Background/Purpose: European League Against Rheumatism Treatment recommendations support implementing a treat-to-target (T2T) approach in psoriatic arthritis (PsA) based on the findings of the TICOPA trial. However, a UK survey estimated that ~90% of clinicians do not follow this. This study explored clinicians’ views on implementing T2T in PsA.

Methods: Individual interviews and a focus group with clinicians, audio-recorded and analysed using thematic analysis. Datasets were compared and integrated for analysis.

Results: Eight rheumatologists and two healthcare professionals (5-26 years’ experience) participated in telephone interviews (25-35 minutes). One consultant delivered PsA-specific clinics. Seven rheumatologists and two trainees (3-22 years’ experience) participated in a focus group (102 minutes). Three clinicians delivered PsA-specific clinics. There were four main themes: 

Individual motivation to change clinical practice: “We have set up weekly psoriatic arthritis clinics at our hospital and it took almost 2 ½ years.” Typically, individual clinicians with a specialist interest developed care pathways for PsA patients. They sought external information, training and support to champion T2T in their local service.  

A lack of consensus on what to measure: “There has to be a strong argument to get me to do any other type of assessment because PsARC is quicker and we’ve been trained appropriately.” Views varied on the assessments needed to inform disease management. A strong justification would be needed for measures that could increase appointment time and patient burden.

What is achievable with limited resources: “If it’s a mixed clinic it isn’t really that feasible”

Lack of nursing support and registrar training in skin/joint scores were barriers to T2T. Challenges were amplified when PsA patients attended general rheumatology clinics and there were no dedicated database systems to support data collection.

Mandatory versus voluntary pressures to change: “Actually knowing somebody’s watching you… with an audit makes a hell of a difference to how you run your service.” Changes in practice were more likely when mandated by service providers and linked to tariffs/funding. Sharing local guidelines and protocols could facilitate T2T implementation.

Conclusion: A driver of T2T implementation was clinicians with a specialist interest in PsA who set up dedicated clinics. Barriers included a lack of consensus about targets, and practical challenges (clinical time, collecting outcomes, insufficient training and database requirements). T2T implementation in PsA requires an integrated approach to address support and resource needs of individual clinicians, teams, local IT systems, and service providers.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/a-qualitative-study-of-clinicians-perspectives-on-barriers-to-implementation-of-treat-to-target-in-psoriatic-arthritis/