Title: The optimisation of foot care for people with arthritis
Funder: Department of Health and Social Care

Abstract: Background to the research In the UK 20 million people are reported to have some form of arthritis. Whilst mobility is a recommended component of healthy living for arthritis it assumes that feet are free from pain. Foot and ankle problems account for 8% of consultations in primary care, however an evidence gap exists for robust research evidence about foot care provision in the UK for patients with rheumatoid arthritis and patients with osteoarthritis. Evidence suggests that podiatric foot care provision does not meet current recommended standards for these patients. Additionally some of these patients are reporting that they are forcing themselves to walk through their foot pain in the requirement to exercise to manage their hip or knee arthritis or other problems such as heart disease. Many of these issues have not been given specific consideration by commissioners and service providers. Aim The aim of this project is to develop a best practice foot care package for patients who have rheumatoid arthritis and patients who have osteoarthritis. A subsequent aim is to test the feasibility of implementing this in NHS clinical practice. Plan of investigation The research involves two phases with a mixed methods approach of explanatory sequential design. A series of investigations will be performed with quantitative data collected first, followed by qualitative explanations providing an understanding of how and in what context the quantitative results occur. The results from these two phases will be integrated to inform the development and testing of a best practice foot care package for patients with rheumatoid arthritis and patients with osteoarthritis. Phase one involves analysis of a large quantitative data set, the Clinical Practice Research Datalink (CPRD), to define the burden of UK foot problems for patients with rheumatoid arthritis and patients with osteoarthritis. Additionally, a systematic review of guidelines will be performed to determine current evidence based recommendations for the management of foot health for patients who have rheumatoid arthritis and patients who have osteoarthritis. This search will be targeted at two levels: UK clinical practice (to inform phase 2) and International (to inform phase 3). Phase two involves qualitative work to follow up and explore findings from phase one. Views of patients, GPs, clinicians, podiatry managers and commissioners will be sought to gain feedback on experiences of barriers and facilitators in the NHS to referral, access, provision and treatment for foot problems for patients with rheumatoid arthritis and patients with osteoarthritis. Phase three will be a feasibility study (25 patients with rheumatoid arthritis; 25 patients with osteoarthritis) of the implementation of the best foot care package within NHS clinical practice. Quantitative and qualitative evaluation of the feasibility study will be performed to refine the foot care package and to inform a future clinical trial. The outcomes will assess the potential for a future clinical trial and application for HTA funding to evaluate the effectiveness and cost effectiveness of best foot care for patients who have rheumatoid arthritis and patients who have osteoarthritis. Potential benefits to patients and the NHS. The primary outcome of this research will be the development and refinement of a robust evidence based best practice foot care package for management of foot problems for patients who have rheumatoid arthritis and patients who have osteoarthritis that could be transferable to other patients. People who do not walk well are much more vulnerable to other problems such as weight gain or lessened resilience to other chronic long term conditions such as heart disease and social isolation. Changing the way current foot care is provided for older people is essential to benefit their long term social health and well-being.

Lay abstract: Title: Best practice foot care for people with arthritis. Aim(s) of the research Through this study I want to find out what the best way of treating foot problems is for people who have arthritis and if people who have arthritis have access to the best foot care. I also want to understand how doctors decide where to refer patients and what services are available to support good foot health for people who have arthritis. In the final part of this work I will use that information to develop and test a package of care for treatment of foot problems for people who have arthritis. Background to the research In the UK 20 million people are reported to have some form of arthritis. The World Health Organization has declared that exercise should be at the core of non-drug treatments for conditions such as arthritis. Walking to bring about a healthy lifestyle is encouraged throughout the UK but to do this feet have to be free from pain. Foot pain is debilitating and linked with falling, tripping, weight gain as well as not being able to get out and about, which can affect quality of life. Some patients report they force themselves to walk through their foot pain in order to manage their hip or knee arthritis or other problems such as heart disease. Some patients also report that there is confusion over how to get an appointment to see someone about their foot pain and that doctors will only refer people who have foot pain and diabetes. The confusion appears to be because information is not currently available to show what foot care people with arthritis need. As a result many people who have arthritis are unable to benefit from foot care and may not be able to have a healthy and active lifestyle because they have trouble walking. Design and methods used The research will involve a number of studies that link together: 1. I will look through all the work that has been published on guidelines to understand what recommendations of best practice for foot care exist for people who arthritis. 2. I will study a large information set used by doctors (GPs) to look at how and why GPs choose to send people who have arthritis for foot care. I will then interview some GPs to find out more about their views of foot care for people who have arthritis. 3. Through focus groups, I will ask patients, podiatrists and Commissioners about their views of foot care services for people who have arthritis. 4. Through a survey, I will ask managers of foot care services what they currently provide for people who have arthritis. 5. The findings from those studies will help us to define the best treatments and best referral routes in a package of foot care developed to benefit people who have arthritis. 6. Finally I will test whether the foot care package can be used by the NHS in a small trial for 50 people with arthritis. Patient and public involvement (PPI) I have involved people with arthritis in several ways to help design this research. Their input has changed our plans for example: PPI representatives on the current foot arthritis study (ELFOAB) have contributed to the concept of the project idea for this application. Feedback from people with arthritis attending an Arthritis Research UK engagement day was that nothing could be done about their foot pain and that they had to live with it unless they had diabetes. PPI representatives have commented on the design of the study and helped improve it. They have been very supportive of the proposal and believe it to be a worthwhile and timely research project. They will continue to work with me in an advisory capacity on the project. Dissemination I want to make sure this research gets to the people it needs to. Therefore I will: Tell patients with arthritis about this by sending press releases to local and national arthritis groups. Use social media (e.g. Twiitter) and website as other ways to reach people who have arthritis. Present the study findings locally for those who have participated within Solent NHS Trust. Publish the research in high quality scientific journals. Present the study findings at national and international scientific conferences that are about arthritis. Write a report of the recommendations to be given to the UK College of Podiatry which will be used for circulation to policy makers and commissioners of foot care services.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;7.3 MANAGEMENT AND DECISION MAKING
Health categories: MUSCULOSKELETAL;INFLAMMATORY AND IMMUNE SYSTEM