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Objectives PMR causes pain, stiffness and disability in older adults. Measuring the impact of the condition from the patient’s perspective is vital to high-quality research and patient-centred care, yet there are no validated patient-reported outcome measures (PROMs) for PMR. We set out to develop and psychometrically evaluate a PMR-specific PROM. Methods Two cross-sectional postal surveys of people with a confirmed diagnosis of PMR were used to provide data for field testing and psychometric evaluation. A total of 256 participants completed the draft PROM. Distribution of item responses was examined, and exploratory factor analysis and Rasch analysis were used to inform item reduction, formation of dimension structure and scoring system development. Some 179 participants completed the PROM at two time points, along with comparator questionnaires and anchor questions. Test–retest reliability, construct validity and responsiveness were evaluated. Results Results from the field-testing study led to the formation of the PMR-Impact Scale (PMR-IS), comprising four domains (symptoms, function, psychological and emotional well-being, and steroid side effects). Construct validity and test–retest reliability met accepted quality criteria for each domain. There was insufficient evidence from this study to determine its ability to detect flares/deterioration, but the PMR-IS was responsive to improvements in the condition. Conclusion The PMR-IS offers researchers a new way to assess patient-reported outcomes in clinical studies of PMR. It has been developed robustly, with patient input at every stage. It has good construct validity and test–retest reliability. Further work is needed to fully establish its responsiveness and interpretability parameters, and to assess its real-world clinical utility.

Background/Aims The substantial personal and socioeconomic costs associated with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and axial spondyloarthritis (SpA) make understanding their epidemiology crucial. The Clinical Practice Research Datalink (Aurum) is an electronic healthcare record (EHR) database, containing primary care records from ∼20% of English practices (>13 million patients currently registered). To determine RA/PsA/axial SpA epidemiology using EHR data, validated methods need to be applied to ascertain patients with these diagnoses. To address this, we updated and applied approaches validated in other primary care EHR databases in Aurum and described the annual incidence/point-prevalence of RA/PsA/axial SpA alongside patient characteristics (providing indirect evidence of coding accuracy). Methods Diagnosis and synthetic disease-modifying anti-rheumatic drug (DMARD) prescription code lists were constructed, and pre-defined approaches for ascertaining patients with RA/axial SpA/PsA applied. The annual incidence and point-prevalence of RA/PsA/axial SpA were calculated from 2004-2020. Samples were stratified by age/gender, and mean age and gender/ethnic-group relative frequencies described. The study was approved by the CPRD Independent Scientific Advisory Committee (reference 20_000244). Results From 2004-2019 the point-prevalence of RA/PsA increased annually, peaking in 2019 (RA 7.79/1,000; PsA 2.87/1,000) then falling slightly. From 2004-2020 the point-prevalence of axial SpA increased annually (except in 2018/2019), peaking in 2020 (1.13/1,000). Annual RA incidence was higher between 2013-2019 (when included in the Quality Outcomes Framework, ranging 0.491 to 0.521/1,000 person-years) than 2004-2012 (ranging 0.345 to 0.400/1,000 person-years). The annual incidence of PsA and axial SpA increased from 2006 (0.108 to a peak of 0.172/1,000 person-years) and 2010 (0.025 to a peak of 0.045/1,000 person-years), respectively. These years were when new disease classification criteria were introduced. Marked falls in the annual incidence of RA, PsA and axial SpA between 2019 and 2020 were seen, reducing by 40.1%, 67.4% and 38.1%, respectively, reflecting the impact of the COVID-19 pandemic on arthritis diagnoses. Stratifying incidence/prevalence by age/gender broadly showed expected patterns (although the incidence of axial SpA/PsA in women increased over time), and the mean age and gender proportions followed those previously reported. Conclusion The approaches we used to determine patients with RA, PsA, and axial SpA in Aurum led to incidence/prevalence estimates broadly consistent with published studies, and patient characteristics as would be expected. These data support the potential of the Aurum-updated ascertainment approaches for use in further studies of RA, PsA and axial SpA. Disclosure I. Scott: None. R. Whittle: None. J. Bailey: None. H. Twohig: None. S. Hider: None. C. Mallen: None. S. Muller: None. K. Jordan: None.

