Unwillingness of rheumatoid arthritis patients to risk adverse effects

Physical function and severe side effects matter most to patients with RA (< 5 years): a discrete choice experiment assessing preferences for personalized RA treatment

AIM

Early assessment of patient preferences has the potential to support shared decisions in personalized precision medicine for patients with rheumatoid arthritis (RA). The aim of this study was to assess treatment preferences of patients with RA (< 5 years) with previous experience of inadequate response to first-line monotherapy.

METHOD

Patients were recruited (March-June 2021) via four clinics in Sweden. Potential respondents (N = 933) received an invitation to answer a digital survey. The survey included an introductory part, a discrete choice experiment (DCE) and demographic questions. Each respondent answered 11 hypothetical choice questions as part of the DCE. Patient preferences and preference heterogeneity were estimated using random parameter logit models and latent class analysis models.

RESULTS

Patients (n = 182) assessed the most important treatment attributes out of physical functional capacity, psychosocial functional capacity, frequency of mild side effects and likelihood of severe side effects. In general, patients preferred a greater increase in functional capacity and decreased side effects. However, a substantial preference heterogeneity was identified with two underlying preference patterns. The most important attribute in the first pattern was the 'likelihood of getting a severe side effect'. Physical functional capacity was the most important attribute in the second pattern.

CONCLUSION

Respondents focused their decision-making mainly on increasing their physical functional capacity or decreasing the likelihood of getting a severe side effect. These results are highly relevant from a clinical perspective to strengthen communication in shared decision making by assessing patients' individual preferences for benefits and risks in treatment discussions.

Oral Conventional Synthetic Disease-Modifying Antirheumatic Drugs with Antineoplastic Potential: a Review

There is an increasing trend of malignancy worldwide. Disease-modifying antirheumatic drugs (DMARDs) are the cornerstones for the treatment of immune-mediated inflammatory diseases (IMIDs), but risk of malignancy is a major concern for patients receiving DMARDs. In addition, many IMIDs already carry higher background risks of neoplasms. Recently, the black box warning of malignancies has been added for Janus kinase inhibitors. Also, the use of biologic DMARDs in patients with established malignancies is usually discouraged owing to exclusion of such patients in pivotal studies and, hence, lack of evidence. In contrast, some conventional synthetic DMARDs (csDMARDs) have been reported to show antineoplastic properties and can be beneficial for patients with cancer. Among the csDMARDs, chloroquine and hydroxychloroquine have been the most extensively studied, and methotrexate is an established chemotherapeutic agent. Even cyclosporine A, a well-known drug associated with cancer risk, can potentiate the effect of some chemotherapeutic agents. We review the possible mechanisms behind and clinical evidence of the antineoplastic activities of csDMARDs, including chloroquine and hydroxychloroquine, cyclosporine, leflunomide, mycophenolate mofetil, mycophenolic acid, methotrexate, sulfasalazine, and thiopurines. This knowledge may guide physicians in the choice of csDMARDs for patients with concurrent IMIDs and malignancies.

Evaluation of an Intervention to Support Patient-Rheumatologist Conversations About Escalating Treatment in Patients with Rheumatoid Arthritis: A Proof-of-Principle Study

Objective

This study’s objective was to test whether an online video intervention discussing appropriate treatment escalation improves willingness to change treatment in people living with rheumatoid arthritis (RA).

Methods

We conducted a controlled, randomized trial among patients with RA enrolled in ArthritisPower, a United States patient registry. We recruited participants by email and surveyed their assessment of disease activity (patient global), satisfaction with disease control (patient acceptable symptom state), attitudes about RA medications, decisional conflict (decisional conflict scale), and willingness to modify RA treatment (choice predisposition scale, higher scores are better) if or when recommended by their rheumatologist. Intervention groups watched educational videos relevant to a treat‐to‐target (T2T) strategy, whereas control groups viewed vaccination‐related videos as an “attention control.” We compared the between‐group difference in patients’ willingness to modify RA treatment (primary outcome) and difference in decisional conflict about changing RA treatment (secondary outcome) after watching the videos using t tests.

Results

Participants with self‐reported RA (n = 208) were 90% White and 90% women, with a mean (standard deviation) age of 50 (11) years, and 52% reported familiarity with the RA T2T strategy. We found a significant improvement in between‐group difference in willingness to change RA treatment among intervention versus control participants (0.49 [95% confidence interval 0.09‐0.88], P = 0.02). The effect size (Glass’s delta) for the intervention was 0.48. Decisional conflict about treatment change decreased, but the between‐group difference was not significant.

Conclusion

This novel educational patient‐directed intervention discussing appropriate treatment escalation was associated with improved willingness to change RA treatment if or when recommended by a rheumatologist. Further studies should evaluate whether this change in patients’ predisposition translates into actual treatment escalation.

Functional capacity vs side effects: treatment attributes to consider when individualising treatment for patients with rheumatoid arthritis

Introduction

Individualisation of rheumatoid arthritis (RA) treatment needs to take account of individual patients’ preferences to increase patient-centeredness in treatment decisions. The aim of this study was to identify patient-relevant treatment attributes to consider when individualising treatment for patients with RA.

Method

Patients with RA in Sweden were invited to rank the most important treatment attributes in an online survey (April to May 2020). Semi-structured interviews were conducted (October to November 2020) to further identify and frame potential attributes for shared decision-making. The interviews were audio-recorded, transcribed and analysed using thematic framework analysis. Patient research partners and rheumatologists supported the selection and framing of the treatment attributes across the assessment.

Results

The highest ranked attributes (N = 184) were improved functional capacity, reduced inflammation, reduced pain and fatigue and the risk of getting a severe side effect. The framework analysis revealed two overarching themes for further exploration: treatment goals and side effects. ‘Treatment goals’ emerged from functional capacity, revealing two dimensions: physical functional capacity and psychosocial functional capacity. ‘Side effects’ revealed that mild and severe side effects were the most important to discuss in shared decision-making.

