Title: Developing A Quality Standard To Deliver Evidence-Based Pain Management To People With Inflammatory Arthritis.
Funder: Department of Health and Social Care

Abstract: BackgroundInflammatory arthritis is an umbrella-term for diseases involving immune-driven joint inflammation. Its three main forms - rheumatoid arthritis (RA), psoriatic arthritis (PsA), axial spondyloarthritis (axial SpA) -h; affect 1-2% of UK adults.Despite significant advances in controlling joint inflammation, pain continues to be a major problem for people with inflammatory arthritis, and the health-area patients most want improving. Emerging evidence suggests current pain management overuses long-term analgesics, despite their relative inefficacy and risks, and underuses evidence-based non-drug treatments like exercise. Such practice reflects neither the clinical evidence, nor guideline recommendations. The fellowship will address this imbalance.AimTo facilitate equitable, evidence-based pain management for people with inflammatory arthritis by combining in-depth evaluations of current care with evidence on treatment efficacy and guidance to co-produce a Quality Standard for pain management in inflammatory arthritis.Objectives Describe analgesia prescribing in inflammatory arthritis, its variability across patient groups, and risks, using existing national electronic healthcare record data. Evaluate key aspects of pain management unavailable in existing electronic healthcare record data, including the non-drug treatments patients receive, if these vary across patient groups, and how people with inflammatory arthritis use analgesia. Co-produce a Quality Standard for inflammatory arthritis pain management to deliver safe, equitable, evidence-based care.Methods Three work-packages will address these objectives.Work-Package 1: Analgesia Prescribing/Risks (Years 1-3)Observational studies will use the Clinical Practice Research Datalink, containing data from 42 million patient lives. Cross-sectional analyses will describe patterns/inequalities in annual analgesia prescriptions. A cohort study will identify predictors of long-term analgesia prescriptions. Case-control studies will examine specific risks associated with analgesia in people with inflammatory arthritis compared to people with osteoarthritis.Work-Package 2: Overall Pain Management (Years 2-4)A cross-sectional survey of 1,800 people with inflammatory arthritis from six West Midlands Rheumatology Units will evaluate what pain treatments people receive, and their associated patterns/inequalities. A nested longitudinal study of 232 patients taking analgesia regularly will use intensive repeated measures delivered via text-messaging over 14-days to examine the frequency of analgesia use together with potential triggers.Work-Package 3: Quality Standard Development (Years 4-5)An evidence synthesis will combine findings from work-packages 2/3 with umbrella reviews of pain treatment efficacy/risks and guidelines in people with inflammatory arthritis. Iterative stakeholder workshops will co-produce a set of Quality Standard statements and indicators, subsequently finalised through an online two-stage Delphi study.Patient and Public Involvement and Engagement6 people with inflammatory arthritis will meet every 6-months, advising on research design/conduct, and helping with interpreting/disseminating research findings.Impact and DisseminationKeele's Impact Accelerator Unit will support free-to-access knowledge mobilisation of the Quality Standard and research findings, ensuring rapid adoption into routine care/widespread dissemination. Patient partners will help ensure messages are understandable and relevant. Existing strong professional, patient and NHS links will facilitate influence of clinical guidelines, healthcare professional/patient resources, and medical education. It is anticipated the Quality Standard will increase the use of evidence-based pain treatments, leading to reduced pain/improved ability to function despite pain, reduced personal/NHS costs from analgesia prescriptions, and improved patient care/clinician knowledge.

Lay abstract: IMPROVING HOW PAIN IS TREATED IN PEOPLE WITH INFLAMMATORY ARTHRITISThe ProblemInflammatory arthritis includes several conditions causing inflamed joints. The commonest types are 'rheumatoid arthritis', 'psoriatic arthritis', and 'axial spondyloarthritis'. It is common, affecting 1 in 100 people in the UK.Despite the availability of powerful new medicines that control joint inflammation, many people with inflammatory arthritis continue to suffer daily pain. This has great impacts on their lives, and is the area of health they most want improving.Although it is commonly believed that pain-killers reduce inflammatory arthritis pain, research has shown they often don't help. Despite this, studies in America show that inflammatory arthritis pain is often treated with long-term pain-killers. This is a worrying problem, as pain-killers often cause side-effects, which can be severe. It is not known if this also happens in the NHS.Non-drug treatments such as exercise and footwear can help arthritis pain, and are safe. Little is known about how often they are used, although one survey of people with rheumatoid arthritis reported that half of people could not access all the non-drug treatments they required.There is an urgent need to improve how pain is managed in people with inflammatory arthritis in the NHS. The first step is to understand how pain is currently treated. The next step is to use this information to develop recommendations promoting safe care that works.AimTo provide safe pain management that works to people with inflammatory arthritis, by answering the following questions relating to them:1. How often are they prescribed pain-killers, and which ones are given?2. How often do pain-killers cause severe side-effects?3. How often do they receive non-drug pain-relieving treatments, and which ones are given?4. How do they use their pain-killers? We will then use these answers, and work with patients, carers and experts, to identify the best way to treat pain in people with inflammatory arthritis.MethodsThis project has three parts.Part 1 - Prescribing and Side-EffectsThis will use the 'Clinical Research Practice Datalink', which contains anonymised health records of patients from hundreds of NHS GP practices across the UK. It will examine which pain-killers are prescribed, and how often they are prescribed and cause side-effects, in people with inflammatory arthritis.Part 2 -h; Non-Drug Treatments and Pain-Killer UsePeople with inflammatory arthritis seen at six hospitals will be invited to complete a short questionnaire when they attend their appointment. This will ask about the non-drug treatments and pain-killers they have received for pain. People that use pain-killers regularly will be asked to take part in an extra study examining how often they take pain-killers, and why. They will receive text-messages on their mobile phone, four-times a day for 14 days. Each text-message will ask short questions about their pain-killer use, and levels of pain.Part 3 -h; RecommendationsPrevious research and guidelines on pain treatment in inflammatory arthritis will be summarised. Experts involved in inflammatory arthritis pain management (including patients) will use this with the findings from parts 1 and 2, to develop recommendations (called a 'Quality Standard') about the best way to treat pain in people with inflammatory arthritis.Patient InvolvementWe will ask people with inflammatory arthritis to meet regularly throughout the research to help: Understand what the results mean to people with inflammatory arthritis. Design and oversee the research. Advise how the findings could be shared.Ways To Share Research FindingsThese will include: Working with professional bodies, patient organisations, and guideline developers. Press releases. Keele University's website, and social media. Presenting at scientific conferences. Publishing in scientific journals.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: INFLAMMATORY AND IMMUNE SYSTEM