Use of Low-Literacy Decision Aid to Enhance Knowledge and Reduce Decisional Conflict Among a Diverse Population of Adults With Rheumatoid Arthritis: Results of a Pilot Study

Development and evaluation of shared decision-making tools in rheumatology: A scoping review

INTRODUCTION

Shared decision-making (SDM) tools are facilitators of decision-making through a collaborative process between patients/caregivers and clinicians. These tools help clinicians understand patient's perspectives and help patients in making informed decisions based on their preferences. Despite their usefulness for both patients and clinicians, SDM tools are not widely implemented in everyday practice. One barrier is the lack of clarity on the development and evaluation processes of these tools. Such processes have not been previously described in the field of rheumatology.

OBJECTIVE

To describe the development and evaluation processes of shared decision-making (SDM) tools used in rheumatology.

METHODS

Bibliographic databases (e.g., EMBASE and CINAHL) were searched for relevant articles. Guidelines for the PRISMA extension for scoping reviews were followed. Studies included were: addressing SDM among adults in rheumatology, focusing on development and/or evaluation of SDM tool, full texts, empirical research, and in the English language.

RESULTS

Of the 2030 records screened, forty-six reports addressing 36 SDM tools were included. Development basis and evaluation measures varied across the studies. The most commonly reported development basis was the International Patient Decision Aids Standards (IPDAS) criteria (19/36, 53 %). Other developmental foundations reported were: The Ottawa Decision Support Framework (ODSF) (6/36, 16 %), Informed Medical Decision Foundation elements (3/36, 8 %), edutainment principles (2/36, 5.5 %), and others (e.g. DISCERN and MARKOV Model) (9/31,29 %). The most commonly used evaluation measures were the Decisional Conflict Scale (18/46, 39 %), acceptability and knowledge (7/46, 15 %), and the preparation for decision-making scale (5/46,11 %).

CONCLUSION

For better quality and wider implementation of such tools, there is a need for detailed, transparent, systematic, and consistent reporting of development methods and evaluation measures. Using established checklists for reporting development and evaluation is encouraged.

OMERACT Core outcome measurement set for shared decision making in rheumatic and musculoskeletal conditions: a scoping review to identify candidate instruments

OBJECTIVES

Shared decision making (SDM) is a central tenet in rheumatic and musculoskeletal care. The lack of standardization regarding SDM instruments and outcomes in clinical trials threatens the comparative effectiveness of interventions. The Outcome Measures in Rheumatology (OMERACT) SDM Working Group is developing a Core Outcome Set for trials of SDM interventions in rheumatology and musculoskeletal health. The working group reached consensus on a Core Outcome Domain Set in 2020. The next step is to develop a Core Outcome Measurement Set through the OMERACT Filter 2.2.

METHODS

We conducted a scoping review (PRISMA-ScR) to identify candidate instruments for the OMERACT Filter 2.2 We systematically reviewed five databases (Ovid MEDLINE®, Embase, Cochrane Library, CINAHL and Web of Science). An information specialist designed search strategies to identify all measurement instruments used in SDM studies in adults or children living with rheumatic or musculoskeletal diseases or their important others. Paired reviewers independently screened titles, abstracts, and full text articles. We extracted characteristics of all candidate instruments (e.g., measured construct, measurement properties). We classified candidate instruments and summarized evidence gaps with an adapted version of the Summary of Measurement Properties (SOMP) table.

RESULTS

We found 14,464 citations, read 239 full text articles, and included 99 eligible studies. We identified 220 potential candidate instruments. The five most used measurement instruments were the Decisional Conflict Scale (traditional and low literacy versions) (n=38), the Hip/Knee-Decision Quality Instrument (n=20), the Decision Regret Scale (n=9), the Preparation for Decision Making Scale (n=8), and the CollaboRATE (n=8). Only 44 candidate instruments (20%) had any measurement properties reported by the included studies. Of these instruments, only 57% matched with at least one of the 7-criteria adapted SOMP table.

CONCLUSION

We identified 220 candidate instruments used in the SDM literature amongst people with rheumatic and musculoskeletal diseases. Our classification of instruments showed evidence gaps and inconsistent reporting of measurement properties. The next steps for the OMERACT SDM Working Group are to match candidate instruments with Core Domains, assess feasibility and review validation studies of measurement instruments in rheumatic diseases or other conditions. Development and validation of new instruments may be required for some Core Domains.

The impact of health literacy: associations with disease activity and medication prescription in patients with rheumatoid arthritis

OBJECTIVE

The aim of this study was to explore the longitudinal associations between health literacy profiles and disease activity and medication prescription in patients with RA.

METHODS

Patients with RA who previously completed the Health Literacy Questionnaire (HLQ) and were assigned 1 of 10 distinct health literacy profiles based on cluster analysis were further aggregated into three groups: 'several health literacy limitations', 'some health literacy limitations' and 'good health literacy'. Linear mixed modelling (LMM) was used to analyse the association between health literacy groups and disease activity over the course of 1 year. Chi-squared tests and logistic regression analyses were used to compare medication prescriptions between the groups.

RESULTS

A total of 108 patients with RA were included. LMM showed a significant effect of health literacy group on disease activity over time (P = 0.010). Patients with 'good health literacy' had significantly lower disease activity over time [28-joint DAS with ESR (DAS28-ESR) = 2.4] than patients with 'several health literacy limitations' (DAS28-ESR = 3.1), independent of age, gender and education level. Patients with 'good health literacy' were most often prescribed a biologic DMARD (50%), whereas patients with 'some health literacy limitations' more commonly received a conventional synthetic DMARD only [72.7%; odds ratio (OR) 4.24], and patients with 'several health literacy limitations' were more often prescribed prednisolone (52.4%; OR 3.56).

CONCLUSION

Significant differences in longitudinal disease activity and medication prescription were observed between groups with different health literacy levels. These results stress the importance of insights into the role of health literacy in treatment and outcomes in patients with RA.

Understanding Heterogeneity in Patients' Conceptualisation of Treatment for Rheumatoid Arthritis: A Cluster Analysis

OBJECTIVE

Uptake of treat-to-target (TTT) strategies for rheumatoid arthritis (RA) management is low. Our objective was to understand the heterogeneity in patients' conceptualisation of RA treatment to inform interventions improving TTT uptake.

DESIGN

Eligible participants recruited from an online research registry rated 56 items (on 5-point scales) reflecting concepts raised from patient interviews. Using items describing adhering to physician recommendations to create a binary criterion variable for medication adherence, we conducted a principal components analysis on the remaining items using Varimax rotation, describing how these factors predict adherence over and above demographic characteristics. We further use optimal sets in regression to identify the individual concepts that are most predictive of medication adherence.

RESULTS

We found significant heterogeneity in patients' conceptualisation of RA treatment among 621 persons with RA. A scree plot revealed a four-factor solution explained 38.4% of the variance. The four factors expected to facilitate TTT uptake were (% variance explained): (1) Access to high quality care and support (11.3%); (2) low decisional conflict related to changing disease-modifying antirheumatic drugs (DMARDs) (10.1%); (3) endorsement of a favourable DMARD risk/benefit ratio (9.9%); and (4) confidence that testing reflects disease activity (7.2%). These factors account for 13.8% of the variance in full medication adherence, fully explaining the only significant demographic predictor, age of the patient. The individual items most predictive of poor adherence centre on the lack of effective patient-physician communication, specifically insufficient access to information from rheumatologists, along with the need to seek information elsewhere.

