Jill Firth

EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis

Objectives The authors aim to develop European League Against Rheumatism recommendations for the role of the nurse in the management of patients with chronic inflammatory arthritis, to identify a research agenda and to determine an educational agenda. Methods A task force made up of a multidisciplinary expert panel including nurses, rheumatologists, occupational therapist, physiotherapist, psychologist, epidemiologist and patient representatives, representing 14 European countries, carried out the development of the recommendations, following the European League Against Rheumatism standardised operating procedures. The task force met twice. In the first meeting, the aims of the task force were defined, and eight research questions were developed. This was followed by a comprehensive, systematic literature search. In the second meeting, the results from the literature review were presented to the task force that subsequently formulated the recommendations, research agenda and educational agenda. Results In total, 10 recommendations were formulated. Seven recommendations covered the contribution of nurses to care and management: education, satisfaction with care, access to care, disease management, psychosocial support, self-management and efficiency of care. Three recommendations focused on professional support for nurses: availability of guidelines or protocols, access to education and encouragement to undertake extended roles. The strength of the recommendations varied from A to C, dependent on the category of evidence (1A–3), and a high level of agreement was achieved. Additionally, the task force agreed upon 10 topics for future research and an educational agenda. Conclusion 10 recommendations for the role of the nurse in the management of chronic inflammatory arthritis were developed using a combination of evidence-based and expert consensus approach.

What influences the impact of pressure ulcers on health-related quality of life? A qualitative patient-focused exploration of contributory factors.

With the recognition of health-related quality of life (HRQL) as an important and relevant outcome in pressure ulceration, it is important to gain better understanding of the complex relationship among the various factors that affect it. A problem with existing literature in this area is that the impact of having a pressure ulcer on HRQL is combined conceptually with contributory factors which may influence outcome. This study identified contributory factors affecting pressure ulcer-related HRQL and explored interrelationships between factors based on views of adults with pressure ulcers. We obtained patient-reported qualitative data through semi-structured interviews with 30 patients with pressure ulcers recruited from hospital and community settings around England and Northern Ireland. Patients described how pressure ulcers affected their lives by recounting specific relevant events. Events (patient-reported issues) were sorted into categories and data framework analysed to produce a taxonomy of contributory factors. Inter-rater reliability established the extent of agreement between two independent raters. We identified 16 contributory factors, into two theme taxonomy: experience-of-care and individual-patient factors, defined by descriptive components. Our taxonomy is a comprehensive theoretical model of factors that contribute to pressure ulcer-related HRQL. We have also identified further research priorities to inform clinical practice.

The prevalence of foot ulceration in patients with rheumatoid arthritis

OBJECTIVE To establish the prevalence of foot ulceration in patients with rheumatoid arthritis (RA) in secondary care. METHODS A postal survey of all patients with RA (n = 1,130) under the care of rheumatologists in Bradford, West Yorkshire, UK was performed. The prevalence data were validated through clinical examination, case-note review, and contact with health professionals. The false-negative rate was investigated in a subsample of patients (n = 70) who denied any history of ulceration. RESULTS The postal survey achieved a 78% response rate. Following validation, the point prevalence of foot ulceration was 3.39% and the overall prevalence was 9.73%. The false-positive rate was initially high at 21.21%, but use of diagrammatic questionnaire data to exclude leg ulceration reduced the rate to 10.76%. The false-negative rate was 11.76%. The most common sites for ulceration were the dorsal aspect of hammer toes, the metatarsal heads, and the metatarsophalangeal joint in patients with hallux abducto valgus, with 33% of patients reporting multiple sites of ulceration. Patients with open-foot and healed-foot ulceration had significantly longer RA disease duration, reported significantly greater use of special footwear, and had a higher prevalence of foot surgery than ulcer-free patients. CONCLUSION Foot ulceration affects a significant proportion of patients with RA. Further work is needed to establish risk factors for foot ulceration in RA and to target foot health provision more effectively.

A realist logic model of the links between nurse staffing and the outcomes of nursing

