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Background: Treat-to-target (T2T) is a management strategy that consists of several elements, including choosing a target that is relevant for the course of a disease to prevent irreversible damage (such as remission or low disease activity), deciding when and how to assess this target and adapting the therapy when the target is not achieved, all in the context of shared decision-making. Despite increasing evidence in support of T2T in SpA, as well as recommendations advocating for this approach, uptake in psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA) has been suboptimal in daily practice. Successful application of T2T requires that barriers and facilitators are identified and subsequently addressed. Objectives: To review the evidence on barriers and facilitators to application of T2T in axSpA and PsA in daily practice. Methods: A systematic search was conducted in MEDLINE/EMBASE up to December 2023, focusing on studies in patients with axSpA or PsA. Any type of original research, either of quantitative or qualitative nature, was eligible for inclusion, as long as barriers or facilitators to application of T2T were explored. Two independent reviewers conducted screening, and one reviewer extracted the data. A qualitative synthesis was conducted, in which barriers/facilitators were classified by the level to which they apply (healthcare provider HCP, patient, organisation), and by the T2T component (e.g. measurement of target, adaptation of therapy) or T2T prerequisite (e.g. resources, education) they related to. Results: The systematic search yielded 821 records (557 after de-duplication). After screening and reference checking, 28 studies were included, all published in the 2015-2023 period. Most focused on PsA (n=21 studies), with the remainder including axSpA patients (n=6 studies) or a mixed axSpA/PsA population (n=1 study). All studies but one (mixed-methods sequential exploratory study) were of quantitative nature. Two studies were randomised controlled trials, 6 were prospective cohort studies, 16 were cross-sectional and 4 had other designs. Most studies included only patients (n=22/28 studies). The sample size in quantitative studies ranged from 83 to 1236, with notable variations in sex distribution (37-67% male), age (mean age 38-58 years) and disease duration (mean duration 15 years). Over 30 barriers and 15 facilitators to application of T2T were identified (Figure 1). The number of studies that supported each barrier/facilitator ranged from 1 to 15. At the level of the HCP most studies focused on the measurement of the target, especially in PsA, highlighting that agreement between instruments (and with the HCP perspective) was suboptimal. Even when certain targets were achieved, residual disease was frequent. Furthermore, many studies demonstrated that certain targets, such as remission or minimal disease activity, could not always be achieved, for example in patients with comorbidity or because treatment escalation was not possible. At the level of the patient, the role of patient-reported outcomes (PROs), while deemed relevant, was repeatedly shown to act as a barrier to achieve certain targets that included PRO components. At the level of the organization, the increased time and resources needed for T2T were considered a barrier, although it was noted that T2T could also reduce (para)medical resource use and work productivity losses. Other important facilitators were the designation of a local champion that could drive change, and availability of nurse support and IT infrastructure supporting T2T. Economic data were conflicting, but indicated that T2T could be cost-effective. Importantly, certain components, such as shared decision-making, were not assessed at all. Conclusion: Various barriers and facilitators were identified, acting on several levels. Most of the evidence was generated in PsA, while data in axSpA were scarce. Furthermore, certain relevant components of T2T were not studied at all. Future research in this area should focus more on axSpA, prioritize the various barriers and facilitators, and explore how these could be targeted to improve application of T2T in daily practice. REFERENCES: NIL. Acknowledgements: This study was supported by Novartis. Novartis had no role in the study design, in the data collection, analysis or interpretation, or in the writing of this abstract. Disclosure of Interests: Casper Webers: None declared, Ivette Essers: None declared, Marin Been: None declared, Annelies Boonen has received honoraria for lectures from AbbVie, Galapagos, Novartis, Pfizer and UCB;, has received consulting fees from Abbvie, Galapagos, Novartis, Pfizer and UCB, has received research grants from Abbvie, Astrid van Tubergen has received consulting fees from Galapagos, Johnson and Johnson, Novartis and UCB, has received unrestricted research grants related to SpA-Net from Novartis, Pfizer and UCB.
Webers et al. (Sat,) studied this question.