Jette Primdahl

Results from systematic screening for cardiovascular risk in outpatients with rheumatoid arthritis in accordance with the EULAR recommendations

Aim To investigate risk factors for the development of cardiovascular disease (CVD) and estimate the risk of cardiovascular death in rheumatoid arthritis (RA) patients in accordance with EULAR recommendations. Materials and methods Outpatients with RA ≤85 years of age from a Danish hospital were invited to participate. Patients’ risk of cardiovascular death was calculated according to the SCORE system, based on total cholesterol/high-density lipoprotein (HDL) ratio, smoking habits, blood pressure, age and gender. The SCORE was adjusted based on disease duration, IgM-RF/anti-CCP positivity and the presence of extra-articular manifestations. Factors such as history of CVD, hypertension or diabetes mellitus (DM), fasting glucose, exercise habits, body mass index (BMI) and waist circumference were explored. Results 836 patients participated; 71.5% women; mean (SD) age 64.3 years (12.0); 152 (19.1%) were already diagnosed with CVD and 74 (9.0%) with DM. Among the 644 patients without CVD or DM, 158 (24.5%) were smokers, 229 (35.8%) had a systolic blood pressure ≥140, 397 (65.6%) total cholesterol ≥5.0 mM/L, 326 (55.4%) low-density lipoprotein cholesterol ≥3.0 mM/L, 18 (4.0%) women and 19 (12.1%) men had a HDL-cholesterol level below 1.2/1.0 mM/L. BMI was >25 in 409 (63.8%). Waist circumference was above 80/94 cm in 297 (63.3%) of female and 111 (63.8%) of male patients, respectively, and 418 (64.9%) exercised ≤5 times a week. Among patients without DM, 14.3% had a fasting glucose ≥6.0 mmol/L. The SCORE was ≥5 in 122 (20.2%). They were referred to follow-up by their GP and community advice services. Conclusions Systematic screening revealed several risk factors that needed medical follow-up or support to initiate lifestyle changes.

Efficacy of embedded nurse-led versus conventional physician-led follow-up in rheumatoid arthritis: a systematic review and meta-analysis

Objective To compare the efficacy of embedded nurse-led versus conventional physician-led follow-up on disease activity in patients with rheumatoid arthritis (RA). Methods In a systematic literature search, we identified randomised controlled trials (RCTs) reporting on the efficacy of nurse-led follow-up on disease control in patients with RA compared with physician-led follow-up. Primary outcome was disease activity indicated by Disease Activity Score (DAS)-28. Secondary outcomes were: patient satisfaction, physical disability, fatigue, self-efficacy and quality of life. Outcomes were assessed after 1-year and 2 year follow-ups. Results Seven studies representing five RCTs, including a total of 723 participants, were included. All but one study included stable patients in low disease activity or remission at baseline. No difference in DAS-28 was found after 1 year (mean difference (MD) −0.07 (95% CI −0.23 to 0.09)). After 2 years, a statistically significant difference was seen in favour of nurse-led follow-up (MD −0.28 (95% CI −0.53 to −0.04)). However, the difference did not reach a clinically relevant level. No difference was found in patient satisfaction after 1 year (standard mean difference (SMD) −0.17 (95 % CI −1.0 to 0.67), whereas a statistical significant difference in favour of nurse-led follow-up was seen after 2 years (SMD: 0.6 (95% CI –0.00 to 1.20)). Conclusion After 1 year no difference in disease activity, indicated by DAS-28, were found between embedded nurse-led follow-up compared with conventional physician-led follow-up, in RA patients with low disease activity or remission.

