Mode of Hospital Rheumatology Appointments in People with Rheumatoid Arthritis: The Impact of the Pandemic in England

Background/Aims During the COVID-19 pandemic rheumatology services were advised to limit face to face contact, with remote telemedicine used instead. Although suitable for some people, issues have been highlighted with telemedicine. The frequency and proportion of remote appointments during the pandemic has not been described, or the socio-demographic characteristics of those accessing remote or in-person rheumatology care. This study aims to describe rheumatology healthcare utilisation and mode of appointment (remote/in-person) in people with rheumatoid arthritis (RA), prior to, and during the pandemic in England. Methods A retrospective prevalent cohort study of people with RA, identified using a validated algorithm, as of 1st April 2019 using electronic health record data (OpenSAFELY). Outpatient rheumatology appointments between 1st April 2019 and 31st March 2022 were identified. For each year, the number of outpatient appointments, mode of appointment (remote/in-person) and patient socio-demographic characteristics were described. Results 130,884 people with RA were identified. Since the start of the pandemic, the proportion of people without any appointments in a 12-month period increased from 28.5% in 2019/20 to 33.3% in 2020/ 21 and has not recovered. Older people were most frequently not seen (51% of people >80 years in 2020/21 and 2021/22). Of appointments where mode was known, 54.4% of people with appointments in the year from April 2020 were only seen remotely, reducing to 35.1% in the year from April 2021 (Table 1). The proportion with all remote appointments increased with increasing age, comprising 62% of people >80 years in 2020. This age gradient persisted in 2021, though proportions of those >80 years with all-remote appointments was lower (44%). Compared to urban dwellers, a higher proportion of those living in rural areas had all remote appointments in 2020 (58% vs 53%) and 2021 (38% vs 34%). Conclusion During the pandemic, one third of people with RA were not seen at all over a 12-month period and these were more frequently older people. Over half of people were only seen remotely in 2020, decreasing to one-third in 2021. Given the limitations of remote appointments it is unknown whether this increased frequency of remote appointments will impact long-term outcomes.

From virtual to hybrid: attendees' ideas for virtual conference improvements and future conferences

Background: COVID-19 forced conferences online, but with easing travel restrictions amid ongoing uncertainty, organisers have begun planning for hybrid (virtual and in-person) formats. Understanding attendees' needs and ideas will improve conference planning. Aim(s): To explore attendees' perspectives on virtual conference improvements and their ideas for the in-person and virtual components of future hybrid conferences. Method(s): An online survey was distributed to 16,888 attendees of an international virtual conference. Result(s): 823 (4.9%) surveys were completed. Frequently mentioned needs were technical improvements (n=77), greater interactivity between delegates (n=54) and fewer simultaneous sessions (n=38). 56% of respondents would prefer a hybrid format in future with virtual sessions held throughout the year and an in-person conference;33% prefer in-person and 11% prefer virtual formats alone. For in-person activity, respondents would prioritize clinical skills workshops (n=132), replication of previous traditional conference presentation formats (n=79) and debates (n=45). For virtual activity, respondents would prioritize having the virtual conference format similar to as conducted in 2021, (n=118), clinical case discussions (n=95) and topic review sessions (n=49). Conclusion(s): Attendees suggest technical improvements and greater interactivity as virtual conference improvements. Future conferences are preferred in a hybrid format, with a virtual component similar to the previous virtual congress and an in-person component including live clinical skills workshops.

BENEFITS OF POST-OPERATIVE SPECIALIST GERIATRIC CARE FOR OLDER PATIENTS UNDERGOING ELECTIVE ORTHOPAEDIC SURGERY

Background: The Covid-19 pandemic changed work practices across many different healthcare institutions. The difficulties with cross-site transfers created an opportunity in our institution to provide on-site post-operative rehabilitation for older patients undergoing elective orthopaedic surgery. The aim of this study is to assess the impact of post-operative specialist geriatric care on older patients. Methods: This is a single-centre, retrospective study that received approval from the local hospital ethics committee. Data were collected on all patients admitted to the on-site specialist rehabilitation unit post-elective orthopaedic surgery between 1st May 2020 and 31st December 2021. Two patients in this group were excluded as they had not attended a pre-operative assessment clinic. Data were collected from hospital Information Technology platform, Bluespiers. Results: 76 patients, 18 males and 58 females, were included in this study. The median age was 80 years. In the specialist rehabilitation unit, evidence of cognitive impairment was established in 40.79% of cases, there were 3 cases of newly diagnosed dementia, a history of falls was identified in 32.89% of patients and 13.16% of patients were found to have sarcopaenia. The median length of stay in the rehabilitation unit was 25 days. 51.32% of patients were discharged home independently, 23.68% of patients went home with a new Home-Care Package (HCP), 15.79% of patients were discharged home with an existing HCP, 6.58% of patients were transferred for further treatment and 2.63% patients were discharged to residential care units. Conclusion: This data demonstrates a clear role for specialist geriatric care in elective rehabilitation, with a significant proportion of patients being discharged home independently. The benefits of a comprehensive geriatric assessment in the peri-operative setting include increased identification of cognitive impairment allowing appropriate implementation of brain health as well as identification of a history of falls, enabling falls risk assessment and management including bone health assessment.

