Arthritis patients' motives for (not) wanting to be involved in medical decision-making and the factors that hinder or promote patient involvement

Development of an Interactive Tool to Support Shared Decision-Making in Rheumatoid Arthritis: Treatment Attribute Preference

OBJECTIVE

An interactive tool identifying treatment attributes important to patients can enhance shared decision-making (SDM) in rheumatoid arthritis (RA). A formative survey was conducted to identify the most important treatment attributes from patients' perspective, which can be used to develop an interactive SDM tool.

METHODS

The survey was performed in two phases: qualitative interviews and quantitative surveys. The qualitative interviews were conducted to inform the design of the quantitative survey. In qualitative interviews, patients with RA (n = 10) and rheumatologists (n = 10) were introduced to the SDM tool concept. Feedback on the design and scope of the SDM tool was used to develop a quantitative survey, conducted in a large sample size of patients. Patient preferences for treatment attributes (route of administration and dosing frequency, serious side effects, out-of-pocket costs, efficacy, and monitoring requirement) were assessed via adaptive conjoint exercise involving ranking of hypothetical RA treatment configurations.

RESULTS

A total of 944 patients (males: 43%, females: 57%) with RA participated in the quantitative survey. Route of administration and dosing frequency (38%) followed by serious side effects (33%) were the two most important treatment attributes for individual patients. The recontact survey (n = 172/944) estimated tool stability of 72% (n = 124/172) in terms of the relative importance of treatment attributes.

CONCLUSION

The findings of this survey could be used in the development of an SDM tool that can potentially provide insights into patient preferences and is generally well received by patients and rheumatologists with good agreement and reliability.

Alignment Among Patient, Caregiver, and Health Care Provider Perspectives on Hemodialysis Vascular Access Decision-Making: A Qualitative Study

Background

Updates to the Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Vascular Access emphasize the "right access, in the right patient, at the right time, for the right reasons." Although this implies a collaborative approach, little is known about how patients, their caregivers, and health care providers engage in vascular access (VA) decision-making.

Objective

To explore how the perspectives of patients receiving hemodialysis, their caregivers, and hemodialysis care team align and diverge in relation to VA selection.

Design

Qualitative descriptive study.

Setting

Five outpatient hemodialysis centers in Calgary, Alberta.

Participants

Our purposive sample included 19 patients receiving maintenance hemodialysis, 2 caregivers, and 21 health care providers (7 hemodialysis nurses, 6 VA nurses, and 8 nephrologists).

Methods

We conducted semi-structured interviews with consenting participants. Using an inductive thematic analysis approach, we coded transcripts in duplicate and characterized themes addressing our research objective.

Results

While participants across roles shared some perspectives related to VA decision-making, we identified areas where views diverged. Areas of alignment included (1) optimizing patient preparedness-acknowledging decisional readiness and timing, and (2) value placed on trusting relationships with the kidney care team-respecting decisional autonomy with guidance. Perspectives diverged in the following aspects: (1) differing VA priorities and preferences-patients' emphasis on minimizing disruptions to normalcy contrasted with providers' preferences for fistulas and optimizing biomedical parameters of dialysis; (2) influence of personal and peer experience-patients preferred pragmatic, experiential knowledge, whereas providers emphasized informational credibility; and (3) endpoints for VA review-reassessment of VA decisions was prompted by access dissatisfaction for patients and a medical imperative to achieve a functioning access for health care providers.

Limitations

Participation was limited to individuals comfortable communicating in English and from urban, in-center hemodialysis units. Few informal caregivers of people receiving hemodialysis and younger patients participated in this study.

Conclusions

Although patients, caregivers, and healthcare providers share perspectives on important aspects of VA decisions, conflicting priorities and preferences may impact the decisional outcome. Findings highlight opportunities to bridge knowledge and readiness gaps and integrate shared decision-making in the VA selection process.

Development of a web-based decision aid for initiating biological or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) in axial spondyloarthritis

OBJECTIVES

To develop a web-based evidence-based decision aid to support shared decision-making in patients with axial spondyloarthritis (axSpA) who face a treatment decision to initiate or switch a biological or targeted synthetic disease modifying antirheumatic drug (b/tsDMARDs).

METHODS

Through an iterative process, we systematically developed a decision aid based on evidence from the literature, explorative needs assessment interviews among patients and care providers, and input from experts of the SpA working group of the Dutch Society for Rheumatology and professionals on patient information employed at the Dutch Arthritis Society. The usability, ease of use and feasibility of the pilot version were tested among stakeholders and feedback was used to adapt the decision aid. Finally, a multifaceted strategy was used to introduce the decision aid in clinical practice.

RESULTS

The decision aid consists of (1) consultation support instructions in the context of disease control and treatment needs, (2) an overview of available treatment options for axSpA, (3) detailed information on b/tsDMARDs and an interactive option grid that facilitates comparison of characteristics and (4) a final check supporting patients to deliberate on the decision to initiate or switch a b/tsDMARD. Rheumatologists introduced the decision aid in several Dutch rheumatology settings and the Dutch Arthritis Society posted it on their website, social media and in their monthly newsletter.

CONCLUSION

We developed an evidence-based decision aid to support axSpA patients who face a treatment decision to initiate or switch a b/tsDMARD and introduced this in clinical practice.

Patient-related characteristics considered to affect patient involvement in shared decision making about treatment: A scoping review of the qualitative literature

OBJECTIVE

To identify patient-related characteristics considered to affect patient involvement in shared decision making (SDM) about treatment.

METHODS

We conducted a scoping review of qualitative studies. We searched for literature across seven databases until March 2022, and included qualitative studies that focused on associations between patient-related characteristics and SDM about treatment in adults. We analyzed studies using an inductive thematic approach.

RESULTS

The search yielded 5948 articles, of which 70 were included. We identified many different patient-related characteristics, which we grouped into four categories related to: (1) the individual who is facing the decision, (2) the decision, (3) the relationship between the patient and the clinician and others involved in the decision, and (4) the healthcare context.

