Table 3 Quotes illustrating Theme 1 ‘Attributes of predictive and preventive approaches’

1

“Those would be blood tests and rheumatoid factor, particularly CCP to look for an inflammatory response”, PPN 1, Rheumatologist.

2

“Sometimes it can be quite difficult to interpret because I don’t think we fully understand ultrasound findings for example. But I think that often we get inflammatory ultrasound findings in osteoarthritis. And you know non rheumatoid, and I don’t think we’re particularly good at really being able to distinguish in some cases, you know what is significant of what I’m finding and what isn’t. […] inflammatory markers, you know they’re not, I’m sure you know, they’re not particularly discriminatory and also people who are overweight, they’re often elevated so, if they’re slightly raised, it can be quite hard I think to inform decision making using, you know the results are equivocal.” PPN 17, Rheumatologist.

3

“So, I think the predictive tests, to be useful and beneficial, have to be sufficiently strong […] in their conclusions that they are useful in either making a negative or positive decision say to treat someone who is going to develop a rapidly progressing disease early to make a lifestyle change early” PPN 01, Rheumatologist.

4

“Even if you’ve got predictive tests, I don’t think you could predict how severe, you know, each individual patient was going to be, just put them in high risk you don’t know if they might develop a more aggressive disease. I don’t think you can really predict onset of how bad it can be you know. It’s tricky.” PPN 05, Rheumatology clinical nurse specialist.

5

“I probably wouldn’t, given our current provision of services, refer somebody who had a marker that said they were likely to develop something unless there was a new strategy that meant that we could act on that.” PPN 11, GP

6

“So, we would want some level of assurance that actually using these drugs in these patients is going to lead some benefit and what are the mitigations for those who never actually develop rheumatoid arthritis? We’ve exposed them to these toxic medications when they didn’t necessarily require them.” PPN 19, Rheumatologist.

7

“If they haven’t got any signs or symptoms alongside the risk, we wouldn’t want to give medications at this stage because these are life-long medications that can have an effect on the blood and body.” PPN 04, Rheumatology clinical nurse specialist.

8

“Your risk of giving somebody a preventive intervention for a disease they haven’t got and they develop a side effect is not great for the patient or the clinician.” PPN 08, Rheumatologist.

9

“You know the other side of this, the disadvantages as well as the anxiety and all the rest of it, it’s a kind of it’s people describe in research terms of treatment burden. But it’s actually, having to attend appointments, having to, you know take medicine, having to have blood tests, having all that time and commitment and work, that’s the other kind of downside of things, isn’t it, that?” PPN 17, Rheumatologist.

10

“I mean there might be positive changes about it might help them to adopt more positive lifestyle behaviours. Like smoking, something about dental health as well because I know that you know people with poor oral dental health have a higher risk of getting RA, particularly if they’ve got anti-CCP so I don’t know if there’s something preventative there around best dental health, I don’t know.” PPN17, Rheumatologist.

11

“It means the patient isn’t exposed to the pain, disability and longer-term consequences of what is a very unpleasant, chronic condition.” PPN 06, GP

12

“It’s not just about the direct illness. It’s almost the other things that happen with RA. People get cardiovascular disease; they get lung disease; they get heart problems. It’s not just about the specific disease itself which would improve outcomes much more long-term for people.” PPN 07, GP

13

“I do wonder if you had somebody that you knew was at risk of development something, then they would know what to look out for and they would be aware that they would need to seek help and advice, perhaps, at the early signs.” PPN 10, GP