Session Title: Medical Education
Session Type: Abstract Submissions (ACR)
Background/Purpose: A rheumatologist’s choice of anti-TNF prescription is likely to be influenced by a number of factors. Doctors believe their prescribing to be evidence-based, rational and justifiable. With greater understanding of health behaviour, it is likely that prescribing decisions about anti-TNF will involve conscious and sub-conscious factors. We conducted a clinical decision exercise with senior rheumatology trainees to try better to understand these influences and whether all doctors take into account patient perceptions and preferences.
Methods: 12 trainees were each given an IPad with details of 30 individual simulated patients, based on real patients with RA. For each individual ‘iPad’ patient doctors were asked to decide whether to start anti-TNF and which brand they would prescribe if they did. Each doctor was in training at a different hospital with different local anti-TNF guidelines for therapy although all purported to follow UK national guidelines for anti-TNF drug therapy. IPad patients differed in gender, age, disease duration and disease activity score, previous drug history and symptoms of stiffness and function. Work status varied as did quality of life measures and aspects of patient choice. iPads were coded to allow attribution of answers and data were analysed anonymously by a third party from the recorded iPad answers at a later time and place.
The analysis of results indicated that doctors could be fitted broadly into one of two categories; Evidence-based decision makers (EBDs) and Intuitive patient-focused decision makers (IPDs) according to the way that doctors in these two groups made decisions. Prescribing choice appeared independent of the background of the doctor and geographical area of training and extent of rheumatological experience.
EBD’s stuck rigidly to guidelines for initiation of anti-TNF therapy and took no account of subjective data or patient specific concerns of preferences. EBD’s were rigid in their choice of anti-TNF and chose the same product for all patients who were going to be initiated onto anti-TNF. EBD’s appeared not to feel that patients could make informed decisions or choices about treatment. EBD’s did not think that adherence would be a problem with ant-TNF therapy. In contrast IPD’s ignored guidelines around the threshold for starting anti-TNF in cases where they felt that patients would benefit from anti-TNF. With IPD’s patient factors were important in driving treatment decisions – quality of life and impact of RA on the ability to work strongly influenced decisions. IPD’s responded to patient requests, concerns and preferences in making prescribing choices and were more likely to tailor their choice to fit best with patient-specific characteristics. IPD’s felt that patients could and should make informed decisions about their treatment and recognised that adherence was potentially a problem even with anti-TNF drugs.
As with many health care decisions there appear to be strong sub-conscious influences on anti-TNF prescribing that introduce variance into treatment decisions. Recognition of different groups of prescribers suggests that information given to doctors might be processed differently by different groups
R. A. Hughes,
A. J. Carr,
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ACR Meeting Abstracts - https://acrabstracts.org/abstract/eliciting-prescribing-choices-of-anti-tumour-necrosis-factor-therapy-from-rheumatology-trainees/