Hospital culture, cost pressures influence divergent anti-TNF prescribing decisions in RA
Factors that impact TNF inhibitor prescribing decisions for patients with rheumatoid arthritis can range from cost pressures, to the pharmaceutical industry, to hospital culture to the desire for more clinical autonomy, and may contribute to regional variation in clinical practice, according to findings published in BMC Rheumatology.
“The decision to prescribe a particular anti-TNF agent may be more complex in practice than the cost-minimization strategy recommended by [National Institute for Health and Care Excellence (NICE)],”Sean P. Gavan, PhD, MSc, BA, FHEA, of the University of Manchester, England, and colleagues wrote. “No study has used [qualitative] methods to explore the factors that may influence anti-TNF prescribing decisions for RA in England; a greater understanding of this phenomenon may contribute to identifying drivers of the observed regional variation in care in the presence of uniform national recommendations.”
To better understand the factors that inform prescribing decisions regarding anti-TNF drugs for patients with RA, Gavan and colleagues conducted semi-structured, one-on-one phone interviews with 11 rheumatologists from various regions in England. Interview questions covered NICE recommendations, as well as prescribing behavior and rheumatologists’ perceptions of anti-TNF medications.
The interviews lasted a mean duration of 30 minutes, and were recorded digitally and later transcribed verbatim while maintaining the anonymity of the rheumatologist. The researchers examined the resulting data using thematic framework analysis with six stages — familiarization, coding, developing the framework, applying the framework, generating the matrix and interpretation.
The researchers ultimately identified 13 factors that influenced prescribing behaviors regarding TNF inhibitors for RA. These factors were categorized by three primary themes — external environment influences, internal hospital influences and individual-level influences.
According to the researchers, important external influences included NICE recommendations, clinical commissioning groups, cost pressures, published clinical evidence, colleagues in other hospitals and the pharmaceutical industry. Internal hospital influences included systems that promote compliance with clinical recommendations, internal treatment pathways and hospital culture. Lastly, the individual-level factors were patient influence, clinical autonomy, consultant experience and perception of DAS28 outcome.
“Factors that influence routine prescribing decisions are multifaceted and may encourage divergence from published clinical recommendations,” Gavan and colleagues wrote. “Actions that demonstrated conflict between clinical autonomy, to benefit identifiable patients, and population-level recommendations, to improve the relative cost-effectiveness of health care, were described. These influences may contribute to understanding variation in clinical practice for RA that has been reported previously.” – by Jason Laday
Disclosure: The researchers report no relevant financial disclosures.