Table 7 Theme 4: Lessons learned from other disease areas

1

“I guess if you compare it to the diabetes literature where you identify people before they’ve got diabetes and they’ve determined pre-diabetes and we’re starting to treat people now with pre-diabetes. So, I guess if the science is similar, maybe you get to a stage where you have pre-RA”. PPN 16, GP.

2

“I think, generally speaking, patients know about the risk of developing diabetes, heart disease, and things like that and can buy into preventive actions for that. I think RA is poorly understood at a population level and so I think patients would struggle to appreciate where RA fits in.” PPN08, rheumatologist.

3

“With something like a cardiac event, if you’ve got a 10% cardiac risk, over a ten-year period this is, then we should be giving people statins which they have to take on a daily basis but actually, most people don’t even notice it. Actually, the biggest faff about it is taking it on a daily basis and remembering because there are no consequences to that. It’s that kind of balance and it really depends on the toxicity of the treatment to prevent RA.” PPN 07, GP.

4

“Hopefully it [lifestyle interventions for RA] would be something like pre-diabetes where you’ve identified that risk, you go on a diabetes prevention course and that’s enough for the patients to change their behaviour so that they don’t become diabetic, that’s what I’d say from a prevention course” PPN 15, GP.

5

“So, it would be entirely something that the patient should be consulted with at every step of this, rather than it being something that we are doing. My feeling is it’s like statins; the requirement of the guidance was about the risk of a heart attack was cut from 20–10% over ten years and it effectively meant that, you know, every single male over 60, regardless of how healthy they were, should be on a statin. At which point, I don’t think that’s individualised or personalised medicine, I think that’s just pathologising old age, and so I think that if it was done in a personalised way that the individual had a proper understating of exactly what their risk was and exactly what the benefit was, then that’s a situation that […] with these medications.” PPN 09, GP.

6

“For example, a two-week wait is the famous one where people come in with altered bowel habits. I think the risk of actually having a cancer with altered bowel habits is about 5%. All of a sudden, you’re having to do 20 colonoscopies or CT scans to pick that one cancer up. It’s going to massively increase it [use of RA tests]”. PPN 07, GP.

7

“So, take a population of people similar to the person in front of me and estimate it over a period of time, cardiovascular disease for example ten years and show how many of that group would then turn out to have the condition and then if there was an intervention how many of those people would be helped. So cardiovascular disease, 10% risk over ten years you’d have 100 people, 10 would look glum at the end of a 10-year period.” PPN 13, GP.

8

“When we’re talking about the risk of stroke with the DOACs and stuff like that, we’re talking about a 4% or 5% risk. When you see the smiley faces and the sad faces, you might be getting four sad faces of getting a stroke. You’re given the medication and now two people are having the stroke. On 100 faces, it doesn’t look like an awful lot, but you could say, ‘This is a 50% reduction of your risk,‘ or something like that.” PPN 07, GP.