ABSTRACT
Background: In March 2020, as part of the UK's COVID-19 prevention strategy, those identifed as 'clinically extremely vulnerable,' were advised to shield. This included a number of patients prescribed anti-rheumatic drugs, who were asked to continue their current treatment unless they developed symptoms of infection. Suboptimal treatment adherence (16.0%-81.0%) has been reported in patients with arthritic diseases, and is associated with psychological factors, including anxiety (1). Previous literature in non-UK cohorts has highlighted suboptimal adherence levels in immunosuppressed patients during the pandemic, although many were single centre studies (2,3). Objectives: The aim of this multi-centre study is to investigate the impact of the COVID-19 pandemic on adherence to anti-rheumatic medications in patients with established rheumatoid (RA) and psoriatic (PsA) arthritis in the UK who had recently commenced a biologic or targeted synthetic DMARD. Methods: Between September 2020 and May 2021, RA and PsA patients prescribed biologic or targeted synthetic anti-rheumatic drugs from two multi-centre observational studies (BRAGGSS and OUTPASS) were sent a questionnaire on medication usage, adherence, and perceptions to establish the impact of COVID-19 on these parameters. Patients were asked about compliance during the COVID-19 pandemic using a 5-point Likert scale (always, often, sometimes, rarely, and never) and the reason for non-adherence. Adherence was defned as never missing or delaying a dose, unless medically advised. Descriptive summary statistics were calculated, and logistic regression and Pearson's chi-squared tests were employed to investigate variables associated with self-reported non-adherence. Results: In total 159 questionnaires were returned (81.1% RA and 18.9% PsA). Methotrexate (53.5%) was the most frequently prescribed agent, followed by etan-ercept (25.2%), sulfasalazine (22.6%), hydroxychloroquine (21.4%) and adalimumab (19.5%). Furthermore, 68.6% of patients were prescribed ≥2 drugs. During the pandemic, 42.1% of patients reported missing or delaying a treatment dose for any reason. Adherence information was available for 97.5% of patients with 25.8% reporting non-adherence which was not medically advised. Methotrexate non-adherence was 27.1%, with similar levels reported for etanercept (20.0%), sulfasalazine (27.8%), hydroxychloroquine (35.3%) and adalimumab (29.0%). No drugs had signifcantly different adherence compared to methotrexate. Furthermore, there was no association between disease type or perception of disease control and adherence. Of non-adherent patients, 17.5% reported increased anxiety, fear, and increased risk due to the COVID-19 pandemic as an influencing factor. Meanwhile, 37.5% of non-adherent patients listed non-COVID-19 intentional reasons and 45.0% reported non-intentional reasons, with forgetting and running out of treatment listed most frequently. Conclusion: In a UK cohort self-reported non-adherence was reported in 25.8% of patients during the COVID-19 pandemic, despite medical advice, with reasons including increased anxiety due to COVID-19.
ABSTRACT
Background/AimsIn 2017 an audit and survey of giant-cell arteritis (GCA) services wereconducted across northwest England (reported previously). This resurvey in 2020, following publication of revised BSR guidance, soughtto identify what changes were made in the intervening period, andprovided the opportunity to assess the impact of COVID-19.MethodsRheumatologists from 16 hospitals in northwest England were invitedto complete a survey in July 2020. Questions focused on serviceprovision for GCA, including pathways, diagnostics and steroidprescription.ResultsResponses were received from 14/16 sites in 2017, and 15/16 in 2020.9/15 (60%) sites reported that the 2017 audit and survey promptedchanges to GCA services, with two (13%) stating that it clarified theneed for implementation of existing plans. Two sites had a GCApathway in 2017. Four of the seven sites who committed to introducingone have now done so, bringing the total in 2020 to six. Eight of thenine remaining sites plan to implement one, six with a specific datewithin six months. Six (40%) have completed additional local audit/QIsince 2017. Temporal artery (TA) ultrasound (US) is now available in anadditional four sites, bringing the total to 6/15 (40%) in 2020. Two sitesreported improvement in both time between first rheumatologyconsultation and TA biopsy, and time to receive results (now <7days for each task in 6/15 (40%)). Six additional sites reportedproviding leaflets on steroids routinely, bringing the total in 2020 to 12/15 (80%), versus 6/14 (43%) previously. Four sites (27%) now have adatabase of GCA patients (one in 2017). There was no major change insites having a standard protocol for steroid taper (n = 8 2017;n = 72020, 89% and 100% of whom respectively use BSR guidance), nor inthe number of patients routinely provided steroid cards (six in 2017;five in 2020). The three sites who do not report giving leaflets onsteroids routinely, all had a pathway. 8/15 (53%) reported COVID-19having an adverse effect upon services, including: reduced access todiagnostics (n = 7: TA US, biopsy, and PET-CT);delayed appointments(n = 4);delayed referrals (n = 3). The tertiary referral centre reported animprovement because access to tocilizumab was facilitated by arelaxation of rules by NHS England.ConclusionThe original audit and survey of current GCA practice in 2017highlighted areas for improvement for each site, and regionally. Sitescontributing to this re-survey report that the exercise stimulated themto improve their current care. The 2017 exercise showed a strongcorrelation between reported practice (survey) and actual practice(audit), leading us to have confidence that responses provided a truepicture of care. This work demonstrates the power of audit to driveimprovement, at a regional level.