Rheumatology patients' perceptions of patient activation and the Patient Activation Measure: A qualitative interview study

Management of refractory disease and persistent symptoms in inflammatory arthritis: qualitative framework analysis of interviews with patients and healthcare professionals

Objectives

This study aims to explore patients' and clinicians' experiences in managing and living with refractory disease (RD) and persistent physical and emotional symptoms (PPES) in patients with RA or polyarticular JIA from their perspectives through interviews and/or focus groups.

Methods

A qualitative exploration with 25 patients and 32 multidisciplinary rheumatology healthcare professionals (HCPs) was conducted to obtain participants respective understanding and experiences of managing RD/PPES and its impact on the patient-professional relationship. A pragmatic epistemology approach with framework analysis was employed.

Results

Four key themes were identified from both patients and professionals in the management of RD/PPES: risk/perpetuating factors/triggers; need for a patient-centred holistic approach to care, diagnosis and treatment; discordance and impact on the patient-practitioner relationship and current problems in managing RD/PPES. These themes covered 22 subthemes, with none being patient specific and seven being HCP specific. Suggestions for potential management strategies were highlighted throughout, such as involving other specialties or a multidisciplinary team, assessing/treating patient-reported outcome measures and psychosocial factors, patient (re)education, need for adjustments/aids or adaptations, checking the diagnosis and further investigations/imaging and optimizing medications.

Conclusion

Management strategies need to be developed that enable appropriate treatment plans for those with RD/PPES that account for wider biopsychosocial factors beyond inflammation and reduce discordance in the patient-practitioner relationship.

Exploring Impact of Multidisciplinary Care on Patient Activation in Saudi Rheumatoid Arthritis Patients: A Cross-Sectional Survey-Extended Results from the COPARA National Project

Introduction

Multidisciplinary setting in healthcare provide positive patient outcomes.

Objective

To evaluate the impact of specialized rheumatology clinics (multidisciplinary settings) on the activation and engagement of rheumatoid arthritis (RA) patients.

Material and Methods

This cross-sectional survey assessed patient activation using the patient activation measure-13. Participants attending Specialized Rheumatology Clinics (SRC multidisciplinary clinics) were compared with age- and sex-matched patients attending Standard of Care (SOC). The study was observational in nature, assessing several demographic and therapeutic options and their relation to the clinical setting and patient activation.

Results

This study included 117 SRC matched RA patients with 117 SOC. The majority of the included patients were female (n=211, 90.2%), >40 years of age (n=177, 75.6%), and had intermediate-to-high education (n=147, 62.8%). Patients in the SRC were also more likely to have activation levels 3 and 4 with an odds ratio of 3.194 (95% confidence interval [CI] 1.835-5.562, p<0.001). In addition, SRC participants were more likely to be in levels 3 and 4 activation, even after adjustment for confounding variables, with an adjusted odds ratio of 2.401 (95% CI 1.121-4.758, p=0.012) and 2.175 (95% CI 1.127-4.196, p=0.020), respectively.

Conclusion

Establishing SRC for RA patients seems to have a positive impact on patient activation and engagement and adds to the previously explored benefits of multidisciplinary care in chronic disease management.

Disseminating and assessing implementation of the EULAR recommendations for patient education in inflammatory arthritis: a mixed-methods study with patients' perspectives

Objectives

To explore patients’ agreement and reasons for agreement or disagreement with the EULAR recommendations for patient education (PE) for people with inflammatory arthritis (IA).

Methods

This mixed-method survey collected data using snowball sampling. The survey had been translated into 20 languages by local healthcare professionals, researchers and patient research partners. It explored the degree to which patients with IA agreed with each recommendation for PE (0=do not agree at all and 10=agree completely) and their rationale for their agreement level in free text questions. Descriptive statistics summarised participants’ demographics and agreement levels. Qualitative content analysis was used to analyse the free text data. Sixteen subcategories were developed, describing the reasons for agreement or disagreement with the recommendations, which constituted the categories.

Results

The sample comprised 2779 participants (79% female), with a mean (SD) age 55.1 (13.1) years and disease duration 17.1 (13.3) years. Participants strongly agreed with most recommendations (median 10 (IQR: 9–10) for most recommendations). Reasons for agreement with the recommendations included the benefit of using PE to facilitate collaborative care and shared decision making, the value of flexible and tailored PE, and the value of gaining support from other patients. Reasons for disagreement included lack of resources for PE, not wanting information to be tailored by healthcare professionals and a reluctance to use telephone-based PE.

Conclusion

The EULAR recommendations for PE have been disseminated among patients with IA. Overall, agreement levels were very high, suggesting that they reflect patients’ preferences for engaging in collaborative clinical care and using PE to facilitate and supplement their own understanding of IA. Reasons for not completely agreeing with the recommendations can inform implementation strategies and education of healthcare professionals.

