Qualitative assessment of medication adherence in patients with rheumatic diseases on biologic therapy

Factors influencing choice of b/ts DMARDs in managing inflammatory arthritis from a patient perspective: a systematic review of global evidence and a patient-based survey from Hong Kong

OBJECTIVES

To investigate factors concerning patients regarding biological/target synthetic disease-modifying antirheumatic drugs (b/ts DMARDs) in treating inflammatory arthritis (IA).

DESIGN

This study consists of a systematic review and a cross-sectional survey in Hong Kong. A systematic review of literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses was conducted on PubMed, Web of Science, Cochrane and Embase between 1 January 2000 and 1 January 2022. Content analysis was conducted to summarise factors grouped by four themes-social aspects (SA), clinical aspects (CA), medicine characteristics (MC) and financial aspects (FA) in the decision-making process. One cross-sectional survey among Hong Kong patients with IA was conducted to add to global evidence.

SETTING

A systematic review of global evidence and a patient-based survey in Hong Kong to complement scarce evidence in Asia regions.

RESULTS

The systematic review resulted in 34 studies. The four themes were presented in descending order consistently but varied with frequency throughout decision-making processes. During decision-making involving medication initiation, preference and discontinuation, MC (reported frequency: 83%, 86%, 78%), SA (56%, 43%, 78%) and FA (39%, 33%, 56%) were the three most frequently reported factors, whereas CA was less studied. Local survey also revealed that MC factors such as treatment efficacy and the probability of severe adverse events, and SA factors such as the availability of government or charity subsidy, influenced patients' initiation and preference for b/ts DMARDs. Meanwhile, self-estimated improvement in disease conditions (SA), drug side effects (MC) and drug costs (FA) were associated with treatment discontinuation.

CONCLUSIONS

Global and local evidence consistently indicate that MC and SA are important considerations in patients' decisions regarding novel DMARDs. Health policies that reduce patients' financial burden and enhances healthcare professionals' engagement in decision-making and treatment delivery should be in place with an efficient healthcare system for managing IA optimistically.

Exploring the emotional impact of axial Spondyloarthritis: a systematic review and thematic synthesis of qualitative studies and a review of social media

BACKGROUND

The psychological burden in people with inflammatory arthritis is substantial, yet little is known about the disease-related affect experienced by individuals with axial Spondyloarthritis (axial SpA). The aim of this study was to conduct a qualitative evidence synthesis and a review of social media to explore the emotional impact of living with axial SpA.

METHODS

We searched nine databases for studies reporting qualitative data about participants' emotional experience of living with axial SpA. In addition, we searched social media platforms for posts from people with axial SpA based in the UK that offered insights into emotional responses to living with the condition. We employed a thematic approach to synthesise the data.

RESULTS

We included 27 studies (1314 participants; 72% men) in our qualitative evidence synthesis and developed seven descriptive themes from the data: 1) delayed diagnosis: a barrier to emotional wellbeing; 2) disruptive symptoms: a source of mood swings; 3) work disability: a loss of self-esteem; 4) obstacles in interpersonal relationships: a trigger of distress; 5) taking up exercise: personal pride or unwelcomed reminders; 6) anti-TNF therapy: hope reignited despite concerns and 7) a journey of acceptance: worry mixed with hope. Posts extracted from social media fora (537; 48% from women) for the most part supported the seven themes. One additional theme-COVID-19, uncertainty and anxiety during the pandemic, was developed, reflecting common emotions expressed during the UK's first wave of the coronavirus pandemic.

CONCLUSION

This study highlights a preponderance of negative affect experienced by people living with axial SpA, conditioned through existing and anticipated symptoms, failed expectations, and lost sense of self. Given the bidirectional relationships between negative emotions and inflammation, negative emotions and perceptions of pain, and the influence of affect in self-care behaviours, this finding has important implications for treatment and management of people with axial SpA.

The Impact of a Theory-Based mHealth Intervention on Disease Knowledge, Self-efficacy, and Exercise Adherence Among Ankylosing Spondylitis Patients: Randomized Controlled Trial

BACKGROUND

Patient education is recommended as an integral part of disease management in ankylosing spondylitis (AS), a chronic rheumatic disease that predominantly affects young males and requires long-term disease management. Convenient and cost-effective approaches to deliver patient education are required to these patients.