Background: There has been a long-standing debate over the definition and nature of the quality of healthcare and factors that influence and enhance quality. Within nursing, the challenge is to identify the outcomes that are measurable and amenable to change as a result of nursing care. Arising originally from concerns over potential nurse staffing shortages and nurse retention within the United States, an extensive literature has developed in the acute sector, exploring nurse staffing and its consequences. All of these studies raise the generic question of what potential causal mechanisms might link nurse staffing levels and skill mix to issues of patient safety and outcome. Objectives: To generate a tentative logic model to understand existing findings and to elucidate possible ways in which nurse staffing and skill mix may affect patient and nurse outcomes. Methods: This study was grounded within the principles of realist evaluation, realist review and logic modelling. The existing literature was reviewed to bring to light the underlying rationale suggested by the authors of this study on how nursing care might affect patient outcomes. A step-by-step process was followed to demonstrate the generation of a tentative logic model of how nurse staffing might influence patient, and nursing, outcomes. Results: The final logic model depicts staffing adequacy as having a complex link with patient outcomes. This is mediated at a general level through factors in the process of care (for example, nurse surveillance, clinical judgement, level of education, level of nurse training and length of nursing experience) and tasks left undone. These operate in conjunction with working with other nurses who are clinically competent, having good nurse–physician relationships and communication, supportive nurse manager/supervisor and good teamwork. Conclusions: This study extends the understanding of the mechanisms through which nurse staffing levels may result in adverse patient outcomes in the acute sector. Key intervening variables are the application of nurse intuition, operation of clinical judgement and missed nursing care/tasks left undone. The tentative logic model can be used to draw up areas and hypotheses to guide the direction of future research and to aid interpretation of existing research.

A review of design and reporting issues in self-reported prevalence studies of leg ulceration

OBJECTIVE The aim of this review was to examine design and reporting issues that affect prevalence estimates of leg ulceration obtained using self-report and outline strategies to strengthen the validity and reliability of research in this area. STUDY DESIGN AND SETTING We identified leg ulcer prevalence studies and evaluated them against the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement. The authors draw upon the wider literature and their own empirical work in discussing strategies to overcome design and reporting issues. RESULTS Common deficiencies in the design and reporting of studies include wide variations in diagnostic criteria and age parameters for participant selection, a lack of description of efforts to address bias/study size rationale, and low participation rates in clinical examination stages. These factors and differences in statistical methods of analysis affect the validity and reliability of findings and hinder interpretation, making comparisons across populations difficult. Opportunities for subgroup analyses are frequently missed. CONCLUSION Self-report is a valuable means of capturing leg ulcer prevalence, but the future design and reporting of studies need to be strengthened, including addressing weaknesses in validation strategies. Capture-recapture analysis or a multiple-methods approach has the potential to yield the most valid and reliable prevalence estimates.

Experiences of Healthcare Provision for Foot Ulceration Occurring in People with Rheumatoid Arthritis

BACKGROUND Participants with rheumatoid arthritis (RA) report that foot ulceration has an impact on their health-related quality of life (HRQL) across physical, social and psychological domains. What is not known is how experiences of healthcare provision influence HRQL. The present study set out to map the patent journey while integrating the impact on HRQL. METHODS A purposive sample of RA patients with open foot ulceration was recruited from podiatry clinics in West Yorkshire (UK) between May 2008 and June 2009. Patients with diabetes were excluded (the impact of foot ulceration in this group is well established). In-depth interviews were taped and transcribed. A framework approach to data management was used to facilitate a case- and theme-based analysis. RESULTS Twenty-three RA patients (18 female, five male; aged 45-88 years) participated. Two themes and five sub-themes were identified. The patient journey theme comprised the following sub-themes: access to care; knowledge acquisition; care pathways and continuity of care. Patient-professional relationships comprised the sub-themes: therapeutic patient-professional relationships and task-orientated care. The journey took a highly variable course that was influenced by patient-specific factors (past experience of ulceration; symptomology; knowledge and self-efficacy); service-specific factors (access to care and care pathways) and professional-specific factors (knowing and trusting someone; holism). CONCLUSIONS The present study highlights the need for clearer care pathways for patients affected by foot ulceration improved patient education and better coordination of care.

AB1010 Achievement of Nice Quality Standards for Patients with New Presentation of Inflammatory Arthritis: Results from The Uk National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis

Background The national audit office reported variation in the quality of services for patients with Inflammatory Arthritis (IA) in the UK in 2009. The Health Quality Improvement Partnership funded a national audit to explore this further. Objectives We set out to assesses whether trusts in England & Wales are achieving the 7 quality standards (QS) published by the National Institute for Health & Care Excellence (NICE). Methods All individuals >16 years presenting to specialist rheumatology services in England & Wales with suspected new onset IA were recruited. Clinician & patient derived data were collected against all NICE QS over the 1st 3 months of specialist care. Results 6,354 patients were recruited nationally from 1 February 2014 to 31 January 2015. 94% of trusts/health submitted data. Patients were predominantly female (66%); white British (79%); and of working age (70%). At recruitment 46% had a diagnosis of Rheumatoid Arthritis (RA); 16% undifferentiated inflammatory arthritis (EIA). Only 17% of patients were referred by their general practitioner (GP) within 3 days of first presentation (QS1); median time interval 34 days. Over 25% waited >3 months. 12% of referrals had no indication that EIA was suspected. Specialist assessment occurred <3 weeks of referral for 38% (QS2). The median time interval was 4 weeks, >25% of patients waited >7 weeks. Higher staffing levels (>1 consultant/100,000 population) & the presence of EIA clinics were associated with shorter waiting times (odds ratio (95%CI) 1.3 (1.1–1.4) & 1.6 (1.4–1.7) respectively). Disease modifying anti-rheumatic drug (DMARD) initiation within 6 weeks of referral (QS3) was achieved in 53% of RA patients; 36% were treated with combination DMARDs & 82% with steroids. Clinicians reported that 59% of patients received structured education (QS4). Treat to target plans were set for 91% of patients. These targets were achieved in only 27% (QS5). Almost all trusts reported access to urgent advice (QS6) & incorporated annual review services (QS7). Conclusions This audit has enabled English & Welsh rheumatology services to measure their performance against NICE QS for the early management of IA & RA, benchmarked to regional & national comparators for the first time. The findings clearly demonstrate where improvement is needed. Delays in referral from primary care as well as delays in offering a first appointment in secondary care have been identified as key barriers to effective early arthritis care. Disclosure of Interest None declared

AB1117-HPR Evaluation of Patient Reported Outcome Data Following Persistent Musculoskeletal Pain Service Redesign

Background Persistent musculoskeletal pain (lasting >3 months) is common in the UK and Europe. Following an independent review of service provision, a person-centred, integrated pathway of bio-psychosocial care was commissioned in Oldham, UK. A stepped care model was introduced comprising a single point of access to multidisciplinary care including psychological medicine, prescribing advice and exercise classes. Objectives To evaluate improvements in pain reported by patient and clinicians discharged from the service and compliance with data capture in the first 6 months. Methods Outcome data was collected on all patients opting in between 1st June-30th November 2015 including Pain Self-Efficacy Questionnaire (PSEQ) and DoloTest scores on entry and discharge and Clinical Global Impression-Improvement scale (CGI-I) on discharge. PSEQ scores range from 0–60; lower scores reflect little/ no confidence in performing daily activities. DoloTest scores range from 0–800 with lower scores reflecting a lower impact on quality of life. CGI-I is a clinician assessment of patient improvement, scores range from 1–7, with low scores reflecting an improvement and high scores reflecting deterioration. Results 369 patients opted in throughout the 6 month period, of which 170 (46%) have been discharged. Mean PSEQ score on entry was 17.3 (n=163), which improved to 30.7 (n=50) on discharge. 86% had an improvement in their PSEQ scores with 60% benefiting from a clinically significant improvement. The mean improvement was a score of 17, the mean improvement of significantly improved patients was 22.2 points. Mean DoloTest score on entry was 546.5 and 431.3 on discharge. 70% had an improvement in their DoloTest results; mean improvement was 154 points. There is no available benchmark for a clinically significant improvement for DoloTest. 72% of patients assessed using CGI-I were scored as having very much or much improved.Table 1 On entry On discharge PSEQ scores – mean; median (range)  All patients with complete data, n=50 17.4; 15 (0–60) 30.7; 29 (4–58)  Improved patients, n=43 (86%) 14.7; 12 (0–50) 31.8; 29 (4–58)  No improvement, n=7 (14%) 33.9; 30 (9–60) 23.6; 17 (9–57)  Improvement ≥10 points 12.8; 8 (0–35) 35; 34 (18–58) DoloTest scores – mean; median (range)  All patients with complete data, n=37 522.5: 526 (191–751) 445.2; 427 (56–772)  Improved patients, n=26 (70%) 538; 520 (191–751) 384.1; 378 (56–725)  No improvement, n=11 (30%) 485.7; 366 (242–538) 589.5; 465 (266–772) 59 patients (35%) had missing discharge data. Reasons included patients failing to attend follow ups or opting out (46%), stepping up care up to secondary care provision for patients with complex needs (25%), and missing data, unknown (29%). 13 (8%) patients were discharged at first appointment therefore no follow up assessments were completed. Conclusions In all assessments, the majority of patients improved throughout their treatment. A change in PSEQ score around 10 is considered clinically significant. Of 7 patients with no improvement in PSEQ score, 2 scored <20 indicating their focus on pain could influence their willingness to engage in activity. Of the remaining 5 patients, 3 had high initial scores (>40) thought to be incongruent with requiring a pain management programme. Missing data affected the evaluation and qualitative work is being undertaken to understand the reasons for this and to inform strategies to increase data capture. Disclosure of Interest None declared