OP0115 Clinical and radiological outcome in outpatients with rheumatoid arthritis followed by medical, nursing or shared care – a two year randomised controlled trial

Background Studies have indicated that follow-up by nursing consultations or different versions of shared care are not inferior to medical follow-up in controlling disease activity in patients with rheumatoid arthritis (RA) (1,2). Objectives To explore whether RA patients disease status, function and progression of erosions would differ depending on the type of follow-up care: 1) planned nursing consultations every three months, 2) shared care with no planned consultations but access to the General Practitioner and a nurse-led telephone help-line or 3) traditional rheumatologist initiated follow-up. Methods In a randomised controlled trial 287 adult outpatients in stable non-biological treatment, DAS-28<3.2, HAQ<2.5 and at least 18 months of disease duration were allocated to one of the three types of follow-up care for the following two years. DAS-28, HAQ, VAS-fatigue and pain were assessed at enrollment, one and two years follow-up. Clinical evaluation was performed yearly by a blinded investigator. Mixed effect models were used to examine the data. Progression of erosions in hands and feet from x-rays at baseline and two-years follow-up were explored in logistic regression analysis controlling for erosions and positive anti-CCP at baseline. Results Across all participants a significant increase was seen in DAS-28 (0.51, p<0.001), HAQ (0.086, p=0.012) and pain (4.26, p=0.019) from baseline till two-years follow-up. VAS-fatigue remained stable during the two years. No significant differences were seen between the groups in these outcome measures or in the number of participants with DAS-28>3.2 at two-year follow up (28 (29%), 19 (20%) and 17 (18%) of the participants in the medical, shared care and nursing group respectively). The odds ratio for progression on x-rays in the shared care and the nursing group did not differ from the medical group (shared care OR 0.56, p=0.264 (CI: 0.28-1.55), nursing group OR 1.03, p=0.945 (CI: 0.44-2.56)). There was no significant difference between the groups in the number of adverse events. Conclusions In patients with established RA and low disease activity it is considered to be safe to implement shared care and nursing consultations without differences in disease control compared to traditional medical follow-up. References [1] Hewlett S, Kirwan J, Pollock J, Mitchell K, Hehir M, Blair PS et al. Patient initiated outpatient follow up in rheumatoid arthritis: six year randomised controlled trial. BMJ 2005; 330(7484):171. [2] Hill J, Thorpe R, Bird H. Outcomes for patients with RA: A rheumatology nurse practitioner clinic compared to standard outpatient care. Musculoskeletal Care 2003; 1(1):5-20. Disclosure of Interest None Declared

Construction of meaningful identities in the context of rheumatoid arthritis, motherhood and paid work: a meta-ethnography

AIMS AND OBJECTIVES To derive new conceptual understanding about how women with rheumatoid arthritis manage their illness, motherhood and paid work, based on a comprehensive overview of existing knowledge, gained from qualitative studies. BACKGROUND Rheumatoid arthritis affects several social aspects of life; however, little is known about how women with rheumatoid arthritis simultaneously manage their illness, motherhood and paid work. DESIGN Qualitative metasynthesis. METHODS A qualitative metasynthesis informed by Noblit and Hares meta-ethnography was carried out, based on studies identified by a systematic search in nine databases. RESULTS Six studies were included. Social interactions in the performance of three interdependent subidentities emerged as an overarching category, with three subcategories: subidentities associated with (1) paid work, (2) motherhood and (3) rheumatoid arthritis. Pressure in managing one of the subidentities could restrict the fulfilment of the others. The subidentities were interpreted as being flexible, situational, contextual and competing. The women strove to construct meaningful subidentities by taking into account feedback obtained in social interactions. CONCLUSIONS The subidentities associated with paid work and motherhood are competing subidentities. Paid work is given the highest priority, followed by motherhood and illness is the least attractive subidentity. Because of the fluctuating nature of the illness, the women constantly reconstruct the three interdependent subidentities. RELEVANCE TO CLINICAL PRACTICE When healthcare professionals meet a woman with rheumatoid arthritis, they should consider that she might not accept the subidentity as an ill person. Health professionals should not expect that women will prioritise their illness in their everyday life. This could be included in clinical conversation with the women.

