Shared decision making requires patients and clinicians to share information about safety, efficacy and treatment burden. But over the past two decades, the expansion of medications for patients with rheumatoid arthritis (RA) has increased the complexity of doctor-patient communication and determining treatment. Additional communication issues, such as language barriers, limited time and lack of health literacy, limit shared decision making and may even affect patient outcome.
“We have found that nearly one-third of adults with RA report suboptimal shared decision-making communication with their clinicians,” write Jennifer L. Barton, MD, of the Oregon Health & Science University in Portland, and her colleagues in their latest research paper. Additionally, “RA patients who are nonwhite, immigrants or who have limited English-language proficiency have higher disease activity and poorer function despite access to effective therapies.”
Dr. Barton and colleagues designed a low-literacy medication guide and decision aid, called RA Choice. Developed in three languages, the program facilitates treatment-related conversations between patients and clinicians to increase patient knowledge and potentially support shared decision making. The program’s efficacy and clinical feasibility were assessed during a practice-based pilot study, the results of which were published in the July 2016 issue of Arthritis Care & Research.
Participants had to have RA, have failed treatment with at least one disease-modifying anti-rheumatic drug and fulfill one of the following criteria: age >65, immigrant, non-English speaker, less than high school education, limited health literacy and racial/ethnic minority. One-hundred and sixty-six patients were sorted into three groups: 1) the control group with patients receiving existing medication guidelines at visits, 2) a group using only the adapted medication guide prior to visits, and 3) a group using both the adapted medication guide before visits plus the decision aid during visits.
The primary endpoints were increased patient knowledge and decreased decisional conflict. Data were collected during post-visit interviews at one week, three months and six months.
“The use of a multilingual, literacy appropriate medication guide and decision tool was acceptable and feasible to vulnerable populations with RA and their clinicians, and increased knowledge,” write the authors in their discussion.
Groups 2 and 3 demonstrated an adequate RA knowledge immediately post visit—63% and 78%, respectively, higher than the control group. Patients who had a medication change (n=65) and were in the intervention groups had a lower (better) mean decisional conflict score immediately post visit. The secondary outcomes of trust in physician and shared decision-making communication did not differ by group. The authors write, “The interventions did not impact secondary outcomes of trust, shared decision-making communication, adherence or change in function at six months.”
Additionally, RA Choice received positive feedback from participating physicians. Seventy-eight percent reported that the decision aid was moderately to greatly helpful in their discussions of RA medications with patients. “Nearly 90% of clinicians predicted that the decision aid would have a positive impact on patient knowledge about medication choices,” write the authors.
Overall, both intervention groups, including patients who changed medication, had a reduction in mean disease activity according to the Clinical Disease Activity Index. But this change was not statistically significant at three months.
The authors conclude, “Adherence and other measures were imprecisely estimated in this pilot, which, along with our findings of acceptability and promising estimates of impact on disease activity, support the conduct of a large, multi-center trial to precisely estimate the effectiveness of RA Choice.”
Barton JL, Trupin L, Schillinger D, et al. Use of low-literacy decision aid to enhance knowledge and reduce decisional conflict among a diverse population of adults with rheumatoid arthritis: Results of a pilot study. Arthritis Care Res (Hoboken). 2015 Nov 25. doi: 10.1002/acr.22801. [Epub ahead of print]