Treatment In Secondary Care Research Articles

TEN YEAR FOLLOW-UP OF PATIENTS WITH RESISTANT HYPERTENSION RANDOMIZED TO RENAL DENERVATION OR ANTIHYPERTENSIVE DRUG TREATMENT

Objective: Renal denervation (RDN) is a treatment option in resistant hypertension. The procedure is considered safe, although randomized trials only demonstrate a moderate blood pressure (BP) lowering effect, when considering medication adherence. Some observational studies describe reduction in BP several years after the procedure. The aim of the study was to describe long-term safety and potential benefits of RDN after ten years, compared to optimized drug treatment, measuring serum concentration of antihypertensive drugs to ensure adherence. Design and method: We report data from ten year follow-up of patients randomized to RDN (n=9) or drug adjustment (n=10). Initially the patients had treatment-resistant hypertension, defined as daytime systolic ambulatory BP >= 135 mmHg after witnessed intake (directly observed therapy, DOT) of >= 3 antihypertensive drugs including a diuretic and therefore considered as adherent. One year after RDN or drug adjustment, we optimized antihypertensive medication for all patients. Thereafter, patients received appropriate antihypertensive treatment in primary or secondary care, according to their BPs. Patients were informed of serum concentration measurements performed at the 7-year visit. At the 10-year visit, serum drug measurements before DOT and ambulatory BP measurement (ABPM) were used for evaluation of adherence. Antihypertensive agents were registered, glomerular filtration rate (eGFR) was estimated by the CKD-EPI formula using creatinine and Cystatin C, and renal arteries were examined by CT or MRI. Results: All living patients (n=18) attended the 10-year visit, now mean age 69 years, using 4±2 antihypertensive agents, with no difference between groups. Serum concentrations confirmed that all patients were adherent to reported medication. There were significant and similar BP reductions in both groups compared to baseline; daytime ABPM -22±15/9±8 mmHg in the RDN group, and -20±15/13±7 mmHg in the control group (figure). No patients developed renal artery stenosis. The decrease in eGFR was similar in both groups. Conclusions: To our knowledge this is the RCT with the longest follow-up supporting long-term safety of RDN in patients with resistant hypertension. Daytime ABPM improved during 10 years of follow-up, not explained by RDN, but due to adjustments in antihypertensive regimens and probably better adherence to medication.

P105 Healthcare use by women with Joint hypermobility and Ehlers-Danlos syndromes in Northumberland

Abstract Background/Aims In 2017, the diagnosis of Joint Hypermobility Syndrome was withdrawn and combined with hypermobile form of Ehlers-Danlos syndrome (hEDS). International Consortium on Ehlers-Danlos syndromes proposed new clinical criteria for hEDS and it recommended the concept of Hypermobility Spectrum Disorders (HSDs) when these criteria are not met. None of these three diagnostic terms JHS, HSD and hEDS fully explain the complexity of this heterogenous condition as the criteria do not take into account many co-morbidities such as anxiety, autism, ADHD, bowel and bladder issues, pregnancy complications, dysautonomia, allergies, and more. Health services are organised on the assumption that it is a benign musculoskeletal condition. Health burden from both joint hypermobility and the associated co-morbidities is not known as these patients are usually discharged after episodic care by most services that work in silos. Hence we sought to measure the pattern and costs of secondary NHS healthcare use in this patient group. Methods Using primary care clinical systems from 30 of 36 GP surgeries in Northumberland (approximately 300,000 total population), we determined the number of people with SNOMED codes synonymous to hypermobility; ‘Benign joint hypermobility’ or ‘Hypermobility syndrome’ was the code recorded in 90% of patients, with less than 10% coded as EDS or subtypes. For the purpose of statistical analysis, we grouped all under the newer diagnostic terms hEDS/HSD. RAIDR, the UK’s leading health intelligence tool, was used to compare secondary healthcare activity and costs between patients with and without hEDS/HSD in Northumberland. Results Prevalence of hEDS/HSD in GP records was 4.4 per 1000. Women of childbearing age are affected more than men (Male : Female ratio 3:1). Hospital admissions to General Medicine, Obstetrics & Gynaecology, Surgery, and Orthopaedics were significantly higher in women with hEDS/HSD. Outpatient attendances to Rheumatology, Physiotherapy, Orthopaedics, and Obstetrics & Gynaecology were also higher in women. Male patients with hEDS/HSD where younger than female patients; they presented more often to mental health, physiotherapy and paediatric outpatients compared to those without hEDS/HSD. The cost of secondary care treatment per patient with hEDS/HSD during 2022 was £932.37 compared to £731.88 in those without. For 1,302 patients with diagnoses synonymous with hEDS/HSD, the total additional cost for A&E, Acute Inpatient and Outpatients in 2022 was £261,037. This excludes mental healthcare costs, although there were around twice the number of appointments. Conclusion We found a diagnosed prevalence of hEDS/HSD of one in 227 people in Northumberland. These patients have a significantly higher usage of secondary care, and thereby a higher average healthcare utilisation cost. The next steps would be expansion of this study, along with more in-depth analysis of reasons for secondary healthcare usage. This should inform commissioning of appropriate integrated health services for people with these complex conditions. Disclosure V. Saravanan: None. E. Reinhold: None. J. Demmler: None. I. Loughran: None. B. Frankel: None.

