DRIVING IMPROVEMENT in AXIAL SPONDYLOARTHRITIS SERVICES: The USE of QUALITY IMPROVEMENT APPROACHES and TOOLS

Background: Quality Improvement (QI) methods have been used in healthcare since the late 1980s across a wide range of healthcare settings. However, in the UK they have not been applied widely within rheumatology including axial Spon-dyloarthritis (axial SpA). In 2017, the UK healthcare regulator, NICE, produced a national clinical guideline for axial SpA, but there was no mechanism to encourage uptake of its recommendations. The National Axial Spondyloarthritis Society created a programme to use QI approaches to help encourage uptake of the Guidelines and act as a catalyst for wider improvement in axial SpA care. Objectives: To encourage service improvement in axial Spondyloarthritis care through the use of quality improvement theory and methods. Methods: In late 2019 six rheumatology departments were selected to participate in the frst cohort. The programme design was underpinned by: A framework for management grounded in systems theory1 A learning system that brings healthcare organisations together2 A set of tools to develop, test and implement changes: the Model for Improvement3. The teams met four times for training in QI methods, plus team-based online coaching. They had time to develop their projects and networking opportunities to share their data and experiences of implementation. We conducted a qualitative review of the programme in year one. We interviewed 31 programme participants and reviewed programme documentation. Results: The review found that: A proven QI framework provides a strong basis to build improvement A competitive programme helps foster motivation and accountability The programme provides the time to use tools to understand the problem and construct improvement aims Measurement is key to understand improvement and to create a story of change Collaboration and engagement is key within the team and with other stakeholders. The teams have: • Trained community-based physiotherapists, leading to improved rheumatology referrals Implemented an infammatory back pain pathway from primary care Introduced an MRI spine IBP protocol to reduce variation in imaging Established a tertiary referral service which has improved time to diagnosis Implemented mental health interventions for patients and reduced the percentage of patients with abnormal scores Established a pathway for physiotherapy self-referral and reduced Did Not Attend rates Used audit to make the business case for an extended scope practitioner Conclusion: Despite the challenges of posed by the Covid-19 pandemic, a structured QI programme has enabled clinicians to stay engaged and implement projects to reduce diagnostic delay and improve care.

HOW FEARS and HOPES HAVE EVOLVED in PATIENTS with RMDS THROUGHOUT the COVID-19 PANDEMIC? RESULTS from the REUMAVID STUDY (PHASE 1 and 2)

Background: The COVID-19 pandemic has generated uncertainties and concerns along with expectations and hopes that may be of relevance to patients with rheumatic diseases. Objectives: The aim of this study is to assess changes in the fears and hopes of patients with rheumatic diseases throughout the two phases of REUMAVID. Methods: REUMAVID is an international cross-sectional study collecting data through an online survey in seven European countries led by the Health & Territory Research group of the University of Seville, together with a multidisciplinary team including patient representatives, rheumatologists, and health researchers. Data were collected in two phases: Phase 1 (P1) between April-July 2020 and Phase 2 (P2) between February-April 2021. Demographics, health behaviours, employment status, access to healthcare services, disease characteristics, WHO-5 Well-Being Index and Hospital Anxiety and Depression Scale (HADS). Participants rated a series of fears (infection, medication consequences, lack of medication, impact on healthcare, lost job, civil disorder) on a scale from zero ('no concern at all') to five ('extremely concerned') and hopes (treatment/vaccine availability, going outside, travel, economic situation, treatment continuation, health status) on a scale from zero ('no hopeful at all') to five ('extremely hopeful'). Descriptive analysis and Mann-Whitney test were used to explore fears and hopes in both phases of REUMAVID. Results: A total of 3,802 participants were recruited across both phases in REU-MAVID with comparable demographic characteristics: mean age 52.6 (P1) vs. 55.0 years (P2), 80.2% female (P1) vs. 83.7% (P2), 69.6% married (P1) vs. 68.3% (P2), and 48.6% university educated (P1) vs. 47.8% (P2). Most prevalent RMD was axial spondyloarthritis in P1 (37.2%), and rheumatoid arthritis in P2 (53.1%). In P1 and P2 the major concern was the impact on healthcare in the future (3.1 and 3.2 out of 5, p=0.051). Compared to P1, patients in P2 had less fears about RMD medications not reaching the country (2.4 vs. 1.9, p<0.001), civil disorders (2.0 vs. 1.8, p=0.001), or losing their jobs (1.4 vs. 1.5, p=0.003). Comparing hopes with P1, patients in P2 had greater hopes about availability of treatments or vaccines suitable for COVID-19 (3.2 vs. 3.9, p<0.001), to be able to go out as before the pandemic (3.1 vs. 3.5, p<0.001), to be able to travel as before the pandemic (2.8 vs. 3.3, p<0.001), maintain and even improve the current economic situation after the pandemic (2.6 vs. 3.0, p<0.001), and to be able to continue their treatment as usual (3.8 vs. 3.8, p=0.049;Table 1) Conclusion: During the frst phase of REUMAVID at the beginning of the pandemic, patients with RMDs were more fearful and less hopeful compared to the second phase. These fears were notable in terms of lack of medication for their RMD, while during the second phase, patients were hopeful of a treatment or vaccine against COVID-19, and of being able to go out and travel as before.

