145 The British Society for Rheumatology’s Choosing Wisely UK recommendations

Background: The Choosing Wisely UK campaign aims to promote shared decision making between patients and clinicians, helping people choose care that is supported by evidence, free from harm, truly necessary and consistent with their values. The Academy of Medical Royal Colleges (AoMRC), which coordinates the campaign, invited the BSR to submit 3-6 recommendations in 2018. The audience includes patients; rheumatologists and other physicians; GPs; nurses ad allied health professionals.

Methods: The 14-member working group included two patient contributors, one consultant nurse, six consultant rheumatologists, one GP staff grade rheumatologist, two rheumatology trainees and two immunologists. The National Rheumatoid Arthritis Society and Versus Arthritis were represented. The working group was convened and recommendation development completed within 12 weeks. For the first part of the abbreviated Delphi-exercise, working group members submitted proposed recommendations with an accompanying evidence summary. These were collated and distributed (verbatim and anonymously) to the group to inform a ranking exercise. Members rated each topic from 5 (highest) to 1 (lowest) anonymously and left remaining topics unscored; topics with the highest scores were selected. A subgroup, including patient contributors, met to draft the recommendations. Evidence summaries were collated from information submitted in the initial proposals and from further contributions from working group members. External experts were consulted on each recommendation, following which consensus was sought from the working group to ratify the recommendations.

Results: Thirty-two proposals were received on 14 discrete clinical topics, from 10 working group members. Twelve members ranked topics. Six final recommendations were developed, all of which were endorsed by the BSR. The AoMRC accepted all six recommendations, proposing that ANA+ENA and C3/C4/dsDNA had clinician facing-recommendations only, due to their technical nature (table 1).

Conclusion: Six recommendations were developed by a multidisciplinary team including people with arthritis. Because of the robust development process, we believe these recommendations are acceptable, meaningful and practical. Their application will lead to more personalised care, increased patient and clinician satisfaction, and better use of limited resources. We encourage all BSR members to engage with and champion these recommendations to inform shared decision-making conversations with patients.

145 Table 1:

BSR Choosing Wisely UK Recommendations

Topic	Our Patient Recommendations	Our Clinician Recommendations
ANA & ENAs	-	Testing ANA and ENAs should be reserved for patients suspected to have a diagnosis of a connective tissue disease, e.g. lupus. Testing ANA and ENAs should be avoided in the investigation of widespread pain or fatigue alone. Repeat testing is not normally indicated unless the clinical picture changes significantly.
Rheumatoid Arthritis	If a doctor suspects that you have rheumatoid arthritis, it is recommended that you are referred to rheumatology without delay, even before any tests are done. There is no single blood test which can determine whether someone does or does not have rheumatoid arthritis.	Patients with suspected inflammatory arthritis should be referred to Rheumatology without delay. Rheumatoid factor and CCP/ACPA are important, but should be avoided as screening tests. A negative result does not exclude rheumatoid arthritis, nor does a positive result equate to a diagnosis of rheumatoid arthritis. Repeat testing is not normally indicated.
Vitamin D	It is important for everyone to take Vitamin D supplements during winter. If you have restricted access to sunlight (e.g. if you live in a care home or cover your skin), or have dark skin, it is recommended that you take a supplement all year round. Vitamin D testing is unlikely to be useful or necessary in most people and future testing is not normally needed for those taking supplements.	Everyone should consider Vitamin D supplementation during winter. People who have restricted access to sunlight (e.g. those living in institutions or who cover their skin), or have dark skin, should consider supplementation all year round. Vitamin D testing should be reserved for people at high risk from deficiency and avoided as part of routine investigation of widespread pain alone. Repeat testing is not normally indicated in those taking supplements.
Osteoporosis	Bisphosphonates are drugs that help reduce fracture risk due to bone thinning (osteoporosis). People who take bisphosphonate treatment should discuss this with their healthcare professional every 3-5 years because it may be advisable for some to have a break in treatment.	Bisphosphonate therapy should be reviewed with every patient after 3-5 years, and a treatment holiday considered. This should follow a shared-decision making conversation which includes the risks and benefits of continued treatment.
Steroid injections	It is recommended that you have a conversation with your healthcare professional before accepting steroid injections for non-inflammatory musculoskeletal conditions. So that you can make an informed decision, this discussion should include the risks, benefits, and alternatives such as exercise and physical therapy. Although some people may experience short term benefit, there are potential long-term risks with repeated injections.	The use of intra-articular and soft-tissue steroid injections for non-inflammatory musculoskeletal conditions should be preceded by consideration of non-invasive alternatives such as exercise and physical therapy. Consent to any invasive procedure such as this must arise from a shared-decision making conversation with every patient, which includes assessment of the risks and benefits.
C3, C4 & dsDNA in connective tissue disease	-	C3, C4 and dsDNA are important tests to help in the diagnosis and assessment of disease activity in lupus. They should be reserved for specialist monitoring of disease activity and should be avoided as screening tests.

Disclosures: C.A. Sharp: Grants/research support; Charlotte A Sharp is supported by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester. I.N. Bruce: Honoraria; Ian N Bruce has received honoraria and/or grant funding from GSK, Eli Lilly, Astra Zeneca and Merck Serono. Grants/research support; Ian N Bruce has received honoraria and/or grant funding from GSK, Eli Lilly, Astra Zeneca and Merck Serono. B.M. Ellis: None. S. Elkhalifa: None. J. Galloway: None. B. Mulhearn: None. J. Firth: None. J. Fox: None. C. Mukhtyar: None. D.J. Murphy: None. A. Rowbottom: None. N. Snowden: None. K. Staniland: None. E. MacPhie: Honoraria; E.M. has been sponsored to attend international meetings by Pfizer and Roche, has accepted honoraria for educational meetings from Pfizer and Roche, her department has received sponsorship from Pfizer.