Impact of COVID-19 containment measures on patients with rheumatic and musculoskeletal disease in the UK and Europe: the REUMAVID study (phase1)

Abstract Objectives The aim was to compare the impact of the first wave of the coronavirus disease 2019 (COVID-19) pandemic and lockdown measures on patients with rheumatic and musculoskeletal diseases (RMDs) in the UK and other European countries (OEC). Methods REUMAVID was an online cross-sectional survey of seven European countries. The data collected included the following: demographics, lifestyle, employment, access to health-care services, disease-specific characteristics, the World Health Organization five well-being index (WHO-5), hospital anxiety and depression scale (HADS), visual analogue scale (VAS) disease activity, and the perceived acceptable symptom scale. Results One thousand eight hundred responses were received between April and July 2020 [UK, n = 558 (31.0%); OEC, n = 1242 (69.0%)]. UK patients were more likely to be older [mean (S.d.): UK 58.5 (13.4) years; OEC 50.0 (12.2) years], university educated [UK n = 302 (54.1%); OEC n = 572 (46.1%), quit smoking [UK n = 92 (59.4%); OEC n = 65 (16.2%)] and continue exercise [UK, n = 216 (49.2%); OEC, n = 228 (33.1%)], although, conversely, alcohol consumption increased [UK n = 99 (36.3%); OEC n = 98 (12.1%)]. UK patients felt informed about COVID-19 (UK 72.7%, OEC 57.4%) and kept their planned rheumatology [UK n = 87 (51.2%); OEC n = 213 (38.6%)] and/or general practice appointments [UK n = 87 (76.3%); OEC n = 310 (53.9%)]. Almost half the patients with RMDs reported a decline in health and well-being, although this was less common in UK patients [UK n = 214 (38.4%), OEC n = 618 (50.2%)], who reported better perceived acceptable symptom scale, VAS pain and HADS scores, but worse WHO-5 scores. Conclusions UK RMD patients performed better in the physical and mental health domains tested, possibly owing to a less restrictive lockdown and better health-care access. These findings have implications for health-care services globally in planning patient care after the COVID-19 pandemic.


Introduction
The COVID-19 pandemic has, and continues to, put an unprecedented strain on health-care systems globally. The speed at which both community and hospital health-care services reorganized to accommodate the influx in COVID-19 patients was remarkable; however, non-COVID-19 acute and elective services suffered significantly as a result [1,2]. Patients with rheumatic and musculoskeletal diseases (RMDs) are potentially more likely to be adversely affected owing to a combination of factors, including reduced detection of flare or adverse treatment effects, lack of continuity of care and access to specialist support, and the requirement for stricter social distancing and shielding practices for those taking immunosuppressive medications [3][4][5][6]. In addition, patients with RMDs are known to have associated morbidities and poorer baseline physical and mental well-being when compared with otherwise healthy individuals [7][8][9].
Strategies to manage the impact of the pandemic locally, regionally, nationally and internationally have varied vastly, reflecting both rapidly evolving research and understanding of severe acute respiratory syndrom coronavirus 2 (SARS-CoV-2) and the inherent differences between populations, health-care systems and the wider socio-economic context [10]. Patients and clinicians alike faced an insurmountable task in interpreting conflicting information from the media, health-care organizations, charities and governments [11], with individual nations adopting different containment measures; for example, outdoor activities and exercise were permitted in the UK, whereas in Spain and Italy people were largely confined indoors [10,12]. Crucially, although stricter lockdown measures might provide more significant reassurance of protection from the virus, the detrimental effects on general health and well-being are also potentially greater. A better understanding of the impact of the pandemic on patients with RMDs is now needed to help rheumatologists and health-care systems address its short-and long-term health effects [13].
The REUMAVID study aimed to assess the impact of the COVID-19 pandemic in people with rheumatic and musculoskeletal disorders across European countries. In the present study, we compared the impact of the first wave of the COVID-19 pandemic and associated lockdown measures on rheumatology patients in the United Kingdom (UK) with RMD patients in other European countries (OEC).

