Exploring the added value of video-stimulated recall in researching the primary care doctor-patient consultation: a process evaluation

Background Video-stimulated recall (VSR) is a method whereby researchers show research participants a video of their own behaviour to prompt and enhance their recall and interpretation after the event, e.g. in a post-consultation interview. This paper describes a process evaluation with the aim of understanding what video stimulated recall (VSR) may have added to findings, to describe participants’ responses to, and the acceptability of,VSR and to explore participants’ perceptions of behaviour change in response to being video-recorded. Methods This evaluation took place in the context of a UK study concerning the discussion of osteoarthritis in primary care consultations. Post consultation VSR interviews were conducted with 13 family physicians (general practitioners, GPs) and 17 patients. Thematic analysis of these interviews and the matched 17 consultations was undertaken, and was both inductive and deductive in approach. Results The findings demonstrate VSR appeared to add value by enabling a deeper understanding of participants’ thoughts and reactions to specific parts of consultation dialogue, by facilitating participants to express concerns and possibly speak more candidly and by eliciting a more multi-layered narrative from participants. The method was broadly acceptable to participants; however, levels of mild anxiety and/or distress were reported or observed by both doctor and patient participants and this may explain in part why some participants reported behaviour change as a result of the video. Any reported behaviour change was used to inform analysis. Conclusions This study demonstrates how VSR may enable a more critical, more specific and more in-depth response from participants to events of interest, and in doing so, generates multiple layers of narrative. This results in a method that goes beyond fact finding and description and generates more meaningful explanations of consultation events, getting straight to the core of what is salient to participants

Incidence and medical management of bisphosphonate-associated atypical femoral fractures in a major trauma centre: a retrospective observational study

BACKGROUND: Atypical femoral fractures (AFFs) are rare events associated with increased duration of bisphosphonate exposure. Recommended management of AFFs include cessation of bisphosphonates and imaging of the contralateral femur. The aims of this study were to identify the local incidence of AFFs in bisphosphonate users and to audit the medical management of AFFs against published recommendations. METHODS: A retrospective analysis of the admissions database for a major trauma centre identified all femoral fractures (3150) in a five-year period (July 2009 to June 2014). Electronic health records and radiographs were reviewed using the 2013 American Society for Bone and Mineral Research (ASBMR) diagnostic criteria for AFF to establish the number of cases. To estimate incidence, the total number of bisphosphonate users was derived from primary care prescription and secondary care day-case records. Medical management of cases with AFF on bisphosphonates was audited against guidance from ASBMR and Medicines & Healthcare Products Regulatory Agency. RESULTS: 10 out of 3150 femoral fractures met criteria for AFF; 7 of these patients had a history of exposure to bisphosphonates (6 oral, 1 intravenous). There were 19.1 AFFs per 100,000 years of bisphosphonate use in our region. Bisphosphonates were stopped and the contralateral femur imaged in only 2 of the 7 patients treated with bisphosphonates. CONCLUSION: Our local incidence is in line with published figures; however, this is the first published evidence suggesting that medical management and identification of AFF may be suboptimal. Managing these patients remains challenging due to their rarity and possible lack of awareness

What influences patients with osteoarthritis to consult their GP about their symptoms? A narrative review

Osteoarthritis (OA) is a common cause of disability and consultation with a GP. However research suggests the majority of sufferers choose not to consult their GP regarding their symptoms. Understanding the reasons for consulting is central to optimising patient outcomes. This review aims to summarise existing literature to identify what influences patients with OA to consult their GP

PREVALENCE OF FRAGILITY FRACTURES AND MEDICATION PRESCRIPTION FOR OSTEOPOROSIS IN PATIENTS WITH POLYMYALGIA RHEUMATICA: RESULTS FROM THE PMR COHORT STUDY

