Eight years' experience of regional audit: an assessment of its value as a clinical governance tool.

Strengthening clinical audit is crucial for improving the quality of healthcare provision. The West Midlands Rheumatology Service and Training Committee coordinates an innovative programme of regional audits and the experience of rheumatology healthcare professionals involved was surveyed. This was a questionnaire-based study in which respondents rated statements relating to regional audit on Likert scales. Out of 105 staff, 70 replied. There was consensus that results of regional audit have been robust, valid and reliable; regional audits benefit patients and units; provide educational opportunities for specialist registrars (SpRs); and are more efficient than local audit by allowing comparison between units. Opinion was divided about how well informed respondents were and how effective they are at closing the audit loop. Many units reported changes in practice. Regional audit is widely perceived to be a valuable clinical governance tool supporting significant changes to clinical practice, and an excellent training opportunity for SpRs. Recommendations for a successful regional audit scheme are described in this article.

Regional survey of tuberculosis risk assessment in rheumatology outpatients commencing anti-TNF-alpha treatment in relation to British Thoracic Society guidelines.

The aim of this study was to analyse tuberculosis (TB) risk assessment for rheumatology patients commencing anti-tumour necrosis factor-alpha (anti-TNF-alpha) therapy using the British Thoracic Society (BTS) guidelines. Data were obtained retrospectively on 856 outpatients regionally receiving anti-TNF-alpha. Prior to commencing treatment, patients had the following assessments documented: respiratory examination, 47.4%; chest X-ray, 84.5%; TB history, 92.9%; and advice about TB risk, 45.8%. Of the 856 patients, 94.3% were on immunosuppressives but 27% had a tuberculin test; 12.6% had > or =1 high-risk factors for TB. In total, 3.4% were referred to a TB specialist and of these, 24.1% had no risk factors for TB. Of patients with > or =1 risk factor, 76.9% were not referred. Only 4/28 patients at high risk for TB due to ethnicity or birthplace received chemoprophylaxis. Marked inter-unit variation was demonstrated and it was evident that patients require improved screening for TB. Greater awareness is necessary of patients with risk factors, particularly ethnicity, to facilitate more appropriate targeting of chemoprophylaxis. Multi-centre audit is a valuable clinical governance tool.

Piloting education days for patients with early rheumatoid arthritis and their partners: a multidisciplinary approach.

OBJECTIVES: To develop, pilot, refine and reassess an education day presented by a rheumatology multidisciplinary team (MDT) for recently diagnosed (less than six months) rheumatoid arthritis (RA) patients and their partners/carers. METHODS: A patient education day was developed drawing on an assessment of local patient educational needs and preferences and input from a rheumatology MDT. Feedback from the first education day (2004) (Day 1; 12 patients; age range 19-63 years (median 46); 10 of whom were accompanied by a partner) informed the development of a second education day (2005) (Day 2; 19 patients; age range 36-75 years (median 57.5); 13 of whom were accompanied by a partner). Participants completed evaluation forms on both days and at follow-up between six and seven weeks later, rating each session on a 5-point scale on dimensions of 'informative', 'useful', 'interesting' and 'enjoyable'. A global rating of the day's 'usefulness' was completed at the end of each day on a 10-point scale. Participants were asked to write comments on each session and on aspects of the entire day. RA knowledge, and general and RA-specific self-efficacy were also measured on day 2 (and at follow-up) using the 12-item Patient Knowledge Questionnaire, the 10-item generalized self-efficacy scale and a four-item RA-specific self-efficacy scale. Both qualitative and quantitative methodologies were used in the analysis. RESULTS: Ratings for individual sessions were all high, with no session being rated below 4 out of 5 (1 = 'totally disagree' to 5 = 'totally agree') on both days. The majority of patients (84%) and their partners (57%) responded to the follow-up. Many had used the information package distributed on the day. Some patients and their partners reported positive changes in RA management. Although patient knowledge did not increase significantly (medians 11 at both time points, p = 0.054) (Day 2), RA self-efficacy improved (baseline 11 and 14, respectively), suggesting that patients were more confident in managing their condition (p = 0.010). CONCLUSIONS: The development of this 'local' education and information intervention was carried out in line with Medical Research Council guidelines, and the lessons learned from Day 1 informed further development for Day 2. A one-day format for education of early RA involving the rheumatology MDT was rated highly by participants and warrants further examination. Although this study was a small 'local' intervention, its strengths are that it informs the possibility of wider developments of this kind using a MDT.

