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Mixed methods study of clinicians’ perspectives on barriers to implementation of treat to target in psoriatic arthritis

Dures, Emma; Taylor, Julie; Shepperd, Sasha; Mukherjee, Sandeep; Robson, Joanna; Vlaev, Ivo; Walsh, Nicola; Coates, Laura C


Emma Dures
Associate Professor in Rheumatology and Self-management

Julie Taylor
Senior Lecturer in Adult Nursing

Sasha Shepperd

Sandeep Mukherjee

Jo Robson
Consultant SL in Rheumatology

Ivo Vlaev

Nicola Walsh
Professor in Knowledge Mobilisation & Muscul

Laura C Coates


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.
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.
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.
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.

Journal Article Type Article
Publication Date May 19, 2020
Journal Annals of the Rheumatic Diseases
Print ISSN 0003-4967
Electronic ISSN 1468-2060
Publisher BMJ Publishing Group
Peer Reviewed Peer Reviewed
Pages annrheumdis-2020-217301
APA6 Citation Dures, E., Taylor, J., Shepperd, S., Mukherjee, S., Robson, J., Vlaev, I., …Coates, L. C. (2020). Mixed methods study of clinicians’ perspectives on barriers to implementation of treat to target in psoriatic arthritis. Annals of the Rheumatic Diseases, annrheumdis-2020-217301.
Keywords Immunology; General Biochemistry, Genetics and Molecular Biology; Immunology and Allergy; Rheumatology