Conclusions

Functional capacity (physical and psychosocial) and potential side effects (mild and severe) are important treatment attributes to consider when individualising RA treatment. Future research should assess how patients with RA weigh benefits and risks against each other, in order to increase patient-centeredness early on the treatment trajectory.

Treatment Satisfaction, Patient Preferences, and the Impact of Suboptimal Disease Control in a Large International Rheumatoid Arthritis Cohort: SENSE Study

BACKGROUND

Patients' needs and perspectives are important determinants of treatment success in rheumatoid arthritis (RA). Assessing patients' perspectives can help identify unmet needs and enhance the understanding of treatment benefits.

OBJECTIVE

The SENSE study assessed the impact of inadequate response to disease-modifying antirheumatic drugs (DMARDs) on treatment satisfaction, disease outcomes, and patient perspectives related to RA disease management.

METHODS

SENSE was a noninterventional, cross-sectional study conducted in 18 countries across Europe, Asia, and South America. Adult patients with poorly controlled RA of moderate/high disease activity were eligible. Patient satisfaction was assessed by the Treatment Satisfaction Questionnaire for Medication (TSQM v1.4). Treatment adherence, healthcare resource utilization (HRU), quality of life (QoL), work ability, digital health literacy (DHL), patient preference information, and treatment strategy were also assessed.

RESULTS

A total of 1624 patients were included in the study: most were female (84.2%) and middle-aged, and mean disease duration was 10.5 years. Mean TSQM global satisfaction subscore was 60.9, with only 13.5% of patients reporting good treatment satisfaction (TSQM global ≥80). The strongest predictor of good treatment satisfaction was treatment with advanced therapies. Most patients (87.4%) reported good treatment adherence. In general, patients had impaired QoL and work ability, high HRU, and 67.4% had poor DHL. Leading treatment expectations were "general improvement of arthritis" and "less joint pain". Most patients preferred oral RA medications (60.7%) and rapid (≤1 week) onset of action (71.1%). "Increased risk for malignancies" and "increased risk for cardiovascular disease" were the least acceptable side effects. Despite suboptimal control, advanced therapies were only used in a minority of patients, and DMARD switches were planned for only half of the patients.

CONCLUSION

Suboptimal disease control negatively impacts treatment satisfaction, work ability, QoL, and HRU. Data collected on patient perspectives may inform shared decision-making and optimize treat-to-target strategies for improving patient outcomes in RA.

Patient and Rheumatologist Perspectives Regarding Challenges to Achieving Optimal Disease Control in Rheumatoid Arthritis

OBJECTIVE

To identify and prioritize patient- and rheumatologist-perceived barriers to achieving disease control.

METHODS

Patients with rheumatoid arthritis (RA) and rheumatologists from the Corrona registry were invited by e-mail to participate in nominal groups. Two separate lists of barriers were created, 1 from RA patient-only nominal groups and the other from rheumatologist-only nominal groups, and barriers were sorted into themes. Next, using an online survey, a random sample of RA patients from the Corrona registry were asked to rank their top 3 barriers to achieving disease control.

RESULTS

Four nominal groups totaling 37 RA patients identified patient barriers to achieving control of RA activity that were classified into 17 themes. Three nominal groups totaling 25 rheumatologists identified barriers that were classified into 11 themes. The financial aspects of RA care ranked first for both types of nominal groups, while medication risk aversion ranked second among the perceived barriers of the physician nominal group and third among those of the RA patient nominal group. Among the 450 RA patients surveyed, 77% considered RA a top health priority, and 51% reported being aware of the treat-to-target strategy for RA care; the 3 most important patient-perceived challenges to achieving disease control were RA prognosis uncertainty, medication risk aversion, and the financial/administrative burden associated with RA care.

CONCLUSION

There are common, potentially modifiable, patient- and rheumatologist-reported barriers to achieving RA disease control, including perceived medication risk aversion, suboptimal treatment adherence, and suboptimal patient-physician communication regarding the benefits of tight control of disease activity in RA. Addressing these obstacles may improve adherence to goal-directed RA care.

Patient Preferences for Disease-modifying Antirheumatic Drug Treatment in Rheumatoid Arthritis: A Systematic Review

Objective.

To summarize patients’ preferences for disease-modifying antirheumatic drug (DMARD) therapy in rheumatoid arthritis (RA).

Methods.

We conducted a systematic review to identify English-language studies of adult patients with RA that measured patients’ preferences for DMARD or health states and treatment outcomes relevant to DMARD decisions. Study quality was assessed using a published quality assessment tool. Data on the importance of treatment attributes and associations with patient characteristics were summarized across studies.

Results.

From 7951 abstracts, we included 36 studies from a variety of countries. Most studies were in patients with established RA and were rated as medium- (n = 19) or high-quality (n = 12). The methods to elicit preferences varied, with the most common being discrete choice experiment (DCE; n = 13). Despite the heterogeneity of attributes in DCE studies, treatment benefits (disease improvement) were usually more important than both non-serious (6 of 8 studies) and serious adverse events (5 of 8), and route of administration (7 of 9). Among the non-DCE studies, some found that patients placed high importance on treatment benefits, while others (in patients with established RA) found that patients were quite risk averse. Subcutaneous therapy was often but not always preferred over intravenous therapy. Patient preferences were variable and commonly associated with the sociodemographic characteristics.

Conclusion.

Overall, the results showed that many patients place a high value on treatment benefits over other treatment attributes, including serious or minor side effects, cost, or route of administration. The variability in patient preferences highlights the need to individualize treatment choices in RA.

Patients' concerns regarding biological agents in rheumatology

OBJECTIVE

The potential side effects of biological agents may increase the anxiety levels of patients and influence not only their desire to use these therapies but also their concordance to treatment. This study aimed to determine the level and prevalence of drug-related concern in patients treated with biological agents and to acquire additional information regarding the related causes.

