BACKGROUND: Guidance for choosing face-to-face vs remote consultations (RCs) encourages clinicians to consider patient preferences, however, little is known about acceptability of, and preferences for RCs, particularly amongst patients with musculoskeletal conditions. This study aimed to explore the acceptability of, and preferences for, RC among patients with osteoporosis and rheumatoid arthritis. METHODS: Three UK qualitative studies, exploring patient experiences of accessing and receiving healthcare, undertaken during the pandemic, with people with osteoporosis and rheumatoid arthritis. Study team members agreed a consistent approach to conduct rapid deductive analysis using the Theoretical Framework of Acceptability (TFA) on transcripts from each data set relating to RC, facilitated by group meetings to discuss interpretations. Findings from the three studies were pooled. RESULTS: Findings from 1 focus group and 64 interviews with 35 people were included in the analysis. Participants' attitudes to RC, views on fairness (ethicality) and sense-making (intervention coherence) varied according to their needs within the consultation and views of the pandemic. Some participants valued the reduced burden associated with RC, while others highly valued non-verbal communication and physical examination associated with face-to-face consults (opportunity costs). Some participants described low confidence (self-efficacy) in being able to communicate in RCs and others perceived RCs as ineffective, in part due to suboptimal communication. CONCLUSIONS: Acceptability of, and preferences for RC appear to be influenced by societal, healthcare provider and personal factors and in this study, were not condition-dependant. Remote care by default has the potential to exacerbate health inequalities and needs nuanced implementation.

OBJECTIVE: Rheumatoid arthritis (RA) is an autoimmune, inflammatory, systemic condition that requires specific drug treatment to suppress disease activity and prevent joint deformity. To manage the ongoing symptoms of joint pain and fatigue patients are encouraged to engage in self-management activities. People with RA have an increased incidence of serious illness and mortality, with the potential to impact on quality of life. This study explored patients' experiences of living with RA on physical, psychological and social well-being as well as their ability to employ self-management skills during the coronavirus pandemic. DESIGN: Qualitative, longitudinal (baseline, 16 September to 23 November 2020 and after 2-4 months, 11 January to the 17 January 2021), semistructured telephone interviews. SETTING: a rheumatology service based in a community hospital. PARTICIPANTS: 15 adults with RA. MAIN OUTCOMES: Data were analysed using interpretative phenomenological analysis. RESULTS: Five themes were identified that related to impact on (1) fear: the dominant emotion, (2) social connections and work practices, (3) physical health, (4) identity and (5) self-management as a coping mechanism. The overriding emotion was one of fear, which remained high throughout both interviews. The negative impact on social well-being increased as the pandemic progressed. Conversely, physical health was not affected at either time point, although participants reported difficulty in interpreting whether physical symptoms were attributable to their RA or COVID-19. Recognition of increased vulnerability led to a reassessment of self-identity; however, respondents reported using previously learnt self-management techniques to cope in the context of the pandemic. CONCLUSIONS: the main impact was on emotional and social well-being. Levels of fear and vulnerability which affected self-identity remained high throughout the pandemic and the impact on social well-being increased over time. Physical health remained largely unaffected. Self-management skills were used to maintain a sense of well-being.