HYDROTHERAPY AND AQUATIC THERAPY PROVISION IN A POST-COVID NHS

Background/Aims Hydrotherapy remains an important part of treatment for a range of rheumatological, musculoskeletal and other conditions. As there is little robust clinical evidence, hydrotherapy is scarcely included in national guidelines, with the exception of the National Institute for Health and Care Excellence (NICE) Guidance for Spondyloarthritis which recommends hydrotherapy as an adjunct therapy. In recent years, hydrotherapy services have often been targeted in cost-saving exercises by commissioners and providers. There was a concern that this would be further exacerbated by the pandemic with pools closing to become storage space and remaining closed beyond this. Methods Via the All Party Parliamentary Group (APPG) for axial spondyloarthritis (axial SpA), we submitted a Freedom of Information Request (FOI) to establish the status of hydrotherapy pools pre- and post-pandemic. The FOI was sent to all NHS trusts in England asking them about the status of their pool before and after COVID, future plans and reasons for any delay in re-opening. Results 90 trusts (69%) responded. 72% of those had an onsite hydrotherapy pool prior to the pandemic, 90% of which were open. 27% of pools had already re-opened and there were plans to re-open 49%. 2% were due to remain permanently shut with 21% unsure of the future of their pool. The most common reasons for delays in pools re-opening were linked to infection prevention control restrictions, including changing area capacity (23%), social distancing and ventilation (38%). The most common reasons for the uncertainty of when they would re-open were changing area capacity (46%), staff to clean (23%), access to pool i.e., still being used for other purposes (30%), social distancing and ventilation (23%). Of those pools that were already open or due to reopen, 93% had a reduced capacity with an average capacity of 37%. This was largely due to changing area capacity (54%), staff to clean (44%), access to the pool (28%), social distancing and ventilation (55%). Of the pools that were open prior to the pandemic, the condition areas which used them included MSK (92%), neurology (74%), physical disability (77%) and children (77%). 8% of users had axial SpA. Conclusion There is a very real threat to NHS hydrotherapy facilities in England. A lack of robust clinical evidence often leaves therapists and patients in limbo, with anecdotal testimony as to the benefits often not being enough to convince of its value. A co-ordinated cross-condition alliance is needed to ensure: clear local pathways are established into hydrotherapy;pools are considered in new build and refurbishments;robust clinical evidence is produced;hydrotherapy is included in national guidelines;tools are available at local level to audit and promote hydrotherapy;local services can become self-funding via community and patient groups.

3D printed models decentralise surgical skills training for retrograde intrarenal surgery and percutaneous nephrolithotomy in the COVID-19 era