An analysis of the diagnoses and costs of pediatric emergency care visits: a single center study

BackgroundChildren’s emergency care visits are common, although the costs and reasons for visits vary. This register-based study examines the costs of pediatric emergency care and the diagnoses related to visits made to the Pediatric Emergency Unit at Tampere University Hospital (Tays), Tampere, Finland.MethodsThis retrospective study described pediatric emergency care visits made between September 2018 and December 2019 to a single center in Tampere, Finland. The data were gathered from medical files and from cost-per-patient software and analyzed in groups by age, season, level of treatment in the ED (primary or secondary), and hospitalization, as well as by diagnosis groups.ResultsDuring the study period, 11,454 visits were made. The total costs were over €3,380,000 ($2,837,758), with a median cost per visit was €260 ($217.90). Higher costs were associated with hospitalization and treatment in secondary care. The most common diagnoses were respiratory tract infections, counseling, other infections, GI symptoms, and other reasons.ConclusionSeriously ill children incur the highest costs per visit in pediatric emergency care. Respiratory tract infections are common reasons for emergency care visits, and the reasons why children come to emergency care in Finland are similar to those in other countries.

P202 Streamlining primary and secondary care pathways reduces the time-to-specialist IBD care: the emergence of FIT and the relative decline of calprotectin testing in primary care

Abstract Background Streamlining primary and secondary care pathways reduces the time-to-specialist IBD care. Prior to the COVID-19 pandemic, using an algorithm that screens endoscopy reports for probable IBD, we halved the time to IBD specialist review and treatment. Previous studies report that faecal immunochemical testing (FIT) could be used like calprotectin to test for suspected IBD. We sought to define the changing use of calprotectin and FIT prior to the diagnosis of IBD, and to determine whether their use influenced the time to secondary care treatment. Methods We conducted a retrospective observational cohort study of the time from endoscopic diagnosis of IBD to initiation of treatment. Demographics, stool testing, referral route, disease type, clinical review and treatment data were recorded from our electronic patient record. We sought factors associated with a delay in treatment defined as the upper quartile of time-to-treatment using logistic regression. Results Between 01/07/16 and 01/09/23 there were 805 new diagnoses of IBD (503 UC, 225 Crohn’s disease and 77 IBD-U). Monthly diagnosis rates were stable across the pandemic, except for March 2020 due to endoscopy unit closure. The median time from endoscopy to specialist review was 19.0 days (IQR7.0-44.0) and time to outpatient treatment 5.0 days (IQR 0.0-29.0 days). Overall, the use of pre-IBD diagnosis stool biomarkers has increased over time, but since 2020 there has been a progressive rise in FIT, and a decrease in calprotectin, testing (Fig 1). By 2023, people with a new diagnosis of IBD were more likely to have FIT than calprotectin testing. Whilst stool biomarker testing did not influence the time-to-IBD treatment, FIT testing was associated with a reduced delay from primary referral to endoscopy (OR 0.17 p=0.023). Factors associated with a delay in treatment were a diagnosis of Crohn’s disease versus UC/IBDU, having your index endoscopy undertake by a colorectal surgeon and being managed on a non-emergency pathway. IBD nurse contact prior to medical clinic review was associated with a significant reduction in delay to treatment (OR 0.55 p=0.003) Conclusion In the Southwest of the UK, pre-IBD diagnosis FIT, is now more common than pre-IBD diagnosis calprotectin testing. Factors linked to a delay in treatment were being diagnosed with Crohn’s disease versus UC/IBDU, having your index endoscopy undertaken by a colorectal surgeon and not specialist nurse or gastroenterologist and being managed on a non-emergency pathway. Further studies are needed to understand the influence of FIT versus calprotectin testing in the primary care diagnosis of IBD.

Incidence and management of mallet finger in Dutch primary care: a cohort study.