OBJECTIVE

This study aimed to examine the effects of a theory-based educational intervention delivered through a social networking app, WeChat, on disease knowledge, self-efficacy, exercise adherence, and health outcomes in Chinese AS patients.

METHODS

This study was a single-blind randomized controlled trial conducted in a tertiary hospital in Chengdu, China. Eligible participants were randomly allocated to the intervention or control group. Participants in the control group received standard care. The intervention group received the health belief model (HBM)-based educational intervention, consisting of 4 individual educational sessions and educational information sharing through WeChat, the predominant social networking app in China. The primary outcomes were disease knowledge, self-efficacy, and exercise adherence. The secondary outcomes were disease activity and physical function. Data were collected at baseline and at the end of the intervention (12th week). Chi-square test, t test, Mann-Whitney U tests were used to examine the effects of educational intervention.

RESULTS

This study included 118 patients with AS. The majority of participants were male (93/118, 78.8%). Around half of them were married (56/118, 47.5%), never smoked (70/118, 59.3%), and had college educational level or above (62/118, 52.5%). At posttest, participants in the intervention group had higher disease knowledge (all P<.001) and self-efficacy (P<.001), and a larger proportion of participants in the intervention group adhered to regular exercise routines than those in the control group (P=.003). The within-group analyses for the intervention group showed increases in all scores of disease knowledge (all P<.001) and self-efficacy score (P<.001), but only correct answer score (P=.04) and general knowledge score (P=.002) of disease knowledge in the control group improved. The within-group analysis for the control group found a decline of physical function (P=.002) but no significant change in disease activity (P>.05). The within-group analysis for the intervention group showed no significant change in disease activity or physical function (P>.05). At posttest, no statistically significant difference was found on disease activity or physical function between the intervention and control groups (P>.05).

CONCLUSIONS

The HBM-based educational intervention through WeChat can effectively improve patient disease knowledge, self-efficacy, and exercise adherence. WeChat is feasible and effective to deliver patient education for patients with chronic diseases such as AS. This mHealth intervention can be integrated into routine rheumatology care.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-IPR-16009293; https://tinyurl.com/swxt8xk7.

Patient-reported adherence to physical exercises of patients with ankylosing spondylitis

Introduction

Studies on adherence to exercise therapy of patients with ankylosing spondylitis (AS) are rare, and the criteria for adherence to exercise are inconsistent. This study aimed to quantify patient-reported adherence to exercise therapy of Chinese outpatients with AS and investigate the factors related to poor adherence.

Methods

The subjects’ sociodemographic, disease-related, radiographic, and laboratory parameters were collected. Patients’ adherence to exercise therapy was assessed using the Exercise Attitude Questionnaire (EAQ) with a 4-point Likert scale. All cases were grouped as good adherence and poor adherence using a cutoff score of 60, according to a previous study. Univariate analysis was conducted to assess the intergroup differences. Then, we built a multivariate logistic regression model to identify possible significant factors related to poor adherence to exercise therapy.

Results

A total of 185 outpatients completed the questionnaire. The mean EAQ score was 49.4 (IQR, 40.7–59.3) and 146 patients (78.9%) were considered to have poor adherence, and 39 patients (21.1%) were considered to have good adherence. The rates of current nonsteroidal anti-inflammatory drugs (NSAIDs), conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), and tumor necrosis factor-α inhibitor (TNF-i) use were significantly higher in the poor adherence group (p=0.001, p=0.027, p=0.018, respectively). Our multivariate logistic regression model revealed that the only significant associated factor was current use of NSAIDs (OR=3.517; p=0.016; 95% CI, 1.259–9.827).

Conclusions

Outpatients with AS had an unacceptable level of adherence to exercise therapy, and current use of NSAIDs was a significantly associated factor.

Key Points • Outpatients with AS had an unacceptable level of adherence to exercise therapy. • Current use of NSAIDs exerted a negative impact on patients’ adherence to exercise therapy.

