IntroductionPrevention of fragility fractures, a source of significant economic and personal burden, is hindered by poor uptake of fracture prevention medicines. Enhancing communication of scientific ...evidence and elicitation of patient medication-related beliefs has the potential to increase patient commitment to treatment. The Improving uptake of Fracture Prevention drug treatments (iFraP) programme aims to develop and evaluate a theoretically informed, complex intervention consisting of a computerised web-based decision support tool, training package and information resources, to facilitate informed decision-making about fracture prevention treatment, with a long-term aim of improving informed treatment adherence. This protocol focuses on the iFraP Development (iFraP-D) work.Methods and analysisThe approach to iFraP-D is informed by the Medical Research Council complex intervention development and evaluation framework and the three-step implementation of change model. The context for the study is UK fracture liaison services (FLS), which enact secondary fracture prevention. An evidence synthesis of clinical guidelines and Delphi exercise will be conducted to identify content for the intervention. Focus groups with patients, FLS clinicians and general practitioners and a usual care survey will facilitate understanding of current practice, and investigate barriers and facilitators to change. Design of the iFraP intervention will be informed by decision aid development standards and theories of implementation, behaviour change, acceptability and medicines adherence. The principles of co-design will underpin all elements of the study through a dedicated iFraP community of practice including key stakeholders and patient advisory groups. In-practice testing of the prototype intervention will inform revisions ready for further testing in a subsequent pilot and feasibility randomised trial.Ethics and disseminationEthical approval was obtained from North West—Greater Manchester West Research Ethics Committee (19/NW/0559). Dissemination and knowledge mobilisation will be facilitated through national bodies and networks, publications and presentations.Trial registration numberresearchregistry5041.
Communities of Practice (CoPs) offer a strategy for mobilising knowledge and integrating evidence-based interventions into musculoskeletal practice, yet little is known about their practical ...application in this context. This study aimed to (i) explore the process of knowledge mobilisation in the context of a CoP to implement evidence-based interventions in musculoskeletal care and (ii) co-develop recommendations to optimise the process of knowledge mobilisation in CoPs.
A qualitative study comprising observation of a CoP and related planning meetings (n = 5), and interviews with CoP stakeholders (including clinicians, lay members, managers, commissioners, academics) (n = 15) was undertaken. Data were analysed using thematic analysis and interpreted considering the Integrated Promoting Action on Research Implementation in Health Services theory. Public contributors were collaboratively involved at key stages of the study.
Four themes were identified: identifying and interpreting knowledge, practical implementation of a CoP, culture and relationship building, and responding to the external context. Resource and infrastructure enabled the set-up, delivery and running of the CoP. Support for lay members is recommended to ensure effective participation and equity of power. CoP aims and purpose can develop iteratively, and this may enhance the ability to respond to contextual changes. Several recommendations for the practical application of CoPs are suggested to create the best environment for knowledge exchange and creation, support an equitable platform for participation, and help members to navigate and make sense of the CoP in a flexible way.
This study identified how a CoP with diverse membership can promote partnership working at the intersection between knowledge and practice. Several important considerations for preparing for and operationalising the approach in implementation have been identified. Evaluation of the costs, effectiveness and impact of CoPs is needed to better understand the value added by the approach. More broadly, research is needed to explore the practical application of online CoPs and the role of international CoPs in optimising the uptake of innovations and best practice.
Accepting that decisions need to be individualised, for the purposes of a practice protocol, I would suggest continuing treatment for 10 years if any of these high risk characteristics are ...present-previous vertebral fracture; age >75 years; femoral neck or hip BMD <=-2.5; new risk factors or conditions associated with fracture risk.
Background:
People with inflammatory rheumatological conditions (IRCs), are at increased risk of comorbidities such as cardiovascular disease, osteoporosis, anxiety and depression. The INCLUDE pilot ...trial evaluated a nurse-delivered review of people with IRCs which sought to identify and initiate management of comorbid conditions.
Aim:
A nested qualitative study was undertaken to examine the acceptability of the INCLUDE review.
Methods:
A qualitative interview-based design in UK primary care settings. A purposive sample of 20 patients who attended an INCLUDE review, were interviewed. Inductive thematic analysis was undertaken. Themes were agreed through multidisciplinary team discussion and mapped onto constructs of the Theoretical Framework of Acceptability (TFA).
Results:
Six themes mapped onto six of the seven TFA constructs. Patients reported the review to be effective by identifying and initiating management of previously unrecognised comorbid conditions. Some participants reported barriers to following recommendations, such as lifestyle modifications or taking more medication.
Conclusion:
A nurse-delivered review to identify comorbidities is acceptable to patients with IRCs. The TFA provided a novel analytical lens.
People with inflammatory rheumatological conditions (IRCs) are at increased risk of common comorbidities including osteoporosis.
To explore the barriers to and facilitators of implementing ...nurse-delivered fracture risk assessments in primary care, in the context of multimorbidity reviews for people with IRCs.