A mallet finger (MF) is diagnosed clinically and can be managed in primary care. The actual incidence of MF and how it is managed in primary care is unknown. To determine the incidence of MF in primary care and to obtain estimates for the proportions of osseous and tendon MF. An additional aim was to gain insight into the management of patients diagnosed with MF in primary care. A cohort study using a healthcare registration database from general practice in the Netherlands. Patients aged ≥18 years with a new diagnosis of MF from 1 January 2015-31 December 2019 were selected using a search algorithm based on International Classification of Primary Care (ICPC) coding. In total, 161 cases of MF were identified. The mean incidence was 0.58 per 1000 person-years. A radiograph was taken in 58% (n = 93) of cases; 23% (n = 37) of cases had an osseous MF. The most applied strategies were referral to secondary care (45%) or conservative treatment in GP practice (43%). Overall, 7% were referred to a paramedical professional. On average, a Dutch GP assesses ≥1 patient with MF per year. Since only a minimal number of patients required surgical treatment and a limited number of GPs requested radiography, the recommendation in the guidelines to perform radiography in all patients with MF should potentially be reconsidered. The purpose of requesting radiographs should not be to distinguish between a tendinogenic or osseous MF, but to assess whether there is a possible indication for surgery.

Completeness of endocrine therapy information in the Primary Care Prescription Database (PCPD) and secondary care treatment datasets: A national population-based cohort study using routine healthcare data

BackgroundEndocrine therapy (ET) is a widely used treatment for breast cancer. In the UK, use is typically initiated in secondary care, with subsequent treatment in primary care. Evaluating use of ET depends on data sources containing accurate and complete information. This study aimed to evaluate the completeness and consistency of ET recorded in primary and secondary care data (SCD) and determine the value of combining data sources in describing use of ET. MethodsThis cohort study included women (50 + years) diagnosed with hormone receptor-positive invasive breast cancer in England, April-2015 to December-2019. Concordance of ET recorded in SCD and the Primary Care Prescription Database (PCPD) was evaluated. Factors associated with recording of ET in each setting were assessed using statistical models. ResultsOverall 110,529 women were included. 94% had ET recorded in either SCD or PCPD. ET captured in SCD varied from 3% (in Systemic Anti-Cancer Therapy data) to 52% (in the Cancer Outcomes and Services Dataset; COSD). By contrast, 93% of patients had an ET prescription in PCPD. Among patients with ET recorded, this was not captured in COSD for 45%. Capture in COSD was lowest for younger women, those with no comorbidity/frailty, with lower stage or HER2-positive disease, or with other treatments recorded. Overall concordance between COSD and PCPD was 57%, but varied substantially across NHS trusts (lowest decile≤28%; highest decile≥86%). Among women with ET recorded in both settings, the earliest record was in COSD for 97%; 59% of initial ET prescriptions recorded in COSD were not captured in PCPD. Combining PCPD and COSD data enabled estimation of ET duration. ConclusionsPCPD is vital for understanding the use of ET within this population. Completeness of SCD could be improved by ensuring information on first ET prescription is recorded. PCPD (linked to SCD) is a valuable resource for examining patterns of care for patients with cancer, including treatment duration and adherence.

Prevalence and treatment patterns of adult atopic dermatitis in the UK Clinical Practice Research Datalink.

The prevalence of active atopic dermatitis (AD) in adults in the UK according to disease severity shows variability. This study evaluated disease prevalence and treatment patterns among the adult UK population with AD. Data were obtained from the Clinical Practice Research Datalink (CPRD) database. Adults with active AD were identified by an AD-related prescription or general practitioner visit within the same calendar year. Prevalence was defined as the number of patients with active AD on 1 January of each year as a percentage of the number of adults in the CPRD population on that date. Moderate-to-severe disease was classified as either referral to a specialist or prescription(s) for topical calcineurin inhibitors, phototherapy, or systemic treatment. Patient characteristics and treatment and referral patterns were analysed for patients with active AD in 2019. The overall prevalence of AD was stable at 2.4% per year during the period 2015-2019. In 2019, mean patient age (± standard deviation) was 52.6±21.0years, 58.2% of patients were female and mean disease duration was 9.4±5.9years. The most prescribed treatment was topical corticosteroids, in 78.5% of patients. 36.7% of patients with moderate-to-severe AD were prescribed systemic agents and 59.8% (vs. 32.3% of patients with mild AD) were referred to any secondary care or specialist treatment. The prevalence of active AD in the adult UK population was stable over the 5-year period (2015-2019) and was comparable to estimates from similar studies based on UK primary healthcare records.

Patient factors associated with receipt of psychological and pharmacological treatments among individuals with common mental disorders in a Swedish primary care setting.

