Background: Despite evidence demonstrating the utility of using Person-Centred Outcome Measures within palliative care settings, implementing them into routine practice is challenging. Most research has described barriers to, without explaining the causal mechanisms underpinning, implementation. Implementation theories explain how, why, and in which contexts specific relationships between barriers/enablers might improve implementation effectiveness but have rarely been used in palliative care outcomes research. Aim: To use Normalisation Process Theory to understand and explain the causal mechanisms that underpin successful implementation of Person-Centred Outcome Measures within palliative care. Design: Exploratory qualitative study. Data collected through semi-structured interviews and analysed using a Framework approach. Setting/participants: 63 healthcare professionals, across 11 specialist palliative care services, were purposefully sampled by role, experience, seniority, and settings (inpatient, outpatient/day therapy, home-based/community). Results: Seven main themes were developed, representing the causal mechanisms and relationships underpinning successful implementation of outcome measures into routine practice. Themes were: Subjectivity of measures; Frequency and version of Integrated Palliative care Outcome Scale; Training, education, and peer support; Building and sustaining community engagement; Electronic system readiness; The art of communication; Reinforcing use through demonstrating value. Conclusions: Relationships influencing implementation resided at individual and organisational levels. Addressing these factors is key to driving the implementation of outcome measures into routine practice so that those using palliative care services can benefit from the systematic identification, management, and measurement of their symptoms and concerns. We provide key questions that are essential for those implementing and using outcome measures to consider in order to facilitate the integration of outcome measures into routine palliative care practice.

BackgroundDespite increasing prevalence of gout in the UK (1), a variety of barriers result in suboptimal care (1,2) with only 40% of gout patients receiving urate-lowering therapy (ULT), usually at fixed dose without titration to a serum uric acid (SUA) target (1,2). Nurses successfully manage many chronic diseases in the community, and we have shown that when people with gout are fully informed and involved in management decisions uptake of ULT is high and subsequent adherence under nurse-led care is excellent (3).ObjectivesTo directly compare nurse-led care to general practitioner (GP) care of people with gout in a 2 year randomised controlled trial (NIHR CRN Portfolio No.12943)Methods517 participants with acute gout in the previous year were identified from 56 local GP practices and randomised to nurse-led or continuing GP care. The nurses were trained about gout and its management according to recommended best practice (EULAR and BSR guidelines) involving full information, addressing illness perceptions, and involving patients in management decisions. Assessments were undertaken at 1 and 2 years. Analysis was intention to treat (last observation carried forward).ResultsNurse (n=255) and GP (n=262) groups were well matched at baseline for mean age (62 v 64yrs), sex (90% v 89% men), mean disease duration (11.6 v 12.7yrs), mean gout attack frequency in prior year (4.2 v. 3.8), tophi (13.7% v. 8.8%), mean SUA (443 v. 439 μmol/L), mean eGFR (71.5 v. 70.2) and ULT use (40% v. 39%) (all p>0.05). By 2yrs, 22 (8.6%) and 54 (20.6%) participants had discontinued the nurse and GP groups (p<0.001), including 2 v. 8 deaths respectively. Comparing nurse and GP groups at 2yrs: 95% v. 29% had SUA <360 μmol/L (primary outcome); 88% v. 16% had SUA <300 μmol/L; mean (SD) SUA was 252±73 v. 418±106; 97% v. 54% were on ULT; and mean (SD) dose of allopurinol was 470 (140) v. 240 (107) mg/day (all p<0.001). Mean (SD) attack frequency during the 2nd year was 0.33 (0.93) in the nurse v. 0.94 (2.03) in the GP group (p<0.001), and at 2yrs tophi were present in 2.6% (reduced) v. 9.6% respectively (p<002). Although equivalent at baseline, mean (SD) SF-36 norm-based physical component scores were better at 2yrs in the nurse group (41.31 (16.76) v. 37.87 (14.31); p<0.05).ConclusionsNurse-led care of people with gout in the UK community can result in high uptake and excellent adherence to ULT over a 2yr period, achievement of target SUA in >9/10 cases and consequent improvements in patient-centred outcomes and quality of life. This study reinforces the benefits of “treat-to-target”. Compared to standard GP care this model is likely to be cost effective long-term and merits further consideration.References Doherty M. et al. Ann Rheum Dis 2012;71:1765–70.Kuo C-F. et al. Ann Rheum Dis 2015;74:661–7.Rees F. et al. Ann Rheum Dis 2013:72:826–30. AcknowledgementsArthritis Research UK (Award No.19703) funded this study.Disclosure of InterestM. Doherty Grant/research support from: AstraZeneca, Consultant for: AstraZeneca, Grunenthal, Mallinckrodt and ...

PurposeTo determine the average time-point at which it is best to define 'sub-optimal response' after ranibizumab treatment for diabetic macular edema (DME) based on the data obtained from real-life clinical practice.MethodsIn this retrospective observational study, 322 consecutive treatment naïve eyes with DME were treated with three loading doses of intravitreal ranibizumab followed by re-treatment based on decision of the treating physician on a case-by-case basis. The demographic data, clinic-based visual acuity measurements and central subfield thickness (CST) assessed on spectral domain optical coherence tomography (OCT) were evaluated at baseline (month 0), 1, 2, 3, 6, and 12 months.ResultsOn an average, the improvement in visual acuity and CST was first seen after the loading dose. However, the maximal response in terms of proportion of patients with improvement in visual acuity and/ or CST in this cohort was observed at 12 months. Patients who presented with low visual acuity at baseline (<37 ETDRS letters) were unlikely to attain driving vision with ranibizumab therapy.ConclusionsOn an average, a 'sub-optimal response' after ranibizumab therapy is best defined at month 12 as patients may continue to improve with treatment.