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Abstract Number: 1758

Low Literacy Decision Aid Enhances Knowledge and Reduces Decisional Conflict Among Diverse Population Of Adults With Rheumatoid Arthritis: Results Of a Pilot Trial

Jennifer Barton1, Laura Trupin2, Gina Evans-Young3, John B. Imboden4, Dean Schillinger5, Victor M. Montori6 and Edward H. Yelin7, 1Medicine, University of California, San Francisco, San Francisco, CA, 2Medicine, UC San Francisco, San Francisco, CA, 3Rheumatology, UCSF, San Francisco, CA, 4Department of Medicine, Division of Rheumatology, UCSF, San Francisco, CA, 5Medicine and Center for Vulnerable Populations, UCSF, San Francisco, CA, 6Divisions of Endocrinology and Diabetes and Health Care and Policy Research, Mayo Clinic, Rochester, MN, 7Arthritis Research Group, University of California, San Francisco, San Francisco, CA

Meeting: 2013 ACR/ARHP Annual Meeting

Keywords: Communication, Education, patient and rheumatoid arthritis (RA)

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Session Information

Session Title: ACR/ARHP Combined Epidemiology Abstract Session

Session Type: Combined Abstract Sessions

Background/Purpose: Vulnerable populations with rheumatoid arthritis (RA) have poorer outcomes and report suboptimal shared decision-making communication. Patient involvement in the choice of disease modifying anti-rheumatic drugs (DMARDs) for RA may result in improved adherence and better outcomes. Our objective was to test the efficacy of an RA decision aid tool, developed for low literacy and non-English-speaking patients, to improve knowledge and enhance patient involvement in treatment decisions.

Methods: We conducted a pilot trial to test the utility of the decision aid, a set of 5 issue cards which described 12 DMARDs by frequency and mode of administration, time to onset of action, cost, side effects and contraindications. Patients at 2 university-affiliated rheumatology clinics faced with a possible medication change were enrolled consecutively into one of three arms: Arm 1 – existing medication summary guide (usual care) provided pre-clinic visit; Arm 2 – low literacy RA guide provided pre-visit; Arm 3 – low literacy guide provided pre-visit and decision aid used during visit. Immediately post-visit and during a telephone interview 3 months post-visit, subjects completed an RA knowledge questionnaire and the low-literacy version of the Decisional Conflict Scale (DCS; range 0-100; higher scores reflect more conflict).  At 3 months, subjects were also asked about self-reported medication adherence. All materials were available in English, Spanish, and Chinese. DCS, knowledge, and adherence were compared by arm using linear (for DCS) or logistic regression with adjustment for gender immediately post-visit and 3 months.

Results: Of 166 patients enrolled, 88% were female, mean age 59±12; 87% were non-white; 54% spoke a language other than English; and 66% had not graduated high school. There were no statistically significant differences by study arm for education, language, or race/ethnicity; however, there were differences by gender (p=0.02). Compared with the existing guide (Arm 1, n=58), patients who received the low literacy guide plus decision aid (Arm 3, n=60), were more likely to have adequate RA knowledge (OR 3.1, 95% CI 1.4-7.0) immediately post-visit; a difference not seen at 3 months (Table). Among patients who reported a medication change during the visit, Arm 3 patients reported lower decisional conflict compared to those in Arm 1 post-visit (mean DCS 11 vs. 24, p =0.05) and at 3 months (17 vs. 32, p<0.05).  Self-reported adherence did not differ by study arm at 3 months.

Conclusion: An innovative, multi-lingual, low literacy decision aid tool effectively reduced decisional conflict among vulnerable patients with RA faced with choices about DMARDs. The decision aid and medication guide also enhanced RA-specific knowledge immediately post-visit. Future studies are needed to assess the impact of the decision aid on health outcomes in vulnerable populations.

 

Decisional conflict, RA knowledge, and medication adherence by study arm immediately post-visit and 3-months

Instrument & time frame

Arm 1
(original guide)

Arm 2
 (revised guide)

Arm 3
(revised guide & decision aid)

n=58

n=48

n=60

Decisional conflict scale (range 0-100)

adjusted means ( 95% CI)

Immediately post-visit

24 (16,33)

18 ( 9,26)

11 (3,19)

*

3 months

32 (22,40)

21 (12,30)

17 ( 10, 25)

*

Adequate RA knowledge (score ≥ 7 out of 8)

OR (95% CI)

Immediately post-visit

ref

1.6 (0.7,3.4)

3.1 (1.4,7.0)

*

3 months

ref

1.4 (0.6, 3.4)

1.8 (0.8, 4.1)

Adherence (%)

3 months

ref

0.4 (0.1,0.9)

0.5 (0.2,1.2)

All results adjusted for gender.

* p<0.05 for difference between Arm 3 and Arm 1

 


Disclosure:

J. Barton,

Pfizer,

2;

L. Trupin,
None;

G. Evans-Young,
None;

J. B. Imboden,
None;

D. Schillinger,
None;

V. M. Montori,
None;

E. H. Yelin,
None.

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