Psychological and pharmacological therapies are the recommended first-line treatments for common mental disorders (CMDs) but may not be universally accessible or utilised. To determine the extent to which primary care patients with CMDs receive treatment and the impact of sociodemographic, work-related and clinical factors on treatment receipt. National registers were used to identify all Stockholm County residents aged 19-64 years who had received at least one CMD diagnosis (depression, anxiety, stress-related) in primary care between 2014 and 2018. Individuals were followed from the date of their first observed CMD diagnosis until the end of 2019 to determine treatment receipt. Associations between patient factors and treatment group were examined using multinomial logistic regression. Among 223 271 individuals with CMDs, 30.6% received pharmacotherapy only, 16.5% received psychological therapy only, 43.1% received both and 9.8% had no treatment. The odds of receiving any treatment were lower among males (odds ratio (OR) range = 0.76 to 0.92, 95% CI[minimum, maximum] 0.74 to 0.95), individuals born outside of Sweden (OR range = 0.67 to 0.93, 95% CI[minimum, maximum] 0.65 to 0.99) and those with stress-related disorders only (OR range = 0.21 to 0.51, 95% CI[minimum, maximum] 0.20 to 0.53). Among the patient factors examined, CMD diagnostic group, prior treatment in secondary psychiatric care and age made the largest contributions to the model (R2 difference: 16.05%, 1.72% and 1.61%, respectively). Although over 90% of primary care patients with CMDs received pharmacological and/or psychological therapy, specific patient groups were less likely to receive treatment.

LOFIT (Lifestyle front Office For Integrating lifestyle medicine in the Treatment of patients): a novel care model towards community-based options for lifestyle change—study protocol

BackgroundA healthy lifestyle is indispensable for the prevention of noncommunicable diseases. However, lifestyle medicine is hampered by time constraints and competing priorities of treating physicians. A dedicated lifestyle front office (LFO) in secondary/tertiary care may provide an important contribution to optimize patient-centred lifestyle care and connect to lifestyle initiatives from the community. The LOFIT study aims to gain insight into the (cost-)effectiveness of the LFO.MethodsTwo parallel pragmatic randomized controlled trials will be conducted for (cardio)vascular disorders (i.e. (at risk of) (cardio)vascular disease, diabetes) and musculoskeletal disorders (i.e. osteoarthritis, hip or knee prosthesis). Patients from three outpatient clinics in the Netherlands will be invited to participate in the study. Inclusion criteria are body mass index (BMI) ≥25 (kg/m2) and/or smoking. Participants will be randomly allocated to either the intervention group or a usual care control group. In total, we aim to include 552 patients, 276 in each trial divided over both treatment arms. Patients allocated to the intervention group will participate in a face-to-face motivational interviewing (MI) coaching session with a so-called lifestyle broker. The patient will be supported and guided towards suitable community-based lifestyle initiatives. A network communication platform will be used to communicate between the lifestyle broker, patient, referred community-based lifestyle initiative and/or other relevant stakeholders (e.g. general practitioner). The primary outcome measure is the adapted Fuster-BEWAT, a composite health risk and lifestyle score consisting of resting systolic and diastolic blood pressure, objectively measured physical activity and sitting time, BMI, fruit and vegetable consumption and smoking behaviour. Secondary outcomes include cardiometabolic markers, anthropometrics, health behaviours, psychological factors, patient-reported outcome measures (PROMs), cost-effectiveness measures and a mixed-method process evaluation. Data collection will be conducted at baseline, 3, 6, 9 and 12 months follow-up.DiscussionThis study will gain insight into the (cost-)effectiveness of a novel care model in which patients under treatment in secondary or tertiary care are referred to community-based lifestyle initiatives to change their lifestyle.Trial registrationISRCTN ISRCTN13046877. Registered 21 April 2022.

Lack of COPD-Related Follow-Up Visits and Pharmacological Treatment in Swedish Primary and Secondary Care.

ObjectiveThe Swedish guidelines recommend that patients with chronic obstructive pulmonary disease (COPD) on maintenance treatment are monitored annually, and within six weeks after an exacerbation. We describe the patterns of COPD-related visits in Sweden, both regular follow-up and post-exacerbation visits.MethodsPatients (>40 years) with a first-time COPD diagnosis between 2006 and 2017 were identified in primary care medical records and linked to hospital contacts and administered drug data. The index date was defined as the first collection of inhaled COPD maintenance treatment after the diagnosis. Regular COPD visits within 15-months after the index, and post-exacerbation visits for COPD within six weeks and 15-months after an exacerbation were estimated using the cumulative incidence function adjusted for competing risk. Visits without a ICD code for COPD were not included in the analyses.ResultsA total of 19,857 patients (mean age 69 years, 57% females) were included. The overall probability of having a regular follow-up visit for COPD within 15 months post-index was 39.1%. In total, 15,095 (76%) patients experienced at least one COPD exacerbation during the observation period. Among them, the probability of having a post-exacerbation visit was 7.0% within six weeks and 29.7% within 15-months. Patients without a regular COPD follow-up visit claimed significantly more oral corticosteroids (25.6% vs 15.6%), more respiratory antibiotics (39.1% vs 23.1%), and less maintenance treatment (10.9% vs 16.5%).ConclusionOnly 39% of COPD patients attended a regular follow-up visit within 15-months from the COPD diagnosis and one-third had a post-exacerbation visit. The adherence to guideline recommendations need to be improved.

Initial treatment choices to achieve sustained response in major depression: a systematic review and network meta-analysis.