Abstract
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. Background/Aims
. The COVID-19 pandemic led to the widespread adoption of remote consultations. Whilst remote consultations offer many potential advantages to patients and healthcare services, they are unlikely to be suitable for all. Guidance encourages clinicians to consider patient preferences when choosing face-to-face vs remote consultations. However, little is known about acceptability of, and preferences for remote consultations, particularly amongst patients with musculoskeletal conditions. This study aimed to explore the acceptability of, and preferences for, remote consultations among patients with osteoporosis and rheumatoid arthritis.
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. Methods
. Data for this study derived from three UK qualitative studies: iFraP (improving fracture prevention study), Blast Off (BO; Bisphosphonate aLternAtive regimenS for the prevenTion of Osteoporotic Fragility Fractures), and ERA (Exploring people with Rheumatoid Arthritis’ experience of the pandemic). Each study explored patient experiences of accessing and receiving healthcare during the pandemic year. Transcripts from each data set relating to remote consulting were extracted. A minimum of two study team members worked independently, following a consistent approach, to conduct a rapid deductive analysis using the Theoretical Framework of Acceptability (TFA). The TFA consists of 7 constructs to understand acceptability of, in this context, remote consultations, including: affective attitudes; intervention coherence; perceived effectiveness; burden; self-efficacy; opportunity-costs; and ethicality. Following coding, the findings of all three studies were pooled. Analysis was facilitated by group meetings to discuss interpretations.
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. Results
. Findings from 1 focus group and 64 interviews with 35 people, who had mostly experienced telephone consultations, were included the analysis. Participants’ emotional attitudes to remote consultations, views on fairness (ethicality) and sense making (intervention coherence) varied according to their specific needs for the consultation and values, relative to the pandemic context; participants perceived remote consultations as making more sense and being ‘fairer’ earlier in the pandemic. Some participants valued the reduced burden associated with remote consultations, while others highly valued, and did not want to give up, non-verbal communication or physical examination associated with face-to-face consults (opportunity costs); although perceived need for physical examination in participants with RA was associated with strong preference for face-to-face consultations, asymptomatic participants with RA and osteoporosis also expressed similar strong preferences. Some participants described low confidence (self-efficacy) in being able to communicate in remote consultations and others perceived remote consultations as ineffective, in part due to suboptimal communication.
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. Conclusion
. Acceptability of, and preferences for remote consultation appear to be influenced by a range of societal, healthcare provider and personal factors and in this study, were not fixed, or condition-dependent. Remote care by default has the potential to exacerbate health inequalities and needs nuanced implementation. The findings have supported the development of patient-centred recommendations for practice that should be considered alongside clinician-focused recommendations when deciding whether remote consultations are appropriate.
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. Disclosure
. Z. Paskins: Grants/research support; NIHR, Clinician Scientist Award (CS-2018-18-ST2-010)/NIHR Academy. L. Bullock: None. F. Manning: Grants/research support; part funded NIHR Clinical Research Network Scholar Programme. S. Bishop: None. P. Campbell: None. E. Cottrell: None. C. Jinks: Grants/research support; part funded by the NIHR Applied Research Collaboration (ARC) West Midlands. M. Narayanasamy: None. I. Scott: Grants/research support; funded by an NIHR Advanced Research Fellowship Award (NIHR300826). O. Sahota: None. S. Ryan: None.
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Abstract
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. Background/Aims
. The COVID-19 pandemic placed patients with rheumatoid arthritis (RA) at increased risk of poor outcomes as a result of their condition, compounded by use of immunosuppressant medication, and higher prevalence of comorbidities. As a consequence, some patients were instructed within the UK to follow strict guidelines to “shield”, severely restricting routine social interactions. This study explored patients’ longitudinal experiences of living with RA during the COVID-19 pandemic.
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. Methods
. Patients with rheumatoid arthritis, from a community hospital-based rheumatology service, participated in two semi-structured telephone interviews at baseline in autumn 2020 and 2-4 months later. Interviews were recorded and transcribed verbatim. Interpretative phenomenological analysis was undertaken by two members of the research team with input from two patient partners (KR and MB).
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. Results
. 15 participants (9 females, 10 retired, age range 45-79 years) were interviewed twice. Five themes were identified: i) fear, ii) social wellbeing, iii) physical health, iv) pre-existing self-management of RA as a coping mechanism, and v) vulnerability. The overriding emotion was one of fear of contracting COVID-19, which remained high throughout both interviews. Fear was influenced by patients’ existing knowledge of their RA and medications and the presence of other significant co-morbidities. Further influences on fear included mainstream media reports (increasing reporting of deaths and new variants) and personal knowledge (family and friends who had contracted COVID-19). The impact on social wellbeing became more pronounced as remote communications could not replicate the benefits of physical interaction. Participants reported no impact on their physical health, with increased rest resulting from restricted social interaction perceived to be beneficial. Many participants utilised the resilience they had learned as a result of having RA to cope, including stress management, pacing, and exercise. Being categorised as “clinically extremely vulnerable” led to a reassessment of self-identity, with participants not wanting to be perceived as being weak or helpless. Finally, many participants used lockdown to reflect on and reassess their personal priorities.
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. Conclusion
. This longitudinal interview study with 15 people with RA highlights that the main impact of the pandemic appeared to be on emotional wellbeing brought about by fear of COVID-19, later compounded by lack of social interaction. In this small study, participants’ physical health was reported to be stable and participants were able to use self-management skills to cope. The realisation of the seriousness of contracting COVID-19 led to feelings of vulnerability and a reassessment of self-identity. The study raises important issues for those providing healthcare to people with RA, including effective communication with awareness of its likely impact, using pre-existing self-management strategies to enhance wellbeing, and recognition of the potential for social isolation and the implications thereof.
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. Disclosure
. P. Campbell: None. Z. Paskins: None. S. Hider: None. A. Hassell: None. F. Crawford-Manning: None. K. Rule: None. M. Brooks: None. S. Ryan: None.
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Objective: People with inflammatory arthritis have an increased incidence of serious illness and mortality, placing them at risk of poor outcomes from coronavirus disease 2019 (COVID-19). This study explored patients' perceptions of risk from COVID-19 over a longitudinal period of the pandemic. Methods: Fifteen adults with inflammatory arthritis attending a National Health Service rheumatology service each took part in three semi-structured telephone interviews conducted between 16 September 2020 and 29 July 2021. Interpretive phenomenological analysis was undertaken by two researchers and two public contributors. Results: Four main themes relating to perceptions of risk from COVID-19 were identified: inflammatory arthritis; medications and co-morbidities; immediate social environment; health policy communication; and media influence. Participants recognized that having inflammatory arthritis increased their individual risk. Perceptions of risk and associated fear increased during the pandemic, influenced by family/friends who had had COVID-19 and health policy communications. The perceived constant use of negative messages led to many participants disengaging with the media. At the final interviews, when the vaccination programme was well established, participants continued to assess the risk and benefits of engaging in activities. Conclusion: This study demonstrates the breadth of factors that influenced perceptions of risk in people with an inflammatory arthritis. As health professionals, we have only a small sphere of influence over some of these factors, namely health-care communications. People with inflammatory arthritis appropriately knew that their condition increased their infection risk, but more could be done to consider how and to what extent we involve patients in explaining risk at times of crisis.

