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

Perspective of Dutch Patients with Gout on Continuation or Discontinuation of Urate-Lowering Therapy During Remission: A Mixed-Methods Study

OBJECTIVE

Long-term gout management is based on reducing serum urate by using urate-lowering therapy (ULT). A lifelong treat-to-target approach is advocated, although a ULT (taper to) stop attempt can be considered (treat-to-avoid symptoms approach) during remission. Exploring the beliefs of patients with gout on long-term ULT strategies during remission is important for optimizing gout management. We aimed to identify factors that influence the decision for continuation or discontinuation of ULT and to determine their relative importance according to patients with gout in remission.

METHODS

A mixed-methods design was used. First, semistructured interviews (substudy 1) were conducted to identify barriers and facilitators for the (dis)continuation of ULT using inductive thematic analysis. Afterwards, these barriers/facilitators were summarized into neutrally phrased items and used in a maximum difference scaling study (substudy 2) to determine their relative importance using the rescaled probability score.

RESULTS

Substudies 1 and 2 included 18 and 156 patients, respectively. Substudy 1 yielded 22 items within 10 overarching themes. Substudy 2 revealed that the perceived risk of joint damage and gout flares and that ULT use gives some assurance were the most important items. The costs, ease of receiving ULT, and its practical use were the least important items.

CONCLUSION

These results can aid shared decision-making and provide input for what is important to discuss with patients with gout in remission when they consider ULT discontinuation. The emphasis should be on the risk of having gout flares and joint damage, not so much on facilitating how easily medication is received.

Drug-related problems reported by patients with rheumatic diseases: an observational study

BACKGROUND

Drug-related problems can negatively influence treatment outcome and well-being for patients with rheumatic diseases. Thus, it is important to support patients in preventing or resolving drug-related problems as quickly as possible. To effectively develop interventions for this purpose, knowledge on the frequency and character of drug-related problems is needed. Therefore, this study aims to quantify and characterize drug-related problems reported by patients with inflammatory rheumatic diseases along their treatment process.

METHODS

A prospective observational study was conducted in a Dutch outpatient pharmacy. Adult patients with rheumatic diseases that were prescribed medication by a rheumatologist were questioned about experienced DRPs by telephone 4 times in 8 weeks using a structured interview-guide. Patient-reported DRPs were scored on uniqueness (i.e., if a specific DRP was reported in multiple interviews by one individual, this was counted as one unique DRP) and were categorized using a classification for patient-reported DRPs and analysed descriptively.

RESULTS

In total, 52 participants (median age 68 years (interquartile range (IQR) 62-74), 52% male) completed 192 interviews with 45 (87%) participants completing all 4 interviews. The majority of patients (65%) were diagnosed with rheumatoid arthritis. Patients reported a median number of 3 (IQR 2-5) unique DRPs during interview 1. In subsequent interviews, patients reported median numbers of 1 (IQR 0-2), 1 (IQR 0-2) and 0 (IQR 0-1) unique DRPs for interviews 2-4 respectively. Participants reported a median number of 5 (IQR 3-9) unique DRPs over all completed interviews. Unique patient-reported DRPs were most frequently categorized into (suspected) side effects (28%), medication management (e.g., medication administering or adherence) (26%), medication concerns (e.g., concerns regarding long-term side-effects or effectiveness) (19%) and medication effectiveness (17%).

CONCLUSIONS

Patients with rheumatic diseases report various unique DRPs with intervals as short as two weeks. These patients might therefore benefit from more continuous support in-between contact moments with their healthcare provider.

Are We on the Same Page? A Cross-Sectional Study of Patient-Clinician Goal Concordance in Rheumatoid Arthritis

OBJECTIVE

Patient-clinician goal concordance is associated with improved outcomes in certain chronic diseases but not explored in rheumatoid arthritis (RA). We examined goal concordance, correlates of concordance, and the association of concordance with health outcomes.

METHODS

Adult patients with RA seen at least 1 time in the prior 12 months at 1 of 2 rheumatology clinics participated. Patients and their clinicians independently ranked top 3 goals for RA treatment from 8 options before a routine visit. Patients completed postvisit surveys on health, demographic information, health literacy, and adherence. Goal concordance was defined as the patient's number 1 goal being among the clinician's top 3 goals for that patient. Bivariable and multivariable logistic regression models were used to examine correlates of concordance.

RESULTS

Patients were 58% female and 16% Spanish-speaking, and 29% had limited health literacy. Among 204 patient-clinician dyads, 20% were goal-discordant. "Have less pain" was selected by both patient and clinician in 81% of dyads, followed by "have fewer problems doing daily activities" by 63%. Otherwise, clinicians prioritized avoiding side effects, whereas patients ranked improved sleep, fatigue, and mood. Longer disease duration was associated with discordance (median 13.3 years, interquartile range [IQR] 5.2-20 among discordant vs. 7 years, IQR 4-14; P = 0.039); higher depressive symptoms were associated with concordance (8.1% vs. 24%; P = 0.04). Goal concordance was associated with higher medication adherence (adjusted odds ratio 2.76 [95% confidence interval 1.01, 7.56]).

CONCLUSION

One in 5 patient-clinician dyads had discordant treatment goals. Goal concordance was associated with higher medication adherence. Studies to improve goal elicitation and communication of patients with RA's priorities are needed.

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.