Major depression is often a relapsing disorder. It is therefore important to start its treatment with therapies that maximize the chance of not only getting the patients well but also keeping them well. We examined the associations between initial treatments and sustained response by conducting a network meta-analysis of randomized controlled trials (RCTs) in which adult patients with major depression were randomized to acute treatment with a psychotherapy (PSY), a protocolized antidepressant pharmacotherapy (PHA), their combination (COM), standard treatment in primary or secondary care (STD), or pill placebo, and were then followed up through a maintenance phase. By design, acute phase treatment could be continued into the maintenance phase, switched to another treatment or followed by discretionary treatment. We included 81 RCTs, with 13,722 participants. Sustained response was defined as responding to the acute treatment and subsequently having no depressive relapse through the maintenance phase (mean duration: 42.2±16.2 weeks, range 24-104 weeks). We extracted the data reported at the time point closest to 12 months. COM resulted in more sustained response than PHA, both when these treatments were continued into the maintenance phase (OR=2.52, 95% CI: 1.66-3.85) and when they were followed by discretionary treatment (OR=1.80, 95% CI: 1.21-2.67). The same applied to COM in comparison with STD (OR=2.90, 95% CI: 1.68-5.01 when COM was continued into the maintenance phase; OR=1.97, 95% CI: 1.51-2.58 when COM was followed by discretionary treatment). PSY also kept the patients well more often than PHA, both when these treatments were continued into the maintenance phase (OR=1.53, 95% CI: 1.00-2.35) and when they were followed by discretionary treatment (OR=1.66, 95% CI: 1.13-2.44). The same applied to PSY compared with STD (OR=1.76, 95% CI: 0.97-3.21 when PSY was continued into the maintenance phase; OR=1.83, 95% CI: 1.20-2.78 when PSY was followed by discretionary treatment). Given the average sustained response rate of 29% on STD, the advantages of PSY or COM over PHA or STD translated into risk differences ranging from 12 to 16 percentage points. We conclude that PSY and COM have more enduring effects than PHA. Clinical guidelines on the initial treatment choice for depression may need to be updated accordingly.

An eReferral Management & Triage System for minor Oral surgery referrals from primary care dentists: a cost-effectiveness evaluation

ObjectiveOral surgery referrals from NHS dental practices are rising, increasing the pressures on available hospital resources. We assess if an electronic referral system with consultant or peer (general dental practitioner) led triage of patient referrals from general dental practices can effectively divert patients requiring minor oral surgery into specialist led primary care settings at a reduced cost whilst providing care of the same or enhanced quality. One year of no triage (all referrals treated in secondary care) was followed by one-year of consultant led triage, which in turn was followed by year of peer-led triage.MethodA health economic evaluation of all patient referrals from 27 UK dental practices for oral surgery procedures. The follow-up is over a three-year period at hospital dental services in two general hospitals, one dental hospital, and a single specialist oral surgeon based in two primary care practices. The evaluation is a comparison of mean outcomes in the hospitals and in specialist primary care dental services between the study periods (i.e. periods with and without the triage system). The main outcomes of interest are mean NHS cost saving per referral (costs to the NHS and costs to broader society), proportion of diverted referrals, case-mix of referrals and patient reports of the quality of dentistry services received at their referral destination.ResultsThe proportion of referrals diverted to specialist primary care was similar during both periods (45% under consultant-led triage and 43% under GDP-led triage). Statistically significant savings per referral diverted were found (£116.11 under consultant-led triage, £90.25 under GDP-led triage). There were no statistically significant changes in the case-mix of referrals. Cost savings varied according to the coding (and hence tariff) of referred cases by the provider hospitals. Patients reported similarly high levels of satisfaction scores for treatment in specialist primary care and secondary care settings.ConclusionsImplementation of electronic referral management in primary care, when combined with triage, led to appropriate diversions to specialist primary care. Although cost savings were realised by referral diversion these savings are dependent on the particular tariff allocation (coding) practices of provider hospitals.