Background/Aims Polymyalgia rheumatica (PMR) is one of the commonest indications for long term glucocorticoid (GC) use, leading to an increased risk of osteoporosis and fragility fractures. Clinical guidelines recommend prescribing medication including vitamin D, calcium and anti-resorptives, such as bisphosphonates. The aim of this study was to examine the association of reported falls and prescriptions of medications for osteoporosis with future fragility fractures in a cohort of people with PMR. Methods  652 people with an incident diagnosis of PMR responded to a baseline survey between June 2012 and June 2014. This included data on general health, sociodemographics, history of falls and medication. Data on fractures and prescriptions were collected at 12 and 24 months. Fragility fractures were defined as fractures of the hip, wrist or spine. Logistic regression models were used to assess the association between baseline characteristics and fractures at 12 and 24 months. Analysis was conducted unadjusted and adjusted for age, gender, reported medication use and falls history. Results  112 (17.2%) baseline respondents reported a previous fragility fracture. 60 (83.3%) of the 72 respondents who reported a fragility fracture between baseline and month 12 also reported a fragility fracture at baseline. 49 (79.1%) of the 60 respondents who reported a fragility fracture at between the month 12 and 24 also reported a fragility fracture at baseline. Falls before baseline was the most significant predictor of fragility fracture at 12 (OR 2.35 95% CI 1.35-4.12) and 24 (OR 1.91 95% CI 1.05-3.49) months. Fewer than 50% of respondents were ever prescribed treatment for osteoporosis. Being prescribed treatment for osteoporosis was associated with a reduced incidence of fragility fractures at 24 months (adjusted OR 0.28 95% CI 0.10-0.80), but an increased incidence at 12 months (adjusted OR 2.10 95% CI (1.3-3.48). Calcium and vitamin D prescription, gender and age were not significantly associated with fracture outcome. Conclusion  Despite guidelines, fewer than 50% of patients were prescribed medications for osteoporosis. This data highlights the risks of fractures in PMR patients who have experienced previous falls. Over a period of two years, medication for osteoporosis was significantly protective, hence more needs to be done to encourage adherence to guidelines. Further studies need to address reasons for non-adherence to guidelines and the effects of long-term treatment

P008 Fracture liaison service management of patients aged 85 and older who sustain fragility fractures: audit and quality improvement

Abstract Background/Aims Osteoporosis is a burdensome disease internationally, that is commonly diagnosed following fragility fracture. In line with national guidance, in 2018 the North Staffordshire Fracture Liaison Service (FLS) changed their management policy of patients aged ≥85 years who sustain fragility fractures. Instead of calling these patients for a dual-energy X-ray absorptiometry (DXA) scan, a letter was sent to the patient’s General Practitioner, advising the empirical commencement of oral bisphosphonates. This audit aimed to evaluate whether the recommendations in this letter were enacted by GPs. Following audit, the text of the letter was changed, and a re-audit conducted to evaluate changes in practice. Methods Patients aged ≥85 years sustaining a fragility fracture between December 2018 and October 2020 were identified from FLS records. Summary Care Records (SCRs) were used to identify whether each patient was receiving a bisphosphonate prescription at time of audit (October 2020). Analysis was descriptive, to report the proportion of patients prescribed a bisphosphonate. Quality improvement methodology informed changes to the standard letter, using GP feedback. Re-audit of fragility fractures occurring between December 2020 and May 2021 was undertaken in July 2021 to assess possible impact. Results 408 eligible patients were identified in the initial audit, of which 79% were female. SCR data was available for 396 patients; median time between fracture and data collection was 9 months. 160 patients (40%) had a bisphosphonate prescribed as an acute or repeat prescription, of which &amp;gt;90% were alendronic acid. Following the first audit cycle, the letter was changed to address barriers to clinical decision-making including advice on relative contraindications and referral. 74 patient SCRs were reviewed in the 2nd audit cycle (85% female) and 38 (51%) were recorded as prescribed a bisphosphonate (median time between fracture and assessment 5-months). Conclusion Rates of bisphosphonate prescribing, in people aged ≥85 following a recommendation letter sent to the GP, have increased from 40% to 51% following quality improvement initiative. Furthermore, the proportion of patients prescribed a bisphosphonate is similar to previous national data in patients post-DXA. This is of interest, particularly given the de-prioritisation of non-communicable diseases during the COVID-19 pandemic, and demonstrates that an intervention which requires little time, can result in changes in practice. Limitations of this work include that the SCR only includes contemporaneous prescribing data so the period of time between drug recommendation and audit was different in 1st and 2nd cycles, meaning that adherence may be expected to be higher in the 2nd cycle, because the period of time between letter and data collection was shorter, and not because of a change in our intervention. Disclosure T. Appleyard: None. K. Bethwaite: None. N. Dale: None. F. Manning: None. Z. Paskins: None. </jats:sec

Exploring the treatment burden of disease-modifying anti-rheumatic drug monitoring in people with rheumatoid arthritis