Methods
REUMAVID is a multidisciplinary international consortium assembled at the start of the pandemic with the aim of assessing its impact on the physical/mental health and overall well-being of patients with RMDs from participating European countries (Cyprus, France, Greece, Italy, Portugal, Spain and the UK), as described in detail previously [14]. Patients were recruited through national RMD patient groups that disseminated the survey link via their organizational websites. All participants were aged 18 years, residing in a REUMAVID-participating country, who had or were expected to have an appointment with their rheumatologist within 12 months of study entry. Before completing the survey, all patients provided informed consent electronically via the online survey platform. REUMAVID was first approved by the ethical committee of University Hospital La Paz under the code PI-4121 and subsequently approved in all other participating countries as legally required.
They then completed a 120-question survey covering multiple domains of physical and mental health and well-being including demographics, lifestyle habits and weight, provision of information on COVID-19, measures of disease activity and mental/physical health, and four validated scales to measure well-being: the World Health Organization five well-being index (WHO-5), which measures overall well-being [15]; the hospital anxiety and depression scale (HADS) to measure anxiety/ depression levels [16,17]; a visual analogue scale (VAS) for disease activity; and the patient acceptable symptom scale [18].
Survey data were analysed using SPSS v.25.0 (IBM Corp., Armonk, NY, USA). For continuous parametric variables, the mean (S.D.) is reported. Statistical significance between groups (the UK and OEC) were determined using Mann-Whitney test for individual variables. Categorical outcome variables are reported as a frequency/percentages, and statistically significant differences between the UK and OEC were determined using the v 2 test. Sample size is reported for each individual variable to highlight any areas of missing data.

Key messages
. The coronavirus disease 2019 pandemic negatively affected the physical and mental health of European rheumatic and musculoskeletal disease patients. . Compared with other European counterparts, UK patients performed better in nearly all health domains tested. . The insights from this survey could help to shape the care of rheumatic and musculoskeletal disease patients post-pandemic.
Stephanie R. Harrison et al.

Results
Overall, 2731 patients with RMDs participated in the first phase of the study. Owing to those patients who completed <70% of the survey, data for 931 patients had to be discarded, leaving 1800 patients for data analysis, of whom 558 respondents (31%) were recruited by the National Ankylosing Spondylitis Society, the National Rheumatoid Arthritis Society and Arthritis Action in the UK.

Access to rheumatology services
More than half of the rheumatology patients in the UK were able to keep scheduled rheumatology appointments during the pandemic, which was more than in the OEC (UK 51.2 vs 38.6%, P ¼ 0.004; Table 2). They were also more likely to be able to discuss the effects of treatment on COVID-19 with either their rheumatologist (81.0 vs 57.6%, P < 0.001) or general practitioner (76.3 vs 53.9%, P < 0.001). In contrast, around half of the patients reported not being able to continue their psychological/psychiatric therapies either online or via telephone, with no significant difference in the UK compared with OEC (45.7 vs 52.2%, P ¼ 0.459; Table 2).

Access to information on COVID-19
Overall, 35.4% of patients in the UK reported receiving no information on how COVID-19 might affect their RMD, compared with 51.6% in the OEC (P < 0.001; Fig. 1). Rheumatologists were the main source of information for patients on how COVID-19 might affect their RMD, with twice as many UK patients (37.9%) reporting receiving such information vs those in the OEC (19.0%) (Fig. 1). The next most common source for this information was patient organizations (UK 33.3%, OEC 25.9%), followed by general practitioners (UK 19.2%, OEC 13.4%) and the national rheumatology societies (UK 9.4%, OEC 12.2%; Fig. 1). Interestingly, although patient organizations played an important role in providing information for patients in all countries, the focus of the information differed. For instance, in the UK, patient organizations provided more COVID-19-related information (UK 72.7%, OEC 57.4%), whereas in the OEC the patient groups provided more disease-related information (UK 30.3%, OEC 59.1%, P ¼ 0.017; Fig. 2). Less information was provided overall on how to access their rheumatologist, home delivery of treatments and emotional/psychological support in both the UK and OEC (Fig. 2).