MATERIALS AND METHODS

A total of 1134 patients who were using biological agents for at least 3 months with a diagnosis of rheumatic diseases were enrolled. General anxiety levels were evaluated using the State-Trait Anxiety Inventory (STAI).

RESULTS

The most common cause for drug-related concerns was the potential side effects of the drugs (59.5%). Among the potential side effects, cancer risk was the most common cause for concern (40.1%), followed by the risk of tuberculosis activation (30.7%). Anxiety levels were higher in patients who experienced side effects than in other patients, and this difference was statistically significant (P < 0.05). STAI trait and state scores were moderately correlated with anxiety levels related to the drug (P < 0.001).

CONCLUSION

Anxiety related to biological agents may significantly affect the patients' anxiety levels. Awareness regarding the patients' concerns and expectations related to the drug is important to ensure drug adherence and concordance to treatment.

Timing and Impact of Decisions to Adjust Disease-Modifying Antirheumatic Drug Therapy for Rheumatoid Arthritis Patients With Active Disease

OBJECTIVE

Guidelines recommend that rheumatoid arthritis (RA) patients with moderate-to-high disease activity (MHDAS) adjust disease-modifying antirheumatic drug (DMARD) therapy at least every 3 months until reaching low disease activity or remission (LDAS). We examined how quickly RA patients with MHDAS adjust DMARD therapy in clinical practice, and whether those who adjust DMARDs within 90 days in response to MHDAS reach LDAS sooner.

METHODS

We identified RA patients with MHDAS in the University of Pittsburgh Rheumatoid Arthritis Comparative Effectiveness Research registry, and conducted a competing risks regression on time to DMARD therapy adjustment and a Cox regression on time to LDAS.

RESULTS

We identified 538 eligible subjects with 943.5 patient-years of followup. Sixty percent of patients with persistent MHDAS adjusted DMARDs within 90 days. Among all subjects, median times to DMARD adjustment and LDAS were 154 (interquartile range [IQR] 1-706) days and 301 (IQR 140-706) days, respectively. Being elderly (subdistribution hazard ratio [SHR] 0.61, P = 0.02), lower baseline disease activity (SHR 0.72, P < 0.01), longer duration of RA (SHR 0.98, P < 0.01), and biologic use (SHR 0.71, P < 0.01) were significantly associated with longer times to therapy adjustment. African American race (hazard ratio [HR] 0.63, P = 0.01), higher baseline disease activity (HR 0.75, P < 0.01), and not adjusting DMARD therapy within 90 days (HR 0.76, P = 0.01) were associated with longer times to LDAS.

CONCLUSION

Adjusting DMARDs within 90 days was associated with shorter times to LDAS, but many patients with persistent MHDAS waited >90 days to adjust DMARDs. Interventions are needed to address the timeliness of DMARD adjustments for RA patients with MHDAS.

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.

Measuring Patient Preferences: An Overview of Methods with a Focus on Discrete Choice Experiments

There is increasing recognition of the importance of patient preferences and methodologies to measure them. In this article, methods to quantify patient preferences are reviewed, with a focus on discrete choice experiments. In a discrete choice experiment, patients are asked to choose between 2 or more treatments. The results can be used to quantify the relative importance of treatment outcomes and/or other considerations relevant to medical decision making. Conducting and interpreting a discrete choice experiment requires multiple steps and an understanding of the potential biases that can arise, which we review in this article with examples in rheumatic diseases.

Gist and verbatim communication concerning medication risks/benefits

OBJECTIVES

To describe the information about medication risks/benefits that rheumatologists provide during patient office visits, the gist that patients with rheumatoid arthritis (RA) extract from the information provided, and the relationship between communication and medication satisfaction.

METHODS

Data from 169 RA patients were analyzed. Each participant had up to three visits audiotaped. Four RA patients coded the audiotapes using a Gist Coding Scheme and research assistants coded the audiotapes using a Verbatim Coding Scheme.

RESULTS

When extracting gist from the information discussed during visits, patient coders distinguished between discussion concerning the possibility of medication side effects versus expression of significant safety concerns. Among patients in the best health, nearly 80% reported being totally satisfied with their medications when the physician communicated the gist that the medication was effective, compared to approximately 50% when this gist was not communicated.

CONCLUSION

Study findings underscore the multidimensional nature of medication risk communication and the importance of communication concerning medication effectiveness/need.

PRACTICE IMPLICATIONS

Health care providers should ensure that patients understand that medication self-management practices can minimize potential risks. Communicating simple gist messages may increase patient satisfaction, especially messages about benefits for well-managed patients. Optimal communication also requires shared understanding of desired therapeutic outcomes.

Examining patient preferences in the treatment of rheumatoid arthritis using a discrete-choice approach

BACKGROUND

Biological disease-modifying antirheumatic drugs (bDMARDs) used in second-line treatment of rheumatoid arthritis (RA) are administered parenterally. However, so-called targeted synthetic DMARDs (tsDMARDs) - developed more recently - offer alternative (ie, oral) administration forms in second-line treatment. Since bDMARDs and tsDMARDs can be regarded as equal in terms of efficacy, the present study examines whether such characteristics as route of administration drive RA patients' treatment choice. This may ultimately suggest superiority of some second-line DMARDs over equally effective options, at least according to RA-patient preferences.

OBJECTIVE

The current study assessed the importance of oral administration among other treatment characteristics differing between available second-line DMARDs for RA patients' preferences using a discrete-choice experiment (DCE).

MATERIALS AND METHODS

The DCE involved scenarios of three hypothetical treatment options in a d-efficient design with varying levels of key attributes (route and frequency of administration, time till onset of drug effect, combination therapy, possible side effects), as defined by focus groups. Further patient characteristics were recorded by an accompanying questionnaire. In the DCE, patients were asked to choose best and worst options (best-worst scaling). Results were analyzed by count analysis and adjusted regression analysis.

