Psoriatic Arthritis PSP Protocol
Purpose of the PSP and background
The purpose of this protocol is to clearly set out the aims, objectives and commitments of the Psoriatic Arthritis (PsA) Priority Setting Partnership (PSP) in line with James Lind Alliance (JLA) principles. The Protocol is a JLA requirement and will be published on the PSP’s page of the JLA website. The Steering Group will review the Protocol regularly and any updated version will be sent to the JLA.
The JLA is a non-profit making initiative, established in 2004. It brings patients, carers and clinicians together in PSPs. These PSPs identify and prioritise the evidence uncertainties, or ‘unanswered questions’, that they agree are the most important for research in their topic area. Traditionally PSPs have focused on uncertainties about the effects of treatments, but some PSPs have chosen to broaden their scope beyond that. The aim of a PSP is to help ensure that those who fund health research are aware of what really matters to patients, carers and clinicians. The National Institute for Health Research (NIHR – www.nihr.ac.uk) coordinates the infrastructure of the JLA to oversee the processes for PSPs, based at the NIHR Evaluation, Trials and Studies Coordinating Centre (NETSCC), University of Southampton.
A Psoriasis PSP, funded by the Psoriasis Association and led by the University of Manchester, recently collected evidence uncertainties in psoriasis culminating in a Psoriasis Top Ten unmet needs which were published in 2019. Members of the psoriasis PSP steering committee are now contributing to this PsA PSP
The Psoriatic Arthritis PSP has been proposed and funded by the British PsA Consortium (BritPACT). It will be led by Dr Laura Coates (Clinician Scientist and honorary Consultant Rheumatologist) who is based at the Nuffield Department for Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford and is also the current chair of the BritPACT group.
Aims, objectives and scope of the PSP
The aim of the Psoriatic Arthritis PSP is to identify the unanswered questions about psoriatic arthritis from patient, carer and clinical perspectives and then prioritise those that patients, carers and clinicians agree are the most important for research to address.
The objectives of the PSP are to:
- work with patients and their families, carers and clinicians to identify uncertainties about psoriatic arthritis including:
- diagnosis and referral;
- all severities of disease;
- peripheral arthritis, enthesitis, axial disease, dactylitis, psoriasis and nail disease;
- symptoms and disease impact (e.g. fatigue, functional ability, practical impacts);
- assessment of disease activity and impact;
- associated conditions (including SpA-related conditions and other comorbidities);
- management strategies ;
- monitoring and treatment of flare;
- impact of lifestyle change on symptoms and outcomes (e.g. diet, smoking, exercise etc)
- to agree by consensus a prioritised list of those uncertainties, for research to publicise the results of the PSP and process
- to take the results to research commissioning bodies to be considered for funding.
The PSP will exclude from its scope questions about:
- PsA in people under 16 years old/juvenile PsA/juvenile idiopathic arthritis (JIA) with psoriasis
A decision was taken by the committee to exclude JIA with psoriasis from the scope of this PSP for multiple reasons. Although arthritis related to psoriasis is seen in those under 16 years of age, the definitions and classifications of psoriatic JIA are very different from adult PsA. The related comorbidities (e.g. uveitis) are also very different in prevalence and presentation. BritPACT (the funder for this PSP) does not address psoriatic JIA, only PsA in adults. The committee, as formed, does not have the expertise to review JIA with no representation from specialist clinicians or patients/carers with juvenile PsA. In addition, there is an active PSP currently addressing JIA (run from the Netherlands) in a separate process.
The Steering Group is responsible for discussing what implications the scope of the PSP will have for the evidence-checking stage of the process. Resources and expertise will be put in place to do this evidence checking.
The Steering Group
The Steering Group includes membership of patients and carers and clinicians, as individuals or representatives from a relevant group.