An Overview on Causes of Nonadherence in the Treatment of Rheumatoid Arthritis: Its Effect on Mortality and Ways to Improve Adherence

Rheumatoid arthritis is one of the most prevalent musculoskeletal disorders that, when insufficiently treated, results in detrimental sequelae including joint damage and reduced quality of life. Poor patient adherence to medication is a significant blockade to effective management. The purpose of this review is to highlight and discuss the factors responsible for defiance of antirheumatic medication and ways to overcome these barriers. Education level, health literacy, cohabitation status, multi-morbidities, complicated drug regimen, intermittent co-payments, prescribed regimen adverse effects, and cognitive impairment are a few among many common barrier factors leading to poorer outcomes in rheumatoid arthritis. While there is an abundance of inhibitory factors leading to worsening disease progression, they each can be easily dealt with an effective approach at the beginning or during the treatment course to ensure a better outcome.

Experiences of the Patients with Behcet's Syndrom from Adherence to Treatment: A Qualitative Content Analysis

Background

Adherence to treatment plays an important role in the effectiveness of treatment in patients with Behcet's Syndrome (BS). An in-depth understanding of the experiences of patients with BS will help to improve the patients' management. The present qualitative study aimed to explore the experiences of patients with BS from adherence to treatment.

Methods

This qualitative study was conducted during February-September 2019 at Shahid Motahari Behcet's Clinic in Shiraz, Iran. Data were collected through eight unstructured observations and 22 individual in-depth semi-structured interviews with 20 participants (15 patients with BS, three family members, and two rheumatologists). Data analysis was performed simultaneously with data collection, using the conventional content analysis as proposed by Graneheim and Lundman. Data were managed using MAXQDA 10 software.

Results

Data analysis resulted in 21 sub-categories, seven categories, and three themes. The themes included barriers to treatment adherence (inability to cope with treatment and challenges in access to health care), facilitators of treatment adherence (incentives, receiving support, and striving to adapt to illness), and missing aspects of the treatment program (inadequate patient education and the neglect of lifestyle modification).

Conclusion

The barriers to and facilitators of treatment adherence as well as the missing aspects of the treatment program of patients with BS were identified. Adherence to treatment is not only determined by the patients, but also affected by the support system and relies upon the existing context and the nature of the treatment plan. These parameters should be considered during patient management to effectively promote treatment adherence.

Factors that influence biological survival in rheumatoid arthritis: results of a real-world academic cohort from the Netherlands

We aim to explore real-world biological survival stratified for discontinuation reason and determine its influenceability in rheumatoid arthritis (RA) patients. Data from the local pharmacy database and patient records of a university hospital in the Netherlands were used. RA patients who started a biological between 2000 and 2020 were included. Data on age, anti-citrullinated protein antibody (ACPA) and rheumatoid factor (RF) status, presence of erosions, gender, body mass index, time to first biological, biological survival time, use of csDMARDs, and discontinuation reasons were collected. Of the included 318 patients, 12% started their first biological within 6 months after diagnosis. The median time to first biological was 3.6 years (95% CI, 1.0–7.2). The median survival of the first- and second-line biological was respectively 1.7 years (95% CI, 1.3–2.2) and 0.8 years (95% CI, 0.5–1.0) (p = 0.0001). Discontinuation reasons for the first-line biological were ineffectiveness (47%), adverse events (17%), remission (16%), pregnancy (30%), or patient preference (10%). Multivariable Cox regression analyses for discontinuation due to inefficacy or adverse events showed that concomitant use of csDMARDs (HR = 1.32, p < 0.001) positively while RF positivity negatively (HR = 0.82, p = 0.03) influenced biological survival. ACPA positivity was associated with the inability to discontinue biologicals after achieving remission (HR = 1.43, p = 0.023). Second-line TNF inhibitor survival was similar between patients with a primary and secondary non-response on the first-line TNF inhibitor (HR = 1.28, p = 0.34). Biological survival diminishes with the number of biologicals used. Biological survival is prolonged if patients use csDMARDs. RF was negatively associated with biological survival. ACPA was negatively associated with the inability to discontinue biologicals after achieving remission. Therefore, tailoring treatment based upon autoantibody status might be the first step towards personalized medicine in RA.

Key Points • Prolonged biological survival is a surrogate for treatment effectiveness; however, an increasing amount of patients will taper treatment due to remission, and factors influencing biological survival based on separate reasons for discontinuation have not been explored. • We found that combining a biological DMARD with a conventional synthetic DMARD increases biological DMARD survival. Rheumatoid factor is negatively associated with biological survival. Anti-citrullinated protein antibody is negatively associated with the inability to discontinue the biological when remission was reached. • The first step towards personalized medicine might be tailoring of treatment based upon autoantibody status.