MONITORING OF METHOTREXATE BLOOD TOXICITY DURING THE COVID-19 PANDEMIC FOR PATIENTS WITH RHEUMATOID ARTHRITIS: DATA FROM THE GREATER MANCHESTER CARE RECORD

Background/Aims Current British Society for Rheumatology guidance suggests 3- monthly blood monitoring for patients prescribed methotrexate whose disease, drug dosage and blood results are stable, although evidence for this recommendation is limited. Anecdotal reports suggest monitoring may have reduced during the pandemic. The study aims were, in patients with rheumatoid arthritis (RA) prescribed methotrexate, to determine: 1) interval length between blood tests during the pandemic, and 2) whether prolonged intervals were associated with abnormal blood test results. Methods Data came from the Greater Manchester Care Record, a database containing electronic health records from both primary and secondary care for people across Greater Manchester. Inclusion criteria were: a diagnosis of RA;regular blood monitoring (<=91 days between blood tests) and regular methotrexate prescriptions in the year prior to the pandemic (01/03/2019-01/03/2020). Blood test intervals during the pandemic were determined, a prolonged interval was defined as>91 days. Cytopenia and transaminitis events were identified between March-December 2020 and March-December 2019 (as a comparator). Proportions of events are presented for each time-period and stratified by whether the interval was prolonged. Results 1011 patients met the inclusion criteria, with a median of 5 blood tests (interquartile range (IQR): 3-7) during the pandemic and a median interval of 57 days (IQR: 34-84). 612 (61%) patients had at least one prolonged interval, with 241 (23.8%) having multiple. Prolonged intervals had a median length of 112 days (IQR: 99-135). 115 (11.4%) people had a prolonged interval but no subsequent blood test before the study end date (median 120 days [IQR: 104-150]). The proportion of cytopenia and transaminitis events was low and similar across time-periods and when stratified by interval length (Table 1). Conclusion Nearly two-thirds of patients on stable methotrexate had at least one prolonged interval and 1 in 10 had a prolonged interval with no subsequent blood test. Initial analyses of test results do not indicate increased occurrence of methotrexate blood toxicity in those with prolonged blood test intervals during the pandemic. Further work is required to determine whether those with prolonged intervals represent a group at lower risk where less frequent blood tests would be appropriate.

Outcomes of COVID-19 infection among children and young people with pre-existing rheumatic and musculoskeletal diseases

Introduction: It remains unknown whether children and young people with rheumatic and musculoskeletal diseases (RMD) who acquire COVID-19 infection have a more severe COVID-19 course, due to either underlying disease or immunosuppressive treatments. Objectives: To describe outcomes among children and young people with underlying RMD who acquire COVID-19 infection. Methods: All children and young people <19 years of age with COVID-19 (presumptive or confirmed) reported to the EULAR COVID- 19 Database, which collects details regarding RMD diagnosis and treatment, COVID infection and outcomes, between 27 March 2020 and 9 April 2021 (cut-off date for this analysis) were included. Patient characteristics and COVID-19 outcomes are presented. Results: A total of 364 children and young people (age range 2-18 years;table) have been reported to the database from 17 countries;mostly France (N=71), Germany (N=71), Czechia (N=59), Spain (N= 50), Israel (N=60), and UK (N=25). Most patients had a diagnosis of juvenile idiopathic arthritis (JIA;N=244;67%). There were 20 (5%) hospitalisations and 1 death reported due to COVID-19. The most commonly reported symptoms were fever (40%) and cough (30%). Only 42 (12%) patients reported glucocorticoid use. Any DMARD therapy was used by 251 (69%) patients;161 (44%) were on csDMARDs, 119 (33%) on anti-TNF. 40% were in remission at time of COVID-19 infection, 28% in low, and 9% in moderate/high disease activity. Among those with hospitalisation data [N=290], patients on any DMARD therapy (cs/b/tsDMARDs) had similar odds for hospitalisation compared with those not on therapy, adjusted for age, sex, rheumatic disease, and disease severity (odds ratio 1.3;95% CI 0.3, 4.6). Conclusion: These initial data on outcomes of COVID-19 infection in paediatric RMDs are very reassuring, only one-in-twenty patients were reported to be hospitalised. Due to the database design and inherent reporting bias, this is likely an overestimate, suggesting that overall outcomes among this population appear to be generally good, with mild infection. Increasing case reports to the database will allow further exploration of drug- and disease-specific outcomes.