A multi-method qualitative study in primary care.
As part of a process evaluation in a pilot trial, semi-structured interviews were conducted with 20 patients, two nurses, and three GPs. Twenty-four patient-nurse INCLUDE review consultations were audiorecorded and transcribed. A framework analysis was conducted using the Theoretical Domains Framework (TDF).
Nurses reported positive views about the value of the Fracture Risk Assessment Tool (FRAX) and they felt confident to deliver the assessments following training. Barriers to implementation, as identified by TDF, particularly related to the domains of knowledge, skills, professional roles, and environmental context. GPs reported difficulty keeping up to date with osteoporosis guidelines and voiced differing opinions about whether fracture risk assessment was the role of primary or secondary care. Lack of integration of FRAX into IT systems was a barrier to use. GPs and nurses had differing views about the nurse role in communicating risk and acting on FRAX findings; for example, explanations of the FRAX result and action needed were limited. Patients reported limited understanding of FRAX outcomes.
The findings suggest that, with appropriate training including risk communication, practice nurses are likely to be confident to play a key role in conducting fracture risk assessments, but further work is needed to address the barriers identified.
Abstract Background/Aims Traditionally patients commencing disease modifying anti-rheumatic medications (DMARDs) attended a face to face consultation with a rheumatology nurse or pharmacist, to ...discuss benefits, concerns and safety monitoring. The pandemic has led to an increase in the use of remote methods of information sharing including telephone consultations. The aim of this service evaluation was to elicit patients preferences on receiving information on arthritis medications to help inform service development. Methods A service evaluation with contributions from patients and stakeholders was designed and registered with the trust. Patients who were commencing or taking DMARDs attending, one of two hospital sites, in North Staffordshire were asked to complete a short questionnaire from November 2022-April 2023. Some patients completed the questionnaire at the end of their telephone drug counselling appointment with the assistance of the nurse whilst others completed the questionnaire whilst attending in person for their appointment. The questionnaire focused on the preferred format for receiving information on arthritis medications including a face to face appointment with a health professional (even if this meant a wait), telephone consultation, attending a group counselling session, having a drug information leaflet with the option to contact a health professional to answer any questions or watching a video on a device with internet access (computer, smart phone or tablet). The importance of receiving information on the same day as commencing treatment was also explored. Results 64 patients took part in the survey. No demographic data was collected. The most popular method for receiving information on arthritis medications was a face to face appointment, even if it meant a delay in starting medication (n = 32,50%). The second most popular method was an information leaflet with the option to discuss any concerns via the telephone (n = 12,19 %). The third preference to receive information were via a video, again with the option to discuss concerns remotely (n = 10, 16%) or a telephone appointment, even if it meant a delay in starting medication (n 10,16%) Surprisingly although no patients expressed a preference to attend a group counselling session, 36 (56%) would attend if offered. When presented with the option of having information on the same day as the decision was made to commence medication, or, having to wait to discuss the mediation with a health professional, there was a strong preference to see a health professional (n = 46, 72%) Conclusion Patients clearly value discussing commencing DMARDs with a health professional even if this means a delay in treatment. Having just one approach to information giving does not equate with individual needs and a range of options regarding information delivery that the patient can select from is required. Disclosure S. Ryan: None. S. Hider: None. Z. Paskins: None.
Evidence on the effectiveness of intra-articular corticosteroid injection for hip osteoarthritis is limited and conflicting. The primary objective of the Hip Injection Trial (HIT) is to compare pain ...intensity over 6 months, in people with hip OA between those receiving an ultrasound-guided intra-articular hip injection of corticosteroid with 1% lidocaine hydrochloride plus best current treatment with those receiving best current treatment alone. Secondary objectives are to determine specified comparative clinical and cost-effectiveness outcomes, and to explore, in a linked qualitative study, the lived experiences of patients with hip OA and experiences and impact of, ultrasound-guided intra-articular hip injection.
The HIT trial is a pragmatic, three-parallel group, single-blind, superiority, randomised controlled trial in patients with painful hip OA with a linked qualitative study. The current protocol is described, in addition to details and rationale for amendments since trial registration. 204 patients with moderate-to-severe hip OA will be recruited. Participants are randomised on an equal basis (1:1:1 ratio) to one of three interventions: (1) best current treatment, (2) best current treatment plus ultrasound-guided intra-articular hip injection of corticosteroid (triamcinolone acetonide 40 mg) with 1% lidocaine hydrochloride, or (3) best current treatment plus an ultrasound-guided intra-articular hip injection of 1% lidocaine hydrochloride alone. The primary endpoint is patient-reported hip pain intensity across 2 weeks, 2 months, 4 months and 6 months post-randomisation. Recruitment is over 29 months with a 6-month follow-up period. To address the primary objective, the analysis will compare participants' 'average' follow-up pain NRS scores, based on a random effects linear repeated-measures model. Data on adverse events are collected and reported in accordance with national guidance and reviewed by external monitoring committees. Individual semi-structured interviews are being conducted with up to 30 trial participants across all three arms of the trial.