Aims The aim of the PULsE-AI trial was to assess the effectiveness of a machine learning risk-prediction algorithm in conjunction with diagnostic testing for identifying undiagnosed atrial fibrillation (AF) in primary care in England. Methods and results Eligible participants (aged ≥30 years without AF diagnosis; n = 23 745) from six general practices in England were randomized into intervention and control arms. Intervention arm participants, identified by the algorithm as high risk of undiagnosed AF (n = 944), were invited for diagnostic testing (n = 256 consented); those who did not accept the invitation, and all control arm participants, were managed routinely. The primary endpoint was the proportion of AF, atrial flutter, and fast atrial tachycardia diagnoses during the trial (June 2019–February 2021) in high-risk participants. Atrial fibrillation and related arrhythmias were diagnosed in 5.63% and 4.93% of high-risk participants in intervention and control arms, respectively {odds ratio (OR) [95% confidence interval (CI)]: 1.15 (0.77–1.73), P = 0.486}. Among intervention arm participants who underwent diagnostic testing (28.1%), 9.41% received AF and related arrhythmia diagnoses [vs. 4.93% (control); OR (95% CI): 2.24 (1.31–3.73), P = 0.003]. Conclusion The AF risk-prediction algorithm accurately identified high-risk participants in both arms. While the proportions of AF and related arrhythmia diagnoses were not significantly different between high-risk arms, intervention arm participants who underwent diagnostic testing were twice as likely to receive arrhythmia diagnoses compared with routine care. The algorithm could be a valuable tool to select primary care groups at high risk of undiagnosed AF who may benefit from diagnostic testing.

This study aimed to determine the association between the Danish Co-morbidity Index for Acute Myocardial Infarction (DANCAMI) and restricted DANCAMI (rDANCAMI) scores and clinical outcomes in patients hospitalized with AMI. Using the National Inpatient Sample, all AMI hospitalizations were stratified into four groups based on their DANCAMI and rDANCAMI score (0 ; 1 to 3 ; 4 to 5 ; >= 6). The primary outcome was all-cause mortality, whereas secondary outcomes were major adverse cardiovascular/cerebrovascular events, major bleeding, ischemic stroke, and receipt of coronary angiography or percutaneous coronary intervention. Multivariate logistic regression was used to deter-mine adjusted odds ratios (aOR) with 95% confidence intervals (95% CIs). Patients with DANCAMI risk score >= 6 were more likely to suffer mortality (aOR 2.30, 95% CI 2.24 to 2.37) and bleeding (aOR 5.85, 95% CI 5.52 to 6.21) and were less likely to receive coronary angiography (aOR 0.34, 95% CI 0.33 to 0.34) and percutaneous coronary intervention (aOR 0.29, 95% CI 0.28 to 0.29) compared with patients with DANCAMI score of 0. Similar results were observed for the rDANCAMI score. In conclusion, increased DAN-CAMI and rDANCAMI scores were associated with worse in- hospital outcomes in patients with AMI and lower odds of invasive management. The use of co- morbidity scores identifies patients at high risk of adverse outcomes and highlights disparities in care.