CONCLUSIONS

Studies report a variety of patient-related characteristics that may affect patient involvement in SDM. Amongst others, patients may need to feel informed, to understand their role in SDM, and be able to communicate. Involvement may be challenging with characteristics such as perceived time pressure, poor patient-clinician relationships, emotional distress, and severe illness.

PRACTICE IMPLICATIONS

In order to truly involve patients in SDM, we might need to focus on characteristics such as patient emotions and relationship building, besides information provision and values clarification.

Nursing interventions for patients with rheumatic and musculoskeletal diseases on biological therapies: a systematic literature review

Investigating unmet needs and identifying the necessary interventions for patients affected by rheumatic and musculoskeletal diseases (RMDs) may help significantly to ensure the continuity and quality of the chronic care pathway. To this aim, the contribution of rheumatology nurses requires further evidence. The aim of our systematic literature review (SLR) was to identify the nursing interventions directed towards patients with RMDs undergoing biological therapy. To retrieve data, a search was carried out in the MEDLINE database, the Cumulative Index to Nursing and Allied Health Literature (CINAHL database), the APA PsycINFO database and the Excerpta Medica Database (EMBASE) from 1990 to 2022. The systematic review was carried out in accordance with the relevant PRISMA guidelines. Inclusion criteria were as follows: (I) adult patients with RMDs, (II) undergoing therapy with Biological Disease-Modifying Anti-Rheumatic Drugs (bDMARDs), (III) original and quantitative research papers in English with available abstract, (IV) specific to nursing interventions and/or outcomes. Two independent reviewers screened the identified records for eligibility according to their title and abstract, full texts were subsequently assessed and, finally, data was extracted. Critical Appraisal Skills Programme (CASP) tools were used to evaluate the quality of the studies included. Among the 2348 records retrieved, 13 articles met the inclusion criteria. These consisted of six randomised controlled trials (RCTs), one pilot study and six observational studies on RMDs. In a total population of 2004 patients, 43% (862/2004) of the cases concerned rheumatoid arthritis (RA) and 56% (1122/2004) of the cases concerned spondyloarthritis (SpA). Three major nursing interventions were identified, namely education, patient-centred care and data collection/nurse monitoring, which were correlated with high satisfaction rates regarding care, increased self-care capacity and treatment adherence among patients. All interventions followed a protocol defined in collaboration with rheumatologists. The large degree of heterogeneity in the interventions did not allow the performance of a meta-analysis. Rheumatology nurses are part of a multidisciplinary team caring for patients with RMDs. Following an accurate initial nursing evaluation, rheumatology nurses can plan and standardise their interventions focusing primarily on patient education and personalised care based on actual needs, such as psychological well-being and disease control. However, the training for rheumatology nurses should define and standardise, as much as possible, the competencies required for the detection of disease parameters. Key Points • This SLR provides an overview of nursing interventions for patients with RMDs. • This SLR considers the specific population of patients on biological therapies. • Training for rheumatology nurses should standardise, as much as possible, the knowledge and methods required for detecting disease parameters. • This SLR highlights the various competencies of rheumatology nurses.

Patients' Perspectives on Shared Decision-Making About Medications in Psoriatic Arthritis: An Interview Study

OBJECTIVE

Decision-making regarding medications to manage psoriatic arthritis (PsA) is complex because of multiple disease manifestations and comorbidities. Fear of side effects from systemic medications and misalignment in priorities between patients with PsA and rheumatologists makes shared decision-making challenging. We aimed to describe the perspectives of patients with PsA on shared decision-making regarding medication taking.

METHODS

Face-to-face semistructured interviews were conducted with 25 adult patients with PsA in Australia. Transcripts were thematically analyzed.

RESULTS

Five themes were identified: lacking agency in decision-making (denied choice, knowledge asymmetry, desperation and necessity, restricted by unfair eligibility criteria, automated approach); overwhelmed by potential harms (daunted by aggressive therapy, anticipating lifestyle disruption from side effects, jeopardizing fertility and pregnancy, avoiding relapse); gaining confidence (discernible benefit in function and mental health, sharpening knowledge over time, expertise of family and peers, empowered by information); opting for alternatives (pursuing normality, suspicion of over-medicalization, seeking comprehensive solutions); and developing trust and fortifying collaboration (assurance through a personable approach, seeking consistency, supported in decisional power, resolution through respectful negotiation).

CONCLUSION

Patients with PsA lack agency in making treatment decisions and are overwhelmed by the potential harms of systemic medication. Improving knowledge and trust with medical teams in a supportive and collaborative environment, and strategies for managing risks and side effects may improve decision-making about pharmacologic management of PsA.

Establishing the Competency Development and Talent Cultivation Strategies for Physician-Patient Shared Decision-Making Competency Based on the IAA-NRM Approach

Shared decision making (SDM) is a collaborative process involving patients and their healthcare workers negotiating to reach a shared decision about medical care. However, various physician stakeholders (attending physicians, medical residents, and doctors in post-graduate years) may have different viewpoints on SDM processes. The purpose of this study is to explore the core competence of physicians in performing SDM tasks and to investigate the significant competency development aspects/criteria by applying the literature research and expert interviews. We adopt the IAA (importance awareness analysis) technique for different stakeholders to evaluate the status of competency development aspects/criteria and to determine the NRM (network relation map) based on the DEMATEL (decision-making trial and evaluation laboratory) technique. The study combines the IAA and NRM methods and suggests using the IAA-NRM approach to evaluate the adoption strategies and common suitable paths for different levels of physicians. Our findings reveal that SDM perception and practice is the primary influencer of SDM competence development for all stakeholders. The current model can help hospital administrators and directors of medical education understand the diverse stakeholders’ perspectives on the core competence of SDM tasks and determine common development plans. It provides strategic directions for SDM competency development and talent cultivation programs.

Personalised written consultation summaries for patients: An 'up-close, in-depth, inside-out' exploration of a rheumatologist's patient-centred strategy

OBJECTIVE

The importance of ensuring that patients understand and remember information from rheumatology consultations is well recognised. However, literature focuses on 'one-size-fits-all' information resources. In this qualitative study our 'upclose, in-depth, inside-out' exploration sought to understand the personalised written consultation summary, a rheumatologist's patient-centred strategy developed through ongoing reflection.

