Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia; Rehabilitation, Ageing, and Independent Living (RAIL) Research Centre, School of Primary and Allied Health Care, Monash University, Frankston, Victoria, Australia; Department of Occupational Therapy, School of Primary and Allied Health Care, Monash University, Frankston, Victoria, Australia.
Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia; The Cairnmillar Institute, Hawthorn East, Victoria, Australia.
Semin Arthritis Rheum. 2022 Aug;55:151988. doi: 10.1016/j.semarthrit.2022.151988. Epub 2022 Feb 27.
Understanding factors that influence prescribing of disease-modifying anti-rheumatic drugs (DMARDs) will inform strategies to optimise care of people with inflammatory arthritis. We performed a systematic review and thematic synthesis of qualitative studies to explore these factors. Inclusion criteria were: use of qualitative or mixed methods; rheumatologist, nurse or pharmacist perspectives; prescription of any DMARD (conventional [cs], targeted synthetic [ts], biologic [b], biosimilars) and/or glucocorticoids; in any healthcare setting in any country. MEDLINE, Embase and EBSCOhost CINAHL Plus were searched from inception to 15 June 2021. Pairs of review authors independently identified studies for inclusion, assessed methodological quality using the Critical Appraisal Skills Programme checklist, and extracted and thematically synthesised data. Confidence in synthesis themes was evaluated using the GRADE Confidence in Evidence from Reviews of Qualitative research (CERQual) approach. We included 15 studies involving 716 clinicians (683 rheumatologists, 27 nurses, 6 pharmacists) across 10 countries, all focusing on management of patients with rheumatoid arthritis (RA). Six themes were identified: Rheumatologist prescribing is influenced by patients' characteristics, preferences, symptoms and negative responses to medication; Rheumatologist knowledge, experience, habits and subjective judgements are strong drivers of prescribing behaviour; High demands on consultation time impede shared decision-making; Costs and complexity of medication funding arrangements limit prescribing options; Clinicians recognise the importance of providing patient education about medication options; and Clinicians value colleagues' opinions and support to inform prescribing decisions. The majority of themes were graded as moderate confidence (n = 4), reflecting they are likely to reasonably represent the factors influencing prescribing of DMARDs to people with RA. Quality improvement strategies that address these factors are likely to support best practice pharmacologic management of RA and may be potentially applicable to other types of inflammatory arthritis. High demand on consultation time and complexity of medication funding arrangements are system factors that may or may not be amenable to change. Easily accessible living national guidelines which include lay summaries and treatment algorithms to support prescribing decisions may address some of the themes.
了解影响疾病修饰抗风湿药物 (DMARD) 处方的因素，将为优化炎症性关节炎患者的治疗策略提供信息。我们进行了系统评价和定性研究的主题综合，以探索这些因素。纳入标准为：使用定性或混合方法；风湿病医生、护士或药剂师的观点；处方任何 DMARD（传统[cs]、靶向合成[ts]、生物[bs]、生物类似物）和/或糖皮质激素；在任何国家的任何医疗保健环境中。从创建到 2021 年 6 月 15 日，在 MEDLINE、Embase 和 EBSCOhost CINAHL Plus 中进行了搜索。由两名综述作者独立确定纳入的研究，使用关键评估技能计划清单评估方法学质量，并提取和主题综合数据。使用从定性研究中评价证据的 GRADE 置信度（CERQual）方法评估综合主题的置信度。我们纳入了 15 项研究，涉及 10 个国家的 716 名临床医生（683 名风湿病医生、27 名护士、6 名药剂师），所有研究都集中在类风湿关节炎（RA）患者的管理上。确定了六个主题：风湿病医生的处方受到患者特征、偏好、症状和对药物的不良反应的影响；风湿病医生的知识、经验、习惯和主观判断是处方行为的主要驱动因素；咨询时间的高需求阻碍了共同决策；药物资金安排的成本和复杂性限制了处方选择；临床医生认识到提供有关药物选择的患者教育的重要性；临床医生重视同事的意见和支持，以告知处方决策。大多数主题被评为中等置信度（n=4），这表明它们可能合理地代表了影响 RA 患者 DMARD 处方的因素。解决这些因素的质量改进策略可能有助于支持 RA 的最佳药理学管理，并且可能适用于其他类型的炎症性关节炎。咨询时间的高需求和药物资金安排的复杂性是可能或不可能改变的系统因素。易于访问的全国性指南，包括通俗易懂的摘要和治疗算法，以支持处方决策，可能会解决其中一些主题。