Introduction & Objectives: Imparting the required psychomotor skills for trainees to become proficient in Percutaneous Nephrolithotomy (PCNL) and Retrograde Intrarenal Surgery (RIRS) is tricky for surgical educators, due to the challenging nature of the procedures and the lack of realistic simulators. The current COVID-19 pandemic has compounded these issues by reducing learning opportunities for trainees through reduced case numbers and availability of surgical skills courses. To address these contemporaneous issues, we have developed 3D printed inexpensive combined RIRS and PCNL training models for both in-person and video conference skills training. Materials & Methods: Anonymised Computed Tomography data was used to develop the training model, using medical image processing software (3D Slicer, version 4.12, Harvard, USA). The model was 3D printed using flesh-coloured resin which best approximated the appearance of the collecting system during ureteroscopy. The face validity of the simulator was assessed by surgical educators for its suitability for both in-person and remote training. Results: The RIRS and PCNL training model was evaluated by expert Urologists involved in the national training of the procedures and found to be more realistic and affordable when compared to available alternatives. The 3D printed model was developed for under €3, allowing multiple identical copies to be 3D printed for both in-person courses and scheduled video conferencing workshops with the models distributed to each participating centre beforehand. This “hub and spoke” method of surgical skills training is greatly facilitated by the affordability of the 3D printed models. Conclusions: We have developed an inexpensive combined RIRS and PCNL training model for both in-person and remote training at USANZ and other international training courses. 3D printed simulators have great future potential in the training of endourological and other urological procedures, enhancing connectivity and facilitating the decentralisation of training courses for the acquisition of key surgical skills.

Creating political levers to improve axial spondyloarthritis care

Background: Research carried out in 2016 by NASS showed that the range and quality of axial spondyloarthritis (axial SpA) services generally offered around the UK were variable 1. The publication by the regulator, the National Institute for Health and Care Excellence (NICE), of a Guideline for Spondyloarthritis (NG65) in 2017 2 and the corresponding Quality Standard (QS170) in 2018 3, for the first time provided national guidance and standards of services that should be available for people with axial SpA. National oversight of the implementation of these however was missing. Objectives: NASS worked with Parliamentarians to establish the All-Party Parliamentary Group for Axial Spondyloarthritis in January 2019. We gave it a very specific objective -to oversee the implementation of NH65 and QS170. The group seeks to improve axial SpA services in England whilst raising awareness of the condition at a parliamentary level, working closely with NASS. Methods: The group is a unique forum in the UK, bringing together patients, clinicians, researchers, policy makers, national bodies and parliamentarians. The group has met five times covering a range of topics including the delay to diagnosis, the uptake of NG65 and hydrotherapy. In 2019 the group carried out a national inquiry into the standards of axial SpA services in the UK, developing a ten-question quality framework, based largely on the NICE Guideline recommendations and Quality Standard. In July 2020 a meeting was convened to discuss the impact of COVID-19 on axial SpA services. The meeting presented research carried out by NASS and M&F Health with patients and clinicians respectively. Results: The results of the national inquiry for England were published in January 2020 4. The inquiry found that large discrepancies remain in the provision of axial SpA services. Only 21% of local commissioning bodies have an inflammatory back pain pathway, and less than half of NHS providers have a specialist axial SpA clinic. The results of COVID survey shows significant impacts on the health of axial SpA patients and on the availability and modality of rheumatology services. The APPG later published a report with a set of recommendations 5, creating minimum service specifications for axial SpA services during crisis periods such as the recent pandemic, as well as service recovery. Comment on this research was also published in The Lancet Rheumatology 6. In September 2020 the work of the APPG led to a debate in Parliament on delayed diagnosis in axial SpA. Discussions on the future of hydrotherapy services has resulted in the mobilisation of stakeholders across condition areas. Conclusion: All All Party Parliamentary Group is already proving to be an effective political lever to improve axial SpA care. It has shown huge variations in the standard of care and provision of services still remain and has brought this to the attention of Parliamentarians, policy makers and clinicians.

Gender differences on the impact of the COVID-19 pandemic and lockdown in patients with rheumatic diseases. results from the reumavid study (phase 1)