Discussion
As the focus shifts from immediate treatment of SARS-CoV-2-infected patients and towards mitigating the effects of the pandemic on patients with chronic health conditions, there is a significant need to gain a better understanding of the indirect effects of the ongoing COVID-19 pandemic on the overall well-being and disease activity of patients with RMDs. This survey compared and contrasted the experience of UK patients with that of OEC patients during the first wave of the COVID-19 pandemic. We felt that this analysis was of interest because political decisions led to different approaches in containment and lockdown measures throughout Europe. British respondents were generally older, with higher educational attainment and more likely to be retired, which is similar to previous surveys [19,20]. As expected from the less stringent containment measures in the UK, more British patients continued to exercise, often outdoors or in a natural environment. They also reported quitting smoking, all of which have positive impacts on physical and mental health, although conversely, many UK respondents increased their alcohol consumption. Teleworking and online/telephone grocery shopping were also more common in the UK. British patients were more likely to keep their appointment with their rheumatologist or general practitioner, received more information on COVID-19 and had higher levels of satisfaction with the quality of that information. Self-reported health status, anxiety and depression levels were better in UK patients, although overall levels of well-being were comparatively worse, possibly owing to the self-reported nature of the instrument used [21]. Despite the comparatively better outcomes for British patients, there was still a significant burden associated with lockdown measures. One reason for this was the significant challenges that all health-care organizations faced in assimilating and disseminating high-quality guidelines in a rapidly changing research environment with no clear standard of best practice. At the start of the pandemic, EULAR published principles for the care of patients with RMDs; however, there were significant ramifications to their recommendations and many obstacles to their implementation, with lockdown, redeployment of health-care staff and strict social distancing [22]. As a result, less than half of the patients kept their rheumatology appointment (UK 51.2%, OEC 38.6%, P ¼ 0.004), the impact of which is reflected in the selfreported disease-specific characteristics seen in this survey.
Nevertheless, British patients still fared better overall, which might be attributable, in part, to less stringent government restrictions. Researchers at the University of Oxford developed a scoring system to compare the stringency of lockdown measures between countries quantitatively [10]. Using this resource, between January and June 2020, the UK had the least strict measures compared with the OEC. Given that adherence to lockdown rules in the first wave was high, especially among patients with RMDs who were considered vulnerable/extremely vulnerable [23,24], it seems reasonable to assume that the stringency of lockdown measures would impact on overall health and well-being.
One notable difference between lockdown measures was that British patients were more likely to continue to exercise outdoors. Exercise and outdoor activity reduce anxiety and depression, improve overall well-being [25,26], maintain mobility and reduce pain in patients with RMDs [5]. British patients also felt that they received better-quality RMD-specific guidance on COVID-19, which is likely to have provided some reassurance at a time of great uncertainty. In addition, more UK patients reported already belonging to patient organizations before the pandemic, and it is possible that having these support networks already established helped British patients to feel more connected to others in their position and facilitated rapid access information, making them feel empowered. Furthermore, UK patients appeared to use more digital technologies; for example, in grocery shopping online and teleworking, which might have provided a This study is the first to report the impact of the first wave of the COVID-19 pandemic on the physical/mental health and overall well-being of patients from seven participating European countries, providing valuable insight into the impact associated with the different containment measures initiated in each country. These results can inform the future planning and delivery of services for patients with RMDs in Europe. There are some limitations, however, similar to other survey studies, with an over-representation of females, those who are retired and those with higher levels of educational attainment [27]. Nevertheless, the sex distribution might be related to the distribution of rheumatic disease in the survey, although approximately one-third of respondents had axial spondyloarthritis, which is more frequently diagnosed in males. Those with higher educational attainment are also more likely to engage with patient support groups and self-help measures and to be able easily to access and understand the rapidly evolving information on the pandemic. Conversely, those who work might have been deterred from participation in the survey owing to the length of time it would take to complete 120 questions, and those from lower socio-economic background and/or ethnic minority groups might not have access to adequate digital facilities or be able to access the survey in their native language [28]. Therefore, the relative impact of the pandemic on those of working age, males and those from a deprived background or ethnic minority group is unclear. In addition, the distribution of RMDs in this survey does not reflect the prevalence of RMDs in real-world practice, with over-representation of axial spondyloarthritis and RA, reflecting the instrumental role played by the patient societies collaborating in the REUMAVID study.
Furthermore, the patient survey does not allow us to detect inter-regional and local differences in the patient experience, which is key information for care providers who need to use already stretched local resources effectively in the aftermath of the first wave of the pandemic. This is even more true of the second wave of the pandemic in the UK, where inter-regional lockdown practices differed significantly compared with the first wave. Future surveys should therefore seek to target under-represented groups and provide local and regional data. This survey is cross-sectional and, as alluded to above, experiences might well differ between different phases of the pandemic, even within the same country. Likewise, our survey does not include all European countries, and the patient experiences there, or indeed in non-European nations, could differ substantially. Finally, there is no control group of patients completing the survey before the pandemic, although in our survey, patients, when asked, did report that their health had worsened relative to the pre-pandemic state.
In conclusion, these data suggest that UK patients with RMDs performed better than OEC patients in the physical and mental health domains tested. UK respondents reported less smoking and greater levels of physical activity, although they consumed more alcohol, and they showed greater adaptation to digital platforms with increased use of online shopping and teleworking. These differences might be attributable to a multitude of factors, both known and unknown. Nevertheless, the REUMAVID survey does highlight some factors that could have played a role in the observed differences, including the fact that UK patients were living under comparatively less stringent lockdown measures with better access to outdoors spaces, health-care professionals and advice on COVID-19. Irrespective of the reasons underlying the differences, the REUMAVID survey highlights the clear negative effects of the first wave of the pandemic on the mental health of all patients with RMDs, even if UK respondents reported comparatively less anxiety and depression. These findings have broad implications for health-care services globally in planning patient care in the aftermath of the pandemic.