Models based on value and probability in health improve shared decision making

Patients' and Doctors' Beliefs about Treatment and Long-Term Adherence in Rheumatic Diseases

Objective:

The aim of this study was to explore the beliefs of rheumatologists and patients about treatment-related factors, long-term adherence, and their communication with regard to rheumatic diseases.

Methods:

In a multicentre, observational study conducted in Greece, a structured questionnaire was administered to 75 rheumatologists and 398 rheumatic patients from different regions. Five domains were investigated: i) effectiveness of treatment, ii) choice of treatment, iii) change of ineffective treatment, iv) long-term adherence, and v) the quality of communication between doctors and patients. Descriptive data, confidence intervals, t-tests and factor analysis were employed.

Results:

Examining the patients’ and rheumatologists’ beliefs and attitudes about treatment profiles and long-term adherence, a statistically significant convergence in their views on effectiveness and safety as the predominant factors concerning choice of treatment and long-term adherence was found. Although patients reported high trust to their doctors, a divergence of views is recorded regarding communication of the two parts. Statistically significant differences in the views between patients and rheumatologists were found with regards to access (p<0.001), time per visit (p<0.001), mutual understanding (p<0.001), and overall communication (p<0.001).

Conclusions:

Our study shows a great rate of agreement between patients and rheumatologists regarding the factors determining the efficacy, choice, switching and adherence to treatment while there was significant divergence in the views regarding the quality of communication between the two parts. Co-ordinated efforts are needed in order to improve the communication level between rheumatic patients and rheumatologists.

The role of depression, anxiety, fatigue, and fibromyalgia on the evaluation of the remission status in patients with rheumatoid arthritis

OBJECTIVE

To investigate the effect of depression, anxiety, fatigue, and fibromyalgia (FM) on the remission status in patients with rheumatoid arthritis (RA), defined according to the 28-joint count Disease Activity Score (DAS28)-erythrocyte sedimentation rate (ESR) and the Boolean-based new American College of Rheumatology/European League Against Rheumatism remission criteria.

METHODS

The subjects were patients with RA who participated in a hospital-based observational cohort. Patients who met the DAS28-ESR remission criteria at their latest visit were invited to participate in our study. The patient groups fulfilling or not fulfilling the Boolean remission criteria were identified and compared with each other with regard to the presence of depression, anxiety, fatigue (0-50), and FM. The relationship between psychosocial factors and Simplified Disease Activity Index (SDAI) remission, which is the index-based definition of remission in RA, was also investigated.

RESULTS

A total of 87 out of 428 patients (20%) with RA met the DAS28-ESR remission criteria and 32 (37%) of these also met the Boolean remission criteria, while 55 (63%) did not. Forty patients were also in SDAI remission. In the Boolean remission group, 2 patients had depression and 2 had anxiety (p = 0.004). In the Boolean nonremission group, 19 patients had depression and 13 had anxiety (p = 0.04). Continuous scales of anxiety (3.34 ± 3.76 vs 5.83 ± 4.70, p = 0.012) and depression (2.18 ± 2.75 vs 4.63 ± 4.10, p = 0.001) were also lower in the Boolean remission group in comparison with the nonremission group. Though FM syndrome was detected in only 1 patient of the Boolean remission group and in 7 patients of the Boolean nonremission group (p = 0.249), patients' polysymptomatic distress scores of FM in the Boolean remission group were significantly lower than those of the nonremission group (3.12 ± 3.25 vs 6.27 ± 5.19, p = 0.001). The mean fatigue scores were 9.5 ± 10.6 in the Boolean remission group and 16.8 ± 12.8 in the Boolean nonremission group (p = 0.006). In multivariate analysis, patient's global assessment (PtGA) and depression were found as the independent discriminators of Boolean-based definition. Similar relationships were also observed between psychosocial factors and SDAI remission.

CONCLUSION

In patients with RA who do not fulfill the Boolean remission criteria, to avoid overtreatment, assessment of anxiety, fatigue, FM, and especially depression must be considered if PtGA scores and disease activity variables are significantly different.

