Facilitators and barriers in diagnosing rheumatoid arthritis as described by general practitioners: a Danish study based on focus group interviews

Figures & data

Table 1. Interview guide.

Pre-interview: brief information

1: Recall a patient

Please recall your last patient diagnosed with RA and speak about that.

2: Incidence locally

How often do you see a patient with newly diagnosed RA in your general practice?

3: GPs’ experience

What is your experience with diagnosing RA?

4: Availability of resources

What are your experiences with available paraclinical testing?

5: Referral to the secondary sector

When do you choose to refer to a rheumatologist?

What are your experiences with referral to rheumatologists?

What are the drivers and barriers in early referral to rheumatologists?

6: Knowledge of treat to target

What are your opinions on the treat-to-target strategy?

7: GPs’ role in diagnosing RA

How can a GP play a part in the early diagnosis of RA?

What are your experiences of collaboration with secondary care?

What are the facilitators and barriers to follow the treat-to-target strategy?

8: Closure

Is there anything missing according to the subject?

Table 2. The four themes A–D with numbered quotes illustrating each theme.

Barriers	Facilitators
Theme A If the patient is not a textbook example
A1 ‘It is rare when I see someone where I think—this is truly RA.’	A8 ‘To examine a finger joint—when is there arthritis?’
A2 ‘If it was only like in the textbooks THEN it would be easy.’	A9 ‘But I think, it could be a topic—as you say—many new things have happened, and the approach has changed [on diagnosing RA]; therefore it could be an area of training [for specialized doctors].’
A3 ‘The debut is so varied. It is not necessarily a textbook example. It is rare that it is like that.’	A10 ‘A 30-second video.. like when you find a younger doctor [at the department of clinical rheumatology] to illustrate.’
A4 ‘I cannot remember looking at a patient’s fingers and thinking oh my God this is classic RA.’	A11 ‘I could dream of that at your webpage for health professionals; maybe sometimes there could be some pictures, a little video.’
A5 ‘Sometimes they [patients] say it is swollen, and you cannot see it, but they are certain. There are some problems, I think. Because if it was bigger, red, asymmetrical, then you have no doubts.’
A6 ’It is difficult when there is no arthritis.’
A7 ‘When we miss something, it is the patients, who come too early to suspect RA.’
Theme B The importance of maintaining the gatekeeper function
B1 ‘We find cancer earlier now, but it has a cost. We use more resources on examining people. How many resources does it take to find the sero-negative [RA patients]?’
B2 ‘I have become more proficient with age. And there lies a—you should not overuse the healthcare system.’
B3 ‘I know I am good at gynecology, and I know a lot about lung diseases, but all of [a] sudden, you [the rheumatologists] need to take this, because I do not know much about it, and I am aware of that, so I will refer earlier [than other GPs].’
Theme C Difficulties in referral of patients to rheumatologists
C3 ‘I get a call from the rheumatologist. Is the list really that long? Or what is the problem since I am interrupted in [the] middle of a patient [consultation], to answer why I have referred a patient? I think that is not acting as a good colleague.’	C1 ‘I think if there is arthritis the patients are seen within a week.’
C4 ‘If the blood tests are positive, then they accept them. They do! But it is the gray areas, that are the difficult ones.’	C2 ‘But I think in xx [city name], they must be praised for saying: ‘Bring them, and we can quickly handle and finish it.’
C6 ’We can often get a phone call from the specialist doctor the next day [after referral], advising us to try this and that, so because of that we often chose the private [practice] rheumatologists more.’	C5 ‘The access [to rheumatologists] is easy if the biomarkers are clear.’
C7 ‘The private [practice] rheumatologists, are more when I think, No it is probably nothing, but there is a big wish [from the patient to be referred] or when it has been going on for a long time.’
C8 ‘When they [patients] have been to a rheumatologist before, I really think that it is a barrier, if they are declared ‘free’ [from a rheumatic disease].’
Theme D Laboratory tests—can they be trusted?
D5 ‘There is a big difference in how to interpret the blood samples—what do we know about blood samples? I did not know anything about the sensitivity on that thing [Anti–citrullinated protein antibody (ACPA)] and we can miss a lot of patients, so we need information about that. I don’t mind admitting that during the diagnosing process, I have to read about the blood tests and the diagnosis.’	D1 ‘The younger colleagues take a big amount of ‘rheuma-tests’ and everything, where I know for sure that they do not have RA.“
	D2 ‘I can tell, what I am trying to tell my intern doctors, that they [the patients] must have a swollen joint, then we can take a CRP [C-reactive protein] and if it is normal, [and] so on and so on, then they do not have RA, then they definitely need to look for something else.’
	D3 ‘It is much easier after the ACPA occurred.’
	D4 ‘The ACPA should be more sensitive. There is also the rheuma factor-negative RA which complicates things […] the ACPA should be more sensitive—that is my impression.’