RESULTS

A total of 1,588 subjects completed the DCE and were eligible for final analyses. Across all characteristics included in the DCE, "oral administration" was most desired and "intravenous infusion" was most strongly rejected. This was followed by "no combination with methotrexate" being strongly preferred and "intake every 1-2 weeks" being strongly rejected. On average, levels of route of administration showed strongest influences on patients' decisions in post hoc bootstrapping analysis.

CONCLUSION

According to the results, an oral DMARD that does not have to be combined with methotrexate and is not administered (only) every 1-2 weeks appears a highly favorable treatment option for patients with RA. DMARDs meeting these preferences may increase compliance and adherence in RA treatment.

Determinants of adherence to disease modifying anti-rheumatic drugs in White British and South Asian patients with rheumatoid arthritis: a cross sectional study

Background

Rheumatoid arthritis (RA) is a common chronic inflammatory disease causing joint damage, disability, and reduced life expectancy. Highly effective drugs are now available for the treatment of RA. However, poor adherence to drug regimens remains a significant barrier to improving clinical outcomes in RA. Poor adherence has been shown to be linked to patients’ beliefs about medicines with a potential impact on adherence. These beliefs are reported to be different between ethnic groups. The purpose of this study was to identify potential determinants of adherence to disease modifying anti-rheumatic drugs (DMARDs) including an assessment of the influence of beliefs about medicines and satisfaction with information provided about DMARDs and compare determinants of adherence between RA patients of White British and South Asian.

Methods

RA patients of either White British (n = 91) or South Asian (n = 89) origin were recruited from secondary care. Data were collected via questionnaires on patients’: (1) self-reported adherence (Medication Adherence Report Scale-MARS); (2) beliefs about medicines (Beliefs about Medicines Questionnaire-BMQ); (3) illness perceptions (Illness Perceptions Questionnaire-IPQ) and (4) satisfaction with information about DMARDs (Satisfaction with Information about Medicines questionnaire-SIMS). In addition, clinical and demographic data were collected.

Results

The results revealed that socio-demographic factors only explained a small amount of variance in adherence whereas illness representations and treatment beliefs were more substantial in explaining non-adherence to DMARDs. Patients’ self-reported adherence was higher in White British than South Asian patients (median 28 (interquartile range 26–30) vs median 26 (interquartile range 23–30) respectively; P = 0.013, Mann–Whitney test). Patients who reported lower adherence were more dissatisfied with the information they had received about their DMARDs (P < 0.001, Spearman correlation, SIMS action and usage subscale; P < 0.001, Spearman correlation, SIMS potential problems subscale) and had more negative beliefs about their DMARDs and were related to ethnicity with South Asian patients having more negative views about medicines.

Conclusions

Socio-demographic factors were found to explain a small amount of variance in adherence. Illness representations and treatment beliefs were more important in explaining non-adherence to DMARDs. Clinicians managing South Asian patients with RA need to be aware that low adherence may be linked to negative beliefs about medicines and illness representations of RA.

Numbers matter to informed patient choices: a randomized design across age and numeracy levels

BACKGROUND

How drug adverse events (AEs) are communicated in the United States may mislead consumers and result in low adherence. Requiring written information to include numeric AE-likelihood information might lessen these effects, but providing numbers may disadvantage less skilled populations. The objective was to determine risk comprehension and willingness to use a medication when presented with numeric or nonnumeric AE-likelihood information across age, numeracy, and cholesterol-lowering drug-use groups.

METHODS

In a cross-sectional Internet survey (N = 905; American Life Panel, 15 May 2008 to 18 June 2008), respondents were presented with a hypothetical prescription medication for high cholesterol. AE likelihoods were described using 1 of 6 formats (nonnumeric: consumer medication information (CMI)-like list, risk labels; numeric: percentage, frequency, risk labels + percentage, risk labels + frequency). Main outcome measures were risk comprehension (recoded to indicate presence/absence of risk overestimation and underestimation), willingness to use the medication (7-point scale; not likely = 0, very likely = 6), and main reason for willingness (chosen from 8 predefined reasons).

RESULTS

Individuals given nonnumeric information were more likely to overestimate risk, were less willing to take the medication, and gave different reasons than those provided numeric information across numeracy and age groups (e.g., among the less numerate, 69% and 18% overestimated risks in nonnumeric and numeric formats, respectively; among the more numerate, these same proportions were 66% and 6%). Less numerate middle-aged and older adults, however, showed less influence of numeric format on willingness to take the medication. It is unclear whether differences are clinically meaningful, although some differences are large.

CONCLUSIONS

Providing numeric AE-likelihood information (compared with nonnumeric) is likely to increase risk comprehension across numeracy and age levels. Its effects on uptake and adherence of prescribed drugs should be similar across the population, except perhaps in older, less numerate individuals.

Multimedia educational interventions for consumers about prescribed and over-the-counter medications

BACKGROUND

Health consumers increasingly want access to accurate, evidence-based information about their medications. Currently, education about medications (that is, information that is designed to achieve health or illness related learning) is provided predominantly via spoken communication between the health provider and consumer, sometimes supplemented with written materials. There is evidence, however, that current educational methods are not meeting consumer needs. Multimedia educational programs offer many potential advantages over traditional forms of education delivery.

OBJECTIVES

To assess the effects of multimedia patient education interventions about prescribed and over-the-counter medications in people of all ages, including children and carers.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2011, Issue 6), MEDLINE (1950 to June 2011), EMBASE (1974 to June 2011), CINAHL (1982 to June 2011), PsycINFO (1967 to June 2011), ERIC (1966 to June 2011), ProQuest Dissertation & Theses Database (to June 2011) and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of multimedia-based patient education about prescribed or over-the-counter medications in people of all ages, including children and carers, if the intervention had been targeted for their use.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of included studies. Where possible, we contacted study authors to obtain missing information.