This is the final version. Available on open access from Oxford University Press via the DOI in this recordData availability: The data underlying this article are available in the article and in its own online supplementary material.OBJECTIVES: People with RA taking DMARDs require safety monitoring to identify potential side effects. The aim of this study was to explore the perspectives of patients and family members on DMARD monitoring and how the associated treatment burden could be minimized to optimize concordance and safety. METHODS: Thirteen adults with RA on DMARDs and three family members participated in semi-structured telephone interviews between July 2021 and January 2022. Data were analysed using a framework method. Findings were discussed with a group of stakeholders to develop implications for practice. RESULTS: Two main themes were identified: (i) making sense of drug monitoring; and (ii) work involved in drug monitoring. Participants perceived DMARDs as necessary to reduce symptoms, with drug monitoring providing an opportunity for a holistic assessment of wellbeing. Participants expressed a preference for face-to-face consultations, which allowed them to share their concerns, rather than remote, often transactional, care. The limited availability of convenient appointment times, travel requirements and parking increased the work involved for patients and family members. CONCLUSION: Drug monitoring was accepted as a necessity of DMARD treatment, but increased the work for people with RA related to organizing and attending appointments. The potential for treatment burden needs to be assessed proactively by clinicians when a DMARD is commenced. Where identified, strategies for minimizing the treatment burden can form part of a shared management plan, including the offer of regular contact with health professionals, with an emphasis on person-centred care.General Nursing Council for England and Wales Trust (GNCT)National Institute for Health and Care Research (NIHR

Clinical decision-making in remote rheumatology consultations: a service evaluation of new patient and inflammatory rheumatic disease follow-up appointments.

Lette

P137 Supporting patients to get the best from their osteoporosis treatment; what works for whom, why and in what circumstance: a rapid realist review

Abstract Background/Aims For two decades, clinicians and academics have been writing about the problem of poor adherence in osteoporosis, while people with osteoporosis have identified a need for more follow up and information about medicines. We aimed to understand what works in supporting people with osteoporosis to get the best from their medicines, and specifically, to understand what mechanisms enable components of interventions to support osteoporosis medication optimisation and the underlying contextual conditions that enabled these mechanisms. Methods We conducted a Rapid Realist Review. The scope was informed by a workshop of the Effectiveness Working Group of the Royal Osteoporosis Society Osteoporosis and Bone Research Academy and the approach informed by background syntheses of qualitative literature and the Perceptions and Practicalities Approach as an underpinning conceptual framework. A primary search identified observational or interventional studies which aimed to improve medicines adherence or optimisation. Included studies were assessed for quality and data extracted relating to context, mechanism and outcomes. A supplementary second search was conducted to gain additional insight on included key papers and emerging mechanisms. Extracted data were interrogated by authors independently for patterns of context-mechanism-outcome configurations and further discussed in weekly team meetings. Recommendations for research and clinical practice were co-developed with clinical and lay stakeholders. Results 41 papers were included. We identified five contextual timepoints for the person with osteoporosis (identifying a problem; starting medicine; continuing medicine) and the practitioner and healthcare system (making a diagnosis and giving a treatment recommendation; reviewing medicine) and mechanisms relating to patient informed decision making, treatment burden, supporting routinisation and memory, supporting clinical decision making, targeting support, and approaches which were integrated and sustainable. Interventions which support patient informed decision making, improve patient knowledge and understanding, have potential to influence long-term commitment to treatment, although few studies explicitly addressed patients’ perceptions of illness and treatment as recommended in NICE guidelines. During treatment, targeting additional consultations to those most in need may be a cost and clinically effective approach to enable this. Supporting primary care clinician decision making and integration of primary and secondary care services also appears to be important, in improving rates of treatment initiation and adherence. Supporting patients’ ability to adhere (eg by lowering treatment burden and issuing reminders) may be helpful to address practical difficulties but there is little evidence to support the use of reminders alone. Conclusion For medicines optimisation for people with osteoporosis, we suggest a need for more patient-centred interventions to address patients’ perceptions of illness and treatment, and reduce treatment burden. Specialist services should consider the extent to which they integrate with, and support primary care clinical decision-making, in order to impact long-term clinical outcomes. Specific research recommendations have been co-developed, to address these knowledge gaps. Disclosure Z. Paskins: Grants/research support; NIHR, Versus Arthritis, Royal Osteoporosis Society. O. Babatunde: None. A. Sturrock: None. L. Toh: None. R. Horne: None. I. Maidment: None. </jats:sec