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Mixed methods study of clinicians’ perspectives on barriers to implementation of treat to target in psoriatic arthritis
  1. Emma Dures1,
  2. Julie Taylor1,
  3. Sasha Shepperd2,
  4. Sandeep Mukherjee3,
  5. Joanna Robson4,
  6. Ivo Vlaev5,
  7. Nicola Walsh6,
  8. Laura C Coates7,8
  1. 1 Department of Nursing and Midwifery, University of the West of England Bristol, Bristol, Bristol, UK
  2. 2 Nuffield Department of Population Health, University of Oxford, Oxford, UK
  3. 3 Department of Rheumatology, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
  4. 4 Health and Applied Sciences, University of the West of England Bristol, Bristol, UK
  5. 5 Behavioural Science Group, Warwick Business School, Coventry, UK
  6. 6 Department of Allied Health Professionals, University of the West of England Bristol, Bristol, UK
  7. 7 Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
  8. 8 NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  1. Correspondence to Dr Laura C Coates, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK; laura.coates{at}


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.

  • psoriatic arthritis
  • treatment
  • outcomes research
  • health services research

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  • Handling editor Josef S Smolen

  • Correction notice This article has been corrected since it published Online First. The acknowledgement statement has been amended.

  • Contributors ED, SS, IV and LC contributed to the study design with data collection led by JT, ED and LC. All authors contributed to data analysis and interpretation. The manuscript was written by ED and LC with feedback and final review by all authors.

  • Funding This research was supported by research grants from AbbVie, Celgene, Eli Lilly, Novartis and Pfizer Ltd.

  • Competing interests None declared.

  • Patient and public involvement This preliminary research focusses on potential interventions to healthcare teams rather than directly to patients. Patient research partners are key members of the overarching project team developing implementation methods to aid treat to target in psoriatic arthritis (PsA). In addition, clinicians without an academic interest in PsA were involved in the design of this study, revised draft survey questions and contributed to the interpretation of results. Patient research partners and non-specialist clinicians continue to contribute to the overarching project committee and the data reported here will be used to inform the design of future interventional studies.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the Health and Applied Sciences Faculty Research Ethics Committee at the University of the West of England, Bristol (reference: HAS.18.11.056).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.