Background/Purpose: Adherence to DMARDs is suboptimal and declines over time, preventing patients from reaching remission. Patient navigators, non-health professionals trained in advocacy, care coordination and basic disease management, have been shown to improve diabetes and heart failure control and cancer screening. We piloted a 6-month intervention, Med Assist, to assess whether rheumatology patient navigators could improve DMARD adherence.

Methods: We enrolled patients >18 years old at an academic rheumatology center with a systemic rheumatic disease, initiating a new oral DMARD within the prior 6 months. Two patient navigators communicated by phone or in person with patients every 2-4 weeks depending on need, for 6 months. Navigators assessed medication use and barriers to care and provided tailored strategies to improve medication adherence. Patients completed validated surveys at baseline and at 6 months. These included the Morisky Medication Adherence Scale (MMAS-8, <6=poor adherence, 6-<8=borderline, 8=high), Mental Health Inventory (MHI-5, <68 indicates depressive symptoms), Beliefs about Medicines Questionnaire, Brief Illness Perception Questionnaire (cognitive and emotional representations of illness), and disease activity indices (SLAQ for SLE, RADAI for RA). We used paired t-tests to compare baseline and 6-month survey scores. We examined the association of age, race/ethnicity, insurance and MHI-5 with change in MMAS-8 score using multivariable linear regression.

Results: We studied 69 patients with rheumatic diseases who engaged with the navigator and completed baseline and 6-month MMAS-8 surveys. The mean age was 55 (±16) years, 93% were female, 50% were white, 11% Hispanic and 7% black; 14% had Medicaid, 32% Medicare and 37% commercial insurance. The mean baseline MMAS-8 score was 6.7 (± 1.3), indicating borderline adherence, and the mean MHI-5 was 60.8 (± 9.1), suggesting prevalent depressive symptoms (Table). At 6 months, there was no significant change in MMAS-8 or MHI-5, or in measures of RA or SLE disease activity. We observed stronger beliefs about medicine efficacy (p=0.03) and a higher illness perception score (p=0.01) at 6-months compared to baseline. Our multivariable model demonstrated a small but statistically significant change in MMAS-8 for each 5-year increase in age (β=0.14, p=0.02).

Conclusion: While this pilot demonstrated the feasibility of a rheumatology-specific navigator, we did not find a significant improvement in DMARD adherence at 6 months. We observed enhanced beliefs about DMARD efficacy, but also a more negative view of the impact of rheumatic diseases on patients lives. A randomized, controlled trial of a rheumatology-specific navigator with longer follow-up is needed to determine whether stable DMARD adherence may demonstrate a beneficial effect, compared to the usual trend in the literature of poorer DMARD adherence over time.