Regional review of patients with psoriatic arthritis in secondary care in the West Midlands: prevalence, disease activity and eligibility for anti-tumour necrosis factor therapy.

OBJECTIVES: Tumour necrosis factor alpha-blockers (TNF-alpha) are licensed for the treatment of psoriatic arthritis (PsA) and their use has been approved by the National Institute for Health and Clinical Excellence (NICE) for use in the United Kingdom under a set of defined clinical criteria. METHODS: In this out-patient study we evaluated PsA in rheumatology secondary care clinics in units across the West Midlands over a 2-week period, assessing prevalence, disease activity and eligibility for anti TNF-alpha treatment as defined by the NICE criteria. RESULTS: Of the 1718 forms returned from the 2000 sent (86% response rate), 175 patients had PsA (10.2%). Of those, 22 (12.6%) were already on anti TNF-alpha treatment. 12 patients were noted to have purely axial disease and as per the NICE guidelines should not be assessed under the PsA criteria. A further 5 patients fulfilled the criteria for treatment with anti TNF-alpha with no contraindications. In the region 22 out of 27 patients (81%) with active disease were correctly on Anti TNF therapy. In total 27 (15.4%) patients with PsA met the NICE criteria for treatment of PsA with anti TNF-alpha therapy. 3 patients had previously failed anti TNF-alpha treatment. No patient fulfilling criteria for treatment were found to have any contraindications to treatment. CONCLUSION: We note the relatively high proportion of PsA patients eligible for treatment with anti TNF-alpha blockers in the region (15.4%) compared to the NICE estimate (2.4%). This may be in part explained by a selection bias. However, the results may have significant implications for healthcare provision given the relatively high cost of anti-TNF-alpha agents. We comment on the limitations of such criteria and the effective use of regional collaboration for both training and audit purposes.

Accessibility and quality of secondary care rheumatology services for people with inflammatory arthritis: a regional survey.

Secondary care rheumatology services for patients with inflammatory arthritis (IA) in the West Midlands were audited using Arthritis and Musculoskeletal Alliance (ARMA) standards of care. Questionnaires were analysed from 1,715 patients in 11 rheumatology departments. ARMA standards recommend full multidisciplinary team assessment; referral rates to nurse specialists (52.3%), physiotherapists (48.7%) and occupational therapists (36.5%) were, however, lower than expected. Attendance at existing hospital-led education groups was rare (8.9%), awareness of existing helplines was moderate (59.2%) but the proportion of patients reporting satisfaction with advice about their disease was high (80.5%). Significant variations were found between departments. For patients with IA < 2 years (n = 236), 84.5% were seen by a rheumatologist within the ARMA standard of 12 weeks of referral; diagnosis of a type of IA was made at the first rheumatology appointment in 66.4%; 82.8% of rheumatoid arthritis patients had commenced disease-modifying drugs, although time to commencement varied across departments. This study raises issues regarding provision of rheumatology services, prioritisation of patient referral and patient education.

Audits of the prevention and treatment of corticosteroid-induced osteoporosis in outpatients with rheumatic diseases in the West Midlands.

The management of corticosteroid-induced osteoporosis in rheumatology outpatients in the West Midlands was audited in relation to the 2002 Royal College of Physicians (RCP) Guidelines and re-audited in relation to the 1998 National Osteoporosis Society (NOS) Guidance. Practice was assessed from prospective data on all follow-up patients over a 2-week period in 13 rheumatology units. Data were analysed on 2,609 patients. Of the 626 patients fulfilling criteria for assessment against the RCP Guidelines, 351 (56.1%) were treated appropriately. The results do not allow for availability of, or wait for, DEXA scanning. Of 197 patients fulfilling the criteria for assessment against the NOS Guidance, 137 (69.5%) were treated appropriately, compared to 63% in a similar audit undertaken in 2000. Regional audit may facilitate clinical governance. These audits will inform discussion on both improving local practice and strengthening cases for improved osteoporosis services.

Experience of six years of a regional peer review scheme in rheumatology.