The Patient Activation Measure in Patients with Rheumatoid Arthritis: A Systematic Review and Cross-Sectional Interview-Based Survey

INTRODUCTION/OBJECTIVE

The patient activation measure (PAM) is considered a reliable tool for measuring patient activation. This study aimed to systematically review the scientific literature regarding the use of PAM -13 in rheumatology patients and to compare PAM scores in patients with rheumatoid arthritis (RA) following two different practices at a single institution with previously published studies.

METHODS

The study consisted of a systematic review of articles reporting the PAM-13 in patients with RA, followed by a cross-sectional study evaluating PAM scores between standard rheumatology clinics and specialized rheumatology clinics (SRCs). The correlation between PAM levels and other variables, such as demographics, disease characteristics, and treatment, was assessed.

RESULTS

Nineteen studies, published between 2012 and 2022, met the inclusion criteria. The studies in this review had inconsistent results and quality, with patient activation in RA ranging from 29 to 76. A total of 197 patients with confirmed RA diagnoses were interviewed (response rate, 88%). Most were female (n=173, 88%) and older than 40 years (n=150, 76%). The average patient activation score was 64.9 (standard deviation, 15.7). Most participants had level 3 and 4 patient activation measures (n=71 [36%] and n=72[37%], respectively). Patients who were attending SRCs also had borderline higher PAM levels. Patients with high PAM scores tended to be older, have active disease, and were taking corticosteroids.

CONCLUSION

Adequate activation of patients was observed from our center, which was higher than that reported in most published literature. The PAM of patients with RA was variable according to the systematic review. Longitudinal interventional studies should be considered to improve activation in patients with low scores.

Factors associated with patient activation in inflammatory arthritis: a multisite cross-sectional study

Objectives

Patient activation covers the skills, abilities and behaviour that impact how able and willing someone is to take an active role in self-managing their health. This study explored clinical and psychosocial factors associated with patient activation in rheumatology patients.

Methods

This was a cross-sectional study using postal survey methods. Participants with inflammatory rheumatic conditions were from six rheumatology centres in England. Patient activation was captured using the Patient Activation Measure (PAM). Twenty-nine explanatory factors were tested for potential association with patient activation in univariable and multivariable analyses. In preliminary multivariable analyses, factors found to have an association with patient activation at a P < 0.1 level were entered into the final multivariable model. Those that remained significant at a P < 0.05 level were considered associated with patient activation.

Results

The sample comprised 251 participants (74% female) with a mean age of 59.31 years (s.d. 12.69), disease duration of 14.48 years (s.d. 12.52) and a PAM score of 58.3 (s.d. 11.46). Of the 29 candidate factors, 25 were entered into a preliminary multivariable analysis. In the final multivariable analysis, four factors (self-efficacy, the illness belief that treatment will control participants’ condition and two dimensions of health literacy) were significantly associated with patient activation. This final model accounted for 40.4% of the variance in PAM scores [F(4, 246) = 41.66, P < 0.001].

Conclusions

Patient activation is important in managing rheumatic conditions. Our data confirm that self-efficacy and health literacy are particular targets for patient activation interventions.

Patients' Characterization of Medication, Emotions, and Incongruent Perceptions around Adherence

Medication nonadherence is prevalent among patients with chronic diseases. Previous research focused on patients’ beliefs in medication or illness and applied risk-benefit analyses when reasoning their behavior. This qualitative study examined rheumatoid arthritis (RA) patients’ perceptions and feelings toward medication in parallel with attitudes about their own adherence. We conducted four 90-min focus groups and seven 60-min interviews with a diverse sample of RA patients (n = 27). Discussions covered dilemmas encountered, emotions, and thought process concerning medication, and included application of projective techniques. Transcripts were analyzed in NVivo-12 using a thematic coding framework through multiple rounds of deduction and categorization. Three themes emerged, each with mixed sentiments. (1) Ambivalent feelings toward medication: participants experienced internal conflicts as their appreciation of drugs for relief contradicted worries about side effects or “toxicity” and desire to not identify as sick, portraying medications as “best friend” and “evil”. (2) Struggles in taking medication: participants “hated” the burden of managing regimen and resented the reliance and embarrassment. (3) Attitudes and behavior around adherence: most participants self-reported high adherence yet also described frequently self-adjusting medications, displaying perception-action incongruency. Some expressed nervousness and resistance while others felt empowered when modifying dosage, which might have motivated or helped them self-justify nonadherence. Only a few who deviated from prescription discussed it with their clinicians though most participants expressed the desire to do so; open communication with providers reinforced a sense of confidence and control of their own health. Promoting personalized care with shared decision-making that empowers and supports patients in managing their long-term treatment could encourage adherence and improve overall health outcome.