Abstract：
Understanding factors that influence prescribing of disease-modifying anti-rheumatic drugs (DMARDs) will inform strategies to optimise care of people with inflammatory arthritis. We performed a systematic review and thematic synthesis of qualitative studies to explore these factors. Inclusion criteria were: use of qualitative or mixed methods; rheumatologist, nurse or pharmacist perspectives; prescription of any DMARD (conventional [cs], targeted synthetic [ts], biologic [b], biosimilars) and/or glucocorticoids; in any healthcare setting in any country. MEDLINE, Embase and EBSCOhost CINAHL Plus were searched from inception to 15 June 2021. Pairs of review authors independently identified studies for inclusion, assessed methodological quality using the Critical Appraisal Skills Programme checklist, and extracted and thematically synthesised data. Confidence in synthesis themes was evaluated using the GRADE Confidence in Evidence from Reviews of Qualitative research (CERQual) approach. We included 15 studies involving 716 clinicians (683 rheumatologists, 27 nurses, 6 pharmacists) across 10 countries, all focusing on management of patients with rheumatoid arthritis (RA). Six themes were identified: Rheumatologist prescribing is influenced by patients\' characteristics, preferences, symptoms and negative responses to medication; Rheumatologist knowledge, experience, habits and subjective judgements are strong drivers of prescribing behaviour; High demands on consultation time impede shared decision-making; Costs and complexity of medication funding arrangements limit prescribing options; Clinicians recognise the importance of providing patient education about medication options; and Clinicians value colleagues\' opinions and support to inform prescribing decisions. The majority of themes were graded as moderate confidence (n = 4), reflecting they are likely to reasonably represent the factors influencing prescribing of DMARDs to people with RA. Quality improvement strategies that address these factors are likely to support best practice pharmacologic management of RA and may be potentially applicable to other types of inflammatory arthritis. High demand on consultation time and complexity of medication funding arrangements are system factors that may or may not be amenable to change. Easily accessible living national guidelines which include lay summaries and treatment algorithms to support prescribing decisions may address some of the themes.
摘要：
了解影响疾病缓解抗风湿药物（DMARDs）处方的因素将为优化炎症性关节炎患者的护理提供策略。我们对定性研究进行了系统回顾和专题综合，以探讨这些因素。纳入标准是：使用定性或混合方法；风湿病学家，护士或药剂师的观点；任何DMARD的处方(常规[cs]，目标合成[ts]，生物[b]，生物仿制药)和/或糖皮质激素；在任何国家的任何医疗保健环境中。MEDLINE,从开始到2021年6月15日，搜索了Embase和EBSCOhostCINAHLPlus。成对的综述作者独立确定了纳入研究，使用关键评估技能计划清单评估方法质量，提取和主题合成的数据。使用定性研究评论（CERQual）方法对综合主题的信心进行了评估。我们纳入了15项研究，涉及716名临床医生(683名风湿病学家，27名护士，6名药剂师)遍布10个国家，所有这些都集中在类风湿关节炎（RA）患者的管理上。确定了六个主题：风湿病学家的处方受患者特征的影响，preferences,症状和对药物的负面反应;风湿病学家知识,经验,习惯和主观判断是处方行为的重要驱动因素;对咨询时间的高要求阻碍了共同决策;药物筹资安排的成本和复杂性限制了处方选择;临床医生认识到向患者提供药物选择教育的重要性;临床医生重视同事的意见和支持以告知处方决策。大多数主题被评为中等置信度(n=4)，反映它们可能合理地代表了影响RA患者处方DMARDs的因素。解决这些因素的质量改进策略可能支持RA的最佳实践药理学管理，并可能适用于其他类型的炎性关节炎。对咨询时间的高需求和药物资助安排的复杂性是可能或可能无法改变的系统因素。容易获得的活生生的国家指南，包括支持处方决策的总结和治疗算法，可能会解决一些主题。