CONCLUSION

Patients' conceptualisation of RA treatment varies; however, almost all patients have difficulty escalating DMARDs, even with access to quality information and an understanding of the benefits of TTT. Tailored interventions are needed to address patient hesitancy to escalate DMARDs.

The role of low health literacy in shared treatment decision-making in patients with kidney failure

The classic paternalist medicine in nephrology has been modified to a shared decision-making model that clearly offers a benefit in patients with kidney disease. One of the cornerstones of shared treatment decision in patients with kidney failure is the understanding of kidney disease. As kidney disease is silent until advanced stages and is also an entity with a complex pathophysiology with little knowledge in the general population, its presence and understanding are difficult for most people. Health literacy (HL) plays a crucial role in the care of patients with kidney disease and the shared treatment decision. Limited HL has been associated with inefficient use of health services, non-compliance of medications, worse quality of life and increased mortality. In this review, we will address the importance of low HL in nephrology in terms of diagnosis, measurement, its effect on shared decision-making and how to increase it in people with kidney disease.

Automated Strategy Feedback Can Improve the Readability of Physicians' Electronic Communications to Simulated Patients

Modern communication between health care professionals and patients increasingly relies upon secure messages (SMs) exchanged through an electronic patient portal. Despite the convenience of secure messaging, challenges include gaps between physician and patient expertise along with the asynchronous nature of such communication. Importantly, less readable SMs from physicians (e.g., too complicated) may result in patient confusion, non-adherence, and ultimately poorer health outcomes. The current simulation trial synthesizes work on patient-physician electronic communication, message readability assessments, and feedback to explore the potential for automated strategy feedback to improve the readability of physicians' SMs to patients. Within a simulated secure messaging portal featuring multiple simulated patient scenarios, computational algorithms assessed the complexity of SMs written by 67 participating physicians to patients. The messaging portal provided strategy feedback for how physician responses might be improved (e.g., adding details and information to reduce complexity). Analyses of changes in SM complexity revealed that automated strategy feedback indeed helped physicians compose and refine more readable messages. Although the effects for any individual SM were slight, the cumulative effects within and across patient scenarios showed trends of decreasing complexity. Physicians appeared to learn how to craft more readable SMs via interactions with the feedback system. Implications for secure messaging systems and physician training are discussed, along with considerations for further investigation of broader physician populations and effects on patient experience.

Are shared decision making studies well enough described to be replicated? Secondary analysis of a Cochrane systematic review

Background

Interventions to change health professionals’ behaviour are often difficult to replicate. Incomplete reporting is a key reason and a source of waste in health research. We aimed to assess the reporting of shared decision making (SDM) interventions.

Methods

We extracted data from a 2017 Cochrane systematic review whose aim was to determine the effectiveness of interventions to increase the use of SDM by healthcare professionals. In a secondary analysis, we used the 12 items of the Template for Intervention Description and Replication (TIDieR) checklist to analyze quantitative data. We used a conceptual framework for implementation fidelity to analyze qualitative data, which added details to various TIDieR items (e.g. under “what materials?” we also reported on ease of access to materials). We used SAS 9.4 for all analyses.

Results

Of the 87 studies included in the 2017 Cochrane review, 83 were randomized trials, three were non-randomized trials, and one was a controlled before-and-after study. Items most completely reported were: “brief name” (87/87, 100%), “why” (rationale) (86/87, 99%), and “what” (procedures) (81/87, 93%). The least completely reported items (under 50%) were “materials” (29/87, 33%), “who” (23/87, 26%), and “when and how much” (18/87, 21%), as well as the conditional items: “tailoring” (8/87, 9%), “modifications” (3/87, 4%), and “how well (actual)” (i.e. delivered as planned?) (3/87, 3%). Interventions targeting patients were better reported than those targeting health professionals or both patients and health professionals, e.g. 84% of patient-targeted intervention studies reported “How”, (delivery modes), vs. 67% for those targeting health professionals and 32% for those targeting both. We also reported qualitative analyses for most items. Overall reporting of items for all interventions was 41.5%.

Conclusions

Reporting on all groups or components of SDM interventions was incomplete in most SDM studies published up to 2017. Our results provide guidance for authors on what elements need better reporting to improve the replicability of their SDM interventions.

Randomized Controlled Trial of Patient Education Tools for Patients With Rheumatoid Arthritis

OBJECTIVE

The present study was undertaken to evaluate the efficacy of 2 educational tools for patients with rheumatoid arthritis (RA) by comparing a newly developed video tool, including storylines and testimonials, combined with a written booklet to the same written booklet alone.

METHODS

We conducted a randomized controlled trial. Our primary outcome was disease knowledge. Secondary outcomes were decisional conflict, self-efficacy, effective health care management, and satisfaction. Outcomes were measured before and after reviewing the materials, and 3 and 6 months later. Linear mixed-effects models were performed to evaluate changes over time.

RESULTS

In total, 221 participants received an educational video and booklet (n = 111) or a booklet alone (n = 110). The mean age was 50.8 years, mean disease duration was 4.8 years, 85% were female, and 24% had limited health literacy levels. Within groups, most outcomes improved between baseline and follow-up, but there were no statistically significant differences across groups. Patients receiving the video and booklet were more likely than those receiving the booklet alone to rate the presentation as excellent for providing information about the impact of RA, medication options, evidence about medications, benefits of medication, and self-care options. Factors significantly associated with greater improvements in knowledge and decisional conflict from baseline to 6 months included limited health literacy, lower educational level, and shorter disease duration.

CONCLUSION

Regardless of the delivery method, outcomes were improved up to 6 months after educational materials were delivered. Our findings support the implementation of self-administered educational materials in clinical settings, as they can result in sustained improvements in disease knowledge and decisional conflict.

Adaptation of a Shared Decision-Making Tool for Early Rheumatoid Arthritis Treatment Decisions with Indigenous Patients

Background

Patient decision aids (PtDAs) enable shared decision-making between patients and healthcare providers. Adaptations to PtDAs for use with populations facing inequities in healthcare can improve the relevancy of information presented, incorporate appropriate cultural context, and address health literacy concerns. Our objective was to adapt the Early RA (rheumatoid arthritis) PtDA for use with Canadian Indigenous patients.

Methods

The Early RA PtDA was modified through an iterative process using data obtained from semi-structured interviews of two sequential cohorts of Indigenous patients with RA. Interview data were analyzed using thematic analysis.

Results

Seven participants provided initial feedback on the existing PtDA. The modifications they suggested were made and shared with another nine participants to confirm acceptability and provide further feedback. The first cohort suggested revisions to clarify medical and cost coverage information, include Indigenous traditional healing practice options, simplify text, and include Indigenous images and colors aligned with Canadian Indigenous community representation. Additional revisions were suggested by the second cohort to increase the legibility of the text, insert more Indigenous imagery, address formulary coverage for non-status First Nations patients, and include information about lifestyle factors in managing RA.