METHODS

A research team of a rheumatologist, practice nurse, two patients, registrar and researcher used a participatory research approach, collaborative inquiry Semistructured interviews were undertaken with 29 patients. Data analysis was dialogical and iterative, moving from descriptive to conceptual.

RESULTS

Implicit within the personalised written consultation summary were domains and actions of: INVOLVEMENT in the process (contributing to the content, clarifying and negotiating the content, being present as it is written), CONTINUITY of information (taking the summary, sharing it with others, storing it at home) and SECURITY for ongoing management (owning the summary, being reminded about management plans, having a basis for re-checking).

CONCLUSION

Aligned with the findings are patient-centred intentions for health literacy, personal health information management and medication adherence. The second highlights an important theoretical basis for patient-centred rheumatology strategies beyond consultations.

PRACTICE IMPLICATIONS

A model and reflective questions are presented to inform ongoing reflections about patient-centred information strategies.

Patient involvement in rheumatoid arthritis care to improve disease activity-based management in daily practice: A randomized controlled trial

OBJECTIVE

To evaluate the effect of an intervention to improve disease activity-based management of RA in daily clinical practice by addressing patient level barriers.

METHODS

The DAS-pass strategy aims to increase patients' knowledge about DAS28 and to empower patients to be involved in treatment (decisions). It consists of an informational leaflet, a patient held record and guidance by a specialized rheumatology nurse. In a Randomized Controlled Trial, 199 RA patients were randomized 1:1 to intervention or control group. Outcome measures were patient empowerment (EC-17; primary outcome), attitudes towards medication (BMQ), disease activity (DAS28) and knowledge about DAS28.

RESULTS

Our strategy did not affect EC-17, BMQ, or DAS28 use. However it demonstrated a significant improvement of knowledge about DAS28 in the intervention group, compared to the control group. The intervention had an additional effect on patients with low baseline knowledge compared to patients with high baseline knowledge.

CONCLUSION

The DAS-pass strategy educates patients about (the importance of) disease activity-based management, especially patients with low baseline knowledge.

PRACTICE IMPLICATIONS

The strategy supports patient involvement in disease activity-based management of RA and can be helpful to reduce inequalities between patients in the ability to be involved in shared decision making.

Healthcare professionals’ perceptions on barriers and facilitators to DMARD use in rheumatoid arthritis

Background

Disease-modifying anti-rheumatic drugs (DMARDs) are the cornerstone of rheumatoid arthritis (RA) treatment. However, the full benefits of DMARDs are often not realized because many patients are sub-optimally adherent to their medication. In order to optimize adherence, it is essential that healthcare professionals (HCPs) understand patients’ barriers and facilitators for medication use. Insight in these barriers and facilitators may foster the dialogue about adequate medication use between HCPs and patients. What HCPs perceive as barriers and facilitators has, so far, scarcely been investigated. This study aimed to identify the perceptions of HCPs on patients’ barriers and facilitators that might influence their adherence.

Methods

This qualitative study was performed using semi structured in-depth interviews with HCPs. An interview guide was used, based on an adjusted version of the Theoretical Domains Framework (TDF). Thematic analysis was conducted to identify factors that influence barriers and facilitators to DMARD use according to HCPs.

Results

Fifteen HCPs (5 rheumatologists, 5 nurses and 5 pharmacists) were interviewed. They mentioned a variety of factors that, according to their perceptions, influence DMARD adherence in patients with RA. Besides therapy-related factors, such as (onset of) medication effectiveness and side-effects, most variation was found within patient-related factors and reflected patients’ beliefs, ways of coping, and (self-management) skills toward medication and their condition. In addition, factors related to the condition (e.g., level of disease activity), healthcare team and system (e.g., trust in HCP), and social and economic context (e.g. support, work shifts) were reported.

Conclusions

This study provided insights in HCPs’ perceptions of the barriers and facilitators to DMARD use patients with RA. Most factors that were mentioned were patient-related and potentially modifiable. When physicians understand patients’ perceptions on medication use, adherence to DMARDs can probably be optimized in patients with RA leading to more effectiveness of treatment outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07459-0.

Monitoring of rheumatoid arthritis: a patient survey on disease insight and possible added value of an innovative inflammation monitoring device

To enable patients with rheumatoid arthritis (RA) and their healthcare professionals to choose the optimal treatment, it is crucial to accurately assess the current state of inflammatory activity. The objectives of this study were to (1) investigate the perspective of RA patients on their insight into the current status of their disease, and to (2) investigate the patients’ perspective on the possible added value of a monitoring device based on optical spectral transmission—called the HandScan—that measures the location and severity of joint inflammation. A survey was distributed online among patients with RA in the Netherlands. Four-hundred and eight patients with RA completed the survey. Of these, 298 (73%) felt they have sufficient insight into their current disease status. Most respondents perceived either a large (n = 242; 59%) or small (n = 148; 36%) added value of the HandScan in their monitoring process, mostly because the device provides additional knowledge on the presence of inflammation. This perceived added value was higher for respondents experienced with the device (n = 46; p = .04). Respondents preferred monitoring with the device on every (n = 192; 47%) or most (n = 171; 42%) visits to the outpatient clinic, or even more often than on every visit (n = 17; 4%). Monitoring RA using an optical spectral transmission device is seen by patients as a possibly valuable addition to the monitoring process of inflammatory activity during visits to an outpatient clinic. Their main reason was that the device can increase insight into their current disease status. More insight may support patients in discussing treatment options with their rheumatologist.

Co-Design of a Disease Activity Based Self-Management Approach for Patients with Rheumatoid Arthritis

Objective:

The systematic development of an intervention to improve disease activity-based management of rheumatoid arthritis (RA) in daily clinical practice that is based on patient-level barriers.

Methods:

The self-management strategy was developed through a step-wise approach, in a process of co-design with all stakeholders and by addressing patient level barriers to RA management based on disease activity.

