The Patient Perspective on Bdmard Dose Reduction: A Mixed Methods Study

L.M. Verhoef¹, E.M.H. Selten¹, J.E. Vriezekolk¹, A.J.L. de Jong², F.H.J. van den Hoogen^1,3, A.A. Den Broeder^1,3 and M.E.J.L. Hulscher⁴, ¹Rheumatology, Sint Maartenskliniek, Nijmegen, Netherlands, ²Department of Rheumatology, Rijnstate Arnhem, Arnhem, Netherlands, ³Rheumatology, Radboud university medical centre, Nijmegen, Netherlands, ⁴Radboud Institute for Health Sciences, IQ healthcare, Radboud university medical centre, Nijmegen, Netherlands

Meeting: 2017 ACR/ARHP Annual Meeting

Date of first publication: September 18, 2017

Keywords: Biologics, patient preferences and rheumatoid arthritis (RA)

Session Information

Date: Tuesday, November 7, 2017

Title: Patient Outcomes, Preferences, and Attitudes II

Session Type: ACR Concurrent Abstract Session

Session Time: 2:30PM-4:00PM

Background/Purpose: biological DMARDs (bDMARDs) are effective in the treatment of RA, but are also associated with side-effects and high costs. Dose reduction of bDMARDs, after low disease activity is reached, is safe and effective¹. To date, few studies have focused on bDMARD dose reduction from the patient perspective. Therefore, the aim of this study was to identify the factors that play a role for patients when considering dose reduction, and to determine their relative importance.

Methods: A mixed methods design was used in which we 1) identified influencing factors by performing qualitative interviews and 2) ranked these factors using a Maximum Difference Scaling questionnaire.

Phase 1: We performed semi-structured interviews with RA patients. Interviews were transcribed verbatim and two researchers analyzed the transcriptions by inductive thematic analysis.

Phase 2: The influencing factors were derived from the interviews and used in a Maximum Difference Scaling experiment with RA patients from 3 different centers in the Netherlands (an academic hospital, a specialized hospital and a large general hospital). The survey included 18 questions in which patients were asked to choose the most and least important factor from a subset of 5 factors. The mean relative importance score (RIS) for each factor was calculated using hierarchical Bayes modeling.

Results: For phase 1 and phase 2, 22 and 195 patients were included respectively (table 1). Thirty factors were identified from the interviews and used in the questionnaire. The 10 factors that were ranked the highest, are shown in table 2. Most respondents had a positive attitude towards bDMARD dose reduction. The results show that patients are concerned that dose reduction will lead to a disease flare that affects their daily life (pain, function). It is important for them to know that it is possible to increase the dose if (further) reduction is not possible and that the bDMARD will be effective again. Patients value the opinion of their rheumatologist, and being involved in the decision to start tapering is highly ranked as well.

Table 1. Patient characteristics (mean (SD) or N (%))
Characteristic	Phase 1 (n=22)	Phase 2 (n=195)
Female	15 (68%)	126 (65%)
Age (years)	62 (7.6)	59 (12.0)
Disease duration (years)	13 (9.4)	16 (10.0)
Number of respondents per center	Specialized hospital: 22 (100%)	Specialized hospital: 69 (35%) Academic hospital: 65 (33%) Large general hospital: 61 (31%)
Experience with bDMARD dose reduction	Yes: 16 (73%) No: 6 (27%)	Yes: 119 (61%) No: 72 (37%) I don’t know: 4 (2%)
General attitude towards bDMARD dose reduction	Not applicable	Very positive: 64 (33%) Positive: 79 (41%) Neutral: 28 (14%) Negative: 12 (6%) Very negative: 2 (1%) I don’t know: 10 (5%)

Table 2. Top-10 factors from the Maximum Difference Scaling questionnaire
Nr.	Factor
1	The possibility to increase the dose when disease symptoms worsen
2	The risk that my disease activity will increase
3	My current disease activity
4	The risk that my physical function will deteriorate (e.g. I won’t be able to work)
5	The confidence I have in my rheumatologist
6	To what extent I’m involved in the decision on bDMARD dose reduction
7	Whether the bDMARD is (still) necessary for the RA
8	What my rheumatologist advises regarding bDMARD dose reduction
9	The risk that I will experience more pain
10	The effect of the bDMARD after increasing the dose

Conclusion: Although preferences will vary between individual patients, the results from this study could facilitate implementation of bDMARD dose reduction by informing care providers on what is important for patients and providing a basis for shared decision making.

1. Nam et al, Ann Rheum Dis. 2017 Jun;76(6):1113-1136

Disclosure: L. M. Verhoef, None; E. M. H. Selten, None; J. E. Vriezekolk, None; A. J. L. de Jong, None; F. H. J. van den Hoogen, Biogen Idec, 5,Celltrion, 5,Janssen Pharmaceutica Product, L.P., 5,Mundipharma, 5,Sandoz, 5; A. A. Den Broeder, CZ, 2,Menzis, 2,ZonMW, 2,Amgen, 5,Boehringer Ingelheim, 5,Bristol-Myers Squibb, 8,Pfizer Inc, 8; M. E. J. L. Hulscher, None.

To cite this abstract in AMA style:

Verhoef LM, Selten EMH, Vriezekolk JE, de Jong AJL, van den Hoogen FHJ, Den Broeder AA, Hulscher MEJL. The Patient Perspective on Bdmard Dose Reduction: A Mixed Methods Study [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/the-patient-perspective-on-bdmard-dose-reduction-a-mixed-methods-study/. Accessed .

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