The Psoriatic Arthritis PSP will be led and managed by a Steering Group involving the following:
Patient and carer representative/s:
- Helen McAteer – Psoriasis Association
- David Chandler – Psoriasis and Psoriatic Arthritis Alliance (PAPAA)
- Russ Cowper
- Lucille Joannes
- Bronagh Kennedy
- Andy Kelly – (additionally works as a physiotherapist at Cardiff)
- Charlie Anderson
- Laura Coates – PsA PSP Lead, Clinician Scientist, University of Oxford
- Jon Packham – Consultant Rheumatologist, Stoke
- Helen Young – Consultant Dermatologist, University of Manchester
- Christine Bundy – Psychologist, University of Cardiff
- Sandeep Mukherjee – Consultant Rheumatologist, Royal Bournemouth and Christchurch Hospitals
- Philip Helliwell – Professor of Rheumatology, University of Leeds
- Elspeth Wise – General Practitioner
- Bath Institute for Rheumatic Diseases, Bath
James Lind Alliance Adviser and Chair of the Steering Group:
- Suzannah Kinsella, JLA
The Steering Group will agree the resources, including time and expertise that they will be able to contribute to each stage of the process, with input and advice from the JLA.
Organisations and individuals will be invited to be involved with the PSP as partners. Partners are organisations or groups who will commit to supporting the PSP, promoting the process and encouraging their represented groups or members to participate. Organisations which can reach and advocate for these groups will be invited to become involved in the PSP. Partners represent the following groups:
people who have psoriatic arthritis and their families
- carers of people who have psoriatic arthritis
- health and social care professionals - with experience of psoriatic arthritis.
Some organisations may be judged by the JLA or the Steering Group to have conflicts of interest. These may be perceived to potentially cause unacceptable bias as a member of the Steering Group. As this is likely to affect the ultimate findings of the PSP, those organisations will not be invited to participate. It is possible, however, that interested parties may participate in a purely observational capacity when the Steering Group considers it may be helpful.
Partners of the PsA PSP
The following groups have committed to partnership with the Psoriatic Arthritis PSP
- British PsA Consortium (BritPACT) – also funders
- British Society for Rheumatology (BSR)
- Psoriasis Association
- Psoriasis and Psoriatic Arthritis Alliance (PAPAA)
- Bath Institute for Rheumatic Diseases
- Royal College of Nursing
- Musculoskeletal Assocation of Chartered Physiotherapists (MACP)
- Primary Care Rheumatology and Musculoskeletal Medicine
- Podiatry Rheumatic Care Association (PRCA)
- Arthritis and Musculoskeletal Alliance (ARMA)
- National Rheumatoid Arthritis Society (NRAS)
- National Axial Spondyloarthritis Society (NASS)
- Arthur’s Place
- Barbara Ansell National Network for Adolescent Rheumatology (BANNAR)
The methods the PSP will use
This section describes a schedule of proposed steps through which the PSP aims to meet its objectives. The process is iterative and dependent on the active participation and contribution of different groups. The methods used in any step will be agreed through consultation between the Steering Group members, guided by the PSP’s aims and objectives. More details of the method are in the Guidebook section of the JLA website at www.jla.nihr.ac.uk where examples of the work of other JLA PSPs can be seen.
Step 1: Identification and invitation of potential partners
Potential partner organisations will be identified through a process of peer knowledge and consultation, through the Steering Group members’ networks. Potential partners will be contacted and informed of the establishment and aims of the Psoriatic Arthritis PSP.
Step 2: Awareness raising
PSPs will need to raise awareness of their proposed activity among their patient, carer and clinician communities, in order to secure support and participation. Depending on budget, this may be done by a face-to-face meeting, or there may be other ways in which the process can be launched, e.g. via social media. It may be carried out as part of steps 1 and/or 3. The Steering Group should advise on when to do this. Awareness raising has several key objectives:
- to present the proposed plan for the PSP
- to generate support for the process
- to encourage participation in the process
- to initiate discussion, answer questions and address concerns.
Step 3: Identifying evidence uncertainties
The Psoriatic Arthritis PSP will carry out a consultation to gather uncertainties from patients, carers and clinicians. A period of 4 months will be given to complete this exercise (which may be revised by the Steering Group if required). Decisions on closing the survey ahead of the planned time point will be taken by the SG. A web-based survey will be used.
The Steering Group will use the following methods to reach the target population:
- web and paper based survey
- promotion to patients via Psoriasis Association and PAPAA
- promotion to health care professionals via British Society of Rheumatologists (includes health care professionals within membership)
- promotion to patients, family, carers and healthcare professionals via other partners
- promotion via the steering group to patients, local support groups and colleagues.