Results:

The resulting DAS-pass strategy consists of decision supportive information and guidance by a specialised rheumatology nurse. It aims to increase patients’ knowledge on DAS28, to empower patients to be involved in disease management, and to improve patients’ medication beliefs. The decision supportive information includes an informational leaflet and a patient held record. The nurse individualises the information, stimulates patients to communicate about disease activity, and offers the opportunity for questions or additional support.

Conclusion:

The DAS-pass strategy was found helpful by stakeholders. It can be used to improve RA daily clinical practice. Our systematic approach can be used to improve patient knowledge and self-management on other RA related topics. Also, it can be used to improve the management of other chronic conditions. We therefore provide a detailed description of our methodology to assist those interested in developing an evidence-based strategy for educating and empowering patients.

Ranking facilitators and barriers of medication adherence by patients with inflammatory arthritis: a maximum difference scaling exercise

Introduction

Facilitators and barriers of adherence to disease-modifying anti-rheumatic drugs (DMARDs) have been identified by patients with inflammatory arthritis earlier. However, the relative importance from the patients’ perspective of these factors is unknown. Knowledge on this ranking might guide the development of interventions and may facilitate targeted communication on adherence. This study aims to examine 1) the relative importance patients attach to facilitators and barriers for DMARDs adherence, and 2) the relationship between patient characteristics and ranking of these factors.

Methods

One hundred twenty-eight outpatients with inflammatory arthritis; (60% female, mean age 62 years (SD = 12), median disease duration 15 years, IQR (7, 23) participated in a Maximum Difference scaling exercise and ranked 35 items based upon previously identified facilitators and barriers to medication adherence. Hierarchical Bayes estimation was used to compute mean Rescaled Probability Scores (RPS; 0–100) (i.e. relative importance score). Kendall’s coefficient of concordance was used to examine a possible association between patients’ characteristics (i.e. age, sex and educational level) and ranking of the items.

Results

The three most important items ranked by patients were: Reduction of symptoms formulated as “Arthritis medications help to reduce my symptoms” (RPS = 7.30, CI 7.17–7.44), maintaining independence formulated as “I can maintain my independence as much as possible” (RPS = 6.76, CI 6.54–6.97) and Shared decision making formulated as “I can decide –together with my physician- about my arthritis medications” (RPS = 6.48, CI 6.24–6.72). No associations between patient characteristics and ranking of factors were found.

Conclusions

Reducing symptoms, maintaining independency and shared decision making are patients’ most important factors for DMARDs adherence. This knowledge might guide the development of interventions and may facilitate communication between health professionals and their patients on medication adherence.

Room for improvement in non-pharmacological systemic sclerosis care? - a cross-sectional online survey of 650 patients

BACKGROUND/ OBJECTIVE

To gain insight in the use of current systemic sclerosis (SSc) care provided by health professionals from the patient perspective. We focused on referral reasons, treatment goals, the alignment with unmet care needs, and outcome satisfaction.

METHODS

Dutch SSc patients from 13 participating rheumatology departments were invited to complete an online survey. Descriptive statistics were used to describe current use of non-pharmacological care and outcome satisfaction. Reasons for referral and treatment goals were encoded in International Classification of Function and Disability (ICF) terms.

RESULTS

We included 650 patients (mean (standard deviation [SD]) age, 59.4 (11.4) years. 50% had contact with a health professional in the past year; 76.3% since disease onset. Physiotherapists were the most frequently visited in the past year (40.0%), followed by dental hygienists (11.4%) and podiatrists (9.2%). The three most common referral reasons were pain, joint mobility and cardiovascular functions. Fatigue, Raynaud's phenomenon, physical limitations, reduced hand function and joint problems were mentioned by more than 25% of all respondents as unmet needs. The proportion of patients treated in the past year by a health professional who were satisfied with knowledge and expertise of their health professionals was 74.4%; 73% reported improved daily activities and better coping with complaints. However, 48.9% perceived that the collaboration between rheumatologist and health professional was never or only sometimes sufficient.

CONCLUSION

Despite the high outcome satisfaction and good accessibility of health professionals, there are obstacles in the access to non-pharmacological care and communication barriers between health professionals and rheumatologists.

Appropriating and asserting power on inflammatory arthritis teams: A social network perspective

Background

Therapeutic interventions for people with inflammatory arthritis (IA) increasingly involve multidisciplinary teams and strive to foster patient‐centred care and shared decision making. Participation in health‐care decisions requires patients to assert themselves and negotiate power in encounters with clinicians; however, clinical contexts often afford less authority for patients than clinicians. This disadvantage may inhibit patients' involvement in their own health care.

Objective

To identify communication attributes, IA patients use to influence and negotiate their treatment with members of their health‐care network.

Method

A qualitative social network approach was used to analyse data from a larger study that investigated IA patients' overall experiences of multidisciplinary care. Fourteen patients with IA attended individual semi‐structured interviews. Researchers used thematic analysis to identify patterns of assertiveness and influence in the data.

Results

Participants experienced loss of identity, control and agency in addition to the physical symptoms of IA. However, they had a sense of personal responsibility for managing their health care. Perceptions of health‐care team support enhanced patients' influence in treatment negotiations. Notably, there appeared to be an underlying tension between being empowered or disempowered.

Discussion and conclusions

The findings have significant implications for treatment decision communication approaches to IA care. A social network perspective may provide a pathway for clinicians to better understand the complexities of communication with their patients. This approach may reduce unequal power dynamics that occur within clinician/patient interactions and afford people with IA agency, control and affirmation of identity within their health‐care network.

Exploring healthcare professionals' knowledge, attitudes and experiences of shared decision making in rheumatology

OBJECTIVES

To explore physicians' and nurses' knowledge, attitudes and experiences of shared decision making (SDM) in rheumatology, to identify barriers and facilitators to SDM, and to examine whether physicians' and nurses' perspectives of SDM differ.

METHODS

A cross-sectional, exploratory, online survey was used. Besides demographic characteristics, healthcare professionals' knowledge, attitudes and experiences of SDM in rheumatology were assessed. Barriers and facilitators to SDM were identified from healthcare professionals' answers. Descriptive statistics were computed and differences between physicians' and nurses' perspectives of SDM were examined with a t-test or Fisher's exact test, as appropriate.

