Background Clinical guidance produced by the National Institute for Health and Care Excellence (NICE) recommends that patients in England with rheumatoid arthritis should be treated with the lowest cost anti-TNFa. In practice, however, it is possible that a number of factors may influence treatment choice.
Objectives To explore the factors which influence consultant rheumatologists when prescribing anti-TNF therapies in England.
Methods Individual semi-structured telephone interviews were conducted with a purposive sample of consultant rheumatologists (n=11) from hospitals across England between January and September 2015. The telephone interviews (mean duration =31 minutes) were recorded and transcribed verbatim. Interviewees were asked to discuss the influences on key treatment decisions, including: the decision to begin anti-TNF therapy; the choice of first-line anti-TNF; treatment decisions in remission. Interview transcripts were analysed by thematic framework analysis. Ethical approval was obtained from The University of Manchester's Research Ethics Committee (Project: 14147).
Results Interviewees' responses clustered around six main themes. Cost was rarely a factor which influenced the participants' choice of first-line anti-TNF, unless their local service commissioners imposed the use of the least-expensive anti-TNF. In contrast, cautious optimism was expressed towards using biosimilar anti-TNF agents first-line on the grounds of potential cost savings. Patient involvement in decision making was viewed to be sacrificed in those units where using the cheapest anti-TNF was enforced. The interpretation of NICE guidance varied between interviewees with some claiming that the guidance was too restrictive whereas others saw benefits in the flexibility it provided. Interviewees tried to maintain clinical autonomy by careful manipulation of the DAS28 measure in patients with insufficient disease activity to receive anti-TNF therapy according to NICE guidance if they believed it to be clinically appropriate. Negotiated local exceptions to NICE guidance also facilitated clinical autonomy, while the use (and success) of individual funding requests for treatments apparently varied between interviewees. Often advances in the clinical evidence were used to justify deviations from guidelines. However the influence of evidence had a lesser role in dose-optimisation decisions in remission, where the evidence to guide such decisions is limited.
Conclusions The results suggest that a range of factors, other than just cost, may influence anti-TNF prescribing decisions including the emergence of evidence, the interpretation of clinical guidelines, patient involvement in decision making, a desire for clinical autonomy and the influence of clinical service commissioners. Such factors generate variability in the treatment received by patients with rheumatoid arthritis across England. Further research could explore whether the variation in deviations from NICE guidance leads to differences in patient outcomes or the cost-effectiveness of care.
a: NICE (2016). Technology Appraisal 375.
Disclosure of Interest S. Gavan Grant/research support from: National Institute for Health Research Manchester Musculoskeletal Biomedical Research Unit PhD Studentship., G. Daker-White: None declared, A. Barton: None declared, K. Payne: None declared