OBJECTIVE: Following discussions on peer review by the British Society for Rheumatology, the West Midlands Rheumatology Service and Training Committee established a peer review scheme for the West Midlands in 1998. We report our initial 6 yr of experience, during which all 14 units have been visited. METHODS: A rotating programme of visits was organized. Following this first cycle of peer review, questionnaires were sent to all consultants and senior allied health professionals in each visited unit and to all members of each visiting team to evaluate the process. RESULTS: There was clear consensus amongst staff from both visited units and visiting teams that a peer review visit is worthwhile and constructive. It is a good opportunity for education and exchange of ideas between staff and to promote the multidisciplinary team in rheumatology. Most recommendations from the reports were considered necessary. The most frequent recommendations were for an increase in consultants and therapy staff. Appointing further consultants has been successful. Opinion was only divided on whether the reports were viewed seriously by Trusts, whether peer review should be regional or national, and how to accurately assess the quality, as well as the quantity, of care provided. Staff would support further cycles of peer review visits. CONCLUSIONS: This has been a successful initiative and a positive learning experience for all staff involved. Specifically, it helped to obtain more staff and secure facilities. We recommend developing this scheme and promoting it to other regions.

A regional audit of the use of COX-2 selective non-steroidal anti-inflammatory drugs (NSAIDs) in rheumatology clinics in the West Midlands, in relation to NICE guidelines.

OBJECTIVES: Whilst all non-steroidal anti-inflammatory drugs (NSAIDs) can cause adverse gastrointestinal events, COX-2-selective inhibitors (COX-2) may have improved gastrointestinal safety compared with non-selective NSAIDs (NSNSAIDs). In 2001, the National Institute for Clinical Excellence (NICE) published guidance on the use of the COX-2 agents celecoxib, rofecoxib, meloxicam and etodolac for rheumatoid arthritis (RA) and osteoarthritis (OA). This study aimed to audit the appropriateness of NSAID use in relation to NICE guidance in rheumatology out-patients. METHODS: Questionnaires were completed for all patients attending clinics in 18 rheumatology units in the West Midlands over a 2-week period. Data collected included patient demographics, NSAID type, indications, duration of use (> or =3 months was considered prolonged), and concomitant prescription of corticosteroids, warfarin and gastroprotective agents. RESULTS: Data were collected on 2846 patients; 1164 (41%) were taking NSAIDs (791 NSNSAIDs, 373 COX-2). Of the 1164 NSAID users, 753 (65%) had a diagnosis of RA or OA (483 NSNSAIDs, 270 COX-2). Overall, 37% of NSAID prescriptions were appropriate. Of the NSNSAID users, 92% had at least one risk factor for adverse gastrointestinal events and were therefore inappropriately treated. Prolonged use (in 89%) and age > or =65 yr (in 23%) were the most frequent risk factors identified. Of the COX-2 users, 97% had one or more risk factors and were appropriately treated. Analysis of the RA/OA subgroup revealed similar findings. Thirty-six per cent were taking NSAIDs appropriately; 97% of NSNSAID use was inappropriate and 97% of COX-2 use was appropriate treatment. In the whole cohort, gastroprotective agents were used in 26% of NSNSAID users, 56% of gastroprotective agents being proton pump inhibitors. CONCLUSIONS: Ninety-two per cent of patients attending rheumatology clinics who were taking NSNSAIDs should have been prescribed a COX-2-selective agent in relation to NICE guidance. Duration of use and age > or =65 yr emerged numerically as the most important risk factors. Significant numbers of patients taking NSNSAIDs may be at risk from adverse gastrointestinal events and clinicians may wish to review their prescribing patterns. Conversely, 97% of patients taking COX-2 agents were treated appropriately. Although practice overall conformed poorly with NICE guidance, NSAID prescribing also needs to be considered in the context of recent concerns regarding the cardiovascular risks of COX-2 agents.

The prevalence of patients with rheumatoid arthritis in the West Midlands fulfilling the BSR criteria for anti-tumour necrosis factor therapy: an out-patient study.