RESULTS

Between April and June 2019, 77 physicians and 70 nurses completed the survey. Although most healthcare professionals lacked a full conceptual understanding of SDM, almost all physicians (92%) and all nurses had a (very) positive attitude toward SDM, which was most frequently motivated by the belief that SDM improves patients' treatment adherence. The majority (>50%) of healthcare professionals experienced problems with the application of SDM in clinical practice, mostly related to time constraints. Other important barriers were the incompatibility of SDM with clinical practice guidelines and beliefs that patients do not prefer to be involved in decision making or are not able to take an active role. Modest differences between physicians' and nurses' perspectives of SDM were found.

CONCLUSIONS

There is a clear need for education and training that equips and empowers healthcare professionals to apply SDM. Furthermore, the commitment of time, resources and financial support for national, regional and organisational initiatives is needed to make SDM in rheumatology a practical reality.

Qualitative Exploration of Triangulated, Shared Decision-Making in Rheumatoid Arthritis

OBJECTIVE

Treat-to-target implementation in rheumatoid arthritis (RA) requires a shared decision-making (SDM) process. However, ability to pay is a major determinant of patient choice, but how this factor affects SDM is under-explored.

METHODS

Visits at 4 RA clinics during which patients faced a decision to change their treatment were audiotaped between May 2016 and June 2017. Audiotapes were transcribed verbatim and analyzed using qualitative framework analysis.

RESULTS

A total of 156 visits were analyzed. Most patients with RA, except those with effective insurance coverage, had deliberations disrupted or sidelined by third-party insurance providers having power to authorize the preferred disease-modifying antirheumatic drug choice. This triangulated SDM complicated efficiency in deliberations and timely treatment and was a barrier to shared engagement about health risks and symptom improvement typically found in patient-provider dyads.

CONCLUSION

Rheumatology care providers should aim to incorporate treatment costs and ability to pay into their deliberations so that individualized out-of-pocket estimates can be considered during triangulated SDM at the point-of-care.

"I'd Like to Have More of a Say Because It's My Body": Adolescents' Perceptions Around Barriers and Facilitators to Shared Decision-Making

PURPOSE

Adolescents living with long-term conditions (LTCs) often feel as though they are left out of discussions and decisions with healthcare professionals, which can give them the impression that their views are not important. Research around decision-making during clinical encounters often fails to represent adolescents' perspectives. This study explores adolescents' perceptions and experiences, focusing on identifying the perceived barriers to, and facilitators for, their involvement in shared decision-making (SDM).

METHODS

Nineteen adolescents (aged 13-19 years) with LTCs were recruited from endocrinology, rheumatology, neurology, and nephrology clinics. Participatory qualitative interviews were conducted using life grids and pie charts, and transcripts were analyzed thematically.

RESULTS

Four overarching themes and nine sub-themes were identified which describe barriers and facilitators around SDM. Adolescents need to feel, as though their involvement is supported by parents and healthcare professionals, that their contribution to the decision-making process is important and will yield a positive outcome. Adolescents often feel it is their right to be involved in decisions that affect them but also feel as though the adults' contributions to the decisions are considered more valuable. Adolescents need to feel capable of being involved, in terms of being able to understand and process information about the available options and ask appropriate questions.

CONCLUSIONS

This work highlights a number of ways SDM can be facilitated between healthcare practitioners and adolescents with LTCs. Identifying the needs of adolescents with LTCs is necessary for optimizing the SDM process and to support them during healthcare consultations.

Management of rheumatoid arthritis: 2019 updated consensus recommendations from the Hong Kong Society of Rheumatology

The expanding range of treatment options for rheumatoid arthritis (RA), from conventional synthetic disease-modifying antirheumatic drugs (DMARDs) to biological DMARDs (bDMARDs), biosimilar bDMARDs, and targeted synthetic DMARDs, has improved patient outcomes but increased the complexity of treatment decisions. These updated consensus recommendations from the Hong Kong Society of Rheumatology provide guidance on the management of RA, with a focus on how to integrate newly available DMARDs into clinical practice. The recommendations were developed based on evidence from the literature along with local expert opinion. Early diagnosis of RA and prompt initiation of effective therapy remain crucial and we suggest a treat-to-target approach to guide optimal sequencing of DMARDs in RA patients to achieve tight disease control. Newly available DMARDs are incorporated in the treatment algorithm, resulting in a greater range of second-line treatment options. In the event of treatment failure or intolerance, switching to another DMARD with a similar or different mode of action may be considered. Given the variety of available treatments and the heterogeneity of patients with RA, treatment decisions should be tailored to the individual patient taking into consideration prognostic factors, medical comorbidities, drug safety, cost of treatment, and patient preference.

Development of a methotrexate educational guide/information/monitoring booklet for inflammatory arthritis

INTRODUCTION

There are over 40,000 people living in Ireland with inflammatory arthritis (IA), a condition that is potentially destructive in nature and can have personal, social and economic consequences. Although we have witnessed dramatic changes in the treatment of IA in the last two decades, methotrexate (MTX) remains the first-line treatment for patients with a diagnosis of IA. Despite the fact that MTX is so commonly prescribed, there is a lack of educational materials both for healthcare professionals (HCPs) and patients. The aim of the present study was to develop a suite of MTX material for patients.

METHODS

A comprehensive literature review of MTX (evidence, educational materials and practice guidelines) in the treatment of IA was undertaken. The content of the documents was developed, and the format and structure of the documents were agreed. A tailored patient educational guide, information/monitoring booklet and alert card were designed to address the lack of educational materials for this condition. A national pilot study of the documents was conducted (a postal questionnaire for patients and electronic survey for clinical nurse specialists). Results and recommendations were incorporated into the final documents. These documents were also incorporated into the National Clinical Care Programme-rheumatology-methotrexate pathway.

RESULTS

A 26-page evidence-based educational guide was produced to support the HCP in educating patients taking MTX, in conjunction with a patient information/monitoring booklet and alert card to support the patient.

CONCLUSIONS

These documents are now widely available and used in clinical practice in Ireland, providing patients with standardized, evidence-based information about MTX.