Conclusion

Incorporating Indigenous-specific adaptations in the design of PtDAs may increase use and relevancy to support engagement in treatment decisions, thereby supporting health-equity oriented health service interventions. Indigenous patient-specific evidence and translation of key words into the end-users’ Indigenous languages should be included for implementation of the PtDA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-021-00546-8.

Development of an Implementation Strategy for Patient Decision Aids in Rheumatoid Arthritis Through Application of the Behavior Change Wheel

OBJECTIVE

Decision aids are being developed to support guideline-based rheumatology care in Canada. The study objective was to identify barriers to decision aid use in rheumatoid arthritis (RA) within a behavior change model to inform an implementation strategy.

METHODS

Perspectives from Canadian health care providers (HCPs) and patients living with RA were obtained on an early RA decision aid and on perceived facilitators and barriers to decision aid implementation. Data were collected through semistructured interviews, transcribed, and then analyzed by inductive thematic analysis. The lessons learned were then mapped to the behavior change wheel COM-B system (C = capability, O = opportunity, and M = motivation interact to influence B = behavior) to inform key elements of a national implementation strategy.

RESULTS

Fifteen HCPs and fifteen patients participated. The analysis resulted in five lessons learned: 1) paternalistic decision-making is a dominant practice in early RA, 2) patients need emotional support and access to educational tools to facilitate participation in shared decision-making (SDM), 3) there are many logistical barriers to decision aid implementation in current care models, 4) flexibility is necessary for successful implementation, and 5) HCPs have limited interest in further training opportunities about decision aids. Implementation recommendations included the following: 1) making the decision aids directly available to patients (O) and providing SDM education (C/M), 2) creating an SDM rheumatology curriculum (C/O/M), 3) using "decision coaches" or patient partners as peer support (C/O/M), 4) linking decision aids to "living" rheumatology guidelines (M), and 5) designing trials of patient decision aid/SDM interventions to evaluate patient-important outcomes (O/M).

CONCLUSION

A multifaceted strategy is suggested to improve uptake of decision aids.

Refugee and Migrant Health Literacy Interventions in High-Income Countries: A Systematic Review

Health literacy is a key determinant of health in refugee and migrant populations living in in high-income countries (HICs). We conducted a systematic review of randomized-controlled trials (RCTs) to characterize the scope, methodology, and outcomes of research on interventions aimed at improving health literacy among these vulnerable populations. We searched EMBASE, MEDLINE, PsycINFO, CINAHL, and Web of Science databases to identify RCTs of health literacy intervenions in our target population published between 1997 and 2018. The search yielded 23 RCTs (n = 5625 participants). Study demographics, health literacy topics, interventions, and outcome measures were heterogeneous but demonstrated overall positive results. Only two studies used a common health literacy measure. Few RCTs have been conducted to investigate interventions for improving the health literacy of refugees and migrants in HICs. The heterogeniety of health literacy outcome measures used impeded a robust comparison of intervention efficacy.

Association between Health Literacy, Patient Activation, and Functional Capacity in Individuals with Rheumatoid Arthritis

Objectives:

To describe health literacy, patient activation, and functional capacity in individuals with rheumatoid arthritis and to evaluate the associations of health literacy and activation level with functional capacity.

Methods:

A cross-sectional study involving patients with rheumatoid arthritis was carried out at the rheumatology service of a teaching hospital. Health literacy was assessed by applying the short version of the Test of Functional Health Literacy in Adults. Patient Activation was measured by using the summarized version of the Patient Activation Measure. The Health Assessment Questionnaire was applied to evaluate functional capacity. Sociodemographic and clinical variables were also collected to carried out univariate and multivariate analyses by using logistic regression.

Results:

The sample was composed of 179 patients, of whom 90.5% (n = 162) were women. The participants’ average age was 58.3 ± 11.4 years. The prevalence of patients with inadequate or marginal health literacy was high (67%). In contrast, 74% of the patients showed high activation levels. The average score on the Health Assessment Questionnaire was 1.08 ± 0.7. Adequate health literacy was negatively associated with higher Health Assessment Questionnaire scores (OR = 0.42; 95% CI 0.20 – 0.86; p = 0.018), and high activation levels were negatively associated with moderate to severe functional limitation (level 3/moderate activation level – OR = 0.24; 95% CI 0.10 – 0.56; p = 0.001; level 4/high activation level – OR = 0.22; 95% CI 0.08 – 0.50; p = 0.000).

Conclusion:

Health professionals must be aware of health literacy and activation levels of patients with rheumatoid arthritis, given that interventions to improve them represent an opportunity to increase functional capacity.

Decision Needs and Preferred Strategies for Shared Decision Making in Rheumatoid Arthritis: Perspectives of Canadian Urban Indigenous Women

OBJECTIVE

Decision making for treatment of rheumatoid arthritis (RA) is complex, with multiple beneficial medication options available, but with the potential for treatment-related adverse effects and significant economic considerations. Indigenous patients make treatment decisions informed by an interplay of clinical, family, and societal factors. Shared decision-making (SDM) may represent an approach to support treatment decisions in a culturally congruent manner. The study identified aspects of arthritis care that Indigenous participants found relevant for SDM and explored preferences for SDM strategies.

METHODS

A purposive sampling from rheumatology clinics that provide services to Indigenous patients in a Canadian urban centre was used to recruit participants for interviews. Seven participants were recruited to reach content saturation. Interview content was coded by two individuals, including an Indigenous patient with RA, and the data were analyzed via thematic analysis.

RESULTS

Participants were all women aged 37-61 years living with RA. Participants supported that SDM would be beneficial, primarily to support decisions around treatment plans and medication changes. SDM approaches would need to reflect Indigenous-specific content areas, such as benefits and risks of therapy informed by data from Indigenous patient populations and inclusion of traditional modes of healing. All participants were interested in having a decision coach and preferred that decision aids be in both paper and electronic formats for accessibility.

CONCLUSIONS

This study advances knowledge in the priority areas and specific content needed in the SDM process, and the preferences of SDM strategies relevant and appropriate for urban Indigenous women living with RA in Canada.

Impact of Limited Health Literacy on Patient-Reported Outcomes in Systemic Lupus Erythematosus

OBJECTIVE

Health disparities in patient-reported outcomes by income and education are well documented; however, the impact of health literacy on patient-reported outcomes has received less attention. We examined independent effects of income, education, and health literacy on patient-reported outcomes in systemic lupus erythematosus (SLE).

METHODS

Data from the California Lupus Epidemiology Study (n = 323 participants) were used. Health literacy was assessed with a validated 3-item measure (ability to understand written information, reliance on others to understand written information, confidence in completing written forms). Patient-reported outcomes were administered by interview in English, Spanish, Cantonese, or Mandarin. Generic and disease-specific patient-reported outcomes were examined using the following: 10 Patient-Reported Outcomes Measurement Information System (PROMIS) short forms; the 8 Short Form 36 (SF-36) health survey subscales; and 3 patient-reported SLE disease activity and damage measures. We conducted 2 sets of multivariable analyses: the first examined education, income, or health literacy individually; the second included all 3 simultaneously. All multivariable models included age, sex, race/ethnicity, language, disease duration, and physician-assessed disease activity and damage.