Outcomes of COVID-19 infection among children and young people with pre-existing rheumatic and musculoskeletal diseases

Background: It remains unknown whether children and young people with rheumatic and musculoskeletal diseases (RMD) who acquire COVID-19 infection have a more severe COVID-19 course, due to either underlying disease or immunosuppressive treatments. Objectives: To describe outcomes among children and young people with underlying RMD who acquire COVID-19 infection. Methods: All children and young people <18 years of age with COVID-19 (presumptive or confirmed) reported to the EULAR COVID-19 Database, which collects details regarding RMD diagnosis and treatment, COVID infection and outcomes, between 27 March 2020 and 29 January 2021 (cutoff date for this analysis) were included. Patient characteristics and COVID-19 outcomes are presented. Results: A total of 151 children and young people (age range 2-17 years;Table 1) have been reported to the database from 12 countries;mostly Spain (N=30), France (N=29), Israel (N=29), and Czechia (N=25). Most patients had a diagnosis of juvenile idiopathic arthritis (JIA;N=92;61%). Other diagnoses were autoinflammatory syndrome (including TRAPS, CAPS, FMF;12%), and systemic lupus erythematosus (4%). There were 14 (9%) hospitalisations and 1 (0.7%) death reported due to COVID-19. The most commonly reported symptoms were fever (46%), cough (34%), anosmia (19%), and headache (19%). Only 19 (13%) patients reported glucocorticoid use. DMARD therapy was used by 104 (69%) patients;67 (44%) were on csDMARDs (methotrexate [N=54], antimalarials [N=7]), 45 (30%) on anti-TNF, 9 (6%) on IL-6 inhibitors, and 7 (5%) on IL-1 inhibitors. Among the 145 patients with hospitalisation data, patients on any DMARD therapy (cs/b/tsDMARDs) had similar odds for hospitalisation compared with those not on therapy, adjusted for age (odds ratio 0.7;95% CI 0.2, 2.4). Conclusion: These initial data on outcomes of COVID-19 in paediatric RMDs are very reassuring, with less than 1 in 10 patients reporting hospitalisation. Due to the database design and inherent reporting bias, this is likely an overestimate, suggesting that overall outcomes among this population appear to be generally good, with mild infection. Increasing case reports to the database will allow further exploration of drug-and disease-specific outcomes.

Patient-reported symptom severity and pulse oximetry in the COVID-19 remote monitoring programme in ireland

Rationale: A total of 60,287 (1,267/100,000) cases of Covid-19 (SARS-CoV-2) were recorded in Ireland by 30 October 2020. An important strategy to free up in-hospital capacity was development of a remote monitoring platform to support at-home care or early discharge of lower-risk patients with mild/moderate Covid-19 symptoms. Methods: The monitoring platform consisted of a patient-facing app + pulse oximeter (Bluetoothconnected Nonin 3230) enabling patients to record symptoms (e.g. breathlessness, diarrhea;severity rated on a 10-point scale), temperature & oxygen saturation (SpO2). Patients were prompted to record measurement 4 times/day. Patient-recorded data was viewed in real time by their healthcare centre via a dedicated web-based monitoring portal. Criteria for remote monitoring included: Covid-19 symptoms, positive for SARS-CoV-2, young age, absence of serious concomitant conditions, need for continued observation post-discharge. Treatment centres emailed app installation instructions and supplied a pulse oximeter to their patients. Treatment centres & patients received alerts if pulse oximetry values crossed pre-defined thresholds. Results: Between 13 March and 31 October 2020, 1,045 patients at 8 primary & 15 secondary care centres had used the remote monitoring platform [median duration: 13 days (interquartile range 10-23 days)]. 11 patients were admitted to hospital and 12 previously hospitalized patients were readmitted. 933 patients (89%) gave consent to use of their pseudonymised data for research. Symptoms and physiological markers of severity of infection varied considerably. 871 patients recorded breathlessness data with 53 rating severity as 6/10 and 23 as 8/10. 300 patients recorded diarrhea data with 24 rating severity as 6/10 and 6 as 8/10 (see Figure). SpO2 data were available for 907 patients. 733 patients reported SpO2 94-96%, 334 reported SpO2 92-93%and 265 patients reported SpO2 ≤91% at least once during the monitoring period. Conclusions: Remote monitoring of Covid-19 in appropriate patients can free up in-hospital capacity. The majority of these patients were willing to provide pseudonymised data to support research on Covid-19. .