Barriers and facilitators to treat-to-target in axial spondyloarthritis in clinical practice: a mixed methods study

This study aimed to explore the perceptions of patients and rheumatologists about a treat-to-target (T2T) strategy in axial spondyloarthritis (axSpA) and identify the barriers and facilitators to its implementation in clinical practice. A mixed methods design was applied. Patients with axSpA who visited the outpatient clinic with active disease (AxSpA Disease Activity Score [ASDAS] ≥ 2.1), but did not receive a treatment adjustment, were identified. These patient cases were discussed in individual semi-structured interviews with the respective treating rheumatologists, and a subgroup of these patients was also interviewed. In parallel, all interviewed participants completed a quantitative survey. Qualitative and quantitative data were analysed thematically and descriptively, respectively. Twenty-three patients were discussed with 11 rheumatologists, and 16 of these patients were interviewed personally. Barriers to T2T included challenges in the measurement of inflammatory disease activity using the ASDAS, and numerous patient-related factors such as concern about treatment adaptations. The limited number of viable treatment options and scarce amount of evidence supporting T2T in axSpA, as well as logistical challenges, were additional obstacles. Facilitators included patients' broad knowledge about axSpA, rheumatologists' awareness of T2T recommendations, and positive doctor-patient relationships with the application of shared decision-making. Moreover, a supporting infrastructure, such as one with high accessibility to the outpatient clinic between scheduled visits, was considered necessary for the application of a T2T strategy. In conclusion, numerous barriers and facilitators to the implementation of a T2T strategy in axSpA are present, which need to be considered when applying this treatment approach in clinical practice.