Using a 'talk' model of shared decision making to propose an observation-based measure: Observer OPTION 5 Item

OBJECTIVE

To propose a revised Observer OPTION measure of shared decision making.

METHODS

We analyzed published models to identify the core components of a parsimonious conceptual framework of shared decision making. By using this framework, we developed a revised measure combining data from an observational study of clinical practice in Canada with our experience of using Observer OPTION(12 Item).

RESULTS

Our conceptual framework for shared decision making composed of justifying deliberative work, followed by the steps of describing options, information exchange, preference elicitation, and preference integration. By excluding items in Observer OPTION(12 Item) that were seldom observed or not aligned to a robust construct, we propose Observer OPTION(5 Item).

CONCLUSION

Although widely used, Observer OPTION(12 Item) did not give sufficient attention to preference elicitation and integration, and included items that were not specific to a core construct of shared decision making. We attempted to remedy these shortcomings by proposing a shorter, more focused measure.

PRACTICE IMPLICATIONS

Observer OPTION(5 Item) requires evaluation; we hope that it will be useful as both a research tool and as a formative measure of clinical practice.

Discrepancies between patients and physicians in their perceptions of rheumatoid arthritis disease activity

OBJECTIVE

Patients and physicians often differ in their perceptions of rheumatoid arthritis (RA) disease activity, as quantified by the patient's global assessment (PGA) and by the evaluator's global assessment (EGA). The purpose of this study was to explore the extent and reasons for this discordance.

METHODS

We identified variance components for the PGA and EGA in RA patients who were starting therapy with methotrexate in an academic outpatient setting. We analyzed predictors of the observed discrepancy in these measures (calculated as the PGA minus the EGA) and in their changes (calculated as the PGA(change) minus the EGA(change) ).

RESULTS

We identified 646 RA patients, and among them, 77.4% of the variability in the PGA and 66.7% of the variability in the EGA were explainable. The main determinants for the PGA were pain (75.6%), function (1.3%, by Health Assessment Questionnaire), and number of swollen joints (0.5%); those for the EGA were the number of swollen joints (60.9%), pain (4.5%), function (0.6%), C-reactive protein (0.4%), and the number of tender joints (0.3%). Increased pain led to a discrepancy toward worse patient perception, while increased numbers of swollen joints led to a discrepancy toward worse evaluator perception, both explaining 65% of the discordance between the PGA and the EGA. Likewise, changes in pain scores and numbers of swollen joints proved to be the main determinants for discrepant perceptions of changes in RA disease activity, explaining 34.6% and 12.5% of the discordance, respectively.

CONCLUSION

The most significant determinants for the cross-sectional and longitudinal discrepancy between the PGA and the EGA are pain and joint swelling, respectively. Understanding the reasons for a discordant view of disease activity will help to facilitate the sharing of decision-making in the management of RA.

Epistemology and ethics of evidence-based medicine: putting goal-setting in the right place

While evidence-based medicine (EBM) is often accused on relying on a paradigm of 'absolute truth', it is in fact highly consistent with Karl Popper's criterion of demarcation through falsification. Even more relevant, the first three steps of the EBM process are closely patterned on Popper's evolutionary approach of objective knowledge: (1) recognition of a problem; (2) generation of solutions; and (3) selection of the best solution. This places the step 1 of the EBM process (building an answerable question) in a pivotal position for the understanding of the whole process, and underscores a few aspects which are often overlooked in EBM courses. First in this step internal evidence (including personal expertise) must be appraised and integrated in the problem. Second, issues of applicability of the possible solution should be anticipated. Third, and possibly more important, the goal of the intervention should be set at this stage (typically by choosing the outcome in a PICO question). Depending whether or not goals depend on the goals of others, and whether they concern others' voluntary behaviour, goals may be classified as self-serving, moral, altruistic or moralistic. Thus, delicate ethical questions must be addressed at this stage, which means that patient preferences and values must be carefully sought, so that empathy, counselling and narrative medicine must be mastered to be able to formulate correctly an answerable question. The need to modify the current description of the EBM process to increase the recognition of implicit assumptions and increase the consistency of this model is discussed.