Lindsey Cherry

The prevalence of self-reported lower limb and foot health problems experienced by participants with systemic lupus erythematosus: Results of a UK national survey:

Objective The main aim of this survey was to determine the frequency of self-reported lower limb or foot and ankle complications experienced by participants with systemic lupus erythematosus (SLE). A secondary aim was to determine the frequency of treatments that have been received or that participants with SLE may like to receive if offered. Method A quantitative, cross-sectional, self-reported survey design was utilized. The developed survey was checked for face and content validity prior to patient partner cognitive debriefing in order to ensure usability, understanding of the process of completion and of the questions posed. The full protocol for survey development has been published previously. Results This is the first comprehensive national UK survey of lower limb and foot health problems reported by participants with SLE. A high prevalence of vascular, dermatological and musculoskeletal complications was reported by survey respondents. Additionally, whilst the relative prevalence of sensory loss was low, a quarter of people reported having had a fall related to changes in foot sensation demonstrating a previously unknown rate and cause of falls. Conclusion Complications related to vascular, dermatological and musculoskeletal health are identified as particularly prevalent in participants with SLE. Further, there is a suggestion that the provision of interventions to maintain lower limb health is highly varied and lacks national standardization, despite there being a strong indication of participant reported need. The findings of this work can be used to inform care guideline development in addition to identifying areas for future research.

National variation in the composition of rheumatology multidisciplinary teams: a cross-sectional study

The objective of this study is to describe the composition of multidisciplinary teams (MDT) working within rheumatology departments across the UK. All rheumatology departments in the United Kingdom (UK) were invited to participate in a national electronic survey between February 2014 and April 2015 as a part of a national audit for the management of rheumatoid and early inflammatory arthritis commissioned by Healthcare Quality Improvement Partnership. Rheumatology departments were asked to report their MDT composition; defined as a rheumatologist (consultant or specialist trainee), specialist nurse, occupational therapist physiotherapist, and podiatrist. The data were collected as Whole Time Equivalent (WTE) of each professional group at each department adjusted to 100,000 population. The data were grouped according to British Society for Rheumatology regions to study regional variations. The survey was completed by 164/167 departments (98% response rate). All departments reported an MDT comprising a rheumatologist (consultant or specialist trainee) and almost all included a specialist nurse but only 28 (17%) of the departments had MDTs comprising all the professional groups. There was a high degree of regional variation in the provision of Allied Health Professionals (physiotherapists, occupational therapists, and podiatrists) in the UK. MDT care is recommended for the management of inflammatory arthritis, but few UK rheumatology departments have a full complement of healthcare professionals within their MDT. There is a high degree of regional variation in the composition and staffing levels of the rheumatology MDT across the UK; the impact of which warrants further investigation.

Patients’ experiences of lupus-related foot problems: a qualitative investigation

Background Systemic lupus erythematosus (SLE) can present with a variety of symptoms. Previous research has shown there is a high prevalence of lower limb and foot problems in patients with SLE associated with the musculoskeletal, vascular and neurological changes. Furthermore, there is a high prevalence of infections affecting the feet and a range of common skin and nail problems. However, it is not known how these foot problems impact upon people’s lives. Therefore, we aimed to explore this using a qualitative approach. Method Following ethical approval, 12 participants were recruited who had a diagnosis of SLE, current and/or past experience of foot problems and were over 18 years in age. Following consent, interviews were carried out with an interpretivist phenomenological approach to both data collection and analysis. Results Seven themes provide insight into: foot problems and symptoms; the impact of these foot problems and symptoms on activities; disclosure and diagnosis of foot problems; treatment of foot problems and symptoms; perceived barriers to professional footcare; unanswered questions about feet and footcare; and identification of the need for professional footcare and footcare advice. Conclusion These participants tend to “self-treat” rather than disclose that they may need professional footcare. A lack of focus upon foot health within a medical consultation is attributed to the participant’s belief that it is not within the doctor’s role, even though it is noted to contribute to reduced daily activity. There is a need for feet to be included as a part of patient monitoring and for foot health management to be made accessible for people with SLE.

