Background/Purpose: There are few published studies describing patient-physician discussions about initiating new rheumatoid arthritis (RA) medications in real world settings. The purpose of this study is to describe the incidence of these discussions, levels of decisional conflict and its correlation with primary adherence.

Methods: We conducted a prospective observational study of consecutive RA patients attending a routine rheumatology clinic visits. Immediately after the visit, we identified all patients whom had a discussion about starting a new medication. We conducted immediate written and 30-day post-visit telephone surveys. This assessed patient preference, actions and decisional conflict about starting the proposed medication.

Results: Of 580 RA patients seen during the observation period, 104 (17.9%) patients confirmed discussing a new medication. 91 (87.5%) completed the follow up survey. Demographics: mean age = 55.4 years, 79.8% female, 7.7% minority, 3.8% with inadequate health literacy RA duration 7.5 years, and mean CDAI 20 (range 0-50). 65.4 % of discussions involved adding or changing disease modifying drug therapy (DMARD). Mean post-visit Decisional Conflict Scale score (DCS)¹ was 18.3 (SD: 18.8), with 11.8% demonstrating high² DCS. Mean 30 day DCS was 16.1 (SD: 18.4). There was no difference between immediate post-visit and 30 day DCS (p=.47). While 97.1% of patients intended to start the discussed medication, primary adherence was 68.3% at 30 days. Most patients identified “Too Risky” as the reason for primary non-adherence. There was no significance difference in decisional conflict between patients considering DMARD vs. non-DMARD therapy.

Conclusion: Discussions to start or change medications occurred daily in community rheumatology practice. Despite short times of deliberation after visits, patients reported high levels of feeling informed about benefits and harms and had relatively low levels of decisional conflict. This raises questions about the depth and quality of patient deliberation following physician – patient discussions about initiating new DMARD therapy.

References:

1. O’Connor AM. Validation of a decisional conflict scale. Med Decis Making. 1995; 15(1):25-30.

2. O’Connor AM. User Manual – Decisional Conflict Scale. Ottawa: Ottawa Hospital Research Institute; © [updated 2010; cited January 20, 2017]. Available from: https://decisionaid.ohri.ca/docs/develop/User_Manuals/UM_Decisional_Conflict.pdf

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/decisional-conflict-in-doctor-patient-discussions-about-disease-modifying-anti-rheumatic-drugs/