Patient Perspectives of the Barriers and Facilitators to Participating in Appointments by Choice: A Qualitative Study of a Patient-Initiated Follow-Up Implementation Pilot Using the Consolidated Framework for Implementation Research

Abstract

We explored the barriers and facilitators of participating in the patient-initiated follow-up strategy Appointments By Choice (ABC) from the perspectives of participating patients with rheumatoid arthritis (RA). Patients enrolled in the ABC pilot were invited via email to participate in semi-structured qualitative interviews. Patients were selected from 2 different time points: mid-study (6 months) and end-of-study (12 months), post-enrollment. Demographic information was collected at study enrollment through an online survey hosted on Qualtrics. Interviews were conducted using Zoom Videoconferencing and were 1 hour in length. Interview transcripts were independently analyzed thematically and in duplicate using the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators to ABC participation.[1] Coders met regularly to address additional themes as they emerged from the transcripts, to discuss and modify codes, and reconcile differences. Interviews ceased once saturation was met. Ten CFIR codes representing key domains (Implementation process, individual, inner setting, innovation, and innovation outcomes) were applied deductively, and 5 additional codes were introduced inductively to capture emergent themes. Ten participants (5 mid-study, 5 end-of-study) were interviewed. The median age was 61 years (IQR = 13.75), and participants had lived with RA for a median of 11.5 years (IQR = 13). Four out of the 10 participants identified as White/European, and 6 out of the 10 participants identified as female. Reported barriers included uncertainty about whom to contact in the event of a flare or other rheumatologic concern, and challenges maintaining regular lab testing when in-person follow-up reminders were absent. Other barriers included missing the physician/patient relationship and the social visit aspect of the rheumatology clinic appointment. Facilitators included shared decision-making with rheumatologists, the availability of a flare action plan promoting self-management,[2] and the use of a self-reported flare questionnaire,[3] as ongoing “check-ins”. Patients valued the flexibility of the ABC model, particularly those living at a distance, and highlighted the responsiveness of the flare clinic and pharmacist support in medication adjustments. An unexpected facilitator was patients’ altruistic motivation, awareness of clinic workload and willingness to defer appointments to allow others with greater needs to be seen sooner. Select domains and patient quotes are displayed (Table 1). Table 1. Selected Barriers and Facilitators to ABC Participation (as Highlighted in Abstract), with Representative Quotes Mapped to CFIR Domains People with RA described ABC as a feasible and acceptable model of care, with minimal barriers identified. Addressing clarity around flare management and lab testing will improve patient experience and willingness to participate in this patient-initiated follow-up model. [1.] Damschroder LJ. Implement Sci 2022;17:75. [2.] Ester M. BMC Rheumatol 2025;9:31. [3.] Bartlett SJ. J Rheumatol 2017;44:1536-43. Supported by a CIORA grant