Improving Decision-Making for Medications in Rheumatoid Arthritis (Text Version)

On September 19, 2011, Ed Yelin made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (345 KB). Plugin Software Help.

Slide 1

Improving Decision-Making for Medications in Rheumatoid Arthritis (RA)

Edward Yelin, Ph.D.,
Jennifer Barton, M.D.
Laura Trupin, M.P.H.
Gina Evans-Young

University of California, San Francisco (UCSF)

Slide 2

Background to Project-1

• Evidence-based consensus that early treatment with disease-modifying agents (DMARDs), including new biological agents, results in improved outcomes for RA.
• Project 2008-2010 to describe prevalence of problems in patient-physician communication in RA for vulnerable populations:
  • Conducted at two UCSF sites: public hospital and tertiary hospital clinics.
  • Observed clinically meaningful discordance between patients and physicians in assessment of disease severity.
  • Found clinically and statistically significant differences in shared decision-making about treatments, disease severity, and functional status by race/ethnicity, language, and immigration status.

Slide 3

Background to Project-2

• Disparities in outcomes differed by site:
  • Pronounced disparities at tertiary care setting, but almost none at public hospital clinic setting.
• Suggests the hypothesis that select features of public hospital clinic reduce disparities in communication, decisionmaking, treatments, and ultimately outcomes:
  • Features include ....
    • Translation services.
    • Clinicians and staff with experience in multicultural care (including language).
    • Clinicians and staff with experience in "working the system" for access to contemporary medications.

Slide 4

Examining Room as One Source of Disparity (But Not Only Source)

Image: Figure 1, shows the Study Model flowchart.

Slide 5

Background to Project-3

• Accumulating evidence that public sector clinical settings may improve treatment choices for vulnerable populations:
  • Investigators found that quality of care for systemic lupus erythematosus may be substantially better in public managed care organizations.
• Trial designed to test one aspect of public hospital clinic's service mix for RA: communication about medication choices:
  • Three arms:
    • Existing RA Medication summary guide (from AHRQ).
    • New RA Medication summary guide modified in consultation with members of vulnerable populations and rheumatologists.
    • New RA medication summary guide plus decision aid tool to be used in clinical encounters.

Slide 6

Background to Project-4

• Outcomes assessed in trial....
  • Primary:
    • Knowledge about medications.
    • Decisional conflict about medications.
  • Secondary:
    • Assessment of interpersonal processes of care ("objective") and satisfaction with providers ("subjective").
    • Treatment uptake for disease-modifying agents and side-effect profile.
    • Disease activity and functional status at six months.
• Trial began last week with goal of 75 persons with RA in each arm.
• Criteria for enrollment:
  • Member of vulnerable population based on one or more of following:
    • Low health literacy, immigrant, elder, non-English speaker, non-white.
  • Currently taking at least one disease-modifying agent.
  • Currently active disease.

Slide 7

RA Treatment Trial and Framework for Evaluating iAdapt Projects

• Reach:
  • All participants will be in targeted population (but we will monitor participation rate by category of vulnerability).
  • Trial is really designed to see if health delivery system can overcome vulnerabilities brought to the ambulatory setting.
• Effectiveness:
  • Secondary goal of trial is to assess impact of summary guide and decision aid on outcomes (outcomes are multi-dimensional).
• Adoption, implementation:
  • Will achieve adoption by FIAT given trial.
  • Implementation snafus will be closely observed despite trial.
• Maintenance:
  • Will measure outcomes at six months (but not primary outcomes of knowledge of and decisional conflict about medications).

Slide 8

Can You Bottle the Essence of a Clinic Focused on Vulnerable Populations?

• Prior project treated the two UCSF clinics as black boxes and found that one clinic was able to reduce disparities in access and outcomes.
• Current project "breaks into" the black box to test whether ability to communicate effectively about treatment choices is key element in improving outcomes in vulnerable populations.
• We will monitor implementation, but basically assume that we are operating in a lab, that is a clinic with an unnaturally small number of snafus dealt with in advance.
• RA may be good test of attempt to improve process of care since role of timely use of DMARDs has been proven effective and made the basis of treatment guidelines.