Background: The COVID-19 pandemic has impacted health, lifestyle, treatment and healthcare of European patients with rheumatic and musculoskeletal diseases (RMDs). Objectives: The aim is to evaluate gender differences on the impact of the first wave of the COVID-19 pandemic in the wellbeing, life habits, treatment, and healthcare access of European patients with RMDs. Methods: REUMAVID is an international collaboration led by the Health & Territory Research at the University of Seville, together with a multidisciplinary team including patient organisations and rheumatologists. This cross-sectional study consisting of an online survey gathering data from 1,800 patients with a diagnosis of 15 RMDs, recruited by patient organisations in Cyprus, France, Greece, Italy, Portugal, Spain, and the United Kingdom during the first phase of the pandemic (April-July 2020). Mann-Whitney and χ2 tests were used to analyse differences between gender regarding sociodemographic characteristics, life style, treatment, healthcare, and patient-reported outcomes. Results: 1,797 patients were included in this analysis. 80.2% were female and a mean age of 52.6 years. The most common diagnosis was inflammatory arthritis (81.7% male vs 73.8% female). There was a higher prevalence of fibromyalgia among females (20% vs 7.0% male). Overall, females reported worse self-perceived health (67.0% vs 51.4%, p<0.001), higher risk of anxiety (59.5% vs 48.1%, p<0.001), and depression (48.0% vs 37.2%, p<0.001). Females reported a greater increase in smoking (26.5% vs 17.5%, p=0.001), although they were less likely to drink alcohol (34.5% vs 25.4%, p=0.013), and also engaged less in physical activity (53.0% vs 60.3%, p=0.045). Overall, females were more likely to keep their scheduled rheumatology appointment (43.3% vs 34.1% of males (p=0.049;Table 1) with a higher proportion of females having their rheumatic treatment changed (17.0% vs 10.7%, p=0.005). Conclusion: The first wave of the COVID-19 pandemic and the containment measures have worsened self-perceived health status of patients with RMDs, affecting genders differently. Females reported worse psychological health and life habits such as increased smoking and reduced physical activity, while males increased their alcohol consumption and were less likely to attend their rheumatology appointments.

Fears and hopes during the COVID-19 pandemic in patients with rheumatic diseases Results from the reumavid study (PHASE 1)

Background: The first wave of the COVID-19 pandemic led to a rapidly evolving global crisis characterized by major uncertainty. Objectives: The objective is to assess COVID-19-related fears and hopes in patients with rheumatic and musculoskeletal diseases (RMDs) during the first wave of the pandemic. Methods: REUMAVID is an international collaboration led by the Health & Territory Research group at the University of Seville, together with a multidisciplinary team including patient organisations and rheumatologists. This cross-sectional study consisting of an online survey gathering data from 1,800 patients with a diagnosis of 15 RMDs recruited by patient organisations in Cyprus, France, Greece, Italy, Portugal, Spain and, the United Kingdom. Data are collected in two phases, the first phase between April and July 2020, the second in 2021. Participants rated a series of fears (infection, medication consequences, lack of medication, impact on healthcare, job loss, civil disorder) on a Likert scale from zero (no concern at all) to five (extremely concerned) and their hopes (treatment/vaccine availability, going outside, travel, economic situation, treatment continuation, health status) on a Likert scale from zero (not hopeful at all) to five (extremely hopeful). The Mann-Whitney and Kruskal-Wallis tests were used to analyse the different fears and hopes according to socio-demographics characteristics, disease and health status. Results: 1,800 patients participated in the first phase of REUMAVID. The most frequent RMDs group was inflammatory arthritis (75.4%), the mean age was 52.6 years and 80.1% were female. The most important fear for patients was the impact of the COVID-19 pandemic on healthcare (3.1 out of 5), particularly for those younger in age (3.0 vs 3.2, p=0.004), female gender (3.2 vs 2. 9 of men, p=0.003), experiencing greater pain (3.1 vs 2.8, p=0.007), with higher risk of anxiety (3.3 vs 2.9 of without anxiety, p<0.001) and depression (3.3 vs 2.9 without depression, p<0.001). The possible impact of anti-rheumatic medication and the development of severe disease if they became infected with COVID-19,was mostly feared (2.8 out of 5), by those receiving biological therapy (3.1 vs 2.5 not biological therapy, p<0.001) or those with underlying anxiety (2.9 vs 2.6 without anxiety, p=0.007). The risk of contracting COVID-19 due to their condition (2.8 out of 5), was especially feared by those with vasculitis (3.2 out of 5), who were female (2.9 vs 2.5, p<0.001), using biologics (2. 9 vs 2.7 of no use, p=0.003), in greater pain (2.8 vs 2.4, p<0.001), with a risk of anxiety (3.0 vs 2.6 without anxiety, p=0.004), and risk of depression (3.0 vs 2.6 without depression, p<0.001). The major hopes were to be able to continue with their treatment as usual (3.7 out of 5), particularly for those taking biologics (3.8 vs 3.6 not taking, p=0.026), those with a better well-being (3.8 vs 3.6 with worse well-being, p=0.021), without anxiety (3.8 vs 3.6 at risk, p=0.004) and without depression (3.8 vs 3.6 at risk, p=0.007). Hoping not to become infected with COVID-19 and to maintain the same health status, were especially those who were older (3.6 vs 3.4 p=0.018) without anxiety (3.4 vs 3.6 at risk, p=0.005), and without depression (3.6 vs 3.4 at risk, p=0.006). Another important hope was the availability of a treatment or vaccine for COVID-19, which was important for patients experiencing better well-being (3.3 vs 3.0 with worse well-being, p<0.001;Figure 1). Conclusion: The outstanding COVID-19-related fear expressed by European patients with RMDs was its impact on healthcare, while the greatest hope was to be able to continue treatment. Younger patients reported more fears while older patients were more hopeful. Those receiving biologics had greater fears and hopes associated with their treatment. In addition, patients at risk of mental disorders presented greater fears and less hopes.