The relationship between role preferences in decision-making and level of psychological distress in patients with head and neck cancer

OBJECTIVE

Is there a relationship between decision-making preferences and psychological distress?

METHODS

Patients who had received treatment for head and neck cancer (HNC) at four institutions within NSW, Australia were invited to complete a single questionnaire.

RESULTS

Five hundred and ninety-seven patients completed the questionnaire. The majority of patients (308, 54%) preferred shared decision making. Significant predictors of a preference towards active decision making were education level (OR 2.1 for tertiary, p < 0.001), primary cancer site (OR 1.9 for thyroid compared to salivary gland, p = 0.024) and gender (OR 1.4 for female, p = 0.028). Mean psychological distress score on Kessler 6 (K6) was 9 (Range: 0-28). Significant predictors of psychological distress were age (p < 0.001), gender (p < 0.001), primary site (p < 0.01), and decision preference (p < 0.01).

CONCLUSION

HNC patients who are either tertiary educated or female are more likely to prefer active involvement in decision-making. Psychological distress is more likely in patients actively involved in decision making, younger patients, and in females.

PRACTICE IMPLICATIONS

Patients experienced paternalistic decision-making, but most preferred active or a shared approached. Clinicians need to be aware of potential for psychological distress in active decision-makers and refer patients for psychosocial support.

Patients' perceived health information needs in inflammatory arthritis: A systematic review

OBJECTIVES

To identify the breadth of the literature regarding patients' perceived health information needs related to inflammatory arthritis care.

METHODS

A systematic scoping review of MEDLINE, EMBASE, CINAHL and PsycINFO was performed to identify relevant articles (1990 -2016) examining patients' perceived needs relating to health information in inflammatory arthritis. Data and themes were identified and categorised and risk of bias assessed.

RESULTS

Twenty nine studies (11 quantitative, 14 qualitative and 4 mixed methods) from 4121 identified articles were relevant for inclusion. Most focussed on rheumatoid arthritis. Key findings included: (1) Reasons for seeking health information often focussed on gaining ownership over their condition and facilitating self-management. (2) Demographic differences in information needs were inconsistent, but women and younger patients generally reported more needs. (3) Desired information content was broad, and included targeted and practical information covering disease treatment and psychosocial wellbeing. (4) Preferred information delivery method was consultation with a Rheumatologist; however group sessions had advantages for psychosocial issues while written information provided useful supplementation. (5) Barriers to meeting health information needs were around timely access.

CONCLUSIONS

Patients with inflammatory arthritis have high information needs, desiring practical and individualised information. When developing strategies to meet patients' information needs, aligning patient expectations with delivery methods that are accessible, cost-effective and flexible may help to optimize patient outcomes.

Rheumatoid Arthritis Patients' Motivations for Accepting or Resisting Disease-Modifying Antirheumatic Drug Treatment Regimens

OBJECTIVE

Patient refusal of and nonadherence to treatment with disease-modifying antirheumatic drugs (DMARDs) can adversely affect disease outcomes in rheumatoid arthritis (RA). This qualitative study describes how RA patients' feelings in response to experiences and information affected their decisions to accept (agree to adopt, initiate, and implement) or resist (refuse, avoid, and discontinue) DMARD treatment regimens.

METHODS

A total of 48 RA patients were interviewed about their experiences making decisions about DMARDs. The interviews were transcribed, coded, and analyzed for themes related to their internal motivations for accepting or resisting treatment regimens, using a narrative analysis approach.

RESULTS

In addition to feelings about the necessity and dangers of medications, patients' feelings towards their identity as an ill person, the act of taking medication, and the decision process itself were important drivers of patient's decisions. For patients' motivations to accept treatment regimens, 2 themes emerged: a desire to return to a normal life, and fear of future disability due to RA. For motivations to resist treatment regimens, 5 themes emerged: fear of medications, maintaining control over health, denial of sick identity, disappointment with treatment, and feeling overwhelmed by the cognitive burden of deciding.

CONCLUSION

Feelings in response to experiences and information played a major role in how patients weighed the benefits and costs of treatment options, suggesting that addressing patients' feelings may be important when rheumatologists counsel about therapeutic options. Further research is needed to learn how best to address patients' feelings throughout the treatment decision-making process.

Patient-perceived health service needs in inflammatory arthritis: A systematic scoping review

BACKGROUND

Care that is patient-centred is more likely to be sustainable and associated with improved health outcomes. This approach to care requires an understanding of patients' health service needs, yet few studies have directly investigated the perceived health service needs of people with inflammatory arthritis.

OBJECTIVES

To systematically identify the existing literature relating to patient perceived health service needs for inflammatory arthritis.

METHODS

A systematic review of MEDLINE, EMBASE, CINAHL, and PsycINFO was conducted (1990-2016). Studies examining patients' perceived needs relating to health services for inflammatory arthritis were identified. Descriptive data regarding study design and methodology were extracted and risk of bias assessed. Findings were collated and categorized thematically.

RESULTS

In total, 27 of 1405 (16 qualitative, 9 quantitative, and 2 mixed-methods) studies were relevant. The main areas of perceived need related to (1) Communication: consumers wanted clear, empathic communication, and to be involved with decision-making. (2) Characteristics of ongoing care: adequate consultation length with continuity and timely care were valued. (3) Factors influencing care-seeking included individual attitudes, disease severity, finances and family expectations. (4) Allied health and complementary and alternative medicines (CAM) were perceived as useful by many. The reporting of CAM use to doctors was variable, with several factors contributing to under-reporting.

CONCLUSIONS

This review identified patients' perceived needs for better communication with their health providers, the heterogeneity of influences determining when care is sought and preferences regarding non-pharmacologic therapies. Aligning patients' perceived needs with evidence-based therapy for people with inflammatory arthritis will be important in optimizing patient outcomes.

Music for anxiety reduction in patients undergoing cardiac catheterization: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Medical diagnostic procedures, such as cardiac catheterization, can cause significant patient anxiety. Patient anxiety can have negative implications for compliance with healthcare visits, medical tests, and treatments. Music interventions may have a role in reducing anxiety related to cardiac catheterization procedures.