OBJECTIVES: There are currently two anti-tumour necrosis factor (anti-TNF) therapies licensed for treatment of rheumatoid arthritis (RA). A British Society for Rheumatology (BSR) working party defined criteria for patients that would be suitable for such treatment. The aim of this study was to determine the prevalence of these patients attending rheumatology out-patient departments across the West Midlands. METHODS: Data were collected over a 2-week period in adult out-patient departments of 12 centres. A questionnaire was completed at each patient review. Disease activity scores (DAS-28) were recorded for those who had failed methotrexate treatment and at least one other disease-modifying anti-rheumatic drug (DMARD) in the absence of contraindications to anti-TNF therapy. Information was also collected on the number of DMARDs failed and the use of steroid therapy. RESULTS: A total of 1441 patients with RA were assessed; 177 (12.3%) patients had failed methotrexate and at least one other DMARD. Of these, 19 had contraindications to the use of anti-TNF therapy. In the remaining 158 patients (11%), 80 (5.6%) had a DAS-28 score of >5.1, thus fulfilling BSR criteria for use of anti-TNF therapy. Those with a DAS-28 score of < or = 5.1 were significantly more likely to have been taking steroids compared with those with a DAS-28 score >5.1 (68.2 and 49.3%, respectively, P=0.024). CONCLUSIONS: Of patients with RA attending adult rheumatology out-patient clinics in the West Midlands, 5.6% would meet BSR criteria for use of anti-TNF therapy. Eligibility may be affected by steroid use.

A regional audit of the prevention and treatment of corticosteroid-induced osteoporosis in patients with rheumatic diseases in the West Midlands.

BACKGROUND: Audit is an important tool in clinical governance. Combining resources from across a region may facilitate data collection and allow variation in practice between individual units to be analysed. This audit is the first such regional audit to be carried out in rheumatology in the West Midlands and the organization and value of regional audit is discussed. This audit assessed the prevention and management of corticosteroid-induced osteoporosis (CIOP). METHODS: Adult patients attending rheumatology follow-up clinics in 10 units, during a 2-week period were assessed using the 1998 National Osteoporosis Society (NOS) guidance on the prevention and management of CIOP. The audit standard adopted was that 80% of eligible patients should be on appropriate therapy. RESULTS: Data was collected on 1766 (95.2%) of 1855 patients during the audit period. Two hundred and thirty-five (13.3%) were currently being prescribed or about to commence >or=7.5 mg daily of oral prednisolone for >or=6 months. Dual X-ray absorptiometry scans were performed in 102 patients (43.4%). Of these, 53 (52%) had a T score of -1.5 or below at the hip or spine. Of the 235 patients, 202 (86%) were receiving osteoporosis treatment. One hundred and forty-eight patients (63%) were receiving appropriate osteoporosis medication according to the NOS 1998 guidelines and 87 (37%) were inappropriately treated. Of these, 71 (81.6%) were under-treated and 16 (18.4%) were over-treated. CONCLUSIONS: Overall, the Region failed to meet the audit standard. The audit highlighted a number of differences and potential problems in the West Midlands with regard to CIOP which are currently being addressed by individual units and the West Midlands Rheumatology Services and Training Committee (WMRSTC). The Committee plan to re-audit in 2 yr.

Educational preferences, psychological well-being and self-efficacy among people with rheumatoid arthritis.

As a basis for developing interventions to meet the psycho-educational needs of rheumatoid arthritis (RA) outpatients attending a regional hospital have been investigated. Specifically, patients' preferences for interventions addressing education (e.g. the disease and its treatment), self-management (e.g. pain-management, exercise) and the consequences (e.g. emotions, impact on work, family relationships) of RA were examined. In addition, psychological well-being and self-efficacy were examined. Results showed that patients preferred education about the disease and its treatment to be delivered on a one-to-one basis by health professionals. Similarly, emotional issues were believed to be best dealt with one-to-one although this could be with a similar other (i.e. a patient). Group interventions were the preferred format for self-management, exercise and relationship issues, whereas videos were thought to be useful for demonstrating use of aids and how other families cope. None of the participants would welcome computer-based interventions. Psychological well-being (e.g. depression, anxiety) remained stable over a 12-month period. Both physical and psychological health status were correlated with arthritis self-efficacy. The implications of these findings are discussed in relation to development of interventions to better meet the psycho-educational needs of outpatients with RA.

Comparison of knowledge and psychological well-being between patients with a short disease duration (< or = 1 year) and patients with more established rheumatoid arthritis (> or = 10 years duration).