MAIN RESULTS

We identified 24 studies that enrolled a total of 8112 participants. However, there was significant heterogeneity in the comparators used and the outcomes measured, which limited the ability to pool data. Many of the studies did not report sufficient information in their methods to allow judgment of their risk of bias. From the information that was reported, three of the studies had a high risk of selection bias and one was at high risk of bias due to lack of blinding of the outcome assessors. None of the included studies reported the minimum clinically important difference for the outcomes that were measured. We have therefore reported results from the studies but have been unable to interpret whether differences were of clinical importance.The main findings of the review are as follows.Knowledge: There is low quality evidence that multimedia education was more effective than usual care (non-standardised education provided as part of usual clinical care) or no education (standardised mean difference (SMD) 1.04, 95% confidence interval (CI) 0.49 to 1.58, six studies with 817 participants). There was considerable statistical heterogeneity (I(2) = 89%), however, all but one of the studies favoured the multimedia group. There is moderate quality evidence that multimedia education was not more effective at improving knowledge than control multimedia interventions (i.e. multimedia programs that do not provide information about the medication) (mean difference (MD) of knowledge scores 2.78%, 95% CI -1.48 to 7.0, two studies with 568 participants). There is moderate quality evidence that multimedia education was more effective when added to a co-intervention (written information or brief standardised instructions provided by a health professional) compared with the co-intervention alone (MD of knowledge scores 24.59%, 95% CI 22.34 to 26.83, two studies with 381 participants).Skill acquisition: There is moderate quality evidence that multimedia education was more effective than usual care or no education (MD of inhaler technique score 18.32%, 95% CI 11.92 to 24.73, two studies with 94 participants) and written education (risk ratio (RR) of improved inhaler technique 2.14, 95% CI 1.33 to 3.44, two studies with 164 participants). There is very low quality evidence that multimedia education was equally effective as education by a health professional (MD of inhaler technique score -1.01%, 95% CI -15.75 to 13.72, three studies with 130 participants).Compliance with medications: There is moderate quality evidence that there was no difference between multimedia education and usual care or no education (RR of complying 1.02, 95% CI 0.96 to 1.08, two studies with 4552 participants).We could not determine the effect of multimedia education on other outcomes, including patient satisfaction, self-efficacy and health outcomes, due to an inadequate number of studies from which to draw conclusions.

AUTHORS' CONCLUSIONS

This review provides evidence that multimedia education about medications is more effective than usual care (non-standardised education provided by health professionals as part of usual clinical care) or no education, in improving both knowledge and skill acquisition. It also suggests that multimedia education is at least equivalent to other forms of education, including written education and education provided by a health professional. However, this finding is based on often low quality evidence from a small number of trials. Multimedia education about medications could therefore be considered as an adjunct to usual care but there is inadequate evidence to recommend it as a replacement for written education or education by a health professional. Multimedia education may be considered as an alternative to education provided by a health professional, particularly in settings where provision of detailed education by a health professional is not feasible. More studies evaluating multimedia educational interventions are required in order to increase confidence in the estimate of effect of the intervention.Conclusions regarding the effect of multimedia education were limited by the lack of information provided by study authors about the educational interventions, and variability in their content and quality. Studies testing educational interventions should provide detailed information about the interventions and comparators. Research is required to establish a framework that is specific for the evaluation of the quality of multimedia educational programs. Conclusions were also limited by the heterogeneity in the outcomes reported and the instruments used to measure them. Research is required to identify a core set of outcomes which should be measured when evaluating patient educational interventions. Future research should use consistent, reliable and validated outcome measures so that comparisons can be made between studies.

Patient preferences for biologic agents in rheumatoid arthritis: a discrete-choice experiment

OBJECTIVES

To assess patients' preferences for rheumatoid-arthritis treatments with biologic agents using a discrete-choice experiment.

METHODS

A discrete-choice experiment was conducted with adult rheumatoid-arthritis patients who had never been treated with biological agents from two university hospitals-public and private-in Buenos Aires, Argentina. We evaluated preferences for seven treatment attributes (with two to three levels each): effectiveness, mode of administration, frequency of administration, local and systemic adverse events, severe infections, and out-of-pocket costs.A probit regression model was used to analyze the relative importance of rheumatoid-arthritis treatment attributes. We estimated attributes' relative importance and their 95% confidence intervals.

RESULTS

Survey responses from 240 patients with rheumatoid arthritis receiving conventional disease-modifying antirheumatic drugs were included in the study. All tested biological agents' attributes significantly affected the choice of treatment. Attributes' relative importance in decreasing order was the following (mean, confidence interval 95%): cost, 0.81 (0.69-0.92); systemic adverse events, 0.66 (0.57-0.76); frequency of administration, 0.61 (0.52-0.71); efficacy, 0.42 (0.32-0.51); route of administration, 0.41 (0.30-0.52); local adverse events, 0.40 (0.31-0.49); and serious infections, 0.29 (0.22-0.37).

CONCLUSIONS

Different treatment attributes had a significant and different influence in rheumatoid-arthritis patients' choice of biological agents. This type of study can not only inform about patients' preferences but also about the trade-offs among different possible treatments or process-related attributes.

Measuring pain impact versus pain severity using a numeric rating scale

BACKGROUND

Routine assessments of pain using an intensity numeric rating scale (NRS) have improved documentation, but have not improved clinical outcomes. This may be, in part, due to the failure of the NRS to adequately predict patients' preferences for additional treatment.

OBJECTIVE

To examine whether patients' illness perceptions have a stronger association with patient treatment preferences than the pain intensity NRS.

DESIGN

Single face-to-face interview.

PARTICIPANTS

Outpatients with chronic, noncancer, musculoskeletal pain.