Summary: Fracture Liaison Services are recommended to deliver best practice in secondary fracture prevention. This modified Delphi survey, as part of the iFraP (Improving uptake of Fracture Prevention drug Treatments) study, provides consensus regarding tasks for clinicians in a model Fracture Liaison Service consultation. Purpose: the clinical consultation is of pivotal importance in addressing barriers to treatment adherence. The aim of this study was to agree to the content of the ‘model Fracture Liaison Service (FLS) consultation’ within the iFraP (Improving uptake of Fracture Prevention drug Treatments) study. Methods: a Delphi survey was co-designed with patients and clinical stakeholders using an evidence synthesis of current guidelines and content from frameworks and theories of shared decision-making, communication and medicine adherence. Patients with osteoporosis and/or fragility fractures, their carers, FLS clinicians and osteoporosis specialists were sent three rounds of the Delphi survey. Participants were presented with potential consultation content and asked to rate their perception of the importance of each statement on a 5-point Likert scale and to suggest new statements (Round 1). Lowest rated statements were removed or amended after Rounds 1 and 2. In Round 3, participants were asked whether each statement was ‘essential’ and percentage agreement calculated; the study team subsequently determined the threshold for essential content. Results: Seventy-two, 49 and 52 patients, carers and clinicians responded to Rounds 1, 2 and 3 respectively. One hundred twenty-two statements were considered. By Round 3, consensus was reached, with 81 statements deemed essential within FLS consultations, relating to greeting/introductions; gathering information; considering therapeutic options; eliciting patient perceptions; establishing shared decision-making preferences; sharing information about osteoporosis and treatments; checking understanding/summarising; and signposting next steps. Conclusions: This Delphi consensus exercise has summarised for the first time patient/carer and clinician consensus regarding clearly defined tasks for clinicians in a model FLS consultation.

Summary: Patient information is important to help patients fully participate in their healthcare. Commonly accessed osteoporosis patient information resources were identified and assessed for readability, quality, accuracy and consistency. Resources contained inconsistencies and scored low when assessed for quality and readability. We recommend optimal language and identify information gaps to address. Introduction: the purpose of this paper is to identify commonly accessed patient information resources about osteoporosis and osteoporosis drug treatment, appraise the quality and make recommendations for improvement. Methods: Patient information resources were purposively sampled and text extracted. Data extracts underwent assessment of readability (Flesch Reading Ease and Flesch-Kincaid Grade Level) and quality (modified International Patient Decision Aid Standards (m-IPDAS)). A thematic analysis was conducted, and keywords and phrases were used to describe osteoporosis and its treatment identified. Findings were presented to a stakeholder group who identified inaccuracies and contradictions and discussed optimal language. Results: Nine patient information resources were selected, including webpages, a video and booklets (available online), from government, charity and private healthcare providers. No resource met acceptable readability scores for both measures of osteoporosis information and drug information. Quality scores from the modified IPDAS ranged from 21 to 64% (7–21/33). Thematic analysis was informed by Leventhal’s Common-Sense Model of Disease. Thirteen subthemes relating to the identity, causes, timeline, consequences and controllability of osteoporosis were identified. Phrases and words from 9 subthemes were presented to the stakeholder group who identified a predominance of medical technical language, misleading terms about osteoporotic bone and treatment benefits, and contradictions about symptoms. They recommended key descriptors for providers to use to describe osteoporosis and treatment benefits. Conclusions: This study found that commonly accessed patient information resources about osteoporosis have highly variable quality, scored poorly on readability assessments and contained inconsistencies and inaccuracies. We produced practical recommendations for information providers to support improvements in understanding, relevance, balance and bias, and to address information gaps.

Introduction Prevention 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 analysis the 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 dissemination Ethical 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 number researchregistry5041.