OBJECTIVE

To perform a comprehensive systematic review and meta-analysis evaluating whether musical interventions reduce anxiety in patients undergoing cardiac catheterization.

DATA SOURCES

MEDLINE, EMBASE, CENTRAL, AMED, and PsychINFO from inception to May 2015. Reference lists of included articles were further hand searched for additional eligible studies.

STUDY SELECTION

Randomized controlled trials evaluating the effectiveness of music interventions for anxiety reduction in patients undergoing cardiac catheterization.

DATA EXTRACTION AND SYNTHESIS

Data on trial design, baseline characteristics and outcomes was extracted using a data extraction table. Study quality and risk of bias were assessed using the JADAD scale.

MAIN OUTCOMES AND MEASURES

The main outcome was the effectiveness of music interventions in reducing anxiety in this patient population. Meta-analysis was pursued using data from studies that had used the Spielberger state anxiety inventory (STAI-S) to measure anxiety reduction. Other outcomes qualitatively reported include the use of anxiolytic medications and effect on physiological parameters such as blood pressure and heart rate.

RESULTS

A total of 15 studies were found to be eligible for inclusion (14 published trials and one conference abstract) in this review. Two-thirds of these studies showed statistically significant reduction in measures of patient anxiety or well-being with musical interventions. Meta-analysis included six studies (n = 695) and showed statistically significant reduction in mean STAI-S scores with music (-3.95 points; 95% confidence -5.53 and -2.37; p value less than 0.005).

CONCLUSION AND RELEVANCE

In conclusion, music is a safe and easily administered intervention that can be used for anxiety reduction among patients undergoing cardiac catheterization. Further research is needed to better evaluate the clinical implications associated with the anxiolytic effects of music interventions during cardiac catheterization.

Development of a web-based patient decision aid for initiating disease modifying anti-rheumatic drugs using user-centred design methods

Background

A main element of patient-centred care, Patient Decision Aids (PtDAs) facilitate shared decision-making (SDM). A recent update of the International Patient Decision Aids Standards (IPDAS) emphasised patient involvement during PtDA development, but omitted a methodology for doing so. This article reports on the value of user-centred design (UCD) methods for the development of a PtDA that aims to support inflammatory arthritis patients in their choice between disease modifying anti-rheumatic drugs (DMARDs).

Methods

The IPDAS development process model in combination with UCD methods were applied. The process was overseen by an eight-member multidisciplinary steering group. Patients and health professionals were iteratively consulted. Qualitative in-depth interviews combined with rapid prototyping were conducted with patients to assess their needs for specific functionality, content and design of the PtDA. Group meetings with health professionals were organized to assess patients’ needs and to determine how the PtDA should be integrated into patient pathways. The current literature was reviewed to determine the clinical evidence to include in the PtDA. To evaluate usability among patients, they were observed using the PtDA while thinking aloud and then interviewed.

Results

The combination of patient interviews with rapid prototyping revealed that patients wanted to compare multiple DMARDs both for their clinical aspects and implications for daily life. Health professionals mainly wanted to refer patients to a reliable, easily adjustable source of information about DMARDs. A web-based PtDA was constructed consisting of four parts: 1) general information about SDM, inflammatory arthritis and DMARDs; 2) an application to compare particular DMARDs; 3) value clarification exercises; and 4) a printed summary of patients’ notes, preferences, worries and questions that they could bring to discuss with their rheumatologist.

Conclusions

The study demonstrated that UCD methods can be of great value for the development of PtDAs. The early, iterative involvement of patients and health professionals was helpful in developing a novel user-friendly PtDA that allowed patients to choose between DMARDs. The PtDA fits the values of all stakeholders and easily integrates with the patient pathway and daily workflow of health professionals. This collaborative designed PtDA may improve SDM and patient participation in arthritis care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-017-0433-5) contains supplementary material, which is available to authorized users.

Shared decision-making for biologic treatment of autoimmune disease: influence on adherence, persistence, satisfaction, and health care costs

BACKGROUND

Shared decision-making (SDM), a process whereby physicians and patients collaborate to select interventions, is not well understood for biologic treatment of autoimmune conditions.

METHODS

This was a cross-sectional survey of adults initiating treatment for Crohn's disease or ulcerative colitis (inflammatory bowel disease, IBD) or psoriatic arthritis or rheumatoid arthritis (RA/PA). Survey data were linked to administrative claims for 6 months before (baseline) and after (follow-up) therapy initiation. Measures included the Shared Decision Making Questionnaire, Patient Activation Measure (PAM), Morisky Medication Adherence Scale (MMAS), general health, and treatment satisfaction. Claims-based Quan-Charlson comorbidity scores, persistence, medication possession ratio (MPR), and health care costs were examined. Patients were compared by participation (SDM) and nonparticipation (non-SDM) in SDM.

RESULTS

Among 453 respondents, 357 were eligible, and 306 patients (204 RA/PA and 102 IBD) were included in all analyses. Overall (n=357), SDM participants (n=120) were more often females (75.0% vs 62.5%, P=0.018), had lower health status (48.0 vs 55.4, P=0.005), and higher Quan-Charlson scores (1.0 vs 0.7, P=0.035) than non-SDM (n=237) participants. Lower MMAS scores (SDM 0.17 vs non-SDM 0.41; P<0.05) indicated greater likelihood of adherence; SDM participants also reported higher satisfaction with medication and had greater activation (PAM: SDM vs non-SDM: 66.9 vs 61.6; P<0.001). Mean MPR did not differ, but persistence was longer among SDM participants (111.2 days vs 102.2 days for non-SDM; P=0.029). Costs did not differ by SDM status overall, or among patients with RA/PA. The patients with IBD, however, experienced lower (P=0.003) total costs ($9,404 for SDM vs $25,071 for non-SDM) during follow-up.

CONCLUSION

This study showed greater likelihood of adherence and satisfaction for patients who engaged in SDM and reduced health care costs among patients with IBD who engaged in SDM. This study provides a basis for defining SDM participation and detecting differences by SDM participation for biologic treatment selection for autoimmune conditions.