AB0634 BELIEFS ABOUT URATE LOWERING THERAPY DIFFER BETWEEN GENERAL PRACTITIONERS AND RHEUMATOLOGISTS

Background:Uric acid lowering therapy (ULT) can be effective in gout if taken correctly (1), but non-adherence is a known problem (2). Although patients’ adherence barriers regarding ULT, such as lack of knowledge on disease and therapy, and beliefs, have been widely studied (3), less is known physicians’ beliefs.Objectives:To investigate the physicians’ beliefs on ULT treatment in both primary and secondary care in the Netherlands.Methods:Cross-sectional study among all rheumatologists of the Sint Maartenskliniek and to all General Practitioners (GPs) of 17 practices, participating in the practice-based research network Family Medicine Network Nijmegen, Netherlands. All participants filled out the beliefs about medication questionnaire (BMQ), adjusted for physicians; in addition data were collected on physician characteristics including working experience in total and gout consultations. The BMQ consists of two parts, a specific part with 10 questions about beliefs on necessity (N=5) and concerns (N=5) regarding ULT and a general part with 8 questions about beliefs on harms (N=4) and overuse (N=4) regarding medication in general. Each question is scored on a Likert-scale from 1-5, a higher score corresponds to higher beliefs on that category. Sum scores for all four categories were calculated. With the total scores on the specific BMQ including necessity and concerns beliefs, physicians were classified in four different categories (Table 1)(4).Results:In total 112 physicians received the questionnaire, 28 of 37 rheumatologists (76%) and 45 of 75 GPs (60%) responded. Rheumatologists had less years of experience than GPs (median 8.5 years (IQR 3 – 14) versus (vs) 13 years (IQR 8-20)) and less hours of patient contact per week (15 hours (IQR 8.5 – 20) vs 24 hours (IQR 20 – 30)). Rheumatologists reported more consultations for gout per week than GPs: median 4 (IQR 1 – 6.6) vs 1 (IQR 0.2– 1).Rheumatologists scored higher on the BMQ necessity scale, 17.5 (95% CI 16.6 – 18.5) compared to GPs 16.1 (95% CI 15.1 – 17.1). GPs scored higher on BMQ concern scale, 12.1 (95% CI 11.4 – 12.7) compared to rheumatologists, 10.4 (95% CI 9.7 – 11.2). On medication in general, GPs scored higher on both overuse and harms scales compared to rheumatologists, 11.3 (95% CI 10.7 – 12) versus 9.9 (95% CI 9 – 10.7)and 8.3 (95% CI 7.9 – 8.7) vs 7.1 (95% CI 6.5 – 7.7), respectively. Table 1 shows classification according to the BMQ specific for both groups.Table 1.Classification based on the adapted BMQRheumatologists (N=28)GPs (N=45)Acceptant (%)19 (67.9)16 (35.6)Ambivalent (%)08 (17.8)Sceptic (%)1 (3.6)5 (11.1)Indifferent (%)8 (28.6)16 (35.6)Conclusion:For the majority of rheumatologist the necessity beliefs outweighs concern beliefs towards the use of ULT outweighs concern beliefs. GPs show a more heterogenic profile, including acceptant, indifferent and ambivalent beliefs towards ULT use. GPs also show higher harm and overuse concerns regarding medication in general. Next step is to investigate possible associations with actual ULT use and disease outcome.

COVID-19 and the multidisciplinary care of patients with lung cancer: an evidence-based review and commentary.

Delivering lung cancer care during the COVID-19 pandemic has posed significant and ongoing challenges. There is a lack of published COVID-19 and lung cancer evidence-based reviews, including for the whole patient pathway. We searched for COVID-19 and lung cancer publications and brought together a multidisciplinary group of stakeholders to review and comment on the evidence and challenges. A rapid review of the literature was undertaken up to 28 October 2020, producing 144 papers, with 113 full texts screened. We focused on new primary data collection (qualitative or quantitative evidence) and excluded case reports, editorials and commentaries. Following exclusions, 15 published papers were included in the review and are summarised. They included one qualitative paper and 14 quantitative studies (surveys or cohort studies), with a total of 2295 lung cancer patients data included (mean study size 153 patients; range 7–803). Review of current evidence and commentary included awareness and help-seeking; lung cancer screening; primary care assessment and referral; diagnosis and treatment in secondary care, including oncology and surgery; patient experience and palliative care. Cross-cutting themes and challenges were identified using qualitative methods for patients, healthcare professionals and service delivery, with a clear need for continued studies to guide evidence-based decision-making.

Surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder: the UK FROST three-arm RCT.

