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Mixed Methods Study of Clinicians


Ann Rheum Dis. 2020 May 18;annrheumdis-2020-217301.doi: 10.1136/annrheumdis-2020-217301. Online ahead of print.

Emma Dures 1, Julie Taylor 1, Sasha Shepperd 2, Sandeep Mukherjee 3, Joanna Robson 4, Ivo Vlaev 5, Nicola Walsh 6, Laura C Coates 7 8

Author Information

1 Department of Nursing and Midwifery, University of the West of England Bristol, Bristol, Bristol, UK.

2 Nuffield Department of Population Health, University of Oxford, Oxford, UK.

3 Department of Rheumatology, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK.

4 Health and Applied Sciences, University of the West of England Bristol, Bristol, UK.

5 Behavioural Science Group, Warwick Business School, Coventry, UK.

6 Department of Allied Health Professionals, University of the West of England Bristol, Bristol, UK.

7 Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK laura.coates@ndorms.ox.ac.uk.

8 NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.


Objectives: In treat to target (T2T), the patient is treated to reach and maintain specified and sequentially measured goals, such as remission or low disease activity. T2T in psoriatic arthritis (PsA) has demonstrated improved clinical and patient-reported outcomes and is recommended in European guidelines. However, most clinicians do not use T2T in PsA. This study examined the barriers and enablers to implementation in practice.

Methods: Sequential mixed methods comprising a qualitative design (interviews and focus group) to inform a quantitative design (survey). Qualitative data were analysed thematically, and quantitative statistics were analysed descriptively.

Results: Nineteen rheumatology clinicians participated in telephone interviews or a face-to-face focus group. An overarching theme 'Complexity' (including 'PsA vs Rheumatoid Arthritis', 'Measurement' and 'Resources') and an underpinning theme 'Changes to current practice' (including 'Reluctance due to organisational factors' and 'Individual determination to make changes') were identified. 153 rheumatology clinicians responded to an online survey. Barriers included limited clinical appointment time to collect outcome data (54.5%) and lack of training in assessing skin disease (35%). Enablers included provision of a protocol (86.4%), a local implementation lead (80.9%), support in clinic to measure outcomes (83.3%) and training in T2T (69.8%). The importance of regular audit with feedback, specialist PsA clinics and a web-based electronic database linked to hospital/national information technology (IT) systems were also identified as enablers.

Conclusions: Implementation of T2T in PsA requires an integrated approach to address the support, training and resource needs of individual clinicians, rheumatology teams, local IT systems and service providers to maximise success.