Existing sources of evidence uncertainties may also be searched. A previous exercise by PAPAA has collected research needs nominated by patients and these will be included. A prior PSP in psoriasis also collected unmet needs in PsA and these will also be included with the survey results.
Step 4: Refining questions and uncertainties
The consultation process will produce ‘raw’ questions and comments indicating patients’, carers’ and clinicians’ areas of uncertainty. These raw questions will be categorised and refined by the information specialist into summary questions which are clear, addressable by research, and understandable to all. Similar or duplicate questions will be combined where appropriate. Out-of-scope and ‘answered’ submissions will be compiled separately. The Steering Group will have oversight of this process to ensure that the raw data is being interpreted appropriately and that the summary questions are being worded in a way that is understandable to all audiences. The JLA Adviser will observe to ensure accountability and transparency.
This will result in a long list of in-scope summary questions. These are not research questions and to try and word them as such may make them too technical for a non-research audience. They will be framed as researchable questions that capture the themes and topics that people have suggested.
The summary questions will then be checked against evidence to determine whether they have already been answered by research. This will be done by the information specialist. The PSP will complete the JLA Question Verification Form, which clearly describes the process used to verify the uncertainty of the questions, before starting prioritisation. The Question Verification Form includes details of the types and sources of evidence used to check uncertainty. The Question Verification Form should be published on the JLA website as soon as it has been agreed to enable researchers and other stakeholders to understand how the PSP has decided that its questions are unanswered, and any limitations of this.
Questions that are not adequately addressed by previous research will be collated and recorded on a standard JLA template by the information specialist. This will show the checking undertaken to make sure that the uncertainties have not already been answered. The data should be submitted to the JLA for publication on its website on completion of the priority setting exercise, taking into account any changes made at the final workshop, in order to ensure that PSP results are publicly available.
The Steering Group has also considered how it will deal with submitted questions that have been answered, and questions that are out of scope. Questions that have already been answered with high quality evidence will be collated and published to identify unmet educational needs for both patients and clinicians in the field of PsA. Questions that are outside of the scope (e.g. health services delivery) will also be collated for future analysis and publication. Whilst outside the scope of the PSP, these still identify key issues that are deserving of future research.
Step 5: Prioritisation – interim and final stages
The aim of the final stage of the priority setting process is to prioritise through consensus the identified uncertainties about psoriatic arthritis. This will involve input from patients, carers and clinicians. The JLA encourages PSPs to involve as wide a range of people as possible, including those who did and did not contribute to the first consultation. There are usually two stages of prioritisation.
- Interim prioritisation is the stage where the long list of questions is reduced to a shorter list that can be taken to the final priority setting workshop. This is aimed at a wide audience and is done using similar methods to the first consultation. With the JLA’s guidance, the Steering Group will agree the method and consider how best to reach and engage patients, carers and clinicians in the process. The most highly ranked questions (around 25) will be taken to a final priority setting workshop. Where the interim prioritisation does not produce a clear ranking or cut off point, the Steering Group will decide which questions are taken forwards to the final prioritisation.
- The final priority setting stage is generally a one-day workshop facilitated by the JLA. With guidance from the JLA and input from the Steering Group, up to 30 patients, carers and clinicians will be recruited to participate in a day of discussion and ranking, to determine the top 10 questions for research. All participants will declare their interests. The Steering Group will advise on any adaptations needed to ensure that the process is inclusive and accessible.
Dissemination of results
The Steering Group will identify audiences with which it wants to engage when disseminating the results of the priority setting process, such as researchers, funders and the patient and clinical communities. They will need to determine how best to communicate the results and who will take responsibility for this. Previous PSPs’ outputs have included academic papers, lay reports, infographics, conference presentations and videos for social media.
It should be noted that the priorities are not worded as research questions. The Steering Group should discuss how they will work with researchers and funders to establish how to address the priorities and to work out what the research questions are that will address the issues that people have prioritised. The dissemination of the results of the PSP will be led by the Steering Group and BritPACT.
The JLA encourages PSPs to report back about any activities that have come about because of the PSP, including funded research. Please send any details to firstname.lastname@example.org.
Agreement of the Steering Group
The PsA PSP Steering Group agreed the content and direction of this Protocol on 15th January 2020.