Background Treatment decisions for any disease are usually informed by reference to published clinical guidelines or recommendations. These recommendations can be developed to improve the relative cost-effectiveness of health care and to reduce regional variation in clinical practice. Anti-tumor necrosis factor alpha (anti-TNF) treatments are prescribed for people with rheumatoid arthritis according to specific recommendations by the National Institute for Health and Care Excellence in England. Evidence of regional variation in clinical practice for rheumatoid arthritis may indicate that different factors have an influence on routine prescribing decisions. The aim of this study was to understand the factors that influence rheumatologists' decisions when prescribing anti-TNF treatments for people with rheumatoid arthritis in England. Methods Semi-structured one-to-one telephone interviews were performed with senior rheumatologists in different regions across England. The interview schedule addressed recommendations by the National Institute for Health and Care Excellence, prescribing behavior, and perceptions of anti-TNF treatments. Interviews were recorded digitally, transcribed verbatim, and anonymized. Data were analyzed by thematic framework analysis that comprised six stages (familiarization; coding; developing the framework; applying the framework; generating the matrix; interpretation). Results Eleven rheumatologists (regional distribution - north 36%; midlands: 36%; south: 27%) participated (response rate: 24% of the sampling frame). The mean duration of the interviews was thirty minutes (range: 16 to 56 min). Thirteen factors that influenced anti-TNF prescribing decisions were categorized by three nested primary themes; specific influences were defined as subthemes: (i) External Environment Influences (National Institute for Health and Care Excellence Recommendations; Clinical Commissioning Groups; Cost Pressures; Published Clinical Evidence; Colleagues in Different Hospitals; Pharmaceutical Industry); (ii) Internal Hospital Influences (Systems to Promote Compliance with Clinical Recommendations; Internal Treatment Pathways; Hospital Culture); (iii) Individual-level Influences (Patient Influence; Clinical Autonomy; Consultant Experience; Perception of Disease Activity Score-28 (DAS28) Outcome). Conclusions Factors that influenced anti-TNF prescribing decisions were multifaceted, seemed to vary by region, and may facilitate divergence from published clinical recommendations. Strategic behavior appeared to illustrate a conflict between uniform treatment recommendations and clinical autonomy. These influences may contribute to understanding sources of regional variation in clinical practice for rheumatoid arthritis.

中文翻译：

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影响风湿病学家抗肿瘤坏死因子α处方决定的因素：一项定性研究。

背景 任何疾病的治疗决定通常都参考已发表的临床指南或建议。可以制定这些建议以提高医疗保健的相对成本效益并减少临床实践中的区域差异。根据英国国家健康与护理卓越研究所的具体建议，为类风湿性关节炎患者开具抗肿瘤坏死因子 α（抗 TNF）治疗。类风湿性关节炎临床实践中存在区域差异的证据可能表明不同的因素对常规处方决策有影响。本研究的目的是了解在为英格兰类风湿性关节炎患者开具抗 TNF 治疗处方时影响风湿病学家决策的因素。方法对英格兰不同地区的高级风湿病专家进行半结构化的一对一电话访谈。访谈时间表涉及国家健康和护理卓越研究所的建议、处方行为和对抗 TNF 治疗的看法。采访以数字方式记录、逐字转录和匿名化。通过包括六个阶段（熟悉；编码；开发框架；应用框架；生成矩阵；解释）的主题框架分析来分析数据。结果 11 名风湿病学家（区域分布 - 北部 36%；中部地区：36%；南部：27%）参与（响应率：抽样框架的 24%）。访谈的平均持续时间为 30 分钟（范围：16 至 56 分钟）。影响抗 TNF 处方决定的 13 个因素按三个嵌套的主要主题分类；具体影响被定义为子主题：(i) 外部环境影响（国家健康和护理卓越研究所建议；临床调试小组；成本压力；已发表的临床证据；不同医院的同事；制药行业）；(ii) 医院内部影响（促进遵守临床建议的系统；内部治疗途径；医院文化）；(iii) 个人层面的影响（患者影响；临床自主权；顾问经验；疾病活动评分 28 (DAS28) 结果的感知）。结论 影响抗 TNF 处方决定的因素是多方面的，似乎因地区而异，并可能促进与已发表的临床建议的分歧。战略行为似乎说明了统一治疗建议和临床自主权之间的冲突。这些影响可能有助于了解类风湿关节炎临床实践中区域差异的来源。