To ensure healthcare services improve outcomes for patients, we need to ensure there is a robust and appropriate evidence-base to support clinical decision making. The HIT trial will answer important questions regarding the clinical and cost-effectiveness of intra-articular corticosteroid injections.
ISRCTN: 50550256 , 28th July 2015.
Background Good quality shared decision-making (SDM) conversations involve people with, or at risk of osteoporosis and clinicians collaborating to decide, where appropriate, which evidence-based ...medicines best fit the person’s life, beliefs, and values. We developed the i mproving uptake of Fra cture P revention drug treatments (iFraP) intervention comprising a computerised Decision Support Tool (DST), clinician training package and information resources, for use in UK Fracture Liaison Service consultations. Two primary objectives to determine (1) the effect of the iFraP intervention on patient-reported ease in decision-making about osteoporosis medicines, and (2) cost-effectiveness of iFraP intervention compared to usual NHS care. Secondary objectives are to determine the iFraP intervention effect on patient reported outcome and experience measures, clinical effectiveness (osteoporosis medicine adherence), and to explore intervention acceptability, mechanisms, and processes underlying observed effects, and intervention implementation. Methods The iFraP trial is a pragmatic, parallel-group, individual randomised controlled trial in patients referred to a Fracture Liaison Service, with nested mixed methods process evaluation and health economic analysis. Participants aged ≥50 years (n=380) are randomised (1:1 ratio) to one of two arms: (1) iFraP intervention (iFraP-i) or (2) comparator usual NHS care (iFraP-u) and are followed up at 2-weeks and 3-months. The primary outcome is ease of decision-making assessed 2 weeks after the consultation using the Decisional Conflict Scale (DCS). The primary objectives will be addressed by comparing the mean DCS score in each trial arm (using analysis of covariance) for patients given an osteoporosis medicine recommendation, alongside a within-trial cost-effectiveness and value of information (VoI) analysis. Process evaluation data collection includes consultation recordings, semi-structured interviews, and DST analytics. Discussion The iFraP trial will answer important questions about the effectiveness of the new ‘iFraP’ osteoporosis DST, coupled with clinician training, on SDM and informed initiation of osteoporosis medicines. Trial registration: ISRCTN 10606407, 21/11/2022 https://doi.org/10.1186/ISRCTN10606407
Abstract
Background/Aims
The 2022 rheumatology curriculum requires trainees to achieve competence in the management of osteoporosis and a number of metabolic bone diseases by the end of their ...training. In addition, the recent 2022 NOGG guidance states that very high-risk osteoporosis patients should be considered for referral to specialist care. Hence there is a need to ensure high quality training in this area. We aimed to assess rheumatology trainees’ experience of osteoporosis and metabolic bone disease.
Methods
A Google form was designed, comprising questions relating to experience of and confidence in managing osteoporosis and other metabolic bone disease. A completion link was circulated to rheumatology trainees via regional trainee representatives. Reminders were sent at intervals during the survey period. Trainees completed the survey anonymously.
Results
41 trainees responded. Training grade ranged from ST4-ST7, with 1 specialty doctor and 1 individual who had completed training. Six regions in England, plus Wales and Northern Ireland were represented. 23 trainees (56.1%) reported having observed at least one osteoporosis clinic, and 18 (43.9%) reported having participated in an osteoporosis clinic on a weekly basis for at least 12 weeks. Fewer trainees (11, 26.8%) had observed a specialist metabolic bone disease clinic, and 9 (22%) had participated in one. In terms of exposure to individual conditions, 31 trainees (75.6%) reported clinical experience of managing postmenopausal osteoporosis and 29 (70.7%) reported experience of managing Paget’s disease. Exposure to rarer metabolic bone diseases was much lower, with over half reporting no clinical experience of: osteomalacia; osteonecrosis; bone marrow oedema syndromes; hypophosphatasia; osteogenesis imperfecta; fibrous dysplasia; or FGF-23 mediated osteomalacia. 12 trainees (29.3%) had experience reporting DXA scans. Table 1 summarises trainees’ confidence levels across a number of areas. Overall, 9 (22%) rated their confidence in assessing and managing patients with osteoporosis and metabolic bone disease as equal to or higher than for patients with inflammatory arthritis. 22% said they were likely or very likely to consider sub-specialising in osteoporosis/metabolic bone disease.
Conclusion
Our survey has identified significant variations in training, particularly for rarer metabolic bone diseases. However, despite this, the sub-specialty appears to remain an attractive career option.
Disclosure
S.A. Hardcastle: None. M. Rutter: Other; M.R. is a Versus Arthritis Clinical Research Fellow and Chair of the BSR trainee committee. Z. Paskins: Consultancies; Unpaid consultancy for non promotional activity with UCB.
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