Evaluation of a patient decision aid for initiating disease modifying anti-rheumatic drugs

BACKGROUND

According to international guidelines, treatment of inflammatory arthritis should be based on a shared decision between patient and rheumatologist. Furthermore, patients with inflammatory arthritis have high need of information and want to be more actively involved in medical decision-making. To facilitate shared decision-making and support patients in choosing between disease modifying anti-rheumatic drugs (DMARDs), a web-based patient decision aid (PtDA) was developed. This study evaluated use, appreciation and effect of this PtDA.

METHODS

A post-test only study with a historical comparison group was conducted. In a two-year period, all patients diagnosed with rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis, who were deciding whether to start a (different) DMARD were invited to participate. In the first year, patients received standard information (comparison group). In the second year, patients were referred to the PtDA (intervention group). In both groups, a questionnaire was sent four weeks after consulting the rheumatologist. Patient characteristics included sociodemographic, health-related and preference-related variables. Process measures were for use and appraisal of the PtDA (intervention group only). The primary outcome measure was patients' perceived role in medical decision-making. Secondary outcome measures comprised satisfaction with the decision-making process and the decision, beliefs about medication, adherence to medication and trust in the physician.

RESULTS

We received 158/232 questionnaires (68 %) from the comparison group and 123/200 (61 %) from the intervention group. The PtDA was used by 69/123 patients (57 %) in the intervention group. Patients who used the PtDA highly appreciated it and perceived it as easy to use and helpful. Relative to the comparison group, patients in the intervention group perceived a more active role in medical decision-making and decisions were more in line with patients' personal preferences. Other outcomes showed no significant difference between the two groups.

CONCLUSION

The web-based PtDA was highly appreciated and perceived as helpful for decision-making. Implementation of the PtDA in rheumatology practice was associated with a significantly larger proportion of patients perceiving an active role in medical decision-making and decisions were more in line with patients' personal preferences. The PtDA can be a valuable aid in improving patient participation in decision-making about DMARDs.

Modes of Decision Making Used by Nursing Home Residents and Their Families When Confronted With Potential Hospital Readmission

The purpose of the current study was to characterize the decision-making processes used by nursing home (NH) residents and their families when confronted with an acute change in condition and the choice of transfer to the hospital or treatment in the NH. Using cognitive task analysis, 96 residents and 75 family members from 19 NHs were asked how they would make this choice. Fifty-one residents (53%) and 61 family members (81%) used a deliberative mode characterized by seeking information and weighing risks and benefits. Ten residents (10%) and five family members (7%) used a predominantly emotion-based mode characterized by references to feelings and prior experiences in these facilities. Thirty-six residents (38%) and nine family members (12%) delegated the decision to a family member or provider. Age and resident/family status were associated with mode used; transfer choice, gender, religion, education, and ethnic group were not. Although classic theories of information processing posit two modes of decision making, deliberative and affective, the current data suggest a third mode, that of delegating the decision to trusted others, particularly family members and providers. [Res Gerontol Nurs. 2016; 9(6):288-299.].

Evolution of Patient Decision-Making Regarding Medical Treatment of Rheumatoid Arthritis

OBJECTIVE

The migration of health care toward a consumer-driven system favors increased patient participation during the treatment decision-making process. Patient involvement in treatment decision discussions has been linked to increased treatment adherence and patient satisfaction. Previous studies have quantified decision-making styles of patients with rheumatoid arthritis (RA); however, none of them have considered the evolution of patient involvement after living with RA for many years. We conducted a qualitative study to determine the decision-making model used by long-term RA patients, and to describe the changes in their involvement over time.

METHODS

Twenty participants were recruited from the ongoing Silicone Arthroplasty in Rheumatoid Arthritis study. Semistructured interviews were conducted and data were analyzed using grounded theory methodology.

RESULTS

Nineteen out of 20 participants recalled using the paternalistic decision-making (PDM) model immediately following their diagnosis. Fourteen of the 19 participants who initially used PDM evolved to shared decision-making (SDM). Participants attributed the change in involvement to the development of a trusting relationship with their physician, as well as to becoming educated about the disease.

CONCLUSION

When initially diagnosed with RA, patients may let their physician decide on the best treatment course. However, over time patients may evolve to exercise a more collaborative role. Physicians should understand that even within SDM, each patient can demonstrate a varied amount of autonomy. It is up to the physician to have a discussion with each patient to determine his or her desired level of involvement.

Japanese physicians' preferences for decision making in rheumatoid arthritis treatment

BACKGROUND

Rheumatoid arthritis (RA) is a complex chronic illness requiring continued medical care. During the past decade, the therapeutic options for RA have increased significantly; these often have a higher risk of adverse effects and are more expensive than traditional drugs. Rheumatologists may hence face difficulties when deciding on the optimal modality in initiating or changing treatment. The aim of this study was to explore the Japanese physicians' usual style of and preferences for decision making regarding RA treatment.

METHODS

This was a cross-sectional study conducted using an Internet survey. Respondents were asked about their usual style of making treatment decisions (perceived style), and their perception of the importance of physicians' actions and patients' attitudes.

RESULTS

Of the 485 physicians who were sent the questionnaire, 157 responded completely (response rate: 32.3%). Ninety-two percent of the respondents were men, and 57% were clinicians with more than 20 years of experience. Their specialties were general medicine (29%), rheumatology (27%), orthopedics (31%), and rehabilitation (12%). Sixty-one (39%) stated that they usually presented multiple treatment options to their patients and selected a decision for them, 42 (27%) shared the decision making with their patients, 34 (22%) let their patients choose the treatment, and 20 (13%) made the treatment decision for the patients. Physicians using the shared decision making (SDM) style desired for their patients to have supportive family and friends, to discuss with nurses, and to follow the doctors' directions more strongly compared with physicians using the other styles. There were no significant differences in sex, duration of clinical experience, major place of clinical work, and number of patients per month by the styles. More number of rheumatologists and physicians with specialist qualifications stated that they practiced SDM.

CONCLUSION

To enhance patient participation, physicians need to recognize the importance of discussing treatment options with patients in addition to giving them information.