Award Title: Improving iDEntification of inflammatory ArthritiS (IDEAS) in Primary Care: a multi-disciplinary team approach
Funder: Health Education England

Abstract: This research aims to address the clinical research question: Can we identify people in the pre-clinical phase of inflammatory arthritis (IA) earlier in primary care? A phase of imminent IA has been demonstrated to precede rheumatoid arthritis (RA) onset. Secondary care models have evolved to predict the early development of RA, even before synovitis is clinically apparent, through anti-CCP antibody testing. Most musculoskeletal complaints first present in primary care. It has been estimated that people who are subsequently diagnosed with RA visit their GPs four times with musculoskeletal complaints, during a nine month period, before being referred to a specialist for their diagnosis and treatment. As a podiatrist I have a specific interest in early identification because 31% of cases of IA are known to have had their first symptoms in their feet. My fellowship will complement existing programmes of research by aiming to improve the early identification of people in the pre-clinical phase of IA through the use of more targeted anti-CCP testing in primary care. Objectives:	To develop and preliminary test a model for the early identification of people in the pre-clinical phase of IA in primary care through targeted anti-CCP testing and by a better understanding of presenting musculoskeletal complaints, such as those in the feet	 	To evaluate the cost-effectiveness of improving early identification of people in the pre-clinical phase of IA in primary care	 	To develop, refine and test the feasibility of the 'IDEAS in Primary Care' (IDEAS-PC) modelUsing existing primary care data from the Leeds 'Co-ordinated Programme to Prevent Arthritis' (n4250) multiple binary logistic regression will be used to identify specific joints or joint groups that are associated with increased probability of anti-CCP positivity. To provide temporal validation for the model two sources of external data will be used to investigate presenting symptoms. A care pathway analysis undertaken with clinicians and patients, literature review and data analysis will inform the structure of the cost-effectiveness decision analytical model to estimate the expected costs and QALYs for the current pathway and implementation of the IDEAS-PC model. Relevant theory, evidence synthesis and co-design with clinicians and patients will be used to develop the IDEAS-PC model with training and education materials to support delivery. Feasibility testing of the IDEAS-PC model will be conducted to explore intervention fidelity and acceptability prior to undertaking a pilot study transitioning into a full clinical trial, following on from my SCL. My training programme will act as a vehicle towards my establishment as a clinical academic leader in musculoskeletal healthcare. This fellowship will maximise the use of existing world-class data and infrastructure, as well as develop new collaborations to support the proposed programme of research and the dissemination and implementation of findings. Research aimed at improving identification of people in the pre-clinical phase of IA will lead to better targeted anti-CCP testing and improve early referral to secondary care. The findings from this programme of research will underpin formal testing in a clinical trial beyond the scope of this SCL.

Lay Abstract: Can we identify people who have rheumatoid arthritis before they get inflammation that damages their joints? Rheumatoid arthritis (RA) is caused by inflammation (swelling) in the joints, generally affecting multiple joints, whereas osteoarthritis normally affects individual joints when overused. People who have RA typically visit their GP four times with musculoskeletal (bone, joint, tendon or muscle) problems before they are referred to a hospital specialist (rheumatologist). As a podiatrist, who looks after foot problems, I know that almost a third of people with RA start with pain in their feet and would like to find out which foot problems occur first. We know that early treatment leads to much better results for patients who have RA. There is an opportunity to identify people who are likely to develop RA before they get swelling in their joints by having a specific blood test (for anti-CCP antibodies) when they complain of new musculoskeletal problems. Unfortunately not everyone can be referred for this test as it is considered too expensive and often GPs don't know when they should be sending patients to be tested. The purpose of this research is to work out whether we can identify people in the very early stages of developing RA when they see their GP. I will look at whether the extra costs of identifying people early saves money for the NHS in the long-term. If it is more expensive, I will work out if people have less problems because they have been referred to see a hospital specialist early. In this study I will: 1) Use research data already collected in Leeds from approximately 4250 people nationwide who saw their GP with a new musculoskeletal problem and had an anti-CCP test. I will work out which musculoskeletal problems occur in the people who are anti-CCP positive and therefore more likely to develop RA. In the people who are anti-CCP positive I will find out specifically what foot problems they had initially. This will help podiatrists recognise those people who should have an anti-CCP test. 2) Work with patients and health professionals to compare what currently happens when a patient sees their GP with a new musculoskeletal problem until they are diagnosed with RA. I will compare this with having the anti-CCP blood test to identify people earlier to see if it saves money and/or means that patients have fewer problems in the long-term. 3) Use research data and the expertise of patients and health professionals to develop a new approach to care and a training package to help health professionals use it in their clinics. It will be tested in 24 GP practices to see if they are able to use it in their normal clinics. Patients will be asked about their experiences of the care they received. People with RA have been actively involved in developing this research. They expressed concern about delay in diagnosis, which was highlighted by one member's comments 'now that I know what the journey was like I would like to have been referred to the consultant sooner'. This research will be developed with patients and health professionals to provide insights into what works. The research team in Leeds are already working with GP practices nationwide, and this will help us share what we find. It will ensure it has the best chance of being used by GPs and other health professionals to identify people in the very early stages of developing RA. The results will also be presented to health professionals at conferences and shared with national charities and patient groups, including Versus Arthritis and the National Rheumatoid Arthritis Society.

Research Activity Codes: 4.2 EVALUATION OF MARKERS AND TECHNOLOGIES;7.3 MANAGEMENT AND DECISION MAKING
Health Categories: INFLAMMATORY AND IMMUNE SYSTEM