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Background: A tightly-controlled, treat-to-target (T2T) approach is advocated for the management of axial spondyloarthritis (axSpA) in international guidelines 1. In practice however, compliance with T2T remains limited in axSpA 2. It is unknown what the driving factors are behind this poor implementation. Objectives: To explore the perceptions of patients and rheumatologists on a T2T approach in axSpA, and identify the barriers and facilitators of its implementation. Methods: A convergent parallel mixed-methods design using semi-structured interviews and quantitative questionnaires was applied. AxSpA patients visiting the outpatient clinic with an Ankylosing Spondylitis Disease Activity Score (ASDAS) of ≥2.1 for whom medication was not adapted were included, alongside their treating rheumatologists. Interviews revolved around the current management strategies for axSpA in practice and the knowledge and opinions held on T2T. Questionnaires focused on the effectiveness and feasibility of the current instruments for disease activity measurement and the T2T approach as a whole. Quantitative and qualitative data were analysed descriptively and thematically, respectively. Results: Seven patients and five rheumatologists participated (Table 1). The key barriers and facilitators identified are summarised in the Figure. Important facilitators highlighted were the expansive knowledge held by patients about axSpA as a disease, and the familiarity of rheumatologists with T2T. Furthermore, regular monitoring of disease activity supported by consistent instruments, such as validated questionnaires, was found to be favourable. Finally, the widespread application of shared-decision making and positive doctor-patient relationships were valued. A recurrent barrier reflected by patients, however, was difficulty in objectively and accurately answering disease activity questionnaires. This was often due to the presence of comorbidities with overlapping symptoms or prominent non-inflammatory complaints (71%). As such, scores at times exaggerated axSpA disease activity (57%). Resistance to tight monitoring and treatment intensification was also prominent among patients, attributed to satisfaction with current therapies (57%), fear associated with new medications (29%), or the view of axSpA disease flares being self-limiting and temporary (71%). Many patients were additionally observed to lack knowledge on the goals and importance of treatment, which may have contributed to this resistance. In the perspective of rheumatologists, doubts on the effectiveness, feasibility and flexibility of T2T in axSpA were apparent. In particular, while (partially) subjective scoring instruments such as the ASDAS were valued as supporting tools, rheumatologists recounted having difficulty basing treatment decisions on these instruments due to their perceived unreliability in reflecting true disease activity (80%). Rheumatologists were therefore inclined to base such decisions on their own judgement or individual components of the ASDAS rather than only on the calculated score as a whole (100%). Furthermore, some felt restricted by the limited number of treatment options available for axSpA. Finally, time pressure (60%) and the lack of adequate tools to facilitate T2T (80%), such as a digital system to regularly collect disease activity scores over time, were reported as barriers from an organisational perspective. Conclusion: While the foundation for the successful implementation of T2T in axSpA in practice is in place, additional attention is required for the barriers experienced by all stakeholders. Patient education, evaluation of the way active disease is defined and measured, and the facilitation of better management of non-inflammatory symptoms and psychosocial factors are opportunities for future improvement. REFERENCES: 1 Smolen J. et al. Ann Rheum Dis 2018, 77(1):3-17, doi: 10.1136/annrheumdis-2017-211734 2 Beckers E. et al. Rheumatology (Oxford) 2022, 61(4):1396-1407, doi: 10.1093/rheumatology/keab516 Acknowledgements: The authors thank all patients and rheumatologists who participated in this study, and the research nurses in the Maastricht UMC+ for their efforts in facilitating the logistics of the interviews. This study was supported by Novartis. Novartis had no role in the study design, in the collection, analysis or interpretation of the data, or in the writing of this abstract. Disclosure of Interests: Marius Smits: None declared, Casper Webers: None declared, Mirte van Dooren: None declared, Astrid van Tubergen Consulting fees from Galapagos, Johnson and Johnson, Novartis and UCB, Research grants from Novartis, Pfizer and UCB.
Smits et al. (Sat,) studied this question.