P13 An analysis of multidisciplinary care in systemic auto-immune rheumatic disease in a single centre
Authors: Sandhu Kieran , Ahmad Nadia , Verdiyeva Ayna , Luqmani Raashid 
Published: April 2020

Abstract

Background
Auto-immune rheumatic diseases are multisystem conditions with high morbidity and mortality, where co-ordinated multidisciplinary (MDT) care is necessary to ensure effective and timely treatment. An NHS England Commissioning for Quality and Innovation was implemented in 2016 to support development of MDTs to achieve earlier diagnosis and intervention and standardise quality of care and access to high-cost drugs.

Methods
A regional network for MDTs was established in one centre, led by Rheumatology with input from other specialities. MDT outcomes are recorded in a bespoke database. We analysed MDT outcomes over a two-year period from September 2017 to August 2019 for the following: disease activity assessments, investigations requested, referrals to other specialists, treatment changes and the reasons for these.

Results
During this period, 2,750 MDT discussions were recorded for 1,270 patients. The most common diagnoses were giant cell arteritis (30%), systemic lupus erythematosus (9%) and granulomatosis with polyangiitis (6%). Disease activity scores were recorded on 2,744 (99.8%) occasions with BVAS (n = 1,658, mean 0.82, range 0-21) and SLEDAI (n = 379, mean 2.04, range 0-20) used most. This underlines that decisions were consistently based on validated outcome measures. Investigations were ordered on 1165 (42%) occasions. Imaging was requested in 1,124 cases, biopsy in 37, functional tests in 221 and other tests in 18. Ultrasound was requested most often (614). Onward referrals were made in 237 (9%), most frequently to respiratory (32) and ENT (32). On 1550 occasions (56%) a treatment change was made: 1049 (38%) had a new change and 501 (18%) had a previously planned change. The most common reasons were good response to therapy (354 [23%]), inefficacy (345 [22%]) or starting additional therapy (214 [14%]). This shows that a significant number of treatment changes were approved by the MDT, both for treatment reduction as well as escalation. A biologic was added on 65 occasions (4% of treatment changes), most commonly in GCA (8 started on tocilizumab), SLE (5) and GPA (5). Biologics were repeated in 121 (8%) and stopped in 25 (2%). Where biologics were added, mean pre-treatment BVAS was 4.7 and post-treatment was 0.6. Mean reduction in BVAS after treatment was 5.2. The equivalent mean scores for SLEDAI were 7 (pre-treatment), 2 (post-treatment) and 7.7 (reduction). On average, the addition of biologics resulted in reductions in disease activity scores, which provides justification for their use.

Conclusion
Our data suggest that the large number of MDT reviews over this two-year period contributed significantly to management of systemic auto-immune rheumatic diseases by approving investigations, referrals and treatment changes. This facilitated timely intervention and avoidance of overtreatment. The auditable recording of these reviews and disease activity scores ensured decisions were guided by objective assessments and the use of high-cost drugs was standardised and justifiable.

Disclosures
K. Sandhu None. N. Ahmad None. A. Verdiyeva None. R. Luqmani None.