Multifaceted Factors Influence Rheumatologists’ Prescribing Practices

Writing a prescription
Writing a prescription
Researchers interviewed rheumatologists in England to determine what factors they use to determine treatment in rheumatoid arthritis.

Multifaceted factors influence the prescribing decisions of rheumatologists who treat patients with rheumatoid arthritis, according to research published in BMC Rheumatology.

Using qualitative methods, researchers sought to understand what factors might influence rheumatologists in England when prescribing anti-TNF treatments for people with rheumatoid arthritis. Investigators conducted semi-structured, one-on-one telephone interviews with senior clinical rheumatologists who had experience treating rheumatoid arthritis, based on the assumption that this population would possess “good working knowledge of the key NICE [National Institute for Health and Care Excellence] recommendations that guide practice,” in addition to extensive experience with anti-TNFs.

Overall, 45 rheumatologists were invited to participate, with a response rate of 24%; 11 rheumatologists were interviewed between January and September 2015. The responses indicated that these clinicians generally made anti-TNF prescribing decisions based on a system of 3 nested primary themes: external environment influences, internal hospital influences, and individual-level influences. Each primary theme included 13 specific influences classified as subthemes, with a mean of 10 (range 8-12) identified in each transcript.

Six external environment influences were identified. These included NICE recommendations, clinical commissioning groups, cost pressures, published clinical evidence, colleagues in different hospitals, and the pharmaceutical industry. Each of these subthemes carried different weight among rheumatologists. Internal hospital influences included systems to promote compliance with NICE recommendations, internal treatment pathways, and hospital culture, while individual-level influences for rheumatologists included patient influence, clinical autonomy, consultant experience, and perceptions of the Disease Activity Score in 28 joints.

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One result of note was a conflict between study participants in terms of interpreting the NICE recommendations, and whether these recommendations should be interpreted as flexible or inflexible.

One limitation of the study was the small sample size, but the investigators cautioned that a larger sample would be “neither necessary or sufficient to obtain an understanding of a phenomenon being researched.”

“Factors that influence routine prescribing decisions are multifaceted and may encourage divergence from published clinical recommendations,” the researchers concluded. “Future research could investigate whether the external environmental and internal hospital factors influence junior rheumatologists to the same extent that their senior colleagues have described.”


Gavan SP, Daker-White G, Payne K, Barton A. Factors that influence rheumatologists’ anti-tumor necrosis factor alpha prescribing decisions: a qualitative study. BMC Rheumatol. 2019;3:47.