Frozen shoulder causes pain and stiffness. It affects around 10% of people in their fifties and is slightly more common in women. Costly and invasive surgical interventions are used, without high-quality evidence that these are effective. To compare the clinical effectiveness and cost-effectiveness of three treatments in secondary care for adults with frozen shoulder; to qualitatively explore the acceptability of these treatments to patients and health-care professionals; and to update a systematic review to explore the trial findings in the context of existing evidence for the three treatments. This was a pragmatic, parallel-group, multicentre, open-label, three-arm, randomised superiority trial with unequal allocation (2 : 2 : 1). An economic evaluation and a nested qualitative study were also carried out. The orthopaedic departments of 35 hospitals across the UK were recruited from April 2015, with final follow-up in December 2018. Participants were adults (aged ≥ 18 years) with unilateral frozen shoulder, characterised by restriction of passive external rotation in the affected shoulder to < 50% of the opposite shoulder, and with plain radiographs excluding other pathology. The inventions were early structured physiotherapy with a steroid injection, manipulation under anaesthesia with a steroid injection and arthroscopic capsular release followed by manipulation. Both of the surgical interventions were followed with post-procedural physiotherapy. The primary outcome and end point was the Oxford Shoulder Score at 12 months post randomisation. A difference of 5 points between early structured physiotherapy and manipulation under anaesthesia or arthroscopic capsular release or of 4 points between manipulation under anaesthesia and arthroscopic capsular release was judged clinically important. The mean age of the 503 participants was 54 years; 319 were female (63%) and 150 had diabetes (30%). The primary analyses comprised 473 participants (94%). At the primary end point of 12 months, participants randomised to arthroscopic capsular release had, on average, a statistically significantly higher (better) Oxford Shoulder Score than those randomised to manipulation under anaesthesia (2.01 points, 95% confidence interval 0.10 to 3.91 points; p = 0.04) or early structured physiotherapy (3.06 points, 95% confidence interval 0.71 to 5.41 points; p = 0.01). Manipulation under anaesthesia did not result in statistically significantly better Oxford Shoulder Score than early structured physiotherapy (1.05 points, 95% confidence interval -1.28 to 3.39 points; p = 0.38). No differences were deemed of clinical importance. Serious adverse events were rare but occurred in participants randomised to surgery (arthroscopic capsular release,n = 8; manipulation under anaesthesia,n = 2). There was, however, one serious adverse event in a participant who received non-trial physiotherapy. The base-case economic analysis showed that manipulation under anaesthesia was more expensive than early structured physiotherapy, with slightly better utilities. The incremental cost-effectiveness ratio for manipulation under anaesthesia was £6984 per additional quality-adjusted life-year, and this intervention was probably 86% cost-effective at the threshold of £20,000 per quality-adjusted life-year. Arthroscopic capsular release was more costly than early structured physiotherapy and manipulation under anaesthesia, with no statistically significant benefit in utilities. Participants in the qualitative study wanted early medical help and a quicker pathway to resolve their shoulder problem. Nine studies were identified from the updated systematic review, including UK FROST, of which only two could be pooled, and found that arthroscopic capsular release was more effective than physiotherapy in the long-term shoulder functioning of patients, but not to the clinically important magnitude used in UK FROST. Implementing physiotherapy to the trial standard in clinical practice might prove challenging but could avoid theatre use and post-procedural physiotherapy. There are potential confounding effects of waiting times in the trial. None of the three interventions was clearly superior. Early structured physiotherapy with a steroid injection is an accessible and low-cost option. Manipulation under anaesthesia is the most cost-effective option. Arthroscopic capsular release carries higher risks and higher costs. Evaluation in a randomised controlled trial is recommended to address the increasing popularity of hydrodilatation despite the paucity of high-quality evidence. Current Controlled Trials ISRCTN48804508. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 71. See the NIHR Journals Library website for further project information.

PCN333 Analysis of Hospital Episode Statistics Data to Demonstrate the Secondary Care Treatment Pathway and Outcomes of Patients with Cutaneous T-Cell Lymphoma in England

This study aimed to describe the real-world demographics, management, clinical outcomes and healthcare resource use (HCRU) and costs of UK patients with Mycosis Fungoides (MF) and Sézary Syndrome (SS). Patients with ICD-10 diagnoses of MF (C84.0) or SS (C84.1) in the National Health Service’s Hospital Episode Statistics (HES) database between 1-Oct-2010 and 31-Mar-2019 were included, with secondary care activity tracked from diagnosis to study end date/death. Overall survival (OS) was calculated from date of diagnosis until death (or censored at study end date, if still alive). Next treatment-free survival (NTFS) was calculated from diagnosis until the date a new systemic (non-topical) treatment (of those available in HES) was started or added to existing treatment, or death. OS and NTFS were also calculated from the start of the next new systemic treatment. HCRU costs were estimated per patient/week. 1,737 patients with MF and 165 patients with SS (MF: mean age at diagnosis=65 years, 62% male; SS: mean age=66 years, 48% male) were included. 513 (30%) patients with MF and 58 (35%) with SS had ≥1 change in treatment and 554 (32%) MF and 88 (53%) SS patients died during the study period. Median OS for SS was 2.6 years (median not reached for MF) and median NTFS was 4.6 years (MF) and 1.0 years (SS). From start of the next new treatment, median OS was 1.5 years (MF) and 1.0 years (SS) and median NTFS was 0.3 years (MF) and 0.3 years (SS). Mean total HCRU costs varied between £53.07-£105.70 (MF) and £ 29.36-£135.93 (SS) per patient/week depending on the treatment line. HES data highlighted the significant real-world burden of MF and SS in England, demonstrating that many patients managed within the secondary care setting experience multiple treatment changes and poor survival outcomes, with high HCRU costs.

What Do Men with Lower Urinary Tract Symptoms Expect from a Urologist in Secondary Care?