AB0328 Gender Differences in Risk Factors for Cardiovascular Disease in Outpatients with Rheumatoid Arthritis

Background People with rheumatoid arthritis (RA) have an increased risk for cardiovascular disease (CVD) [1,2]. Although male gender is generally associated with a greater risk for cardiovascular related mortality and death, there is, as yet, little knowledge of the impact of gender on the risk factors for CVD in patients with RA. Objectives To explore gender differences in the distribution of risk factors and in the risk factors that exceed national recommended levels in outpatients with RA. Methods We used data from the first 836 outpatients in a hospital population with RA screened in 30-minute nursing consultations according to the EULAR recommendations [1,2]. Risk factors, such as history of CVD, hypertension or diabetes mellitus (DM), smoking, fasting glucose, total, LDL, HDL cholesterol and Triglycerides, exercise habits, alcohol use, Body Mass Index (BMI) and waist circumference were explored. Logistic regression analyses were used to test for gender differences. Results Fewer female than male patients were diagnosed with CVD (OR 0.662; CI 0.452, 0.965; p=0.032) and there were no gender differences in those diagnosed with DM. In the 644 patients without CVD or DM, male patients were more likely to smoke, drink more alcohol than recommended (p<0.001), and to have higher blood pressure (p=0.026) and lower total cholesterol (p=0.006), but to have a higher total-cholesterol/HDL-cholesterol ratio (p<0.001) than female patients. More male patients than female patients displayed too low HDL-cholesterol levels (p=0.014). When comparing female and male patients, and taking the deviations from the recommended levels for the different risk factors into account, female patients had a small but significantly lower risk for elevated blood pressure (OR 0.987) but a higher risk for an increase in waistline above the recommended limits than the male patients (OR 1.023). In addition, female patients had a lower odds ratio (OR 0.681) for an increase in fasting glucose compared to male patients. Conclusions In clinical practice, we need to be aware of gender differences in risk factors for development of CVD in order to target interventions. References Peters, M.J., et al., EULAR evidence-based recommendations for cardiovascular risk management in patients with rheumatoid arthritis and other forms of inflammatory arthritis. Ann Rheum Dis, 2010. 69(2): p. 325-31. Primdahl J, Clausen J, Hørslev-Petersen K. Results from implementation of systematic screening for cardiovascular risk according to the EULAR recommendations in outpatients with rheumatoid arthritis. Ann Rheum Dis 2013; 72: 11:1771-6 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2828

Mortality and its predictors in patients with rheumatoid arthritis: a Danish population-based inception cohort study.

Objectives: To investigate mortality and its predictors in a retrospectively defined population-based rheumatoid arthritis (RA) inception cohort Method: We included patients ascertained with incident RA from a region in the southern part of Denmark from 1995 to 2002. All patients fulfilled the 1987 American College of Rheumatology criteria for RA. The patients were followed from RA classification until death, emigration, or end of follow-up on 31 December 2013. We used personal record linkage with national public registers to obtain information on education, employment, cohabitation, comorbidity, and vital status. Results: The cohort comprised 509 patients, of whom 200 (39%) died during 6079 person-years. The most frequent underlying causes of death were cardiovascular disease (34%), neoplasms (26%), and respiratory disease (12%). In rheumatoid factor (RF)-positive males, the standardized mortality ratio (95% confidence interval) from all causes was 1.47 (1.15–1.88), from cardiovascular disease 1.63 (1.09–2.46), from respiratory disease 2.03 (1.06–3.90), and from neoplasms 2.26 (1.02–5.03) in the age group < 70 years, and 2.45 (1.23–4.90) in the age group > 79 years. On applying Cox models after multiple imputations by chained equations, we found that RF modified the effect of age. Employment status, comorbidity, and gender were independent baseline predictors of subsequent mortality. Conclusion: In this cohort, significant excess mortality was confined to RF-positive males. The effect of age was modified by RF, and employment status and comorbidity were independent predictors of mortality.

