Healthcare systems and the sciences of health professional education.

Health professions education is that part of the education system which applies educational philosophy, theory, principles and practice in a complex relationship with busy clinical services, where education is not the primary role. While the goals are clear-to produce the health workforce that society needs to improve health outcomes-both education and healthcare systems continue to evolve concurrently amidst changes in knowledge, skills, population demographics and social contracts. In observing a significant anniversary of this journal, which sits at the junction of education and healthcare systems, it is appropriate to reflect on how the relationship is evolving. Health professions educators must listen to the voices of regulators, employers, students and patients when adapting to new service delivery models that emerge in response to pressures for change. The recent COVID-19 pandemic is one example of disruptive change, but other factors, such as population pressures and climate change, can also drive innovations that result in lasting change. Emerging technology may act as either a servant of change or a disruptor. There is a pressing need for interdisciplinary research that develops a theory and evidence base to strengthen sustainability of change.

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.

Beneficial effects of a 3-week course of intramuscular glucocorticoid injections in patients with very early inflammatory polyarthritis: results of the STIVEA trial.

OBJECTIVE: To evaluate whether treating patients with very early inflammatory polyarthritis (IP) with a 3-week course of intramuscular (IM) methylprednisolone acetate may postpone the need for disease-modifying antirheumatic drugs (DMARDs) and prevent IP from evolving into rheumatoid arthritis (RA). METHODS: Patients with very early IP (4-10 weeks' duration) were randomised to receive three injections of either 80 mg IM methylprednisolone acetate or placebo, given at weekly intervals. Assessments were monthly until 6 months after the first injection, and then concluded at 12 months. The primary outcome was the need to start DMARDs by the 6-month assessment. Secondary outcomes included disease activity and final clinical diagnosis by the rheumatologist at 12 months. RESULTS: Patients in the placebo group (76%) were more likely to need DMARDs during the first 6 months of the trial than patients in the glucocorticoid group (61%) (adjusted OR = 2.11, 95% CI 1.16 to 3.85, p = 0.015). Disease activity did not differ between the two groups at 12 months, probably because many patients in the placebo group started DMARDs early in the study. After 12 months, the arthritis had resolved without the need for DMARDs in 9.9% (11/111) of the patients in the placebo group and in 19.8% (22/111) in the glucocorticoid-treated group (adjusted OR = 0.42, 95% CI 0.18 to 0.99, p = 0.048). CONCLUSION: Treatment of patients with very early IP with IM methylprednisolone acetate appears to postpone the prescription of DMARDs and prevent one in 10 patients from progressing into RA.

A survey of rheumatology nurse specialists providing telephone helpline advice within England and Wales.

OBJECTIVE: To characterize provision of telephone helpline services in rheumatology units in England and Wales. METHODS: A questionnaire study of rheumatology nurse specialists (RNS) providing advice by a designated telephone helpline in England and Wales. RESULTS: Responses were obtained from 164/185 rheumatology units (89%). Of the responding units, 154 (94%) employed RNS and 146 units provided telephone advice either by Allied Health Professionals or RNS. A total of 135 units confirmed that only RNS gave telephone advice via a designated helpline. Completed questionnaires were analysed from 126 RNS working in 121 rheumatology units with a designated telephone helpline. Most RNS implemented both a manned and answerphone helpline service. The average number of calls varied from <10 to >100 per week. Fifty-six percent of RNS had performed an audit of the service. Twenty-four percent possessed helpline protocols or standards. RNS' rheumatology experience ranged from 4 months to 25 yrs. Seventy-five percent had undertaken post registration study. Three out of 126 RNS reported having specific training in giving telephone advice and 25% had received in-house training or supervision. Seventy-eight percent had not been assessed in providing this service. CONCLUSIONS: The telephone helpline is an established service in many rheumatology units. Provision varies throughout England and Wales and a lack of protocols, formal training and assessment in giving telephone advice is common. This prompted the Royal College of Nursing Rheumatology Forum to form a working party to compile a guidance document for nurses and practitioners providing telephone advice.

Factorial randomised controlled trial of glucocorticoids and combination disease modifying drugs in early rheumatoid arthritis.