MAIN MEASURES

Experience of pain was measured using 18 illness perception items. Factor analysis of these items found that five factors accounted for 67.1% of the variance; 38% of the variance was accounted for by a single factor labeled "pain impact." Generalized linear models were used to examine how NRS scores and physical function compare with pain impact in predicting preferences for highly effective/high-risk treatment.

KEY RESULTS

Two hundred forty-nine subjects agreed to participate. Neither NRS nor functioning predicted patient preference (NRS: χ2 = 1.92, df = 1, p = 0.16, physical functioning: χ2 = 2.48, df = 1, p = 0.11). In contrast, pain impact was significantly associated with the preference for a riskier/more effective treatment after adjusting for age, comorbidity, efficacy of current medications and numeracy (χ2 = 4.40, df = 1, p = 0.04).

CONCLUSIONS

Tools that measure the impact of pain may be a more valuable screening instrument than the NRS. Further research is now needed to determine if measuring the impact of pain in clinical practice is more effective at triggering appropriate management than more restricted measures of pain such as the NRS.

It is not always about gains: utilities and disutilities associated with treatment features in patients with moderate-to-severe psoriasis

BACKGROUND

Patient-centered care has been proposed as a strategy for improving treatment outcomes in the management of psoriasis and other chronic diseases. A more detailed understanding of patients' utilities and disutilities associated with treatment features may facilitate shared decision-making in the clinical encounter. The purpose of this study was to examine the features of psoriasis treatment that are most and least preferred by patients and to identify correlates of these preferences.

METHODS

A cross-sectional survey of 163 patients with moderate-to-severe psoriasis was conducted in a German academic medical center. We assessed patients' characteristics, elicited their preferences for a range of potential treatment features, and quantified preference scores (utilities) associated with each treatment feature using hierarchical Bayes estimation. After identifying the most and least preferred treatment features, we explored correlates of these preferences using multivariate regression models.

RESULTS

Mean preference scores (MPS) for the least preferred treatment features were consistently greater than those for the most preferred treatment features. Patients generally expressed strong preferences against prolonged treatments in the inpatient setting (MPS = -13.48) and those with a lower probability of benefit (MPS = -12.28), while treatments with a high probability of benefit (MPS = 10.51) were generally preferred. Younger patients and women were more concerned with treatment benefit as compared with older patients and men.

CONCLUSION

Both negative and positive preferences appear important for shared decision-making. Recognition of characteristics associated with strong negative preferences may be particularly useful in promoting patient-centered environments.

Satisfaction and attitudes toward therapy in patients with rheumatoid arthritis

We examined associations between patient satisfaction and data obtained in routine clinical practice, and associations with therapeutic attitude in patients with rheumatoid arthritis (RA). A total of 220 patients with RA were enrolled in this cross-sectional evaluation. Demographic data, current disease state of RA, history of adverse events and self-reported questionnaire of patient satisfaction, attitudes toward therapy and reasons for being unwilling to change therapy were collected and analyzed. Multiple linear regression was used to identify characteristics. Age, Stanford Health Assessment Questionnaire (HAQ) score, and a visual analogue scale score of general health were the dominant correlates of satisfaction. Among the participants, 70% reported that they would not want to change therapy. The main reasons given were satisfaction with the current disease state (58%) and concern about the risk of side effects if therapy were to be changed (34%). Patients who were unwilling to change therapy due to concerns about side effects of new drugs did not have a significantly higher frequency of a past history of side effects, but showed significantly higher disease activity and a lower level of satisfaction with therapy. To summarize, patient satisfaction was associated with the HAQ. Patients who worried about the risk of side effects showed poor physical function and higher disease activity.

Treating rheumatoid arthritis to target: the patient version of the international recommendations

To transcribe the treat-to-target (T2T) recommendations into a version that can be easily understood by patients. A core group of physicians and patients involved in the elaboration of the T2T recommendations produced a draft version of the T2T recommendations in lay language. This version was discussed, changed and reworded during a 1-day meeting with nine patients with rheumatoid arthritis (RA) from nine different European countries. Finally, the level of agreement with the translation and with the content of the recommendations was assessed by the patient participants. The project resulted in a patient version of the T2T recommendations. The level of agreement with the translation and the content was high. The group discussion revealed a number of potential barriers for the implementation of the recommendations in clinical practice, such as inequalities in arthritis healthcare provision across Europe. An accurate version of the T2T recommendations that can be easily understood by patients is available and can improve the shared decision process in the management of RA.

The incidence of gastrointestinal perforations among rheumatoid arthritis patients

OBJECTIVE

Gastrointestinal (GI) perforation has emerged as a novel safety concern in relation to medications used to treat rheumatoid arthritis (RA). This study was undertaken to characterize the incidence and risk factors for GI perforation in RA patients.

METHODS

Using administrative databases of a large US health plan, we identified RA patients treated with biologic agents, methotrexate (MTX), oral glucocorticoids, and nonsteroidal antiinflammatory drugs (NSAIDs). Additional risk factors we evaluated included diverticulitis. Hospitalization with GI perforation was identified using a validated algorithm. Incidence rates and risk factors were evaluated using Cox proportional hazards models.

RESULTS

Among 40,841 RA patients, 37 hospitalizations with GI perforation were identified. The rate of GI perforation among patients currently being treated with biologic agents who were also receiving oral glucocorticoids was higher (1.12 per 1,000 person-years [95% confidence interval (95% CI) 0.50-2.49]) than for patients being treated with biologic agents who were not also receiving glucocorticoids (0.47 per 1,000 person-years [95% CI 0.22-0.98]) or for patients being treated with MTX who were also receiving glucocorticoids (0.87 per 1,000 person-years [95% CI 0.36-2.10]). Neither biologic agents nor MTX was significantly associated with GI perforation, in contrast to current treatment with glucocorticoids and NSAIDs together (hazard ratio 4.7 [95% CI 1.9-12.0]) or glucocorticoids alone (hazard ratio 2.8 [95% CI 1.3-6.1]). Diverticulitis also was a strong risk factor (hazard ratio 9.1 [95% CI 3.1-26.4]). Seventy percent of patients with GI perforation received glucocorticoids, had antecedent diverticulitis, or both.

