164. BIOLOGIC DOSE REDUCTION IN RHEUMATOID ARTHRITIS: WHAT STOPS US?

Abstract

Background: Biologic dose reduction (BDR) in patients with stable rheumatoid arthritis involves using smaller doses, extending the interval between doses or a mixture of both. For patients there is less exposure to long-term effects from biologics and fewer injections. For rheumatology departments and clinical commissioning groups (CCGs) there are significant cost savings to be had and this in turn may offer the opportunity to fund further service development. Success depends on CCGs and rheumatology units working together to resolve complex local clinical and practical issues. This exploratory study aimed to build greater understanding of organizational factors affecting implementation of BDR. Method(s): Consultant rheumatologists (2), specialist pharmacists (2), specialist nurses (2) and commissioning medicines optimization leads (2) from two rheumatology units/CCGs were interviewed to explore their experiences with the local implementation process of BDR. The organizations selected had each successfully implemented a BDR pathway. The aim was to identify factors that facilitated BDR and any barriers to implementation. Result(s): Common themes emerged, although participating organizations operated very differently. Rheumatologists regarded the flexibility of BDR pathways as advantageous to clinician engagement and local adoption. The lack of any clinical guidelines on BDR was seen as a significant barrier to less experienced clinicians practicing BDR. Participation in professional network gatherings was linked to willingness to adopt BDR by rheumatologists. Patient needs and safety were highly influential in the decision to implement BDR. Discussion with patients about their disease/remission was needed for effective shared decision making. Although all participants recognized the need to improve services to provide better care to patients, limited resources (mainly staff) was a significant barrier to BDR. Larger organizations seemed less able to implement BDR pathways quickly. Engagement between senior trust management and rheumatologists/clinicians was crucial and needed to be driven by an implementation lead consultant or specialist pharmacist. Rheumatology departments were more likely to implement BDR if funding for additional resources (e.g. staffing and ultrasound equipment) would be made available. Data collection and analysis of cost savings and CCG return on investment was complex and more suited to the skill set of the specialist pharmacist. Conclusion(s): There are opportunities for local and national stakeholders to encourage wider implementation of BDR. Currently, best practice is unclear and specialist teams encounter numerous barriers to implementation. This study indicates that we need to explore patient views and attitudes toward BDR, unify best clinical practice guidelines and agree on resources needed for implementation and for CCGs to explore benchmarking of BDR rates between providers. Recruitment of a specialist pharmacist is crucial to successful implementation, and a competency framework to aid pharmacist development in rheumatology has just been developed by the British Society of Rheumatology.