OBJECTIVE: Treating early active rheumatoid arthritis (RA) with disease modifying antirheumatic drug (DMARD) monotherapy achieves incomplete outcomes and intensive treatment seems preferable. As the relative benefits of combining two DMARDs, one DMARD with glucocorticoids and two DMARDs with glucocorticoids are uncertain we defined them in a factorial trial. METHODS: A 2-year randomised double-blind factorial trial in patients with RA within 2 years of diagnosis treated with methotrexate studied the benefits of added ciclosporin, 9 months intensive prednisolone or both (triple therapy). The primary outcome was the number of patients with new erosions. Secondary outcomes included Larsen's x-ray scores, disability, quality of life and adverse events. FINDINGS: 1391 patients were screened and 467 randomised. Over 2 years 132 (28%) changed therapy and 88 (19%) were lost to follow-up. The number of patients with new erosions was reduced by nearly half by adding ciclosporin or prednisolone (p = 0.01 and 0.03); both treatments reduced increases in Larsen's x-ray scores by over 2 units (p = 0.008 and 0.003). A further reduction in erosive damage was seen with combined use of both treatments. Their effects on erosive damage appeared independent. Triple therapy reduced disability and improved quality of life compared with methotrexate; ciclosporin and prednisolone acted synergistically. More patients withdrew because of adverse events with triple therapy, without an increase in serious adverse effects. CONCLUSIONS: This study confirms the existence of a "window of opportunity" in early RA, when intensive combination therapy produces sustained benefits on damage and disability. Although methotrexate-prednisolone combinations reduce erosive damage, the synergistic effect of two DMARDs is needed to improve quality of life.

The overall status in rheumatoid arthritis (OSRA) measure--further evidence to support its use in clinical practice.

OBJECTIVES: The overall status in rheumatoid arthritis (OSRA) instrument is a simple summary of health status, including disease activity (OSRA-A) and damage (OSRA-D) scores. Despite evidence of the validity of the OSRA, uptake has been low. This study aimed to assess the responsiveness and re-examine the validity of the OSRA using the measures from the British Rheumatoid Outcome Study Group (BROSG) randomized controlled trial of aggressive vs symptomatic treatment of rheumatoid arthritis (RA) patients. METHODS: 466 patients were recruited. Outcome measures included the OSRA, the OMERACT core set and the DAS28, and were collected at baseline and annually for the 3 yrs of the trial. X-rays of the hands and feet were taken at baseline and 3 yrs. Patients were assigned a Townsend score (a measure of social deprivation) according to area of residence. Construct validity was assessed by correlating the OSRA with a range of outcome measures, and testing for the known inequality in RA outcome between patients classified by social deprivation. Responsiveness to change was assessed against self-reported change over the first year of the trial. RESULTS: The OSRA-A and OSRA-D measures demonstrated construct validity, performing as hypothesized. The OSRA-A was the most responsive measure in the BROSG trial in detecting patient reported improvement and deterioration. The OSRA-D demonstrated similar responsiveness to alternative measures. CONCLUSIONS: Our results demonstrate the validity and responsiveness of the OSRA, and its potential for inclusion in clinical trials. More important, as the OSRA is quick and easily calculated, uses routinely collected information, and provides useful quantitative information about a patient's status and progress it is suitable for use in the routine clinic.

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.

Patients with stable long-standing rheumatoid arthritis continue to deteriorate despite intensified treatment with traditional disease modifying anti-rheumatic drugs--results of the British Rheumatoid Outcome Study Group randomized controlled clinical trial.

OBJECTIVE: Patients with rheumatoid arthritis (RA) should start treatment early with the aim of suppressing the inflammatory process completely. It is not known if this strategy should, or can, be continued in later disease. METHODS: In a multicentre, randomized, observer-blinded, controlled trial, 466 patients with established RA (>5 yr), on stable therapy for at least 6 months, were randomized to adequate symptom control/shared care setting (SCSC) or aggressive treatment/hospital setting (ATH). All were reviewed annually by a rheumatologist. The primary outcome after 3 yr was the Health Assessment Questionnaire (HAQ). Others included the OMERACT core set and the Disease Activity Score (DAS) 28. RESULTS: Three hundred and ninety-nine patients completed the trial. There was a significant deterioration in HAQ in both arms. Only the physician global score differed between the arms. CONCLUSIONS: The trial showed no additional benefit of intensified treatment with traditional disease modifying anti-rheumatic drugs (DMARDs) in patients with stable, established RA. It proved hard to suppress C-reactive protein levels. Patients in the SCSC arm were able to initiate treatment changes when their symptoms deteriorated without frequent hospital assessment. Pending further evidence, the model of shared care with annual hospital review is as good as 4-monthly hospital review for these patients.