Impact of patient-reported flares on radiographic progression and functional impairment in patients with rheumatoid arthritis: a cohort study based on the AMBRA trial

Objective: To investigate the impact of patient-reported flares on radiographic damage and disability in rheumatoid arthritis (RA). Method: Patients with low-active (Disease Activity Score based on 28-joint count with C-reactive protein < 3.2) RA were followed for 2 years. Based on annual questionnaires about incidence of flares, three ‘flare phenotypes’ were distinguished: no flares (NF), transient flares (TF), and a mixed category reporting persistent joint complaints (PJC) in at least one year. Baseline and 2 year radiographs of hands and feet were evaluated according to the Sharp/van der Heijde method. Major outcomes were change from baseline in Total Sharp Score (ΔTSS) and functional impairment, expressed by the Health Assessment Questionnaire (ΔHAQ). Their association with flare phenotype was analysed by logistic regression. Results: The study included 268 RA patients (70% female; 73% immunoglobulin M rheumatoid factor positive), with a median age (interquartile range) of 63 (55–70) years, and 7 (4–13) years’ disease duration. Flares were recalled as NF (n = 77), TF (n = 141), and PJC (n = 50). ΔTSS > 0 was observed in 35%, 37%, and 46%, respectively (p = 0.42), but statistically significantly (p = 0.01) more patients progressed in the TF (10%) and PJC (14%) compared to NF (0%), based on the smallest detectable change (> 4.4 ΔTSS unit). ΔHAQ above the minimal clinically important difference (> 0.22) was seen in 13% (NF), 21% (TF), and 40% (PJC) (p = 0.0015), with PJC being associated with statistically significant impairment in function (odds ratio 4.47, 95% confidence interval 1.87–10.69) compared to NF. Conclusion: In RA patients with low disease activity, the incidence of radiographic progression and functional impairment was higher in patients with flares and persistent complaints, compared to those without flares.

Juggling identities of rheumatoid arthritis, motherhood and paid work – a grounded theory study

Abstract Purpose: To explore how women with rheumatoid arthritis manage their illness, motherhood, and work life. Methods: A constructivist, grounded theory approach based on individual interviews and participant observations with 20 women with rheumatoid arthritis who participated in work life and had children living at home or were pregnant. After initial and focused coding Goffman’s concepts of social identity were applied. Results: A core category: “Juggling meaningful identities” and three conceptual categories were developed: (1) Work life as the strongest identity marker; (2) Motherhood: a two-sided act; (3) Living with rheumatoid arthritis as an identity? Paid work, motherhood, and illness are linked to the women’s social identities. The women construct and change their identities in interactions with children, partners, other parents, colleagues, and employers. Conclusion: The women attribute the highest priority to their professional identity, spending the majority of their time and energy in an effort to appear as “good stable workers”. The disease is seen as a hindrance in this regard, and the illness identity is almost completely rejected. In motherhood, the women prioritize close interaction with their children, and deprioritize external activities. Extended outbreaks of the disease and issues regarding the children force the women to deprioritize working life. Implications for rehabilitation Juggling meaningful identities of rheumatoid arthritis, motherhood, and paid work challenge women in managing their everyday lives. Therefore, rehabilitation professionals should support individuals to develop new strategies to manage the challenges they experience regarding juggling motherhood and work ability. Work is a dominant identity marker for women with rheumatoid arthritis therefore, rehabilitation professionals have an important role to play in investigating possible ways for the individual to maintain employment or return to work. Living with rheumatoid arthritis and being a paid worker challenge women’s role performance and thereby their identification as mothers. Therefore, rehabilitation professionals have to support the women and their families.

Nurse-led screening: changes in cardiovascular risk profile and association to socio-economic status in outpatients with inflammatory arthritis.