Identifying the primary outcome for a randomised controlled trial in rheumatoid arthritis: the role of a discrete choice experiment

BackgroundThis study sought to establish the preferences of people with Rheumatoid Arthritis (RA) about the best outcome measure for a health and fitness intervention randomised controlled trial (RCT). The results of this study were used to inform the choice of the trial primary and secondary outcome measure.MethodsA discrete choice experiment (DCE) was used to assess people’s preferences regarding a number of outcomes (foot and ankle pain, fatigue, mobility, ability to perform daily activities, choice of footwear) as well as different schedules and frequency of delivery for the health and fitness intervention. The outcomes were chosen based on literature review, clinician recommendation and patients’ focus groups. The DCE was constructed in SAS software using the D-efficiency criteria. It compared hypothetical scenarios with varying levels of outcomes severity and intervention schedule. Preference weights were estimated using appropriate econometric models. The partial log-likelihood method was used to assess the attribute importance.ResultsOne hundred people with RA completed 18 choice sets. Overall, people selected foot and ankle pain as the most important outcome, with mobility being nearly as important. There was no evidence of differential preference between intervention schedules or frequency of delivery.ConclusionsFoot and ankle pain can be considered the patient choice for primary outcome of an RCT relating to a health and fitness intervention. This study demonstrated that, by using the DCE method, it is possible to incorporate patients’ preferences at the design stage of a RCT. This approach ensures patient involvement at early stages of health care design.

The reliability of a novel magnetic resonance imaging-based tool for the evaluation of forefoot bursae in patients with rheumatoid arthritis: the FFB score

OBJECTIVE The aim of this study was to determine the reliability of an MRI-based score that evaluates forefoot bursae (FFBs) in patients with RA. METHODS Items for inclusion, grading criteria and MRI sequences were determined iteratively. The score was evaluated in 30 patients with established RA. Reader agreement was evaluated using the percentage of exact/close agreement, Bland-Altman plots, kappa and intraclass correlation coefficient analyses. RESULTS The FFB score assesses nine forefoot regions and contains four items: presence, shape, enhancement and magnetic resonance characteristics. The FFB score showed moderate to good intra- and interreader agreement (κ range = 0.5-0.9 and 0.47-0.87, respectively). CONCLUSION The FFB score is adequately reliable in the evaluation of bursa-like lesions of the forefoot in patients with RA.

Survey of ultrasound practice amongst podiatrists in the UK

BackgroundUltrasound in podiatry practice encompasses musculoskeletal ultrasound imaging, vascular hand-held Doppler ultrasound and therapeutic ultrasound. Sonography practice is not regulated by the Health and Care Professions Council (HCPC), with no requirement to hold a formal qualification. The College of Podiatry does not currently define ultrasound training and competencies.This study aimed to determine the current use of ultrasound, training received and mentorship received and/or provided by podiatrists using ultrasound.MethodsA quantitative study utilising a cross-sectional, on-line, single-event survey was undertaken within the UK.ResultsCompleted surveys were received from 284 podiatrists; 173 (70%) use ultrasound as part of their general practice, 139 (49%) for musculoskeletal problems, 131 (46%) for vascular assessment and 39 (14%) to support their surgical practice. Almost a quarter (n = 62) worked for more than one organisation; 202 (71%) were employed by the NHS and/or private sector (n = 118, 41%).Nearly all (93%) respondents report using a hand-held vascular Doppler in their daily practice; 216 (82%) to support decisions regarding treatment options, 102 (39%) to provide diagnostic reports for other health professionals, and 34 (13%) to guide nerve blocks.Ultrasound imaging was used by 104 (37%) respondents primarily to aid clinical decision making (n = 81) and guide interventions (steroid injections n = 67; nerve blocks n = 39). Ninety-three percent stated they use ultrasound imaging to treat their own patients, while others scan at the request of other podiatrists (n = 28) or health professionals (n = 18). Few use ultrasound imaging for research (n = 7) or education (n = 2).Only 32 (11%) respondents (n = 20 private sector) use therapeutic ultrasound to treat patients presenting with musculoskeletal complaints, namely tendon pathologies.Few respondents (18%) had completed formal post-graduate CASE (Consortium for the Accreditation of Sonographic Education) accredited ultrasound courses.Forty (14%) respondents receive ultrasound mentorship; the majority from fellow podiatrists (n = 17) or medical colleagues (n = 15). Over half (n = 127) who do not have ultrasound mentorship indicated they would like a mentor predominantly for ultrasound imaging. Fifty-five (19%) report they currently provide ultrasound mentorship for others.ConclusionsUnderstanding the scope of ultrasound practice, the training undertaken and the requirements for mentorship will underpin the development of competencies and recommendations defined by the College of Podiatry to support professional development and ensure safe practice.

