Background/Purpose: Suboptimal communication in shared decision-making among vulnerable populations has been reported in rheumatoid arthritis (RA). National and international recommendations for quality health care highlight the importance of patient-centered care and involvement of patients in decision-making. The concept of decisional conflict captures the extent to which patients lack adequate information and support to make an informed health care decision. The objective of this study was to identify patient-level factors associated with high decisional conflict in RA treatment decisions among vulnerable populations who are at highest risk for poor health outcomes.

Methods: Data derive from a subset of participants in the RA Cohort Study, which enrolls adult RA patients from university-affiliated rheumatology clinics at an urban county hospital and a tertiary care facility. Enrollment for the present study occurred from September 2011 to May 2012; eligibility included having moderate to high disease activity, defined as a RAPID-3 score >6, and being a member of a vulnerable population based on the following criteria: immigrant, ethnic/racial minority, non-English speaker, age >65, or limited health literacy. Eligible patients completed a questionnaire in English, Spanish, or Chinese immediately after their clinic appointment. The questionnaire included a screening measure of health literacy, a series of true-false questions about RA and its treatments, and a low-literacy version of the 10-item Decisional Conflict Scale (DCS), given to patients who reported discussing a medication change with their doctor. DCS scores were compared by gender, race/ethnicity, age, and language using non-parametric ANOVA (Kruskal-Wallis) tests. Correlations among DCS, RA knowledge, and health literacy were assessed with Spearman correlation coefficients.

Results: Of 163 cohort members screened, 97 had active disease according to their RAPID-3 score and were enrolled in the study; 48 of those patients reported receiving a new prescription or discussing a medication change and were included in this analysis. Mean age was 59 (±12), 75% were women, 58% immigrants, 82% ethnic minorities, 35% Spanish or Chinese speakers, 61% had limited health literacy. DCS scores ranged from 0 to 80 (higher scores indicate more decisional conflict). Scores were significantly higher (p<0.01) among Chinese (45±7) and Spanish speakers (23±6) compared with African Americans (14±7) and Whites (12±8), but did not differ by age or gender. Higher decisional conflict was associated with lower levels of health literacy (Spearman’s r=-0.35, p=0.01) and poorer RA knowledge (Spearman’s r=-0.36, p=0.01).

Conclusion: Limited health literacy and non-English language were associated with greater levels of decisional conflict about a real-time RA treatment decision. Providing low literacy decision aid tools to reduce decisional conflict and promote shared decision-making may lead to more patient-centered care, treatment decisions that align with patient preferences, and ultimately, improved health outcomes among vulnerable populations with RA.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/decisional-conflict-among-vulnerable-patient-populations-with-rheumatoid-arthritis-is-associated-with-limited-health-literacy-and-non-english-language/