Competence-based assessment of specialist registrars: evaluation of a new assessment of out-patient consultations.

OBJECTIVE: To implement and evaluate formal assessment of the performance of West Midlands rheumatology specialist registrars (SpRs) in conducting out-patient consultations. METHODS: SpRs conducted a full out-patient clinic while being observed by one or two consultants who scored each SpR's performance on a structured pro forma. The assessment was conducted within the examining consultant's hospital trust (in which the SpR was not working). The process was evaluated by trainees and trainers by means of a questionnaire. RESULTS: Sixteen SpRs were assessed. No trainee failed to reach the required standard. Six trainees scored 'borderline' for management planning and four had a borderline performance recorded for examination skills. Overall the process was valued by trainers and trainees, although consensus was that it would be more practicable for the trainee to be examined within the hospital in which they were working by a visiting consultant examiner. It was also felt that a broader range of scoring options would be preferable. CONCLUSION: Formal assessment, by direct observation, of the skills of SpRs in conducting an out-patient clinic is practicable and offers information which is useful to trainer and trainee. A culture of direct observation of performance can be achieved within the context of rheumatology higher medical training.

The treatment of inflammatory arthritis with methotrexate in clinical practice: treatment duration and incidence of adverse drug reactions.

OBJECTIVE: To identify the proportion of patients with inflammatory arthritis who remain on methotrexate in the medium to long term and the incidence of side-effects in clinical practice. METHOD: The study population comprised all patients with inflammatory arthritis treated with methotrexate and monitored in clinics under the auspices of Staffordshire Rheumatology Centre. Two clinical auditors collected data retrospectively from the computer database used to support monitoring of patients on disease-modifying anti-rheumatic drugs. Information was collected on duration of treatments and reasons for stopping treatment. For patients identified as having potentially serious side-effects or who died whilst taking methotrexate, further information on their outcome was collected from patients' medical notes and where applicable post mortem reports and death registers. RESULTS: Between 1986 and 1999, 673 patients were treated with methotrexate, of whom 551 had a diagnosis of rheumatoid arthritis. From the Kaplan-Meier analysis, the probability of patients remaining on treatment 5 yr after starting methotrexate was 0.74. Three hundred and sixteen patients stopped methotrexate between 1986 and 1999. In 117 patients, the methotrexate was restarted. Seventy-two patients (10.7% of all patients) stopped because of inefficacy or patient choice or situation. Thirty-seven patients (5.5%) stopped methotrexate due to abnormal haematology (usually low neutrophils). Thirty-seven patients (5.5%) stopped methotrexate due to abnormalities in liver function tests. Life-threatening side-effects were identified in 12 patients (1.8%). These included six pneumonitis, five cytopenias and one disseminated varicella zoster. Two of these patients (0.3%) died, one from pneumonitis and one from disseminated varicella zoster. A total of 25 patients (3.7%) died while taking methotrexate and four died (0.6%) within 3 months of stopping methotrexate. One death (0.15%) was directly attributable to methotrexate (methotrexate pneumonitis). CONCLUSION: This study has shown that methotrexate is well tolerated in clinical practice in the medium to long term. It has produced accurate data on the incidence of adverse effects of methotrexate in a local population in a non-research setting. It has identified the incidence of life-threatening side-effects to be 1.7% with one death (0.15%) directly due to methotrexate. This information should prove useful when recommending such treatment to patients with inflammatory arthritis.

Control perceptions in patients with rheumatoid arthritis: the impact of the medical consultation.

OBJECTIVE: To identify factors that patients perceive as influencing control in living with the symptoms of rheumatoid arthritis (RA). METHOD: A sample of 40 patients with RA were recruited randomly from an out-patient population. The participants of the sample were interviewed in depth by one researcher to identify perceptions of control. They also completed two self-administered questionnaires, the Health Assessment Questionnaire and the Rheumatology Attitude Index. RESULTS: Four major categories were identified that positively influenced perceptions of control in patients living with the consequences of RA. These included: (i) the reduction of physical symptoms; (ii) social support matching perceived need; (iii) the provision of information; and (iv) the medical consultation. Components of the consultation included patient involvement, provision of information, feedback and reassurance, empathy and access to an expert. CONCLUSION: The categories identified can be influenced by health-care professionals in the management of the patient, and if the medical consultation is utilized to its full potential it can play a major role in enabling patients with RA to manage the daily symptoms of their condition.