Impact of the COVID-19 pandemic and lockdown on wellbeing on patients with rheumatic diseases. results from the reumavid study (phase 1)

Background: The COVID-19 pandemic has impacted the wellbeing of patients with Rheumatic and Musculoskeletal Diseases (RMDs). Objectives: The aim is to assess emotional well-being and its associated factors in patients with RMDs during the first wave of the COVID-19 pandemic. Methods: REUMAVID is an international collaboration led by the Health & Territory Research group at the University of Seville, together with a multidisciplinary team including patient organisations and rheumatologists. This cross-sectional study consisting of an online survey gathering data from patients with a diagnosis of 15 RMDs in Cyprus, France, Greece, Italy, Portugal, Spain, and the United Kingdom. 1,800 participants were recruited by patient organisations. Data was collected between April and July 2020. Participants were divided into two groups: 1) Participants with poor wellbeing (World Health Organization-Five Wellbeing Index (WHO-5) ≤ 50), 2) Participants with good wellbeing (WHO-5 ≥50). The Mann-Whitney and χ2 tests were used to analyse possible relations between sociodemographic characteristics, lifestyle, and outdoor contact with wellbeing during the first wave of the COVID-19 pandemic. Univariate and multivariate binary logistic regression was used to determine the impact of the independent variables associated with poor wellbeing. Results: 1,777 patients with 15 different RMDs were included. The mean age was 52.7, 80.2% female, 48.7% had a university degree, and 69.7% were married or in a relationship. The most frequent diagnoses were inflammatory arthritis (75.4%). 49.0% reported poor wellbeing. 57.7% of patients who belonged to a patient organisation reported good wellbeing (vs 46.3% who did not, p<0.001). Those who reported poor wellbeing had higher disease activity (51.4% vs 41.3%, p<0.001), a higher risk of anxiety (54.3% vs 41.7%, p<0.001) and depression (57.0% vs 42.1%, p<0.001), and poorer self-perceived health (53.0% vs 41.8%, p<0.001), compared to those who did not. A higher proportion of those who engaged in physical activity presented good wellbeing (54.0% vs 46.5%, p=0.012). 57.4% of the patients who were unable to attend their appointment with their rheumatologist reported poor wellbeing, compared to 48.2% who did attend (p=0.027). Patients who did not walk outside (56.2%) or who lacked elements in their home to facilitate outside contact (63.3%) experienced poor wellbeing (p<0.001). The factors associated with poor wellbeing were lack of elements in the home enabling contact with the outside world (OR=2.10), not belonging to a patient organisation (OR=1.51), risk of depression (OR=1.49), and not walking outside (OR=1.36) during the COVID-19 pandemic (Table 1). Conclusion: Almost half of the patients with RMDs reported poor emotional wellbeing during the first wave of the COVID-19 pandemic. The lack of elements in the home that facilitate outdoor contact, not belonging to a patient organisation, the presence of anxiety, and not walking outside during the pandemic increase the probability of poor emotional well-being. These results highlight the importance of environmental factors and the role of patient organisations in addressing the effects of the pandemic and its containment measures.