RESULTS

More than one-third of participants (38%) had limited health literacy (LHL), including >25% with greater than high school education. In multivariable analyses simultaneously considering education, income, and health literacy, LHL was associated with significantly worse scores on all patient-reported outcomes except disease damage. In contrast, disparities by income were seen in only 3 PROMIS scales, 3 SF-36 subscales, and 1 disease activity measure. No disparities by education level were noted.

CONCLUSION

We found significantly worse patient-reported outcome scores among individuals with LHL, even after controlling for disease activity and damage. Whether disparities are due to actual differences in health or measurement issues requires further study.

What Are the Preferences of Patients With Rheumatoid Arthritis for Treatment Modification? A Scoping Review

OBJECTIVES

Optimal care of rheumatoid arthritis (RA) patients entails regular assessment of disease activity and appropriate adjustment of disease-modifying antirheumatic drugs (DMARDs) until a predefined treatment goal is achieved. This raises questions about the approach to treatment decision making among RA patients and their preference for associated treatment changes. We aimed to systematically identify and synthesize the available evidence of RA patients' preferences regarding DMARD modification with an emphasis on escalating, tapering, stopping, or switching of DMARDs.

METHODS

A scoping review was undertaken to gauge the breadth of evidence from the range of studies relating to RA patients' preferences for DMARD modification. Pertinent databases were searched for relevant studies published between 1988 and 2019. Conventional content analysis was applied to generate themes about how patients perceive changes to their RA treatment.

RESULTS

Of the 1730 distinct articles identified, 32 were included for review. Eight studies investigated RA patients' perceptions of switching to other DMARDs, 18 studies reported RA patients' preferences for escalating treatment, and six studies explored the possibility of tapering or stopping of biologic DMARDs. Four overarching themes relating to RA patients' preferences for treatment modification were identified: (i) patient satisfaction, (ii) patients' beliefs, (iii) information needs, and (iv) patient-clinician relationships.

CONCLUSION

Uptake of treatment changes in clinical practice can be improved by understanding how RA patients approach the decision to modify their treatment and how this relates to their satisfaction, beliefs, information needs, and relationships with clinicians. Future work is needed to systematically determine the significance of these factors in RA patients' decision-making processes.

Understanding the Role and Challenges of Patient Preferences in Disparities in Rheumatologic Disease Care

Evidence suggests patient preferences, including values and perspectives, have affected clinical outcomes, such as compliance, patient well-being, and satisfaction with care. A literature review was conducted with the purpose of exploring the tools used to elicit patients' treatment preferences and their roles in clinical outcomes. This review revealed racial differences in treatment preferences among patients with rheumatic and musculoskeletal diseases. The use of decision aids is a proactive intervention with potential for reducing race disparities and improving clinical outcomes. The utilization of patient preferences and values can improve outcomes by complementing the shared decision-making approach between patients and rheumatologists.

Sex and gender considerations in implementation interventions to promote shared decision making: A secondary analysis of a Cochrane systematic review

Background

Shared decision making (SDM) in healthcare is an approach in which health professionals support patients in making decisions based on best evidence and their values and preferences. Considering sex and gender in SDM research is necessary to produce precisely-targeted interventions, improve evidence quality and redress health inequities. A first step is correct use of terms. We therefore assessed sex and gender terminology in SDM intervention studies.

Materials and methods

We performed a secondary analysis of a Cochrane review of SDM interventions. We extracted study characteristics and their use of sex, gender or related terms (mention; number of categories). We assessed correct use of sex and gender terms using three criteria: “non-binary use”, “use of appropriate categories” and “non-interchangeable use of sex and gender”. We computed the proportion of studies that met all, any or no criteria, and explored associations between criteria met and study characteristics.

Results

Of 87 included studies, 58 (66.7%) mentioned sex and/or gender. The most mentioned related terms were “female” (60.9%) and “male” (59.8%). Of the 58 studies, authors used sex and gender as binary variables respectively in 36 (62%) and in 34 (58.6%) studies. No study met the criterion “non-binary use”. Authors used appropriate categories to describe sex and gender respectively in 28 (48.3%) and in 8 (13.8%) studies. Of the 83 (95.4%) studies in which sex and/or gender, and/or related terms were mentioned, authors used sex and gender non-interchangeably in 16 (19.3%). No study met all three criteria. Criteria met did not vary according to study characteristics (p>.05).

Conclusions

In SDM implementation studies, sex and gender terms and concepts are in a state of confusion. Our results suggest the urgency of adopting a standardized use of sex and gender terms and concepts before these considerations can be properly integrated into implementation research.

Predicting the readability of physicians' secure messages to improve health communication using novel linguistic features: Findings from the ECLIPPSE study

Background

Low literacy skills impact important aspects of communication, including health-related information exchanges. Unsuccessful communication on the part of physician or patient contributes to lower quality of care, is associated with poorer chronic disease control, jeopardizes patient safety and can lead to unfavorable healthcare utilization patterns. To date, very little research has focused on digital communication between physicians and patients, such as secure messages sent via electronic patient portals.

Method

The purpose of the current study is to develop an automated readability formula to better understand what elements of physicians' digital messages make them more or less difficult to understand. The formula is developed using advanced natural language processing (NLP) to predict human ratings of physician text difficulty.

Results

The results indicate that NLP indices that capture a diverse set of linguistic features predict the difficulty of physician messages better than classic readability tools such as Flesch Kincaid Grade Level. Our results also provide information about the textual features that best explain text readability.

Conclusion

Implications for how the readability formula could provide feedback to physicians to improve digital health communication by promoting linguistic concordance between physician and patient are discussed.

Enhancing Patient Understanding of Medication Risks and Benefits

Objective

To evaluate the effectiveness of 2 interventions, including the DrugFactsBox format for presenting written medication information and the SMART (Strategic Memory Advanced Reasoning Training) program designed to enhance gist (i.e., “bottom‐line” meaning) reasoning ability.

Methods

We used a 2 × 2 factorial research design. A total of 286 patients with rheumatoid arthritis were randomly assigned to 1 of 4 groups, including DrugFactsBox with the SMART program, DrugFactsBox without the SMART program, other consumer medication information (CMI) with the SMART program, and other CMI without the SMART program. Data were collected via telephone interviews and online questionnaires at 4 time points, including baseline and 6‐week, 3‐month, and 6‐month time points following baseline. The primary outcome variable was informed decision‐making, which was defined as making a value‐consistent decision concerning use of disease‐modifying antirheumatic drugs based on adequate knowledge.

Results

We found no main effects for the 2 interventions, either alone or in combination. However, there was a significant interaction between assignment to the SMART/no SMART groups and informed decision‐making at baseline. Among participants in the SMART groups who did not meet the criteria for informed decision‐making at baseline, 42.5% met the criteria at the 6‐month follow‐up, compared to 23.6% of participants in the no SMART groups (mean difference 18.9 [95% confidence interval 5.6, 32.2]; P = 0.007). This difference was driven by increased knowledge in the SMART groups. Among participants who met the criteria for informed decision‐making at baseline, the difference between the SMART and no SMART groups was not statistically significant.

Conclusion

Participation in a theory‐driven program to enhance gist reasoning may have a beneficial effect on informed decision‐making among patients with inadequate knowledge concerning therapeutic options.

