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Project

TOWARDS IMPLEMENTATION OF INTENSIVE COMBINATION TREATMENT STRATEGIES FOR EARLY RHEUMATOID ARTHRITIS

Intensive combination treatment strategies (ICTS) −combining one or more disease-modifying anti-rheumatic drugs with glucocorticoids in a remission induction step down approach- are most effective in the management of early rheumatoid arthritis (RA), to achieve clinical remission, in order to prevent joint destruction and long-term disability. Despite the availability and demonstrated effectiveness of ICTS for early RA, a discrepancy seems to exist between treatment recommendations and the evidence upon which they are based, and actual prescription in daily clinical practice. Implementation research, using qualitative methods, is vital when recommendations are not incorporated into routine practice. Qualitative research contributes to improve healthcare professionals’ adherence to treatment guidelines and to make management of early RA more evidence-based by exploring actual care and perceived barriers among stakeholders.

 

This PhD thesis covers several studies investigating barriers and facilitators regarding the provision of ICTS among stakeholders involved in early RA care. Firstly, interviews were carried out with rheumatologists and nurses within the CareRA study to identify factors influencing the prescription of ICTS. Secondly, the influential factors were reformulated as barriers and these were included in a survey prioritizing the identified barriers by importance, which was administered to rheumatologists. Thirdly, interviews were carried out with general practitioners to explore general practice perspective on early RA management. Fourthly, we conducted a longitudinal, qualitative study involving interviews with early RA patients within the CareRA study to understand their treatment experiences. Lastly, in addition to the identification of barriers and facilitators we reviewed the scientific literature on the effectiveness of quality improvement interventions to change prescribing behaviour of health care professionals.

 

Our study findings from interviews with rheumatologists and nurses revealed a heterogeneous set of factors influencing ICTS provision related to the treatment, the health care professional, the patient and/or the environment. Identified facilitators included supporting scientific evidence, personal faith in treatment strategy, staff support and low treatment costs. Barriers for prescribing ICTS included need for more extensive patient education, fear for patients’ preconceptions, concerns about applicability to the individual patient, difficulties with breaking routine, interference with organizational structures and processes, time constraints and lack of financial support. Prioritizing the identified barriers showed that the dominant barriers hindering ICTS prescription from a rheumatologists’ perspective were patient-related barriers and barriers related to the complexity of prescribing a combination therapy including glucocorticoids. Interviews with GPs revealed that GPs believed that early and intensive treatment was beneficial for patients with early RA. However, they experienced multiple barriers including low confidence in their own detection skills, limited accessibility of the rheumatologist for patient referral and poor professional collaboration with the rheumatologist. Using a longitudinal qualitative study, we identified patients’ experiences with ICTS. As treatment progressed, patients’ concerns shifted from the treatment and its immediate side effects to long-term health consequences of the treatment and experiencing loss of treatment effect resulting in flares. Despite their concerns at treatment initiation, most patients had positive experiences with ICTS. From our literature review we could conclude that the interventions that showed some positive effect on the implementation of treatment recommendations were educational meetings with active involvement of prescribers in combination with feedback on prescribing and task shifting from physicians to other health care professionals.

 

The results of this doctoral thesis are a solid source of information to design and implement strategies for supporting health care professionals in the management of early RA. For optimizing the management of early RA in Flanders, the detection process in general practice, a swift referral to rheumatologists and the preferential initiation of ICTS need to be facilitated. To improve detection and referral of patients with early RA, the practical skills of GPs for RA detection should be enhanced and the limited availability of rheumatologists should be addressed. Strategies to promote treatment initiation of ICTS in daily clinical practice will have to be multidimensional and should focus on the familiarity of rheumatologists with ICTS and the provision of patient education. Educational interventions for rheumatologist with active involvement and task shifting to nurses could facilitate the provision of ICTS. In preparing for treatment initiation, taking time for patient education that is tailored to individual needs and concerns appears to be a prerequisite to gain patients’ trust and to embark patients on ICTS. Moreover, GPs should actively be involved in early RA care.

Date:1 Oct 2011 →  31 Dec 2015
Keywords:sheumatoïd arthritis
Disciplines:Orthopaedics, Genetics, Gynaecology and obstetrics, Molecular and cell biology, Morphological sciences
Project type:PhD project