Background: Empathic communication and positive messages are important components of “placebo” effects and can improve patient outcomes, including pain. Communicating empathy and optimism to patients within consultations may also enhance the effects of verum, i.e., non-placebo, treatments. This is particularly relevant for osteoarthritis, which is common, costly and difficult to manage. Digital interventions can be effective tools for changing practitioner behavior. This paper describes the systematic planning, development and optimization of an online intervention—“Empathico”–to help primary healthcare practitioners enhance their communication of clinical empathy and realistic optimism during consultations.Methods: The Person-Based Approach to intervention development was used. This entailed integrating insights from placebo and behavior change theory and evidence, and conducting primary and secondary qualitative research. Systematic literature reviews identified barriers, facilitators, and promising methods for enhancing clinical empathy and realistic optimism. Qualitative studies explored practitioners' and patients' perspectives, initially on the communication of clinical empathy and realistic optimism and subsequently on different iterations of the Empathico intervention. Insights from the literature reviews, qualitative studies and public contributor input were integrated into a logic model, behavioral analysis and principles that guided intervention development and optimization.Results: The Empathico intervention comprises 7 sections: Introduction, Empathy, Optimism, Application of Empathico for Osteoarthritis, Reflection on my Consultations, Setting Goals and Further Resources. Iterative refinement of Empathico, using feedback from patients and practitioners, resulted in highly positive feedback and helped to (1) contextualize evidence-based recommendations from placebo studies within the complexities of primary healthcare consultations and (2) ensure the intervention addressed practitioners' and patients' concerns and priorities.Conclusions: We have developed an evidence-based, theoretically-grounded intervention that should enable practitioners to better harness placebo effects of communication in consultations. The extensive use of qualitative research throughout the development and optimization process ensured that Empathico is highly acceptable and meaningful to practitioners. This means that practitioners are more likely to engage with Empathico and make changes to enhance their communication of clinical empathy and realistic optimism in clinical practice. Empathico is now ready to be evaluated in a large-scale randomized trial to explore its impact on patient outcomes.

Clinical records in primary healthcare settings in low- and middle-income countries (LMIC) are often lacking or of too poor quality to accurately assess what happens during the patient consultation. We examined the most common methods for assessing healthcare workers' clinical behaviour: direct observation, standardized patients and patient/healthcare worker exit interview. The comparative feasibility, acceptability, reliability, validity and practicalities of using these methods in this setting are unclear. We systematically review and synthesize the evidence to compare and contrast the advantages and disadvantages of each method. We include studies in LMICs where methods have been directly compared and systematic and narrative reviews of each method. We searched several electronic databases and focused on real-life (not educational) primary healthcare encounters. The most recent update to the search for direct comparison studies was November 2019. We updated the search for systematic and narrative reviews on the standardized patient method in March 2020 and expanded it to all methods. Search strategies combined indexed terms and keywords. We searched reference lists of eligible articles and sourced additional references from relevant review articles. Titles and abstracts were independently screened by two reviewers and discrepancies resolved through discussion. Data were iteratively coded according to pre-defined categories and synthesized. We included 12 direct comparison studies and eight systematic and narrative reviews. We found that no method was clearly superior to the others-each has pros and cons and may assess different aspects of quality of care provision by healthcare workers. All methods require careful preparation, though the exact domain of quality assessed and ethics and selection and training of personnel are nuanced and the methods were subject to different biases. The differential strengths suggest that individual methods should be used strategically based on the research question or in combination for comprehensive global assessments of quality.