New galaxies in the universe of shared decision-making and rheumatoid arthritis

PURPOSE OF REVIEW

Implementing shared decision-making (SDM) is a top international priority to improve care for persons living with rheumatoid arthritis. Using SDM tools, such as decision aids improve patients' knowledge and support communication with their clinicians on treatment benefits and risks. Despite calls for SDM in treat-to-target, studies demonstrating effective SDM strategies in rheumatology clinical practice are scarce. Our objective was to identify recent and relevant literature on SDM in rheumatoid arthritis.

RECENT FINDINGS

We found a burgeoning literature on SDM in rheumatoid arthritis that tackles issues of implementation. Studies have evaluated the SDM process within clinical consultations and found that uptake is suboptimal. Trials of newly developed patient decision aids follow high methodological standards, but large-scale implementation is lacking. Innovative SDM strategies, such as shared goals and preference phenotypes may improve implementation of treat-to-target approach. Research and patient engagement are standardizing measures of SDM for clinical uses.

SUMMARY

Uptake of SDM in rheumatoid arthritis holds promise in wider clinicians' and patients' awareness, availability of decision aids, and broader treat-to-target implementation strategies, such as the learning collaborative. Focused attention is needed on facilitating SDM among diverse populations and those at risk of poorer outcomes and barriers to communication.

Parental role in decision-making for pediatric surgery: Perceptions of involvement in consultations for tonsillectomy

OBJECTIVE

Parental role in decision-making has implications for quality of care. We describe roles of parent participation in decision-making for tonsillectomy.

METHODS

Parents reported preferred role in decision-making before consultations for tonsillectomy and the role they experienced after their consult. Parents completed questionnaires, including items evaluating clinician/parent communication. Clinicians rated perception of parents' preferred role in decision-making. Congruence between parent and clinician responses was evaluated via kappa analysis. Logistic regression identified associations between decision-making roles and socioemotional and communication factors.

RESULTS

Consults between 63 parents and 8 otolaryngologists were analyzed.There was inadequate agreement between clinician and parent ratings of preferred roles (37%, p = 0.6, 95% CI [-0.09, 0.001]). Parents perceived greater involvement when clinicians discussed reasons to have (OR = 4.3, p = 0.03) or not have (OR = 4.1, p = 0.005) surgery. Parents perceived less involvement when clinicians used jargon (OR = 0.1, p = 0.03), and when parents trusted clinicians (OR = 0.4, p = 0.049), or experienced greater decisional conflict (OR = 0.9, p = 0.03).

CONCLUSIONS

Parents and clinicians perceived parental preference for decision-making involvement differently during consultations for tonsillectomy. Clinician information-sharing, jargon use, and parent trust in clinician predicted extent of perceived engagement.

PRACTICE IMPLICATIONS

Findings may enhance understanding of strategies to effectively communicate and engage parents in shared decision-making for pediatric surgical care.

Patient Decision Aid (PDA) for Patients with Rheumatoid Arthritis Reduces Decisional Conflict and Improves Readiness for Treatment Decision Making

OBJECTIVES

The aim of this study was to develop and assess the effectiveness of a patient decision aid (PDA) to support treatment decision making in Spanish patients with moderate-to-severe rheumatoid arthritis (RA) who fail to achieve the therapeutic goal with the current disease-modifying antirheumatic treatment strategy.

METHODS

The PDA was developed in accordance with the International Patient Decision Aids Standards recommendations. A steering group led the project. Three literature reviews and two focus groups were performed to develop the PDA prototype. To check its comprehensibility, acceptability, and feasibility, alpha-testing was performed using the Decision Support Acceptability Scale (DSAS). Beta-testing was conducted to assess preliminary evidence of PDA efficacy using the Decisional Conflict Scale (DCS) before and after PDA use. Readiness was evaluated using the Preparation for Decision Making Scale (PDMS).

RESULTS

The PDA included (1) a brief description of RA, (2) treatment information, and (3) a values clarification section. Alpha-testing revealed that most patients considered that the information was presented in a good or excellent way and it could help clarify their values and facilitate treatment decision making. Most rheumatologists agreed that the PDA was easy to understand, to use, and allowed them to reach a shared decision. Beta-testing showed that PDA significantly reduced overall patients' decisional conflict [33.2 (DE: 21.4) vs 24.6 (23.5); p < 0.001] and prepared the patient for decision making [PDMS: 67.5 (21.0)].

CONCLUSIONS

We developed a PDA for Spanish patients with moderate-to-severe RA that reduces patients' decisional conflict and increases their readiness for decision making. The use of this PDA in routine clinical practice may improve the quality of the decision-making process and the quality of the choices made.

Universal Health Literacy Precautions Are Associated With a Significant Increase in Medication Adherence in Vulnerable Rheumatology Patients

OBJECTIVE

Our objective was to determine the impact of the Health Literacy Universal Precautions Toolkit, adapted for rheumatology, on medication adherence, patient satisfaction, and feasibility in all patients; its effect on the clinical disease activity index (CDAI) was studied in a rheumatoid arthritis (RA) subpopulation.

METHODS

Data collected during a 6-month prospective quality assurance intervention was compared with data from a prior 6-month period. Interventions included 1) encouraging questions, 2) teach-back communication, and 3) brown-bag medication review. Analysis was performed using linear regression or generalized estimating equation (GEE) regression.

RESULTS

During the intervention period, 46 physicians completed 1737 patient visits. Questions were encouraged, and teach-back communication was performed in more than 90% of visits. Brown-bag medication reviews were performed in 47% of visits overall and 69% of visits in a subgroup that received additional reminder calls. Visit duration and patient satisfaction were not significantly increased. Adherence for rheumatology-related medications that were prescribed both before and during the intervention increased by 22% (P ≤ 0.001; by GEE). Teach-back communication predicted a statistically significant improvement in medication adherence in this subpopulation (by linear regression). The mean CDAI did not improve; however, African American race and Hispanic ethnicity were associated with a decreased CDAI (by GEE).

CONCLUSION

Implementation of the Health Literacy Universal Precautions Toolkit, adapted for rheumatology, improved medication adherence in our safety-net clinic, with particularly strong effects seen with teach-back communication. In certain populations, use of the toolkit may also improve RA disease activity. This is the first study to document improved medication adherence with this intervention in a real-world setting.

Adherence and health literacy as related to outcome of patients treated for rheumatoid arthritis : Analyses of a large-scale observational study

BACKGROUND

Disabilities in daily living and quality of life are key endpoints for evaluating the treatment outcome for rheumatoid arthritis (RA). Factors possibly contributing to good outcome are adherence and health literacy.

METHODS

The survey included a representative nationwide sample of German rheumatologists and their patients with RA. The physician questionnaire included the disease activity score (DAS28) and medical prescriptions. The patient questionnaire included fatigue (EORTC QLQ-FA13), health assessment questionnaire (HAQ), quality of life (SF-12), health literacy (HELP), and patients' listings of their medications. Adherence was operationalized as follows: patient-reported (CQR5), behavioral (concordance between physicians' and patients' listings of medications), physician-assessed, and a combined measure of physician rating (1 = very adherent, 0 = less adherent) and the match between physicians' prescriptions and patients' accounts of their medications (1 = perfect match, 0 = no perfect match) that yielded three categories of adherence: high, medium, and low. Simple and multiple linear regressions (controlling for age, sex, smoking, drinking alcohol, and sport) were calculated using adherence and health literacy as predictor variables, and disease activity and patient-reported outcomes as dependent variables.