PurposeTo identify the expectations of men with LUTS referred to a urologist and to study the association between those expectations and satisfaction with the care provided.MethodsIn this prospective cohort study, adult men with LUTS completed a questionnaire before their first outpatient appointment, and again at 6 and 12 weeks. The questionnaires included IPSS and OABq-SF, and self-constructed questions on patient expectations, outcome of expectations and satisfaction.ResultsData from 182 participants showed positive expectations about the urologist performing examinations, providing explanations and finding the underlying cause, but mostly neutral expectations for treatment plans and outcomes. Positive treatment expectations were associated with positive expectations about outcomes after physiotherapy, drug treatment and surgery. Higher symptom scores and age were associated with higher expectations about drug treatment. Expectations were subjectively and objectively fulfilled for 66.4% and 27.3%, respectively. Symptom improvement (decrease in IPSS scores) was significantly more in men with objectively fulfilled expectations than in men with no unfulfilled expectations. No significant difference was present between men with subjectively fulfilled expectations and men with unfulfilled expectations. However, satisfaction was significantly higher for patients with subjectively fulfilled expectations at 6 and 12 weeks compared with those who had unfulfilled expectations.ConclusionMost men referred to a urologist with LUTS do express clear expectations about treatment in secondary care. Patients with higher expectations for treatment outcomes are more likely to expect to receive that treatment. Satisfaction with the care of a urologist is also higher when patients self-report that they receive the treatment they expected.

Service evaluation of referrals to secondary care: A question of complexity?

To evaluate referral patterns to secondary care and categorise referrals by complexity level. To assess compliance with commissioning guidelines for cases accepted for treatment in secondary care, comparing complexity to Index of Orthodontic Treatment Need (IOTN) data. Service evaluation of all referrals during study period recorded prospectively. The standard was set that >85% of cases offered treatment in secondary care should be complexity level 3b. Seven NHS orthodontic departments within a regional clinical effectiveness group in secondary care in England. All patients seen as new referrals during the three-month study period. Data recorded at clinic appointment on data collection proforma including referral information, complexity, IOTN and outcome of the first appointment. Data were collated on a spreadsheet and simple statistics were applied. A total of 493 patients were included in data analysis. Median waiting time for a new patient appointment was 11.0 weeks. For the whole study group, 53.8% were IOTN 5, 30.8% IOTN 4, 9.7% IOTN 3; complexity levels were 54.2% complexity 3b, 37.1% 3a and 6.7% 2. Of the patients, 30.0% were offered treatment in secondary care at their first attendance; of these, 74.3 % were IOTN 5, 93.2% were complexity level 3b. The gold standard has been met in the region as a whole and at each individual unit. There is a large discrepancy between the IOTN score and complexity level in those patients offered orthodontic treatment in secondary care. Routine recording of complexity level is recommended for all patients seen in the secondary care setting.

Factors associated with the needs of specialised dental treatment among adults aged 35-44 years old in the state of Minas Gerais, Brazil: a multilevel cross-sectional study.

This study evaluated the individual and contextual factors associated with the specialised dental treatment needs of a population of adults aged 35 to 44 years old in the state of Minas Gerais. The individual variables were obtained from the database of the SB Minas Gerais project - a survey of oral health status of the population of Minas Gerais, Brazil. The variables at the municipal level were derived from any available public databases related to oral health services. A multilevel analysis was performed to evaluate the association of independent individuals and contextual variables with or without dental treatment needs in the secondary care of the oral health network. Individuals with a higher income (OR 0.53; CI95% 0.31-0.93) and with greater access to oral health care (OR 0.94; CI95% 0.90-0.99) had less secondary care treatment needs. Income and access to oral health care are related to the needs of specialised dental treatment in Minas Gerais.

The impact of the COVID-19 outbreak on liver transplantation programs in Northern Italy.

In January 2020, Novel Coronavirus Disease 2019 (COVID‐19) resulted in a global pandemic, creating uncertainty toward the management of liver transplantation (LT) programs. Lombardy has been the most affected region in Italy: the current mortality rate of COVID‐19 patients is 18.3% (10 022 deaths; April 10th) with hospitals in Lombardy having to expand the total number of ICU beds from 724 to 1381 to accommodate infected patients. There has been a drastic decrease in liver donors. From February 23rd until April 10th, 17 LTs were performed in Lombardy. Mean donor age was 49 years (range 18‐74) whereas mean recipient age was 55 (13‐69); mean MELD score was 12 (6‐24). All donors underwent screening for SARS‐CoV‐2 prior to LT. Two patients tested positive after LT, and one patient died for COVID on POD 30. Sixteen patients are alive after an average of 30 days post‐LT (range 3‐46). 10 patients have been discharged. This study has found no specific reason concerning the safety of recipients, to stop LT programs. Several key lessons from our experience are reported. However, due to the complex circumstances which surround the viral outbreak, the cessation or a reduction in LT activity is a pragmatic requirement.