Developing a novel intervention to support clinicians to identify people at risk of rheumatoid arthritis in primary care through targeted anti-CCP testing – what are the key considerations?

Problem

The early symptoms of rheumatoid arthritis (RA) are often non-specific. Correspondingly, delays in identifying RA in primary care are common. Anti-cyclic citrullinated peptide (anti-CCP) testing of people who present to primary care with new-onset, non-specific musculoskeletal symptoms could help address this, as around one third who test positive for anti-CCP develop RA within a year. Inappropriate anti-CCP testing could have negative effects, so targeting anti-CCP testing is vital. This project aims to develop a novel intervention, the ‘Improving iDEntification of rheumatoid ArthritiS (IDEAS) in primary care’ (IDEAS-PC) model, to support clinicians to identify people at risk of RA in primary care through targeted anti-CCP testing.

Approach

This project is a qualitative intervention development study with three sequential phases.

Phase 1 (completed)

• Semi-structured interviews with eight General Practitioners (GPs) and eight Musculoskeletal First Contact Practitioners (FCPs).

• Data were analysed using the framework method and Behaviour Change Wheel to develop themes and a list of candidate components for the IDEAS-PC model.

Phase 2 (completed)

• Two workshops with three GPs and five FCPs.

• Data were analysed using content analysis to create a refined and prioritised list of components and inform the creation of an IDEAS-PC model prototype.

Phase 3 (ongoing)

• Think-aloud interviews with six to twelve primary care clinicians to test the IDEAS-PC model prototype.

• Data will be analysed using a ‘Table of changes’ to enable the prototype to be iteratively refined.

A Project Advisory Group, involving Patient and Public Involvement representatives and professionals, are overseeing the study and contributing to the IDEAS-PC model development.

Findings

Four intersecting themes were developed from the Phase 1 findings.

‘Variations in current practice’ is an overarching theme that highlights how clinicians’ anti-CCP test requesting practices and other aspects of current RA diagnostic pathways vary widely. These variations appeared to underpin participants’ differing views of the IDEAS-PC model.

The following themes relate to additional factors that are likely to influence whether clinicians will use the IDEAS-PC model:

• ‘Considering interpersonal influences across the whole healthcare system’

• ‘Balancing potential benefits versus risks’

• ‘Promoting access to and usability of the IDEAS-PC model’

The Phase 1 findings were used to develop a list of nine candidate components for the IDEAS-PC model. During the Phase 2 workshops four components were prioritised for inclusion in the IDEAS-PC model:

• Decision tool

• Guidance on using the decision tool and associated actions

• Evidence for the decision tool

• Patient education resources

Consequences

Addressing unwarranted variations in primary care clinicians’ anti-CCP test requesting practices is a priority.

The IDEAS-PC model could be valuable for guiding targeted anti-CCP testing in primary care, but whether it is used in practice will depend on key considerations such as whether clinicians believe its benefits outweigh its risks and its usability.