CONCLUSION

GI perforation is an uncommon but serious adverse event among RA patients. Because a majority of patients with GI perforation were being treated with glucocorticoids or had previously experienced diverticulitis, these individuals should be considered at higher risk.

If You Want Patients with Knee Osteoarthritis (OA) to Exercise: Tell them about NSAIDS

PURPOSE: Exercise is an important adjunctive treatment for knee OA; however it is underutilized, in part because of the known difficulties related to initiating and adhering to exercise programs. Although there are ample data documenting the latter, patient preferences for exercise in comparison to other options have not been examined. METHODS: Participants were recruited as part of an intervention trial to improve decision-making in knee OA. Patients with knee pain on most days of the preceding month completed an Adaptive Conjoint Analysis interactive computer survey designed to elicit patient preferences for a cream (capsaicin), oral medications, [acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)], intra-articular (IA) injections (up to four times per year) and exercise (low impact aerobic exercise and/or strength training three times per week). Preferences were determined based on individual respondent's trade-offs between: route of administration, probability of having less pain, probability of improved strength and endurance, risk of dyspepsia, and risk of ulcer. Preferences were calculated as "shares" which sum to 100. RESULTS: 90 subjects completed the computer tool; mean age ± SD = 68 ± 9 (range = 53-87). Patients preferred exercise over other treatment options whether IA injections and NSAIDs were described as being 20% or 50% more effective at decreasing symptoms compared to other options. The relative importance assigned to treatment benefits and risks were 29% and 41% respectively. Patient demographic characteristics were not related to preferences; however, patients with more self reported knee pain were less likely to prefer exercise compared to their counterparts (r = -0.3, p=0.004). CONCLUSIONS: In this study, patients preferred exercise over pharmacologic options for treatment of knee OA. Preferences were driven by patients' unwillingness to accept the risk of adverse effects. Our findings also suggest that subjects with greater knee pain may be more reluctant to exercise compared to their counterparts. Presentation of exercise in the context of other available therapies might increase patient willingness to try exercising by making the trade-offs between exercise and medications more apparent.

Refusal of medical and surgical interventions by older persons with advanced chronic disease

BACKGROUND

Patients with advanced chronic disease are frequently offered medical and surgical interventions with potentially large trade-offs between benefits and burdens. Little is known about the frequency or outcomes of treatment refusal among these patients.

OBJECTIVE

To assess the frequency of, reasons for, factors associated with, and outcomes of treatment refusal among older persons with advanced chronic disease.

DESIGN

Observational cohort study.

PARTICIPANTS

Two hundred twenty-six community-dwelling persons with advanced cancer, chronic obstructive pulmonary disease, or congestive heart failure, interviewed at least every 4 months for up to 2 years.

MEASUREMENTS

Participants were asked if they had refused any treatments recommended by their physicians, and why.

RESULTS

Thirty-six of 226 patients (16%) reported refusing 1 or more medical or surgical treatments recommended by their physician. The most frequently refused interventions were cardiac catheterization and surgery. The most common reason for refusal was fear of side effects (41%). Treatment refusal was more frequent among patients who wanted prognostic information (10% vs 2%, p = .02) or estimated their own longevity at 2 years or less (18% vs 5%, p = .02). There was an increased risk of mortality among refusers compared with non-refusers (HR 1.98, 95% CI 1.02-3.86).

CONCLUSIONS

Refusal of medical and surgical interventions other than medications is common among persons with advanced chronic disease, and is associated with a greater desire for, and understanding of, prognostic information.

Probabilistic threshold technique showed that patients' preferences for specific trade-offs between pain relief and each side effect of treatment in osteoarthritis varied

OBJECTIVES

Therapeutic decisions in osteoarthritis (OA) often involve trade-offs between accepting risks of side effects and gaining pain relief. Our objectives were (1) to determine patients' maximum acceptable risk increments (MARI) for different adverse effects from OA medication and (2) to identify the predictors of these preferences.

STUDY DESIGN AND SETTING

MARI were measured with a probabilistic threshold technique (TT). Risk and pain levels in the TT scenarios were controlled for in a 2x2 randomized factorial design. Clinical, sociodemographic, and psychological characteristics (decisional conflict and locus of control) of the participants were assessed using a self-administered questionnaire.

RESULTS

For 196 subjects, MARI varied by type of adverse effect, level of pain relief, and baseline risk. Mean MARI ranged from 3% to 5% for heart attack/stroke, 5% to 8% for stomach bleed, 13% to 21% for hypertension, 22% to 33% for fluid retention, and 23% to 35% for dyspepsia. Age, gender, education, physical and mental health, pain, disability, and locus of control were not associated with MARI.

CONCLUSION

Participants varied widely in the level of risk they would accept, but their clinical, sociodemographic, and psychological characteristics did not explain this variation. These observations are important for the development of practice guidelines for physicians and patients' decision aids that can foster individualized, evidence-based yet preference-sensitive care for patients with OA.

Resistance of rheumatoid arthritis patients to changing therapy: Discordance between disease activity and patients' treatment choices

OBJECTIVE

Despite advances in rheumatoid arthritis (RA) treatment, patients' decisions regarding therapy often deviate from expert recommendation. This study was undertaken to investigate patients' acceptance and satisfaction with therapy, willingness to change therapy, and reasons for not changing.

METHODS

Participants (n = 6,135) completed an 11-item questionnaire concerning treatment preferences. Eight questions assessed reasons for not wanting to change therapy. The contribution of individual predictors was determined by logistic regression analysis.