Country comparison on the impact of the COVID-19 pandemic on patients with rheumatic diseases. results from the reumavid study (phase 1)

Background: The COVID-19 pandemic has impacted every aspect of life of European patients with rheumatic and musculoskeletal diseases (RMDs). Objectives: The aim is to evaluate country differences on the impact of the first wave of the COVID-19 pandemic on life habits, healthcare access, health status, mental health and wellbeing in European patients with RMDs. Methods: REUMAVID is an international collaboration led by the Health & Territory Research group at the University of Seville, together with a multidisciplinary team including patient organisations and rheumatologists. This cross-sectional study consisting of an online survey gathering data from patients with a diagnosis of 15 RMDs in Cyprus, France, Greece, Italy, Portugal, Spain, and the United Kingdom. Participants were recruited by patient organisations (April-July 2020). The Kruskal-Wallis and χ2 tests were used to analyse differences between countries and independent variables. Results: 1,800 patients participated in the first wave of the COVID-19 pandemic (REUMAVID). 37.8% of Spanish patients increased their smoking consumption during the pandemic followed by Cyprus (32.1%) and Portugal (31.0%), while alcohol consumption was higher in the UK (36.3%) and France (27.0%). 82.3% of patients in Spain unable to attend their appointment with their rheumatologist, either due to cancellations or other personal reasons. Access to primary care was most limited in Portugal and Italy, where only 45.0% and 51.6% got access. 61.9% in Italy and 53.3% in Spain experienced a worsening of their health during the pandemic. 68.5% in Spain and 67.8% in Portugal were at risk of anxiety. The highest proportion at risk of depression was found in Greece (55.4%), Cyprus (55.1%), and Italy (54.8%). 66.9% of patients in Spain reported poor wellbeing, compared to 23.8% in Italy and 30.1% in Portugal (Table 1). Conclusion: The first wave of the pandemic and the related containment measures heterogeneously affected patients with RMDs across European countries, who overall increased harmful habits, experienced more difficulties in accessing healthcare and, reported poor mental health and well-being.

Impact of COVID-19 pandemic in overall health and functioning in patients with axial spondyloarthritis: Results from the reumavid study (phase 1)

Background: Evidence on the impact of the COVID-19 pandemic on the overall health and functioning in patients with axial spondyloarthritis (axSpA) is scarce. Objectives: To analyse the impact of the COVID-19 pandemic on the overall health and functioning in patients with axSpA. Methods: Data from axSpA patients participating in the first phase of the REUMAVID study were analysed. REUMAVID is a cross-sectional, observational study collecting data through an online questionnaire of unselected patients with rheumatic and musculoskeletal diseases (RMDs), recruited by patient organizations. The survey was disseminated during the beginning of the COVID-19 pandemic (April-July 2020) in seven European countries (Cyprus, France, Greece, Italy, Portugal, Spain, and the United Kingdom). Patients with axSpA who completed the ASAS health index (ASAS-HI) questionnaire were included in this analysis. Descriptive analyses were used to present socio-demographic and clinical characteristics, as well as daily habits. Overall health and functioning were defined according to the ASAS-HI (0-17), as follows: good health (ASAS-HI ≤5), acceptable health (ASAS-HI 6-11), and poor health (ASAS-HI ≥12). As secondary outcomes, well-being (WHO-5), self-perceived health status, and HADS for anxiety and depression were assessed. Results: Out of 670 axSpA patients, 587 (87.6%) completed ASAS-HI. Of these, 70.4% were female, 72.6% were married or in a relationship, 46.7% had university studies and 37.6% were currently employed. Mean age was 49.9±12.8 years and mean BMI was 26.7±5.5. Regarding extraarticular manifestations, 13.6% had psoriasis, 12.1% inflammatory bowel disease and 18.7% uveitis. Before the COVID-19 pandemic, 50.9% were receiving biological drugs, 46.3% NSAIDs, 26.4% painkillers, 24.7% conventional DMARDs, and 11.9% oral corticosteroids. According to the ASAS-HI, 19.6 % of patients were classified as having poor health, with the most affected aspects being pain (92.0%), movement (86.5%), maintenance of body position (80.6%), energy (79.0%) and sleep (75.3%). Regarding self-perceived health status, 14% reported their health status as bad or very bad, and 46.8% reported worsening health during the pandemic (Table 1). A distribution of the results of the total ASAS-HI scores can be seen in Figure 1. Conclusion: One out of five patients with axSpA reported poor health and functioning according to the ASAS-HI, and almost half of patients reported worsening self-perceived health status during the first wave of the COVID-19 pandemic.