Control perceptions in patients with rheumatoid arthritis: the role of social support.

OBJECTIVE: To identify factors that patients perceive as influencing control in living with rheumatoid arthritis. METHOD: A sample of 40 patients with rheumatoid arthritis were randomly recruited from an outpatient population and partook in an in depth, qualitative interview by one researcher to identify control perceptions. The data were analysed utilizing Colaizzi's procedural steps. RESULTS: Four major categories were identified that positively influenced control perceptions: The reduction of physical symptoms. Social support matching perceived need. The provision of information. The nature of the clinical consultation. Three components were identified in relation to social support: Remaining involved in family activities. Ongoing support from family members. Achieving a balance between support needs and support provision. CONCLUSION: The categories identified can be influenced by practitioners enabling patients with RA to obtain perceived control over their condition.

Assessment of specialist registrars in rheumatology: experience of an objective structured clinical examination (OSCE).

OBJECTIVES: Assessment of higher medical trainees (specialist registrars) in rheumatology is an important challenge facing the rheumatology community, particularly with the advent of the implemention of the changes recommended by the Calman Report in the UK. So far there has been remarkably little work in this area. Our aim was to implement and evaluate an objective structured clinical examination (OSCE) for rheumatology specialist registrars (SpRs). METHODS: Twelve SpRs completed a 12-station OSCE designed to assess core rheumatological clinical skills. The OSCE was designed and manned by consultant members of the West Midlands Rheumatology Services and Training Committee. The OSCE was evaluated by the SpRs, the participating consultant supervisors and the patients, by means of questionnaires. RESULTS: We present the details of the OSCE stations and the scores for each station. In terms of evaluation, 11 out of 12 SpRs felt that it was a very worthwhile exercise. Participating patients found it interesting, if tiring. All would be happy to participate in such an examination again. All participating consultants found it interesting and useful in terms of establishing the level of competence among trainees. CONCLUSION: The OSCE represents one practical approach to assessing clinical skills in rheumatology SpRs. It has potential in both formative and summative assessment. The broader issues around the assessment of rheumatology trainees are discussed.

Teaching consultation skills in higher specialist training: experience of a workshop for specialist registrars in rheumatology.

OBJECTIVES: To design, implement and evaluate an initial communication skills workshop for higher specialist trainees in rheumatology, and to determine their prior experience of and attitude towards such training. METHODS: The setting for this study was a rheumatology specialist registrar study day in the West Midlands region of the UK. The workshop was jointly facilitated by a hospital specialist and a general practitioner educationist, providing both the credibility of subject expertise and experience of teaching consultation skills to groups of doctors. Simple, structured observations of pre-recorded consultations and simulations, based on scenarios from within the specialist field, were used. RESULTS: There was strong agreement amongst the trainees that the workshop was enjoyable and useful, that prior training and experience in this area was inadequate, and that it is feasible and important to develop the communication skills of hospital specialists. CONCLUSIONS: Undergraduate teaching in communication skills has been inadequate in the past and it receives little or no attention in most specialist training. There is a compelling argument for the inclusion of communication skills teaching in higher medical training within rheumatology. More work is required to research the optimum methods of delivering teaching in this area in a postgraduate setting, and to assess the impact of communication skills teaching on clinical practice.

The mechanical joint score: a new clinical index of joint damage in rheumatoid arthritis.

OBJECTIVES: To evaluate the mechanical joint score (MJS) in terms of its reliability between observers and over time, its ease of use and its relationship with conventional measures of rheumatoid arthritis (RA) disease activity, severity and functional outcome. METHODS: The MJS was evaluated in 103 patients with reference to the following joints: total proximal interphalangeal (PIP) joints, total metacarpophalangeal (MCP) joints, wrists, elbows, shoulders, hips, knees, ankles and total metatarsophalangeal (MTP) joints. The score was based on the appearance of the joints on a scale of 0-3, 0 representing no abnormality and 3 severe abnormality or previous surgery. The MJS was evaluated in terms of its intra- and inter-observer variability and its content, construct and criterion validities. A subset of 29 patients were re-evaluated after 5 yr to examine change in MJS over time. RESULTS: The MJS performed well in terms of inter-observer and intra-observer reliability. The MJS showed strong correlation with the Larsen X-ray score of hands and feet (Spearman correlation coefficient 0.74) and with the modified Health Assessment Questionnaire (Spearman correlation coefficient 0.56) and only weak correlation with indices of disease activity, such as the Ritchie index and erythrocyte sedimentation rate. The MJS showed highly significant positive change over time. CONCLUSION: The MJS is a reliable clinical index of joint damage and may be a useful new outcome measure in RA.