To estimate the prevalence of burnout among primary health-care professionals in low- and middle-income countries and to identify factors associated with burnout.We systematically searched nine databases up to February 2022 to identify studies investigating burnout in primary health-care professionals in low- and middle-income countries. There were no language limitations and we included observational studies. Two independent reviewers completed screening, study selection, data extraction and quality appraisal. Random-effects meta-analysis was used to estimate overall burnout prevalence as assessed using the Maslach Burnout Inventory subscales of emotional exhaustion, depersonalization and personal accomplishment. We narratively report factors associated with burnout.The search returned 1568 articles. After selection, 60 studies from 20 countries were included in the narrative review and 31 were included in the meta-analysis. Three studies collected data during the coronavirus disease 2019 pandemic but provided limited evidence on the impact of the disease on burnout. The overall single-point prevalence of burnout ranged from 2.5% to 87.9% (43 studies). In the meta-analysis (31 studies), the pooled prevalence of a high level of emotional exhaustion was 28.1% (95% confidence interval, CI: 21.5-33.5), a high level of depersonalization was 16.4% (95% CI: 10.1-22.9) and a high level of reduced personal accomplishment was 31.9% (95% CI: 21.7-39.1).The substantial prevalence of burnout among primary health-care professionals in low- and middle-income countries has implications for patient safety, care quality and workforce planning. Further cross-sectional studies are needed to help identify evidence-based solutions, particularly in Africa and South-East Asia.Estimer la prévalence de l’épuisement professionnel (burnout) chez les professionnels des soins de santé primaires dans les pays à revenu faible ou intermédiaire et identifier les facteurs associés à l’épuisement professionnel.Nous avons effectué une recherche systématique dans neuf bases de données jusqu’en février 2022 afin d’identifier les études portant sur l’épuisement chez les professionnels des soins de santé primaires dans les pays à revenu faible ou intermédiaire. Il n’y avait aucune limitation linguistique et nous avons inclus des études observationnelles. Deux examinateurs indépendants ont effectué le screening, la sélection des études, l’extraction des données et l’évaluation de la qualité. Une méta-analyse à effets aléatoires a été utilisée pour estimer la prévalence globale de l’épuisement professionnel, évaluée à l’aide des sous-échelles d’épuisement émotionnel, de dépersonnalisation et d’accomplissement personnel du Maslach Burnout Inventory. Voici un rapport narratif des facteurs associés à l’épuisement professionnel.Nos recherches ont permis d’identifier 1568 articles. Après sélection, 60 études provenant de 20 pays ont été incluses dans l’examen narratif, et 31 ont été incluses dans la méta-analyse. Trois études ont recueilli des données pendant la pandémie de Covid-19, mais ont fourni des preuves limitées de l’impact de cette maladie sur l’épuisement professionnel. La prévalence globale à point unique de l’épuisement professionnel variait de 2,5 à 87,9% (43 études). Dans la méta-analyse (31 études), la prévalence collective d’un niveau élevé d’épuisement émotionnel était de 28,1% (intervalle de confiance (IC) à 95%: 21,5–33,5), un niveau élevé de dépersonnalisation était de 16,4% (IC à 95%: 10,1–22,9) et un niveau élevé d’accomplissement personnel réduit était de 31,9% (IC à 95%: 21,7–39,1).La prévalence notable de l’épuisement professionnel