Background: the prevention of self-harm is an international public health priority. It is vital to identify at-risk populations, particularly as self-harm is a risk factor for suicide. This study aims to examine the risk of self-harm in people with vertebral fractures. Methods: Retrospective cohort study. Patients with vertebral fracture were identified within the Clinical Practice Research Datalink and matched to patients without fracture by sex and age. Incident self-harm was defined by primary care record codes following vertebral fracture. Overall incidence rates (per 10,000 person-years (PY)) were reported. Cox regression analysis determined risk (hazard ratios (HR), 95 % confidence interval (CI)) of self-harm compared to the matched unexposed cohort. Initial crude analysis was subsequently adjusted and stratified by median age and sex. Results: the number of cases of vertebral fracture was 16,293, with a matched unexposed cohort of the same size. Patients were predominantly female (70.1 %), median age was 76.3 years. Overall incidence of self-harm in the cohort with vertebral fracture was 12.2 (10.1, 14.8) /10,000 PY. There was an initial crude association between vertebral fracture and self-harm, which remained after adjustment (HR 2.4 (95 %CI 1.5, 3.6). Greatest risk of self-harm was found in those with vertebral fractures who were aged below 76.3 years (3.2(1.8, 5.7)) and male (3.9(1.8, 8.5)). Conclusions: Primary care patients with vertebral fracture are at increased risk of self-harm compared to people without these fractures. Male patients aged below 76 years of age appear to be at greatest risk of self-harm. Clinicians need to be aware of the potential for self-harm in this patient group.

Objective to explore the acceptability of different bisphosphonate regimens for the treatment of osteoporosis among patients, clinicians and managers, payers and academics. Design a systematic review of primary qualitative studies. Seven databases were searched from inception to July 2019. Screening, data extraction and quality assessment of full-articles selected for inclusion were performed independently by two authors. A framework synthesis was applied to extracted data based on the theoretical framework of acceptability (TFA). The TFA includes seven domains relating to sense-making, emotions, opportunity costs, burden, perceived effectiveness, ethicality and self-efficacy. Confidence in synthesis findings was assessed. Setting Any developed country healthcare setting. Participants Patients, healthcare professionals, managers, payers and academics. Intervention Experiences and views of oral and intravenous bisphosphonates. Results Twenty-five studies were included, mostly describing perceptions of oral bisphosphonates. We identified, with high confidence, how patients and healthcare professionals make sense (coherence) of bisphosphonates by balancing perceptions of need against concerns, how uncertainty prevails about bisphosphonate perceived effectiveness and a number of individual and service factors that have potential to increase self-efficacy in recommending and adhering to bisphosphonates. We identified, with moderate confidence, that bisphosphonate taking induces concern, but has the potential to engender reassurance, and that both side effects and special instructions for taking oral bisphosphonates can result in treatment burden. Finally, we identified with low confidence that multimorbidity plays a role in people's perception of bisphosphonate acceptability. Conclusion By using the lens of acceptability, our findings demonstrate with high confidence that a theoretically informed, whole-system approach is necessary to both understand and improve adherence. Clinicians and patients need supporting to understand the need for bisphosphonates, and clinicians need to clarify to patients what constitutes bisphosphonate treatment success. Further research is needed to explore perspectives of male patients and those with multimorbidity receiving bisphosphonates, and patients receiving intravenous treatment. PROSPERO registration number CRD42019143526.

Summary: the COVID-19 pandemic is influencing methods of healthcare delivery. In this short review, we discuss the evidence for remote healthcare delivery in the context of osteoporosis. Introduction: the COVID-19 pandemic has undoubtedly had, and will continue to have, a significant impact on the lives of people living with, and at risk of, osteoporosis and those caring for them. With osteoporosis outpatient and Fracture Liaison Services on pause, healthcare organisations have already moved to delivering new and follow-up consultations remotely, where staffing permits, by telephone or video. Methods: in this review, we consider different models of remote care delivery, the evidence for their use, and the possible implications of COVID-19 on osteoporosis services. Results: Telemedicine is a global term used to describe any use of telecommunication systems to deliver healthcare from a distance and encompasses a range of different scenarios from remote clinical data transfer to remote clinician-patient interactions. Across a range of conditions and contexts, there remains unclear evidence on the acceptability of telemedicine and the effect on healthcare costs. Within the context of osteoporosis management, there is some limited evidence to suggest telemedicine approaches are acceptable to patients but unclear evidence on whether telemedicine approaches support informed drug adherence. Gaps in the evidence pertain to the acceptability and benefits of using telemedicine in populations with hearing, cognitive, or visual impairments and in those with limited health literacy. Conclusion: There is an urgent need for further health service evaluation and research to address the impact of remote healthcare delivery during COVID-19 outbreak on patient care, and in the longer term, to identify acceptability and cost- and clinical-effectiveness of remote care delivery on outcomes of relevance to people living with osteoporosis.