Health professionals and policymakers in Albania should be aware of the magnitude and consequences of this chronic condition in the adult population.

Памяти профессора Казанского государственного медицинского университета Р.Ш. Абдрахмановой, к 100-летию со дня рождения посвящается

The article is devoted to the 100th anniversary of Professor R. Sh. Abdrakhmanova, Head of the Department of Faculty Therapy at Kazan State Medical Institute in 1971–1982. Raisa Sharafutdinovna participated in the organization of therapy and rheumatology services in the Republic of Tatarstan. Together with Kazan Medfizpribor Company, she developed and introduced into practice a series of diagnostic devices. Furthermore, R.Sh. Abdrakhmanova was an honored scientist, the author of more than 100 scientific papers and an outstanding doctor. She was a leading freelance pulmonologist of the Republic of Tatarstan and an excellent teacher and mentor. Professor Abdrakhmanova devoted her entire life to medicine. Most part of her labor activity was connected with the Republic Clinical Hospital. Raisa Sharafutdinovna was a highly qualified professional and an outstanding scientist; she left a rich academic legacy and a bright memory among colleagues, department staff and patients.