Factors that influence rheumatologists’ anti-tumor necrosis factor alpha prescribing decisions: a qualitative study

Abstract

BackgroundTreatment decisions for any disease are usually informed by reference to published clinical guidelines or recommendations. These recommendations can be developed to improve the relative cost-effectiveness of health care and to reduce regional variation in clinical practice. Anti-tumor necrosis factor alpha (anti-TNF) treatments are prescribed for people with rheumatoid arthritis according to specific recommendations by the National Institute for Health and Care Excellence in England. Evidence of regional variation in clinical practice for rheumatoid arthritis may indicate that different factors have an influence on routine prescribing decisions. The aim of this study was to understand the factors that influence rheumatologists’ decisions when prescribing anti-TNF treatments for people with rheumatoid arthritis in England.MethodsSemi-structured one-to-one telephone interviews were performed with senior rheumatologists in different regions across England. The interview schedule addressed recommendations by the National Institute for Health and Care Excellence, prescribing behavior, and perceptions of anti-TNF treatments. Interviews were recorded digitally, transcribed verbatim, and anonymized. Data were analyzed by thematic framework analysis that comprised six stages (familiarization; coding; developing the framework; applying the framework; generating the matrix; interpretation).ResultsEleven rheumatologists (regional distribution - north 36%; midlands: 36%; south: 27%) participated (response rate: 24% of the sampling frame). The mean duration of the interviews was thirty minutes (range: 16 to 56 min). Thirteen factors that influenced anti-TNF prescribing decisions were categorized by three nested primary themes; specific influences were defined as subthemes: (i) External Environment Influences (National Institute for Health and Care Excellence Recommendations; Clinical Commissioning Groups; Cost Pressures; Published Clinical Evidence; Colleagues in Different Hospitals; Pharmaceutical Industry); (ii) Internal Hospital Influences (Systems to Promote Compliance with Clinical Recommendations; Internal Treatment Pathways; Hospital Culture); (iii) Individual-level Influences (Patient Influence; Clinical Autonomy; Consultant Experience; Perception of Disease Activity Score-28 (DAS28) Outcome).ConclusionsFactors that influenced anti-TNF prescribing decisions were multifaceted, seemed to vary by region, and may facilitate divergence from published clinical recommendations. Strategic behavior appeared to illustrate a conflict between uniform treatment recommendations and clinical autonomy. These influences may contribute to understanding sources of regional variation in clinical practice for rheumatoid arthritis.

Clinician and patient views on janus kinase inhibitors in the treatment of inflammatory arthritis: a mixed methods study

“…As newer drugs, JAKi do not have the evidence-base that biologics do, particularly from clinician and patient perspectives [ 15 – 17 ]. Although there are recent studies comparing the real-world effectiveness of JAKi with biologics, through registry data analysis of patients with RA [ 18 , 19 ], there is currently a lack of published literature on what clinicians and IA patients think about the awareness, prescription and use of JAKi; how they compare with biologics; and, relevant to current times, how the COVID-19 pandemic has affected JAKi use and prescription.…”

Clinician and patient views on janus kinase inhibitors in the treatment of inflammatory arthritis: a mixed methods study

“…As newer drugs, JAKi do not have the evidence-base that biologics do, particularly from clinician and patient perspectives [15][16][17]. Although there are recent studies comparing the real-world effectiveness of JAKi with biologics, through registry data analysis of patients with RA [18,19], there is currently a lack of published literature on what clinicians and IA patients think about the awareness, prescription and use of JAKi; how they compare with biologics; and, relevant to current times, how the COVID-19 pandemic has affected JAKi use and prescription.…”

“…This led to the UK Medical Health and Regulatory Authority (MHRA) issuing a warning to limit the use of tofacitinib and, with uncertainty as to whether this was a class effect, the US Food and Drug Administration putting black box warnings on all licensed JAKi used for the treatment of IA in the USA in late 2021 [12,13]. In early 2022, The European Medicines Agency (EMA) started a safety review on all JAKi used in IA [14].As newer drugs, JAKi don't have the evidence-base that biologics do, particularly from clinician and patient perspectives [15][16][17]. Although there are recent studies comparing the real-world effectiveness of JAKi with biologics, through registry data analysis of patients with RA [18,19], there is currently a lack of published literature on what clinicians and IA patients think about the awareness, prescription and use of JAKi; how they compare with biologics; and, relevant to current times, how the COVID-19 pandemic has affected JAKi use and prescription.…”

Real-Life Retention Rates and Reasons for Switching of Biological DMARDs in Rheumatoid Arthritis, Psoriatic Arthritis, and Ankylosing Spondylitis

“…Biologic (b-) and targeted synthetic (ts-) disease-modifying anti-rheumatic drugs (DMARDs) represent a major therapeutic advance in rheumatology. However, response rates to b/tsDMARDs are variable ( 1 ); the evidence-base for directing switching from one agent to another is limited with most switches being empirical ( 2 , 3 ); and, responses to b/tsDMARDs regardless of the mechanism of action are generally similar ( 4 ). Furthermore, the overall rates of sustained remission and improvement in function are relatively modest ( 5 ), owing to several potential factors including lack of established criteria to direct initial or subsequent choice of one b/tsDMARD over another with a different MoA, following failure or inadequate response.…”