Background/Purpose: The prescription of a Disease Modifying Anti-rheumatic Drugs (DMARD) for patients with rheumatoid arthritis (RA) is considered a standard of effective care^.  However a recent study of Medicare managed care enrollees, only 63% received a DMARD.  The explanation for underutilization is not fully known. In a sample of 144 patients, Constantinescu et al found compared to white adults with RA, African American patients assigned greater importance to the risks of treatment over the likelihood for benefit.  The purpose of our study was to evaluate the determinants of risk perception (RP) in a large cohort of community RA patients and predictors of their willingness to take a proposed DMARD (DMARD willingness).

Methods: A single center, cross-sectional mail survey of RA patients in a community rheumatology practice.  Patient characteristics including heath literacy screening index (HL), depression, RA duration, DMARD experience including bother from current DMARD side effects, satisfaction with RA control, Decision Regret Scale,TNFi knowledge, happiness, HAQ2, and CDAI were collected.  Patients were presented a hypothetical decision scenario where they were asked to consider switching DMARDs.  They evaluated how risky the proposed medication was and how likely they would be to take it.  Predictors of RP and DMARD willingness were identified with hierarchical linear regression modeling.

Results: The completed sample included 1009 RA patients.  The overall survey response rate was 71%.  Patient characteristics: age 61.6 years (range 18-93), 75% female, minority 6.5%, low or marginal health literacy 8.8%, depression 15.0%, duration RA 13.1 years (range 0.5 – 68).   A regression model evaluating predictors of RP demonstrated a R² = 13.5.  The standardized regression coefficients show the strongest predictor of RP was HAQ2 disability (B=.152), followed by HL (B= -.149), and current or past experience of DMARD related bother(B=.146).  Age, TNFi knowledge, happiness and depression, and other demographics did not significantly add to the predictive power of the model.   A second model of predictors of DMARD willingness had a R²= 12.7%.  The standardized regression coefficients show the strongest predictors of DMARD willingness were satisfaction with control of RA (B=-1.67) and regret related to their previous DMARD choice (B=-1.60), and HL (B= 1.49).  Age and other demographic characteristics, extent of past RA and general DMARD related experience, happiness and depression did not significantly add to the predictive power of the model. 

Conclusion: RP was influenced by negative RA disease and treatment experience, while DMARD willingness was affected by perceived disease control.  Health literacy, independent of low educational achievement or other demographic, was a predictor of both RP and DMARD willingness.  When proposing to initiate a new DMARD, clinicians must be alert for cognitive impairment whether derived from educational, language, age related decline in information processing that could affect patient decision making.   Time pressures increase cognitive load, which might justify extending the time of deliberation beyond the constraints of the office visit by using decision aids.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/does-biased-risk-perception-explain-the-underuse-of-disease-modifying-anti-rheumatic-drugs/