Patients with rheumatoid arthritis (RA) of short disease duration (i.e. < or = 1 year) compared with patients of longer disease duration (i.e. > or = 10 years) in terms of RA knowledge, symptoms of anxiety, symptoms of depression and disease acceptance. In addition, the predictors of psychological distress (i.e. symptoms of anxiety and depression) were examined. Data were collected by self-administered questionnaires. As expected, patients with more established disease were significantly older and had more physical dysfunction. However, there were no statistically significant differences on anxiety, depression, acceptance of illness, pain or knowledge about RA. The need for education regarding RA and its implications was expressed by all participants regardless of disease duration. Illness acceptance beliefs were identified as significant predictors of both anxiety and depression.

Abnormal regulation of interferon-gamma, interleukin-12, and tumor necrosis factor-alpha in human interferon-gamma receptor 1 deficiency.

Mycobacterial infections are critically controlled by interferon-gamma (IFN-gamma) and the cellular responses it elaborates, as shown by patients with mutations in the IFN-gamma receptor ligand-binding chain (IFN-gamma R1) who have disseminated nontuberculous mycobacterial infections. The immunologic sequelae of IFN-gamma R1 deficiency were characterized in 2 unrelated patients from the Indian subcontinent with novel homozygous recessive IFN-gamma R1 mutations. In vitro, these patients' peripheral blood mononuclear cells produced 10% of normal IFN-gamma and interleukin-12 (IL-12) in response to phytohemagglutinin (PHA) but normal amounts of IFN-gamma in response to PHA plus IL-12. Tumor necrosis factor-alpha (TNF-alpha) production was normal in response to endotoxin and to PHA but was not augmented by the addition of IFN-gamma. An abnormal phenotype was not found in heterozygous patient relatives. These patients demonstrate the critical role that the IFN-gamma receptor plays in the regulation of IFN-gamma, IL-12, and TNF-alpha.

Septic bone, joint and muscle lesions associated with human immunodeficiency virus infection.

Ten episodes of musculoskeletal sepsis have been seen in nine patients with HIV infection. Seven patients had AIDS, circulating CD4-positive lymphocyte counts being less than 0.1 x 10(9)/l in six. Septic arthritis recurred in seven patients, osteomyelitis in three and pyomyositis and bursitis each occurred in one patient. Staphylococcus aureus was isolated from four patients, atypical micro-organisms being found in three. Presentation of musculoskeletal infection in this patient group may be atypical but rapid diagnosis is important as early antimicrobial therapy is often successful.

Arthritis in the acquired immunodeficiency syndrome and other viral infections.

Musculoskeletal conditions occurring in individuals with human immunodeficiency virus infection are becoming increasingly well documented. Arthritis with features of Reiter's syndrome or psoriatic arthritis has been further studied; an association with HLA-B27 but not with HLA antigens chemically associated with psoriasis or psoriatic arthritis has been demonstrated. Human immunodeficiency virus has been identified in synovial fluid dendritic cells and in the synovium; immunohistochemical analysis is revealing the nature of the lymphocyte infiltrate in the synovium of affected individuals. Postmortem studies suggest that there may be histologic evidence of premature aging in clinically unaffected joints from patients with acquired immunodeficiency syndrome. Epidemiologic studies are needed to elucidate which rheumatic lesions occur as a direct consequence of human immunodeficiency infection and which may be chance associations.

Echocardiographic diastolic abnormalities of the left ventricle in inflammatory joint disease.

Echocardiographic early diastolic abnormalities have been shown recently in 50% of men with ankylosing spondylitis. Similar techniques were used to investigate subjects with rheumatoid arthritis and psoriatic arthritis with or without spondylitis. These subjects had no clinical, radiographic, or electrocardiographic evidence of cardiac or respiratory disease. Echocardiographic abnormalities seen resembled those of ankylosing spondylitis in that the interval between minimum left ventricular dimension and mitral valve opening was prolonged in 12 of 22 subjects with rheumatoid arthritis and in seven of 11 subjects with psoriatic arthritis. Isovolumic relaxation time was significantly prolonged in four subjects with rheumatoid arthritis and one with psoriatic arthritis. Unlike ankylosing spondylitis, however, there was consistent reduction in peak rate of left ventricular dimension increase in subjects with rheumatoid arthritis and psoriatic arthritis. In addition, the dimension increase during atrial systole was greater than normal in nine subjects with rheumatoid arthritis and two with psoriatic arthritis. The most likely cause of these abnormalities is increased connective tissue deposition in the myocardium.