RESULTS

708 pairs of patient and physician questionnaires were analyzed. The mean patient age (73% women) was 60 years (SD = 12). Multiple regression analyses showed that high adherence was significantly associated with 5/7 outcome variables and health literacy with 7/7 outcome variables.

CONCLUSION

Adherence and health literacy had weak but consistent effects on most outcomes. Thus, enhancing adherence and understanding of medical information could improve outcome, which should be investigated in future interventional studies.

Preference Phenotypes in Support of Shared Decision-Making at Point-of-Care for Patients With Rheumatoid Arthritis: A Proof-of-Concept Study

OBJECTIVE

In this proof-of-concept study, we sought to evaluate whether a value clarification tool enabling patients to view a set of rheumatoid arthritis (RA) treatment preference phenotypes could be used to support shared decision-making at the point-of-care.

METHODS

We conducted a pretest/post test study. English-speaking patients with RA presenting to their scheduled outpatient visits were asked to participate. Visits for patients with active RA were transcribed. Shared decision-making components were measured using a quantitative coding scheme based on an established model of shared decision-making.

RESULTS

Forty-six visits were included in the pretest and 40 in the post test phases. Providers offered more disease-modifying antirheumatic drugs (DMARDs) (2 or more) in the post test visits (60%) compared to the pretest visits (47.8%). Overall, more patients vocalized their values and/or preferences in the post test visits compared to the pretest visits for treatment escalation decisions including a choice of 1 new DMARD (90.9% versus 56.3%), 2 or more new DMARDs (95.8% versus 86.4%), as well as prednisone (87.5% versus 66.7%). Providers were also more likely to base their recommendations on patients' values and/or preferences in the post test (100% of 6 visits) than the pretest (64.3% of 14 visits) phases during visits in which a recommendation was made. The mean ± SD length of the visit was 29.9 ± 11.6 minutes and 25.1 ± 10.7 minutes in the pretest and post test phases, respectively.

CONCLUSION

This study provides an early indication that a value clarification tool allowing patients to consider a set of preference phenotypes can support shared decision-making at the point-of-care without extending visit time.

Effect of patient education on medication adherence of patients with rheumatoid arthritis: a randomized controlled trial

PURPOSE

There is a general understanding that patient educational interventions for enhancing medication adherence are important. However, their success at improving adherence is debatable. This study aimed to assess the influence of different modes of patient education on medication adherence in patients with rheumatoid arthritis (RA).

MATERIALS AND METHODS

One hundred and twenty RA patients with non-adherence, defined as pill count ≥80% or medication-taking behavior questionnaire for Thai patient ≥23, were randomized by block randomization and assigned in a 1:1 allocation ratio to two study arms: multi-component intervention group or single intervention group. The multi-component intervention group received 30-minute directed counseling and a disease information pamphlet. The single intervention group received only a disease information pamphlet. The primary outcomes were an improvement in an adherence rate measured by pill count after 12 weeks. The Thai Clinical Trial Registry number is TCTR20171207003.

RESULTS

After 12 weeks, the pill count adherence rate increased significantly from baseline in both study groups. In the multi-component intervention group, adherence rate increased from 92.21±14.05 to 97.59±10.07 (P=0.002) and in the single intervention group, it increased from 88.60±19.66 to 92.42±14.27 (P=0.044). However, the mean difference between the multi-component intervention group and the single intervention group was not significant (5.38±12.90 vs 3.18±14.23, P=0.531). Clinical outcomes, including disease activity score 28, EuroQoL-5D, EuroQol visual analog scale, pain score, and physician global assessment were unchanged from baseline in both groups.

CONCLUSION

Patient education significantly improved adherence. However, there were no differences between single education intervention and multi-component education intervention in improving medication adherence. Provision of a disease information pamphlet with or without directed counseling can equally enhance medication adherence of patients with RA.

Factors Influencing the Uptake of Canadian Research Findings into the Care of Children with Arthritis: A Healthcare Provider Perspective

OBJECTIVE

To determine barriers and facilitators to the uptake of findings from the Research in Arthritis in Canadian Children emphasizing Outcomes (ReACCh-Out) study into clinical care by pediatric rheumatologists (PR) and allied health professionals (AHP) caring for children with juvenile idiopathic arthritis (JIA) in Canada.

METHODS

PR and AHP participated in this qualitative study through telephone interviews. Interview guides were developed using the Theoretical Domains Framework and focused on the use of information from the ReACCh-Out study in the practice of counseling patients and families. A directed content analysis approach was used for coding.

RESULTS

Nineteen interviews (8 PR and 11 AHP) were completed. All PR had knowledge of the ReACCh-Out study. Three major themes were identified: (1) both groups are motivated to use information from research in clinical care; (2) volume and emotional effect of information on families are barriers; and (3) specific timepoints in care trigger providing this information. AHP had less knowledge of the ReACCh-Out study, did not feel it was their primary role to provide this information, and have a desire for more opportunity to participate in academic forums related to research.

CONCLUSION

We have described a comprehensive overview of the barriers and facilitators perceived by healthcare providers in the translation of knowledge from JIA research into use in clinical practice. These findings provide a foundation for the development of knowledge translation strategies in the care of children with JIA and other rheumatic diseases.

Methods to improve medication adherence in patients with chronic inflammatory rheumatic diseases: a systematic literature review

Objective

Lack of adherence to treatment is frequent in chronic inflammatory rheumatic diseases and is associated with poorer outcomes. The objective of this study was to describe and evaluate interventions that have been proposed to enhance medication adherence in these conditions.

Methods

A systematic literature review was performed in Pubmed, Cochrane, Embase and clinicaltrials.gov databases completed by the rheumatology meeting (ACR, EULAR and SFR) abstracts from last 2 years. All studies in English or French evaluating an intervention to improve medication adherence in chronic inflammatory rheumatic diseases (rheumatoid arthritis (RA), spondyloarthritis (SpA), crystal related diseases, connective tissue diseases, vasculitis and Still's disease) were included. Interventions on adherence were collected and classified in five modalities (educational, behavioural, cognitive behavioural, multicomponent interventions or others).

Results

1325 abstracts were identified and 22 studies were finally included (18 studies in RA (72%), 4 studies in systemic lupus erythematosus (16%), 2 studies in SpA (8%) and 1 study in gout (4%)). On 13 randomised controlled trials (RCT) (1535 patients), only 5 were positive (774 patients). Educational interventions were the most represented and had the highest level of evidence: 8/13 RCT (62%, 1017 patients) and 4/8 were positive (50%). In these studies, each patient was individually informed or educated by different actors (physicians, pharmacists, nurses and so on). Supports and contents of these educational interventions were heterogenous.

Conclusion

Despite the importance of medication adherence in chronic inflammatory rheumatic disorders, evidence on interventions to improve medication adherence is scarce.