Evaluation of the impact of the COVID-19pandemic on patients with rheumatic diseases in theUK: Results from the REUMAVID study

Background/AimsThis study presents the impact of the COVID-19 pandemic on healthcare, access to treatment, daily activities, well-being and mental health and the role of patient organisations from the perspective of the patientwith rheumatic disease in the UK.MethodsREUMAVID is an international collaboration led by HTR of the University ofSeville, together with a multidisciplinary team of rheumatologists andpatient organisations from 7 European countries (in the UK: NASS, NRASand Arthritis Action). The study consists of an online survey, including thefollowing instruments: Self-Perceived Health, WHO-5 Well-Being Indexand Hospital Anxiety and Depression Scale (HADS). Data are collected intwo phases: the first wave of the pandemic (from May 14th to July 18th2020) and the second wave (to be conducted in winter 2020).Results558 patients with rheumatic diseases participated in REUMAVID UK.The most frequently reported diagnoses were axial spondyloarthritis(44.6%), rheumatoid arthritis (44.1%) and osteoarthritis (25.6%). Themean age was 58.513.4 years, 78.7% women, 70.8% married or in arelationship and 54.1% having university studies. 45.8% perceivedtheir health status being "fair to very poor" with 38.4% reporting aworsening during lockdown. 48.8% had their rheumatology appointment cancelled. Of these, 46.9% were offered either online ortelephone follow-up, while the remaining 50.6% were not given anyalternative. 15.6% changed their medication, of which 66.3% wereindicated to do so by the medical team and 21.7% did so out ofconcern with COVID-19 with the major fear being that their treatmentwould lead to serious illness if they contracted SARS-CoV-2, while thegreater hope was to be able to continue with their treatment as usual.10.3% smoked more than before, 59.4% quit smoking and 36.3%drank more alcohol than before. 20.7% were unable to physicallyexercise at home and 39.2% reported weight gain. According to theWHO-5 scale, 52.5% declared poor well-being (-50). A total of 43.6%were at risk of anxiety and 33.6% at risk of depression according tothe HADS scale. During the lockdown, 54.3% were able to continuetheir psychological therapy. The main source of COVID-19 informationwas the patient organisations (reaching 63.6% of members), compared to 45.3% of non-members who did not receive any information.ConclusionThe REUMAVID study has allowed us to measure and quantify theexperience of British patients with rheumatic disease during anunprecedented public health crisis. A reduction in healthcare access, concern about treatment, changes in daily life habits and worsening ofwell-being and mental health were reported during the first wave.Patient organisations were the main source of COVID-19-relatedinformation. Further data will be gathered during the second wave.

Microalbuminuria screening in individuals living with type 2 diabetes: A multi-practice primary care audit

Aims: Diabetic kidney disease (DKD) is associated with increased mortality. Microalbuminuria screening allows early identification and treatment of DKD. National guidelines advocate annual screening in individuals with type 2 diabetes. We aimed to assess current standards of microalbuminuria screening in primary care, and additionally compare standards against other key care processes/treatment targets. Methods: Criteria for this audit were based on current clinical guidelines for both type 2 diabetes management and chronic kidney disease. Data were extracted retrospectively from primary care electronic records, for general practices in West Kent, UK, for the period 01/02/2019 to 01/02/2020. As part of the audit/quality improvement cycle, multi-faceted workshops were subsequently held at practices. Current screening processes and barriers/facilitators were considered, and protocols/ guidance were implemented to facilitate change. Results: Data were collected for 18,566 individuals with type 2 diabetes from 50 practices. Overall, annual microalbuminuria screening was poorly achieved;38.4% (range 8%-68%). In comparison, standards for most other key care processes were higher (≥74%). Practices achieving microalbuminuria screening appeared to also have higher completion of other care processes. Workshops were implemented in around one-quarter of practices (n = 12). These were well received but restrictions due to covid-19 prevented further workshops being held. A schedule for further implementation and re-audit is currently being planned. Conclusions Baseline audit suggested standards of microalbuminuria screening are suboptimal, but with variations between practices. Fragmented processes and poor staff awareness appeared to contribute to low standards. Addressing practice level barriers utilising a multi-faceted approach, has the potential to improve screening rates and reduce DKD progression.