RESULTS

Questionnaire responses showed that 63.8% of the patients would not want to change therapy as long as their condition didn't get worse; 77.3% were satisfied with their medications, while 9.4% were dissatisfied. These assessments were weakly related to RA activity and functional status. Side effects had occurred in 22.4% of the patients during the previous 6 months, and in 65.5% at some period during their lifetime. Predictors of unwillingness to change therapy were satisfaction with RA control, which had an odds ratio (OR) of 6.8 (95% confidence interval [95% CI] 5.8-8.0), risk of side effects (OR 4.4 [95% CI 3.8-5.2]), physician opinion (OR 1.9 [95% CI 1.6-2.2]), fear of loss of control (OR 1.8 [95% CI 1.6-2.1]), lack of better medications (OR 1.4 [95% CI 1.2-1.6]), and costs (OR 1.3 [95% CI 1.1-1.6]). There was little difference in results between patients who were receiving biologic agents and those who were not.

CONCLUSION

There is substantial discrepancy between declared satisfaction with therapy and measured RA activity and functional status. Most RA patients are satisfied with their therapy, even many with abnormal scores. Fear of loss of control of RA and fear of side effects are major patient concerns. Maintenance of current status, rather than future improvement, appears to be a high priority for patients.

Measuring Process of Arthritis Care: The Arthritis Foundation’s Quality Indicator Set for Rheumatoid Arthritis

OBJECTIVE

To describe the scientific evidence that supports each of the explicit process measures in the Arthritis Foundation's Quality Indicator Set for Rheumatoid Arthritis.

METHODS

For each of the 27 measures in the Arthritis Foundation's Quality Indicator set, a comprehensive literature review was performed for evidence that linked the process of care defined in the indicator with relevant clinical outcomes and to summarize practice guidelines relevant to the indicators.

RESULTS

Over 7500 titles were identified and reviewed. For each of the indicators the scientific evidence to support or refute the quality indicator was summarized. We found direct evidence that supported a process-outcome link for 15 of the indicators, an indirect link for 7 of the indicators, and no evidence to support or refute a link for 5. The processes of care described in the indicators for which no supporting/refuting data were found have been assumed to be so essential to care that clinical trails assessing their importance have not, and probably never will be, performed. The process of care described in all but 2 of the indicators is recommended in 1 or more practice guidelines.

CONCLUSION

There are sufficient scientific evidence and expert consensus to support the Arthritis Foundation's Quality Indicator Set for Rheumatoid Arthritis, which defines a minimal standard of care that can be used to assess health care quality for patients with rheumatoid arthritis.

Beliefs about medications: a questionnaire survey of people with rheumatoid arthritis

OBJECTIVES

To investigate beliefs about medications held by people with rheumatoid arthritis (RA), what factors are related to these specific medication beliefs, and whether these beliefs influence adherence.

METHODS

The design was a cross-sectional postal questionnaire survey of people with RA. The Beliefs about Medicines Questionnaire was used to assess beliefs about the necessity of medication and concerns about it. Questionnaires were mailed to 600 out-patients with RA.

RESULTS

The response rate was 57.3%. Most (74.3%) respondents agreed or strongly agreed that their arthritis medications are necessary for their health. However, 47.4% were concerned about potential adverse consequences. The overall necessity score (mean 19.2, s.d. 3.13) was higher than the concerns score (mean 15.84, s.d. 3.53; P<0.001). Greater disability was associated with higher necessity scores (r = 0.36; P<0.001). Greater helplessness correlated with higher concerns scores (r = 0.49; P<0.001). There was no association between RA knowledge and beliefs about medications (necessity scale, r = 0.02, P = 0.66; concerns scale, r=-0.08, P = 0.14). Concerns scores for non-adherent participants (mean 17.88, s.d. 3.29) were higher than for the adherent group (mean 15.64, s.d. 3.51; P = 0.002).

CONCLUSIONS

Most people with RA have positive beliefs about the necessity of their medication. However, levels of concern are high and associate with helplessness and non-adherence. The Beliefs about Medicines Questionnaire may identify people at risk of poor adherence and provide a focus for patients to discuss their beliefs, providing opportunities to improve adherence.

Benefit-risk analysis : a brief review and proposed quantitative approaches

Given the current status of benefit-risk analysis as a largely qualitative method, two techniques for a quantitative synthesis of a drug's benefit and risk are proposed to allow a more objective approach. The recommended methods, relative-value adjusted number-needed-to-treat (RV-NNT) and its extension, minimum clinical efficacy (MCE) analysis, rely upon efficacy or effectiveness data, adverse event data and utility data from patients, describing their preferences for an outcome given potential risks. These methods, using hypothetical data for rheumatoid arthritis drugs, demonstrate that quantitative distinctions can be made between drugs which would better inform clinicians, drug regulators and patients about a drug's benefit-risk profile. If the number of patients needed to treat is less than the relative-value adjusted number-needed-to-harm in an RV-NNT analysis, patients are willing to undergo treatment with the experimental drug to derive a certain benefit knowing that they may be at risk for any of a series of potential adverse events. Similarly, the results of an MCE analysis allow for determining the worth of a new treatment relative to an older one, given not only the potential risks of adverse events and benefits that may be gained, but also by taking into account the risk of disease without any treatment. Quantitative methods of benefit-risk analysis have a place in the evaluative armamentarium of pharmacovigilance, especially those that incorporate patients' perspectives.

Investigating sleep disturbances in adults with rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune disease characterized by inflammation and joint involvement. Most adults with RA experience sleep disturbances, including longer times before falling asleep, numerous awakenings during the night, and early morning wakening, resulting in excessive daytime sleepiness and fatigue. This article will review what is known about sleep disturbances and the biologic basis in adults with RA, the influence of ovarian hormone levels in women with RA, how medications may influence sleep in RA, and complementary and alternative therapies that may be useful in reducing sleep disturbances.