Interventions for increasing the use of shared decision making by healthcare professionals

BACKGROUND

Shared decision making (SDM) is a process by which a healthcare choice is made by the patient, significant others, or both with one or more healthcare professionals. However, it has not yet been widely adopted in practice. This is the second update of this Cochrane review.

OBJECTIVES

To determine the effectiveness of interventions for increasing the use of SDM by healthcare professionals. We considered interventions targeting patients, interventions targeting healthcare professionals, and interventions targeting both.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and five other databases on 15 June 2017. We also searched two clinical trials registries and proceedings of relevant conferences. We checked reference lists and contacted study authors to identify additional studies.

SELECTION CRITERIA

Randomized and non-randomized trials, controlled before-after studies and interrupted time series studies evaluating interventions for increasing the use of SDM in which the primary outcomes were evaluated using observer-based or patient-reported measures.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 87 studies (45,641 patients and 3113 healthcare professionals) conducted mainly in the USA, Germany, Canada and the Netherlands. Risk of bias was high or unclear for protection against contamination, low for differences in the baseline characteristics of patients, and unclear for other domains.Forty-four studies evaluated interventions targeting patients. They included decision aids, patient activation, question prompt lists and training for patients among others and were administered alone (single intervention) or in combination (multifaceted intervention). The certainty of the evidence was very low. It is uncertain if interventions targeting patients when compared with usual care increase SDM whether measured by observation (standardized mean difference (SMD) 0.54, 95% confidence interval (CI) -0.13 to 1.22; 4 studies; N = 424) or reported by patients (SMD 0.32, 95% CI 0.16 to 0.48; 9 studies; N = 1386; risk difference (RD) -0.09, 95% CI -0.19 to 0.01; 6 studies; N = 754), reduce decision regret (SMD -0.10, 95% CI -0.39 to 0.19; 1 study; N = 212), improve physical (SMD 0.00, 95% CI -0.36 to 0.36; 1 study; N = 116) or mental health-related quality of life (QOL) (SMD 0.10, 95% CI -0.26 to 0.46; 1 study; N = 116), affect consultation length (SMD 0.10, 95% CI -0.39 to 0.58; 2 studies; N = 224) or cost (SMD 0.82, 95% CI 0.42 to 1.22; 1 study; N = 105).It is uncertain if interventions targeting patients when compared with interventions of the same type increase SDM whether measured by observation (SMD 0.88, 95% CI 0.39 to 1.37; 3 studies; N = 271) or reported by patients (SMD 0.03, 95% CI -0.18 to 0.24; 11 studies; N = 1906); (RD 0.03, 95% CI -0.02 to 0.08; 10 studies; N = 2272); affect consultation length (SMD -0.65, 95% CI -1.29 to -0.00; 1 study; N = 39) or costs. No data were reported for decision regret, physical or mental health-related QOL.Fifteen studies evaluated interventions targeting healthcare professionals. They included educational meetings, educational material, educational outreach visits and reminders among others. The certainty of evidence is very low. It is uncertain if these interventions when compared with usual care increase SDM whether measured by observation (SMD 0.70, 95% CI 0.21 to 1.19; 6 studies; N = 479) or reported by patients (SMD 0.03, 95% CI -0.15 to 0.20; 5 studies; N = 5772); (RD 0.01, 95%C: -0.03 to 0.06; 2 studies; N = 6303); reduce decision regret (SMD 0.29, 95% CI 0.07 to 0.51; 1 study; N = 326), affect consultation length (SMD 0.51, 95% CI 0.21 to 0.81; 1 study, N = 175), cost (no data available) or physical health-related QOL (SMD 0.16, 95% CI -0.05 to 0.36; 1 study; N = 359). Mental health-related QOL may slightly improve (SMD 0.28, 95% CI 0.07 to 0.49; 1 study, N = 359; low-certainty evidence).It is uncertain if interventions targeting healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.30, 95% CI -1.19 to 0.59; 1 study; N = 20) or reported by patients (SMD 0.24, 95% CI -0.10 to 0.58; 2 studies; N = 1459) as the certainty of the evidence is very low. There was insufficient information to determine the effect on decision regret, physical or mental health-related QOL, consultation length or costs.Twenty-eight studies targeted both patients and healthcare professionals. The interventions used a combination of patient-mediated and healthcare professional directed interventions. Based on low certainty evidence, it is uncertain whether these interventions, when compared with usual care, increase SDM whether measured by observation (SMD 1.10, 95% CI 0.42 to 1.79; 6 studies; N = 1270) or reported by patients (SMD 0.13, 95% CI -0.02 to 0.28; 7 studies; N = 1479); (RD -0.01, 95% CI -0.20 to 0.19; 2 studies; N = 266); improve physical (SMD 0.08, -0.37 to 0.54; 1 study; N = 75) or mental health-related QOL (SMD 0.01, -0.44 to 0.46; 1 study; N = 75), affect consultation length (SMD 3.72, 95% CI 3.44 to 4.01; 1 study; N = 36) or costs (no data available) and may make little or no difference to decision regret (SMD 0.13, 95% CI -0.08 to 0.33; 1 study; low-certainty evidence).It is uncertain whether interventions targeting both patients and healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.29, 95% CI -1.17 to 0.60; 1 study; N = 20); (RD -0.04, 95% CI -0.13 to 0.04; 1 study; N = 134) or reported by patients (SMD 0.00, 95% CI -0.32 to 0.32; 1 study; N = 150 ) as the certainty of the evidence was very low. There was insuffient information to determine the effects on decision regret, physical or mental health-related quality of life, or consultation length or costs.

AUTHORS' CONCLUSIONS

It is uncertain whether any interventions for increasing the use of SDM by healthcare professionals are effective because the certainty of the evidence is low or very low.

Guidance on Noncorticosteroid Systemic Immunomodulatory Therapy in Noninfectious Uveitis: Fundamentals Of Care for UveitiS (FOCUS) Initiative

TOPIC

An international, expert-led consensus initiative to develop systematic, evidence-based recommendations for the treatment of noninfectious uveitis in the era of biologics.

CLINICAL RELEVANCE

The availability of biologic agents for the treatment of human eye disease has altered practice patterns for the management of noninfectious uveitis. Current guidelines are insufficient to assure optimal use of noncorticosteroid systemic immunomodulatory agents.

METHODS

An international expert steering committee comprising 9 uveitis specialists (including both ophthalmologists and rheumatologists) identified clinical questions and, together with 6 bibliographic fellows trained in uveitis, conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol systematic review of the literature (English language studies from January 1996 through June 2016; Medline [OVID], the Central Cochrane library, EMBASE, CINAHL, SCOPUS, BIOSIS, and Web of Science). Publications included randomized controlled trials, prospective and retrospective studies with sufficient follow-up, case series with 15 cases or more, peer-reviewed articles, and hand-searched conference abstracts from key conferences. The proposed statements were circulated among 130 international uveitis experts for review. A total of 44 globally representative group members met in late 2016 to refine these guidelines using a modified Delphi technique and assigned Oxford levels of evidence.

RESULTS

In total, 10 questions were addressed resulting in 21 evidence-based guidance statements covering the following topics: when to start noncorticosteroid immunomodulatory therapy, including both biologic and nonbiologic agents; what data to collect before treatment; when to modify or withdraw treatment; how to select agents based on individual efficacy and safety profiles; and evidence in specific uveitic conditions. Shared decision-making, communication among providers and safety monitoring also were addressed as part of the recommendations. Pharmacoeconomic considerations were not addressed.

