From October to November 2019, we interviewed a total of nine participants prior to their switch from biologics to biosimilars, and in July 2020, we re-interviewed a total of six participants post-switch to biosimilars. When invited to participate in a second, follow-up interview, three remaining participants could not be contacted to schedule a follow-up interview. The average age of participants was 60.7 (range: 47–80) with 67% (n = 6) of respondents aged 65 years or less. The majority of the respondents were of European descent (89%; n = 8). Participants were based in two geographical health regions in BC. Additional participant characteristics are listed in Table 2.
Thematic analyses of the pre-switch interviews identified four major themes: (1) impact of switch on disease management; (2) baseline knowledge of the policy change; (3) perceived enablers to the switch; and (4) perceived barriers to the switch. These major themes, sub-categories, thematic descriptions, and corresponding sample quotations are listed in Table 3.
Many participants shared their anxiety surrounding the impact of the switch on disease management (Theme 1A) and their disagreement with the policy change expressing that “when you start switching drugs, you do not know the side effects or what’s going to happen” (P1-9). Participants spoke about the expected impact the policy change would have on their health-related quality of life, sharing previous challenging experiences when starting their biologics and their fear of these challenges re-emerging when switching over to the biosimilar. For the most part, participants had good baseline knowledge of the policy change (Theme 2A) and understood the differences and similarities between biologics and biosimilars. Generally, participants sought information and gained knowledge about the policy change through self-research, or from their healthcare providers such as their rheumatologist or pharmacist. Prior to their switch, participants understood the lower cost to the Government of BC associated with biosimilars, and the presence of healthcare and family support systems as well as their overall positivity towards the change acted as perceived enablers to the switch (Theme 3A). Overall, participants felt that they had the necessary information and resources regarding their health and medication management. Conversely, participants also shared perceived barriers to the switch (Theme 4A), notably, concerns over the potential differences in efficacy and safety profiles of biosimilars compared to biologic drugs. Many participants shared feelings of apprehension and displeasure towards the change. Cumulatively, these concerns and attitudes led participants to express frustration over this decision and a desire for more information and justification over the change.
Thematic map of major themes from participants pre-switch
Relationships between and within themes drawn from interviews pre-switch are depicted in Fig. 1. Baseline knowledge of the policy change (Theme 2A) informed both participants’ perceived enablers (Theme 3A) and barriers (Theme 4A) to the switch. Perceived enablers (Theme 3A), including financial motives and participant support systems, both contributed to participants sharing a positive outlook on the policy change. These drivers of change reinforced participants’ acceptance of the policy change. Conversely, perceived barriers (Theme 4A), including cost concerns and the biosimilars’ efficacy profiles, informed participants’ negative outlook on the switch. These factors contributed to participants’ expressed resistance towards the policy change. Both perceived enablers and barriers of the switch are encompassed by the overarching theme of impact of switch on disease management (Theme 1A).
The resultant themes from the post-switch interviews include: (1) preconceived ideas of switch; (2) experienced enablers of switch; (3) experienced barriers of switch; (4) support systems; and (5) effect of COVID-19 pandemic on switch. These themes, sub-categories, and corresponding example quotations are listed in Table 4.
During these interviews, participants were asked to reflect back on their baseline opinions and attitudes prior to the switch (Theme 1B), where they shared negative expectations, apprehension, and concerns surrounding disease control. During the switch, participants shared that their experienced enablers (Theme 2B) included their informed acceptance of the policy change, successful management of their medical condition throughout the changeover, as well as the limited adverse effects experienced. Cumulatively, these factors made for an overall positive experience for the majority of the participants. Participants also shared experienced barriers of the switch (Theme 3B) including some participants who experienced adverse effects (e.g., discomfort or pain at injection site) which were potentially attributed to the change in needle type from the biologics. Collectively, these negative experiences led some participants to express the desire to revert to their originator drug. Participants also shared the presence of their support systems (Theme 4B) made up from family, friends, and their healthcare providers. One participant shared that they “really [trusted] and [appreciated] the informed atmosphere” from which their rheumatologist was operating.
The timing of the switch coincided with the onset of the global COVID-19 pandemic, and participants described impacts on their mental health, namely, an increase in feelings of anxiety. There were also changes, secondary to the pandemic, in the way participants received healthcare and the delivery mechanisms of this care. Whilst participants experienced difficulty physically seeing rheumatologists and making appointments, they reported an increase in the use of telehealth.
Thematic map of major themes from participants post-switch
Relationships between and within themes drawn from interviews post-switch are depicted in Fig. 2. Participants’ baseline opinion on the switch (Theme 1B) informs both enablers (Theme 2B) and barriers (Theme 3B) experienced by participants during the policy change. Participants’ informed decisions regarding the switch may be linked with their ability to manage their disease, their experiences of efficacy from the biosimilar, and the minimal adverse effects experienced. Conversely, barriers to the policy change, including an experience of adverse effects, changes to the drug packaging and/or administration, cost concerns, and a loss of disease control reinforced participants’ desire to revert to their originator drug. Both experienced enablers (Theme 2B) and barriers (Theme 3B) are influenced by participants’ support systems (Theme 4B). Specifically, the presence of support from healthcare providers or family members contributing to the enablers, while lack of support contributing to barriers of the switch. The effect of the COVID-19 pandemic on the switch (Theme 5B) encompasses the participants overall experience, affecting participants’ enablers (Theme 2B), barriers (Theme 3B), and support systems (Theme 4B).