Variation in the provision and composition of multidisciplinary teams in rheumatology services across the UK: A cross-sectional study

Background Care by the multidisciplinary team (MDT) is recommended by the current treatment guidelines in the UK and elsewhere in Europe. In rheumatology the evidence to support the effectiveness of multidisciplinary working is limited.1,2 Furthermore, the availability of all members of the MDT in rheumatology teams across the UK is unclear. Objectives To describe the national provision of MDT care within Rheumatology services across the UK. Methods This was a “service” survey conducted in all rheumatology departments within the UK. In England, the survey was a part of a broader national audit for rheumatoid and early inflammatory arthritis commissioned by Healthcare Quality Improvement Partnership (HQIP). The approval to undertake this sub-analysis was gained from HQIP and supported by the British Society for Rheumatology research committee and British Health Professionals in Rheumatology. Scotland and Northern Ireland were not included in the national audit therefore a separate, but identical, survey was conducted. The design of the service survey content was agreed in consultation with the BHPR committee, which is formed of health professionals with clinical and research experience in rheumatology. The survey collected organisation data regarding the specific inclusion of, or direct access to, medical, nursing, physiotherapy, podiatry and occupational therapy practitioners as part of the MDT. Detail regarding the whole time equivalent (WTE) availability of each named speciality was recorded and summarised by region. Results The survey response rate was 98% (164/167). Table 1 shows the overall rheumatology staffing levels measured in WTE between professional groups. All departments reported having medical staff present and almost all had a nurse but the inclusion of physiotherapists, occupational therapists and podiatrists in the MDT was variable. Only 48% of the teams surveyed had access to a podiatrist. There was a high degree of regional variation in the provision of health professionals and only 28 (17%) of the surveyed teams had all the named professional groups represented in their multidisciplinary teams.Table 1. Overall rheumatology MDT staffing levels between professional groups Profession Adjusted mean* SD Range Represented within MDT WTE Y/N (%) Medical 1.05 0.62 0.70–3.09 164 (100) Medical trainee 0.32 0.08 0.22–0.54 132 (80) Nursing 0.99 0.34 0.51–1.55 162 (99) Physiotherapy 0.30 0.14 0.00- 0.60 120 (73) Occupational therapy 0.28 0.11 0.15–0.52 123 (75) Podiatry 0.11 0.06 0.00–0.20 79 (48) *Adjusted to per 100,000 population. Conclusions There is a high degree of regional variation in the composition and staffing levels of the Rheumatology MDT across the UK. Further research is required determine the most efficient configuration of the MDT in rheumatology services. References Martínez-González NA, Berchtold P, Ullman K, et al. Integrated care programmes for adults with chronic conditions: a meta-review. Int. J. Qual. Health Care 2014;26(5):561–70. Bearne LM, Byrne AM, Segrave H, et al. Multidisciplinary team care for people with rheumatoid arthritis: a systematic review and meta-analysis. Rheumatol. Int. 2015;doi:10.1007/s00296-015-3380-4. Disclosure of Interest None declared