Dr. Barton developed a multi-lingual rheumatoid arthritis decision aid (RA Choice) for rheumatologists and patients with limited health literacy and limited English proficiency, and tested it in a pilot study. The study showed the low literacy tools increased knowledge, decreased decisional conflict, and improved disease activity, and the decision aid improved the quality of the decision-making process for vulnerable populations with RA.3 She and colleagues currently are conducting a study of a multicomponent shared decision making intervention (which includes the RA Choice decision aid) in more than 400 patients and more than 45 clinicians in three in U.S. Veterans Health Administration rheumatology clinics, the results of which (including intervention materials and clinician training) will be shared among local and national VA rheumatologists.4 Images of decision aid tools are included in a supplement to the study.
She also pointed out that shared decision making is included in a number of treatment guidelines, but that there must be “support for better conversations between clinicians and patients that includes awareness of options, discussion of risks and harms of those options, [and] what matters most to patients. A collaborative decision is critical for optimal patient-centered care.”
Barriers
Dr. Dey provided a deeper look at the many barriers to shared decision making in rheumatology, pointing out that although shared decision making is widely promoted in guidelines, “we all know that achieving it in practice is not straightforward.” On the patient level, these barriers include social determinants of health, health and digital literacy, culture and language, the patient’s emotional state and illness perceptions, to name a just a few. On the physician-level, barriers include time pressures, limited training, culture and language, implicit biases, and discomfort and uncertainty with engaging in shared decision making. And on a system level, barriers include fragmented care, a lack of accessible materials, insufficient interpreter or navigator support, and inequities in access to therapies or input from specialists.
For example, Dr. Dey said, implicit bias (i.e., unconscious assumptions based on factors such as age, race, gender, body size, disability or socioeconomic status) are shown to influence prescribing decisions, referral patterns and even the quality of doctor-patient dialogue. “In rheumatology, studies have shown that patients from minoritized ethnic groups are less likely to be prescribed methotrexate or achieve early remission, and older patients are often excluded from aggressive treatment simply because of age-based assumptions,” she said.5-7
She also highlighted the deleterious effects of health literacy on shared decision making. She pointed to her recent systematic review of more than 16,000 patients with inflammatory arthritis that showed low health literacy, among other factors, was associated with less participation in shared decision making.8