chez les professionnels des soins de santé primaires dans les pays à revenu faible ou intermédiaire a des implications pour la sécurité des patients, la qualité des soins et la planification des effectifs. D’autres études transversales sont nécessaires pour aider à identifier des solutions empiriques, en particulier en Afrique et en Asie du Sud-Est.Estimar la prevalencia del desgaste profesional entre los profesionales de la atención primaria de salud en los países de ingresos bajos y medios e identificar los factores que se asocian a este síndrome.Se realizaron búsquedas sistemáticas en nueve bases de datos hasta febrero de 2022 para identificar estudios que investigaran el desgaste profesional en profesionales de la atención primaria de países de ingresos bajos y medios. No hubo limitaciones de idioma y se incluyeron estudios observacionales. Dos revisores independientes completaron el cribado, la selección de estudios, la extracción de datos y la evaluación de la calidad. Se utilizó el metanálisis de efectos aleatorios para estimar la prevalencia global del desgaste profesional, evaluada mediante las subescalas de agotamiento emocional, despersonalización y realización personal del Maslach Burnout Inventory. En este documento, se describen los factores asociados al síndrome de desgaste profesional.La búsqueda arrojó 1568 artículos. Tras la selección, se incluyeron 60 estudios de 20 países en la revisión narrativa y 31 en el metanálisis. Tres estudios recopilaron datos durante la pandemia de la enfermedad por coronavirus de 2019, pero proporcionaron pruebas limitadas sobre el impacto de la enfermedad en el desgaste profesional. La prevalencia global de un único punto sobre el desgaste profesional osciló entre el 2,5 y el 87,9 % (43 estudios). En el metanálisis (31 estudios), la prevalencia conjunta de un nivel alto de agotamiento emocional fue del 28,1 % (intervalo de confianza del 95 %, IC: 21,5-33,5), un nivel alto de despersonalización fue del 16,4 % (IC del 95 %: 10,1-22,9) y un nivel alto de disminución de la realización personal fue del 31,9 % (IC del 95 %: 21,7-39,1).La considerable prevalencia del desgaste profesional entre los profesionales de la atención primaria en los países de ingresos bajos y medios tiene implicaciones para la seguridad de los pacientes, la calidad de la atención y la planificación del personal. Se necesitan más estudios transversales para ayudar a identificar soluciones fundamentadas en la evidencia, en especial en África y Asia Sudoriental.تقدير مدى انتشار الإرهاق بين أخصائيي الرعاية الصحية الأولية في الدول ذات الدخل المنخفض والدخل المتوسط، وتحديد العوامل المرتبطة بالإرهاق. الطريقة قمنا بالبحث بشكل منهجي في تسع قواعد للبيانات حتى فبراير/شباط 2022، لتحديد الدراسات التي تقوم بالاستقصاء في الإنهاك لدى أخصائيي الرعاية الأولية في الدول ذات الدخل المنخفضة والدخل المتوسطة. لم تكن هناك قيود تتعلق باللغة، وقمنا بتضمين دراسات قائمة على الملاحظات. قام اثنان من المراجعين المستقلين بإكمال عمليات الفحص، وتحديد الدراسة، واستخراج البيانات، وتقييم الجودة. تم استخدام التحليل التلوي للتأثيرات العشوائية لتقدير مدى انتشار الإرهاق الكلي كما تم تقييمه باستخدام المقاييس الفرعية Maslach Burnout Inventory للإرهاق العاطفي، وفقدان الشخصية، والإنجاز الشخصي. نحن نقوم بالإبلاغ عن العوامل المرتبطة بالإرهاق عن طريق السرد. النتائج أسفر البحث عن 1568 مقالةً. بعد الاختيار، تم تضمين 60 دراسةً من 20 دولة في المراجعة السردية، وتضمين 31 دراسة في التحليل التلوي. جمعت ثلاث دراسات البيانات أثناء جائحة مرض فيروس كورونا 2019، ولكنها قدمت أدلة محدودة على تأثير المرض على الإرهاق. تراوح معدل الانتشار الكلي للإرهاق في نقطة واحدة من 2.5 إلى 87.9% (43 دراسة). في التحليل التلوي (31 دراسة)، كان معدل الانتشار المجمع لمستوى عالٍ من الإرهاق العاطفي هو 28.1% (بفاصل ثقة مقداره 95%: 21.5 إلى 33.5)، ومستوى عالٍ من فقدان الشخصية هو 16.4% (بفاصل ثقة مقداره 95%: 10.1 إلى 22.9)، ومستوى عالٍ من الإنجاز الشخصي هو 31.9% (بفاصل ثقة مقداره 95%: 21.7 إلى 39.1). الاستنتاج إن الانتشار الكبير للإرهاق بين أخصائيي الرعاية الصحية الأولية في الدول ذات الدخل المنخفض والدخل المتوسط، له آثار على سلامة المرضى، وجودة الرعاية، وتخطيط القوى العاملة. هناك حاجة إلى مزيد من الدراسات المقطعية للمساعدة في تحديد الحلول القائمة على الأدلة، وخاصة في أفريقيا وجنوب شرق آسيا.评估低收入和中等收入国家初级医疗护理工作者的职业倦怠率，并确定引起职业倦怠的相关因素。.