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Factors influencing rheumatologists prescription of biological treatment in rheumatoid arthritis: an interview study
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
2014 (English)In: Implementation Science, ISSN 1748-5908, Vol. 9, no 153Article in journal (Refereed) Published
Abstract [en]

Background: The introduction of biological drugs involved a fundamental change in the treatment of rheumatoid arthritis (RA). The extent to which biological drugs are prescribed to RA patients in different regions in Sweden varies greatly. Previous research has indicated that differences in health care practice at the regional level might obscure differences at the individual level. The objective of this study is to explore what influences individual rheumatologists decisions when prescribing biological drugs. Method: Semi-structured interviews, utilizing closed-and open-ended questions, were conducted with senior rheumatologists, selected through a mix of random and purposive sampling. The interview questions consisted of two parts, with a "parallel mixed method" approach. In the first and main part, open-ended exploratory questions were posed about factors influencing prescription. In the second part, the rheumatologists were asked to rate predefined factors that might influence their prescription decisions. The Consolidated Framework for Implementation Research (CFIR) was used as a conceptual framework for data collection and analysis. Results: Twenty-six rheumatologists were interviewed. A constellation of various factors and their interaction influenced rheumatologists prescribing decisions, including the individual rheumatologists experiences and perceptions of the evidence, the structure of the department including responsibility for costs, peer pressure, political and administrative influences, and participation in clinical trials. The patient as an actor emerged as an important factor. Hence, factors both at organizational and individual levels influenced the prescribing of biological drugs. The factors should not be seen as individual influences but were described as influencing prescription in an interactive, nonlinear way. Conclusions: Potential factors explaining differences in prescription practice are experience and perception of the evidence on the individual level and the structure of the department and participation in clinical trials on the organizational level. The influence of patient attitudes and preferences and interpretation of scientific evidence seemed to be somewhat contradictory in the qualitative responses as compared to the quantitative rating, and this needs further exploration. An implication of the present study is that in addition to scientific knowledge, attempts to influence prescription behavior need to be multifactorial and account for interactions of factors between different actors.

Place, publisher, year, edition, pages
BioMed Central , 2014. Vol. 9, no 153
Keyword [en]
Prescription; Rheumatoid arthritis; Biological drugs; Implementation; Physicians; Clinical decision-making; Practice variations; Qualitative; CFIR
National Category
Clinical Medicine
Identifiers
URN: urn:nbn:se:liu:diva-113028DOI: 10.1186/s13012-014-0153-5ISI: 000345438200001PubMedID: 25304517OAI: oai:DiVA.org:liu-113028DiVA: diva2:778912
Available from: 2015-01-12 Created: 2015-01-08 Last updated: 2015-01-15
In thesis
1. Diffusion, implementation and consequences of new health technology: The cases of biological drugs for rheumatoid arthritis and the Swedish national guidelines
Open this publication in new window or tab >>Diffusion, implementation and consequences of new health technology: The cases of biological drugs for rheumatoid arthritis and the Swedish national guidelines
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Improvements in health technology raise hopes for better patient outcomes and a more efficient delivery of health care. However, the processes of diffusion and implementation of new health technology have been shown to be complicated and to pose a number of challenges for the healthcare sector. Many at tempts have been made to influence and manage the introduction and diffusion of health technology. One prominent example is the Swedish nat ional guidelines that aim at influencing both clinical and political decision - making in the health sector.

The overall aim of this thesis is to describe and analyze the factors influencing the diffusion and economic consequences of the introduction of a new technology with large variations in use, and to explore the process of implementation of nationally produced guidelines as an instrument for improv ing effectiveness and equity. The empirical focus is kept on the biological drugs (bDMARDs) for rheumatoid arthritis (RA), since they implied a substantial treatment change when they were first int roduced and they are relatively costly; and on the national guidelines for cardiac care, since they were the first nat ional guidelines, hence allowing a long-term perspect ive in the exploration of their implementat ion.

Paper I presents a register study that uses data from national and regional registries on healt hcare use and work disability of patients with RA and shows that there was a 32 percent increase in the total fixed cost of RA during 1990-2010, mainly after the introduct ion of bDMARDs. Paper II shows that choosing to initiate treatment with bDMARDs varied substantially among 26 rheumatologists presented with hypothetical patient cases, and that there were also disparities between rheumatologists practicing in the same clinic. Paper III presents data from the Swedish Rheumatology Quality Register covering 4010 patients with RA, and shows that when using multivariate logistic regression to adjust for patient characterist ics, disease activity and t he physician’s local context, physician preference was an import ant predict or for prescription of bDMARDs. Paper IV is a qualitative study about prescribing decisions, showing that a constellat ion of various factors and their interact ion influenced the prescribing decisions according to the 26 interviewed rheumatologists. The factors included the individual rheumatologist ’s experiences and perceptions of t he evidence, the structure of the department including responsibility for costs, peer pressure, political and administrative influences, and participat ion in clinical trials. The patient as an actor emerged as an important factor. Paper V is a longitudinal qualitat ive study exploring the responses among four Swedish county councils to the national guidelines for cardiac care through 155 interviews with politicians, administ rators and clinical managers. The results show that unilateral responses to the national guidelines within the county councils have been rare, but there have been at tempts to compromise and to at tain a balance between multiple constituents. There are examples of local information meetings, the use of the national guidelines in local healthcare programs, and performing audits with the national guidelines as a base. However, performing explicit prioritizat ion as advised in the NGCC is rarely found. Over t ime, however, a more systematic use of the national guidelines has been noted.

In conclusion, the diffusion of new health technology is influenced by a wide array of factors both at individual and organizational levels, as well as their interact ion. The diffusion resulted in large economic consequences and unequal access due to variations also at clinical level. Moreover, given that healthcare decision-making is influenced by many different factors, the simple influx of evidence-based guidelines will unlikely result in automat ic implementat ion. At tempts to influence healthcare decisions need to have a systems perspect ive and to account for the interact ion of factors between different actors.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. 104 including Appendix A and B p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1431
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-113306 (URN)10.3384/diss.diva-113306 (DOI)978-91-7519-177-5 (print) (ISBN)
Public defence
2015-02-06, Berzeliussalen, Ingång 65, Campus US, Linköpings universitet, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2015-01-15 Created: 2015-01-15 Last updated: 2016-03-02Bibliographically approved

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