Renal effects of nitric oxide in endotoxemia.

Nitric oxide (NO) is postulated to play a key role in the pathophysiology of renal failure in sepsis. Whether the renal effects of increased NO are beneficial or harmful remains unclear. In a porcine model of lipopolysaccharide (LPS)-induced shock, we evaluated the effect of LPS on glomerular filtration rate (GFR) and renal blood flow (RBF). We then administered the nonselective nitric oxide synthase (NOS) inhibitor N(G)-L-arginine methyl ester (L-NAME), and compared its effects on GFR and RBF with those of S-methylisothiourea (SMT), a selective NOS inhibitor, and those of saline. We postulated that SMT, by maintaining constitutive NO, would be more beneficial than either L-NAME or saline. LPS infusion decreased mean arterial pressure (MAP), and increased cardiac output, RBF, and medullary NO content. The increased RBF was diverted to the medulla. There was no evidence of renal dysfunction in the saline-resuscitated group. Both NOS inhibitors increased MAP but decreased RBF, but only L-NAME reduced GFR and increased sodium excretion and renal oxygen extraction. We conclude that NO in endotoxemia is beneficial because it maintains RBF and GFR. Additionally, selective NOS inhibition did not offer any advantages over saline resuscitation.

Oxindole-based inhibitors of cyclin-dependent kinase 2 (CDK2): design, synthesis, enzymatic activities, and X-ray crystallographic analysis.

Two closely related classes of oxindole-based compounds, 1H-indole-2,3-dione 3-phenylhydrazones and 3-(anilinomethylene)-1,3-dihydro-2H-indol-2-ones, were shown to potently inhibit cyclin-dependent kinase 2 (CDK2). The initial lead compound was prepared as a homologue of the 3-benzylidene-1,3-dihydro-2H-indol-2-one class of kinase inhibitor. Crystallographic analysis of the lead compound bound to CDK2 provided the basis for analogue design. A semiautomated method of ligand docking was used to select compounds for synthesis, and a number of compounds with low nanomolar inhibitory activity versus CDK2 were identified. Enzyme binding determinants for several analogues were evaluated by X-ray crystallography. Compounds in this series inhibited CDK2 with a potency approximately 10-fold greater than that for CDK1. Members of this class of inhibitor cause an arrest of the cell cycle and have shown potential utility in the prevention of chemotherapy-induced alopecia.

Independent association of rheumatoid factor and the HLA-DRB1 shared epitope with radiographic outcome in rheumatoid arthritis.

OBJECTIVE: Findings of a recent study suggested that HLA-DRB1 alleles encoding the rheumatoid arthritis (RA) "shared epitope" (SE) were not predictive of erosive damage at 2 years in patients with early inflammatory arthritis who were rheumatoid factor (RF) positive, but were predictive in those who were RF negative. The present study was undertaken to determine whether RF status was also important in the association between the SE and radiographic outcome in patients with longstanding RA. METHODS: The association between radiographic outcome, HLA-DRBI, and RF status was examined in 299 RA patients with established disease (5-30 years). Radiographic outcome was measured by scoring radiographs of the hands and feet using the standard radiographs of Larsen. HLA-DRB1 typing was performed using polymerase chain reaction methodology. Results were stratified by RF status and analyzed by multiple regression. RESULTS: An association between radiographic severity and the SE was found in RF-, but not RF+, patients. RF- patients carrying an SE allele had higher Larsen scores than RF- patients lacking the SE, although there was no association with SE dosage. The mean Larsen score was significantly higher in RF+ patients than in RF- patients, but there were no differences between RF+ patients with 0, 1, or 2 SE alleles. Multiple regression analysis confirmed independent associations of RF and SE positivity with radiographic outcome. No significant associations were found between RF and the SE, or RF and individual SE alleles. CONCLUSION: Our data indicate that RF and the SE are independently associated with radiographic outcome in RA. In RF+ patients with longstanding RA, there is no apparent association between the presence of the SE and radiographic damage. However, in RF-patients, although radiographic outcome is generally less severe, there is an association between severity and presence of the SE.