我们系统地搜索了截至 2022 年 2 月的九个数据库，以确定调查低收入和中等收入国家初级医疗护理工作者职业倦怠情况的研究。搜集的研究没有语言限制，而且我们纳入了观察性研究。由两位独立评审员完成了筛查、研究选择、数据提取和质量评估。我们采用随机效应元分析法来评估整体职业倦怠率，并使用《马氏职业倦怠量表》作为子量表来评估情绪疲劳、人格解体和个人成就感的情况。我们对于职业倦怠相关的因素进行了叙述性报告。.搜索出 1568 篇论文。经过筛选，来自 20 个国家的 60 项研究被纳入叙述性回顾，31 项研究被纳入元分析。有三项研究收集了新型冠状病毒肺炎大流行期间的数据，但该疾病对职业倦怠的影响方面的证据有限。职业倦怠的总体单点流行率范围为 2.5% 至 87.9%（43 项研究）。在元分析（31 项研究）中，严重级别情绪疲劳的综合流行率为 28.1% （95% 置信区间，CI：21.5–33.5），严重级别人格解体的流行率为 16.4% (95% CI: 10.1-22.9），个人成就感严重缺失的流行率为 31.9% (95% CI: 21.7-39.1）。.低收入和中等收入国家初级医疗护理工作者的高职业倦怠率对患者安全、护理质量和人力规划会产生影响。需要开展进一步的横断面研究来帮助确定有证据支持的解决方案，特别是在非洲和东南亚地区。.Оценить распространенность профессионального выгорания среди специалистов первичной медико-санитарной помощи в странах с низким и средним уровнем дохода, а также выявить факторы, связанные с профессиональным выгоранием.Авторы провели систематический поиск по девяти базам данных, собранных до февраля 2022 года, и выявили исследования о профессиональном выгорании среди специалистов первичной медико-санитарной помощи в странах с низким и средним уровнем дохода. Языковых ограничений не было. Были включены обсервационные исследования. Два независимых эксперта провели скрининговое обследование, отбор исследований, извлечение данных и оценку качества. Для оценки общей распространенности профессионального выгорания использовался метаанализ случайных эффектов с помощью подшкал опросника выгорания Маслач для определения эмоционального истощения, деперсонализации и личных достижений. Авторы описательно сообщают о факторах, связанных с профессиональным выгоранием.В результате поиска обнаружено 1568 статей. После завершения отбора 60 исследований из 20 стран были включены в описательный анализ, а 31 – в метаанализ. Три исследования собрали данные во время пандемии коронавирусной инфекции 2019 года, но представили ограниченные данные о влиянии болезни на профессиональное выгорание. Общая распространенность профессионального выгорания колебалась от 2,5 до 87,9% (43 исследования). В метаанализе (31 исследование) общая распространенность высокого уровня эмоционального истощения составила 28,1% (95%-й ДИ: 21,5–33,5), высокий уровень деперсонализации составил 16,4% (95%-й ДИ: 10,1–22,9), а высокий уровень снижения личных достижений составил 31,9% (95%-й ДИ: 21,7–39,1).Значительная распространенность эмоционального выгорания среди специалистов первичной медико-санитарной помощи в странах с низким и средним уровнем дохода влияет на безопасность пациентов, качество медицинской помощи и планирование трудовых ресурсов. Необходимы дальнейшие поперечные исследования для поиска основанных на фактических данных решений, особенно в Африке и Юго-Восточной Азии.

BackgroundThe best management of hypertension in frail oldest-old (≥80 years of age) remains unclear and we still lack guidelines that provide specific recommendations. Our study aims to investigate guideline use in general practitioners (GPs) and to examine if guideline use relates to different decisions when managing hypertension in frail oldest-old.Design/settingCross-sectional study among currently active GPs from 29 countries using a case-vignettes survey.MethodsGPs participated in a survey with case-vignettes of frail oldest-olds varying in systolic blood pressure (SBP) levels and cardiovascular disease (CVD). GPs from 26 European countries and from Brazil, Israel and New Zealand were invited. We compared the percentage of GPs reporting using guidelines per country and further stratified on the most frequently mentioned guidelines. To adjust for patient characteristics (SBP, CVD and GPs' sex, years of experience, prevalence of oldest-old and location of their practice), we used a mixed-effects regression model accounting for clustering within countries.ResultsOverall, 2,543 GPs from 29 countries were included. 59.4% of them reported to use guidelines. Higher guideline use was found in female (p = 0.031) and less-experienced GPs (pConclusionMany GPs reported using guidelines to manage hypertension in frail oldest-old patients, however guideline users did not decide differently from non-users concerning hypertension treatment decisions. Instead of focusing on the fact if GPs use guidelines or not, we as a scientific community should put an emphasis on what guidelines suggest in frail and oldest-old patients.