Ultraviolet A radiation and COVID-19 deaths in the USA with replication studies in England and Italy.

BACKGROUND: Understanding factors impacting deaths from COVID-19 is of the highest priority. Seasonal variation in environmental meteorological conditions affects the incidence of many infectious diseases and may also affect COVID-19. Ultraviolet (UV) A (UVA) radiation induces release of cutaneous photolabile nitric oxide (NO) impacting the cardiovascular system and metabolic syndrome, both COVID-19 risk factors. NO also inhibits the replication of SARS-CoV2. OBJECTIVES: To investigate the relationship between ambient UVA radiation and COVID-19 deaths. METHODS: COVID-19 deaths at the county level, across the USA, were modelled in a zero-inflated negative-binomial model with a random effect for states adjusting for confounding by demographic, socioeconomic and long-term environmental variables. Only those areas where UVB was too low to induce significant cutaneous vitamin D3 synthesis were modelled. We used satellite-derived estimates of UVA, UVB and temperature and relative humidity. Replication models were undertaken using comparable data for England and Italy. RESULTS: The mortality rate ratio (MRR) in the USA falls by 29% [95% confidence interval (CI) 40% to 15%) per 100 kJ m-2 increase in mean daily UVA. We replicated this in independent studies in Italy and England and estimate a pooled decline in MRR of 32% (95% CI 48% to 12%) per 100 kJ m-2 across the three studies. CONCLUSIONS: Our analysis suggests that higher ambient UVA exposure is associated with lower COVID-19-specific mortality. Further research on the mechanism may indicate novel treatments. Optimized UVA exposure may have population health benefits.

Ultraviolet A correlates inversely with risk of COVID-19 death

Seasonal variation in temperature, humidity and ultraviolet (UV) radiation are related to the incidence of several infectious diseases. COVID-19 arose only 6 months ago, and it is thus not possible to describe seasonal variation. Nonetheless, spatial variation in the levels of environmental UV in the early pandemic allows for an early exploration of its relationship with COVID-19 mortality. We explored whether UVA exposure might be associated with COVID-19 deaths. We used an ecological model across counties (n = 2474) for the contiguous U.S.A. during their 'vitamin D winter' (monthly mean UVvitd < 165 KJ m-2). We derived UVA measures over this period for each area and estimated, in a multilevel zero-inflated negative binomial model, their relationship with COVID-19 mortality with a random effect for states. The 'atrisk' population was the total county population, with the state-level random effect;proportion of population tested positive for COVID-19 at the state level;and measure of infection susceptibility (county population density and urban-rural status) used to incorporate spatial infection into the model. We then replicated this model for excess deaths across 6755 municipalities in Italy, and for COVID-19 deaths in 6274 areas of England. We corrected each model for multiple confounders at the small area level. We generated a pooled overall estimate of risk with a meta-analysis. Daily mean UVA (January-April 2020) varied between 450 and 1000 KJ m-2 across the three countries. Our fully adjusted model showed an inverse correlation between UVA and COVID-19 mortality with a mortality risk ratio (MRR) of 0.73 (0.62-0.87) per 100 KJ m-2 increase in UVA in the U.S.A., 0.81 (0.71-0.93) in Italy and 0.51 (0.39-0.66) in England. The pooled MRR was 0.68 (0.53-0.66). Our analysis, replicated in three independent national datasets, suggests that ambient UVA exposure is associated with lower COVID-19-specific mortality. This effect is independent of vitamin D, as it occurred at irradiances below those likely to induce significant cutaneous vitamin D3 synthesis. Cardiovascular disease worsens prognosis in COVID-19. We have previously described a novel UVA-driven, vitamin D-independent mechanism by which sunlight lowers blood pressure via nitric oxide (NO) release from skin and reduces incident myocardial infarctions. This nonspecific benefit may account for the UV-COVID-19 mortality relationship. Additionally, and more directly, NO inhibits the replication of the closely homologous severe acute respiratory syndrome-coronavirus 1 by post-translational modification of the spike protein blocking ligation of the angiotensin-converting enzyme 2 receptor. Causal interpretations must be made cautiously in observational studies. Nonetheless, this research suggests strategies for a reduction in COVID-19 mortality.