Background: Persons with inflammatory arthritis have an increased risk for cardio-vascular (CV) disease and screening is therefore recommended (1) Objectives: To investigate changes in the patient’s risk for CV disease and whether risk reduction was associated with socio-economic status in a hospital population of outpatients with inflammatory arthritis (IA) (rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS)) Methods: Outpatients with IA ≤85 years of age connected to King Christian X’s Hospital for Rheumatic Diseases in Graasten, Denmark, who had participated in a 30-minute nurse-led screening consultation (SC) (2) based on the EULAR recommendations between July 2012 and July 2015 were included. During the SC the patients’ risk for cardiovascular death was calculated according to the SCORE system (3). Elements of motivational interviewing were used. Data was entered in a national rheumatology quality database, DANBIO, and combined with national registers. Whether socio-economic status influenced changes in risk factors from first to second screening consultation was explored in simple logistic regression analyses for each risk factor including the socio-economic variables sex, age, marital status, education, and income separately one at a time Results: A total of 1266 patients, 18–85 years of age, were included; 72.5% with RA and 27.5% with AS or PsA. 447 patients had high risk (≥5% risk) for CV death in 10 years and 819 had low to moderate risk (<5%). Number of patients achieving relevant changes from the first to the subsequent yearly or biannual screening consultation, are reported for high and low risk patients in table 1. For all the patients, female gender significantly decreased the odds for increased exercise frequency (OR, [CI], p-value) (0.40[0.17; 0.92], 0.0320), being single decreased the odds of reduced BMI (0.57[0.32; 0.99, 0.0472] and age ≥65 years increased the odds of a normalization of SBP (2.13[1.30; 3.50], 0.0027). In high risk patients, higher education (1.94[1.05; 3.57], 0.0338) and higher income (2.07[1.00; 4.28], 0.0508) increased the odds off a normalization of SBP although not significant, we include this effect based on the confidence interval not including any values indicating a decreased oddsTable 1 Changes in CV risk profile from first to subsequent screening consultation for high and low risk patients Conclusions: Clinically relevant reductions in CV risk factors were seen after SC for CV risk in both high and low risk patients. Surprisingly female patients improved their exercise habits less often than male patients did. Older age increased the odds to reach a normal SBP. In high-risk patients, education and income positively influenced the odds to reduce SBP to normal References 1. Agca R, et al. Ann Rheum Dis. 2017Jan;76(1):17–28. 2. Primdahl J, et al. Ann Rheum Dis2013; 72(10):1771–1776. 3. Conroy R, et al. 2003;24(11):987–1003. Disclosure of Interest: None declared

AB1455-HPR The experience of living with fatigue among people with rheumatoid arthritis – a qualitative meta-synthesis

Background People with Rheumatoid Arthritis (RA) experience fatigue as the most significant symptom of their illness. Despite a substantial body of knowledge about fatigue, there is a need for an overall comprehensive understanding of the experience of living with fatigue among people with RA Objectives To identify, appraise and synthesise qualitative studies on experiences of living with fatigue in people with RA Methods We conducted a qualitative meta-synthesis, inspired by Sandelowski and Barroso1. This included a systematic literature search conducted in February 2017, for studies published in the past 15 years, in the databases PubMed, Cinahl, Embase, SveMed, PsychInfo and Web of Science. To be included the studies had to include findings regarding the experience of adults with RA living with fatigue. The international Critical Appraisal Skills programme was used to assess the quality. The analysis and synthesis were inspired by Malterud’s systematic text condensation2 Results Eight qualitative articles were included. The synthesis resulted in an overall theme ‘fatigue: the vicious cycle of an unpredictable symptom’. In addition, the analysis derived five subthemes, ‘being alone with fatigue‘, ‘necessary prioritising in everyday life’, ‘when time gets a different meaning’, ‘language as a tool for increased understanding’ and ‘strategies to manage fatigue’. Fatigue affects all areas of everyday life for people with RA. They strive to plan and prioritise, pace, relax and rest. In addition, they try to make use of a variety of words and language to help others understand that the RA-related fatigue they experience is not ‘normal’ fatigue. People with RA-related fatigue experience feeling alone with their symptom, but they develop their own strategies to manage fatigue in their everyday life Conclusions The unpredictability of RA-related fatigue is dominant, pervasive and is experienced as a vicious cycle, which can be described in relation to its physical, cognitive, emotional, social and behavioural impact. Acknowledgement and support from health professionals can make a difference to people with RA-related fatigue References [1] Sandelowski, M & Barosso, J. 2007: Handbook for synthesizing qualitative research. New York, Springer. [2] Malterud, K. 2012: Systematic text condensation: a strategy for qualitative analysis. Scand J Public Health, 40, 795–805 Disclosure of Interest None declared