CONCLUSIONS

Consensus guidelines were developed based on published literature, expert opinion, and practical experience to bridge the gap between clinical needs and medical evidence to support the treatment of patients with noninfectious uveitis with noncorticosteroid immunomodulatory agents.

The added value of musculoskeletal ultrasound to clinical evaluation in the treatment decision of rheumatoid arthritis outpatients: physician experience matters

BACKGROUND

Musculoskeletal ultrasound improves the accuracy of detecting the level of disease activity (DA) in RA patients, although its impact on the final treatment decision in a real clinical setting is uncertain. The objectives were to define the percentage of clinical scenarios from an ongoing cohort of RA outpatients in which the German Ultrasound Score on 7 joints (GUS-7) impacted the treatment and to explore if the impact differed between a senior rheumatologist (SR) vs. a trainee (TR).

METHODS

Eighty-five consecutive and randomly selected RA outpatients underwent 170 assessments, 85 each by the SR and the TR. Initially, both physicians (blinded to each other) performed a rheumatic assessment and recommended a preliminary treatment. Then, the patients underwent the GUS-7 evaluation by an experienced rheumatologist blinded to clinical evaluations; selected joints of the clinically dominant hand were assessed by gray-scale and power Doppler (PD). In the final step, the TR and the SR integrated the GUS-7 findings with their previous evaluation and reviewed their recommendations. The patients received the final recommendation from the SR to avoid patient confusion. The study was approved by the Internal Review Board and all the patients signed informed consent. GUS-7 usefulness was separately evaluated by the SR and the TR according to a visual analogue scale (0 = not useful at all, 10 = very useful). Descriptive statistics were used.

RESULTS

The patients were primarily middle-aged females (91.4%) with (mean ± SD) disease duration of 7.5 ± 3.9 years. The majority of them (69.2% according to TR and 71.8% to SR) were in DAS28-ESR-remission. In 34 of 170 clinical scenarios (20%), the GUS-7 findings modified the final treatment proposal; 24 of these scenarios were determined by the TR vs. 10 by the SR: 70.5% vs. 29.5%, p = 0.01. Treatment changes (increase, decrease and joint injection) were similar between both specialists. As expected, the TR rated the GUS-7 usefulness higher than the SR, particularly in the clinical scenarios where the GUS-7 findings impacted treatment.

CONCLUSIONS

Musculoskeletal ultrasound added to standard rheumatic assessments impacted the treatment proposal in a limited number of patients; the impact was greater in the TR.

Design and implementation of a decision aid for juvenile idiopathic arthritis medication choices

BACKGROUND

Randomized trials have demonstrated the efficacy of patient decision aids to facilitate shared decision making in clinical situations with multiple medically reasonable options for treatment. However, little is known about how best to implement these tools into routine clinical practice. In addition, reliable implementation of decision aids has been elusive and spread within pediatrics has been slow. We sought to develop and reliably implement a decision aid for treatment of children with juvenile idiopathic arthritis.

METHODS

To design our decision aid, we partnered with patient, parent, and clinician stakeholders from the Pediatric Rheumatology Care and Outcomes Improvement Network. Six sites volunteered to use quality improvement methods to implement the decision aid. Four of these sites collected parent surveys following visits to assess outcomes. Parents reported on clinician use of the decision aid and the amount of shared decision making and uncertainty they experienced. We used chi-square tests to compare eligible visits with and without use of the decision aid on the experience of shared decision making and uncertainty.

RESULTS

After 18 rounds of testing and revision, stakeholders approved the decision aid design for regular use. Qualitative feedback from end-users was positive. During the implementation project, the decision aid was used in 35% of visits where starting or switching medication was discussed. Clinicians used the decision aid as intended in 68% of these visits. The vast majority of parents reported high levels of shared decision making following visits with (64/76 = 84%) and without (80/95 = 84%) use of the decision aid (p = 1). Similarly, the vast majority of parents reported no uncertainty following visits with (74/76 = 97%) and without (91/95 = 96%) use of the decision aid (p = 0.58).

CONCLUSIONS

Although user acceptability of the decision aid was high, reliable implementation in routine clinical care proved challenging. Our parsimonious approach to outcome assessment failed to detect a difference between visits with and without use of our aid. Innovative approaches are needed to facilitate use of decision aids and the assessment of outcomes.

Medication Risk Communication in Rheumatology: Where Are We and Where Do We Go from Here?

This paper reviews findings from recent research examining issues related to the risk communication process within the context of rheumatologic conditions. Five specific questions are addressed. First, to what extent do patients with rheumatic disorders exhibit adequate knowledge relevant to disease and medication risks and risk management? Second, what sources do patients use when attempting to find information about disease and medication risks and risk management? Third, what types of information about disease and medication risks and risk management do rheumatologists provide during routine office visits. Fourth, what governmental regulations attempt to increase consumer access to information about medication risks and risk management? Finally, what other educational resources are available to facilitate patient-provider communication concerning disease and medication risks and risk management? The findings reported identify gaps in patient knowledge concerning medication risks and risk management, highlight areas for improvement, and identify resources that may enhance medication risk communication.

Shared Decision Making in the Emergency Department Among Patients With Limited Health Literacy: Beyond Slower and Louder

Although studies suggest that patients with limited health literacy and/or low numeracy skills may stand to gain the most from shared decision making (SDM), the impact of these conditions on the effective implementation of SDM in the emergency department (ED) is not well understood. In this article from the proceedings of the 2016 Academic Emergency Medicine Consensus Conference on Shared Decision Making in the Emergency Department we discuss knowledge gaps identified and propose consensus-driven research priorities to help guide future work to improve SDM for this patient population in the ED.

Shared Decision Making With Vulnerable Populations in the Emergency Department

The emergency department (ED) occupies a unique position within the healthcare system, serving as a safety net for vulnerable patients, regardless of their race, ethnicity, religion, country of origin, sexual orientation, socioeconomic status, or medical diagnosis. Shared decision making (SDM) presents special challenges when used with vulnerable population groups. The differing circumstances, needs, and perspectives of vulnerable groups invoke issues of provider bias, disrespect, judgmental attitudes, and lack of cultural competence, as well as patient mistrust and the consequences of their social and economic disenfranchisement. A research agenda that includes community-engaged approaches, mixed-methods studies, and cost-effectiveness analyses is proposed to address the following questions: 1) What are the best processes/formats for SDM among racial, ethnic, cultural, religious, linguistic, social, or otherwise vulnerable groups who experience disadvantage in the healthcare system? 2) What organizational or systemic changes are needed to support SDM in the ED whenever appropriate? 3) What competencies are needed to enable emergency providers to consider patients' situation/context in an unbiased way? 4) How do we teach these competencies to students and residents? 5) How do we cultivate these competencies in practicing emergency physicians, nurses, and other clinical providers who lack them? The authors also identify the importance of using accurate, group-specific data to inform risk estimates for SDM decision aids for vulnerable populations and the need for increased ED-based care coordination and transitional care management capabilities to create additional care options that align with the needs and preferences of vulnerable populations.