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Curtis JR, Ford K, Fiore S, Mikuls TR, Shaney K, Sethi V. Development of an Interactive Tool to Support Shared Decision-Making in Rheumatoid Arthritis: Treatment Attribute Preference. Arthritis Care Res (Hoboken) 2024; 76:181-190. [PMID: 37652871 DOI: 10.1002/acr.25223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/03/2023] [Accepted: 08/24/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE An interactive tool identifying treatment attributes important to patients can enhance shared decision-making (SDM) in rheumatoid arthritis (RA). A formative survey was conducted to identify the most important treatment attributes from patients' perspective, which can be used to develop an interactive SDM tool. METHODS The survey was performed in two phases: qualitative interviews and quantitative surveys. The qualitative interviews were conducted to inform the design of the quantitative survey. In qualitative interviews, patients with RA (n = 10) and rheumatologists (n = 10) were introduced to the SDM tool concept. Feedback on the design and scope of the SDM tool was used to develop a quantitative survey, conducted in a large sample size of patients. Patient preferences for treatment attributes (route of administration and dosing frequency, serious side effects, out-of-pocket costs, efficacy, and monitoring requirement) were assessed via adaptive conjoint exercise involving ranking of hypothetical RA treatment configurations. RESULTS A total of 944 patients (males: 43%, females: 57%) with RA participated in the quantitative survey. Route of administration and dosing frequency (38%) followed by serious side effects (33%) were the two most important treatment attributes for individual patients. The recontact survey (n = 172/944) estimated tool stability of 72% (n = 124/172) in terms of the relative importance of treatment attributes. CONCLUSION The findings of this survey could be used in the development of an SDM tool that can potentially provide insights into patient preferences and is generally well received by patients and rheumatologists with good agreement and reliability.
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Affiliation(s)
| | | | | | - Ted R Mikuls
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
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Stajszczyk M, Świerkowska G, Smolik K, Domysławska I, Charkiewicz K, Samborski W. The perspective of Polish patients with rheumatoid arthritis - treatment expectations, patient-reported outcomes, and digital literacy (the SENSE study). Reumatologia 2023; 61:331-338. [PMID: 37970121 PMCID: PMC10634413 DOI: 10.5114/reum/171625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/28/2023] [Indexed: 11/17/2023] Open
Abstract
Introduction A widely accepted treat-to-target strategy for rheumatoid arthritis (RA) requires the patient's perspective in making treatment decisions. However, data on treatment preferences and expectations of Polish patients with RA are scarce. The aim of the study was to determine the satisfaction with treatment and the nature of therapeutic preferences and expectations of Polish patients with moderate to severe RA. Material and methods Fifty-two adult Polish patients with moderately to highly active RA were asked to complete patient-reported outcomes and patient-provided information questionnaires. Additionally, patient sociodemographic and clinical data and information on patient current and planned treatment strategies were collected. Results The mean global assessment of patient satisfaction with treatment was 64.1 ±24.6, below the level of indicating satisfaction. Rheumatoid arthritis negatively impacted patients' lives, resulting in a 37.8% impairment of work efficiency and 45% impairment of total activity. Primary treatment expectations for patients were lasting relief of RA symptoms, reduced pain and swelling in joints, increased flexibility of joints, and general improvement of arthritis. The most acceptable potential side effect was weight gain and the least acceptable were increases in the risk of cardiovascular disease, infection, and malignancies. The rapid onset of the drug effect (up to 1 week) was a preference of 48.1% of patients. Access to internet health resources was important for 44.2% of patients, but the median total eHealth literacy score in the study population was 24.0 (interquartile range: 20.5-28.0, range 8-37), which means low digital health literacy (DHL). Conclusions Understanding these treatment preferences and expectations of patients with RA is essential for clinical practitioners to facilitate shared treatment decision-making. Digital health literacy data suggest the need of further improvement.
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Affiliation(s)
- Marcin Stajszczyk
- Department of Rheumatology and Autoimmune Diseases, Silesian Center for Rheumatology, Orthopedics and Rehabilitation, Ustron, Poland
| | - Grażyna Świerkowska
- Division of Rheumatology, Provincial Multispecialist Center of Oncology and Traumatology – N. Copernicus Memorial Hospital in Lodz, Poland
| | | | - Izabela Domysławska
- Formerly: Department of Rheumatology and Internal Diseases, Medical University of Bialystok, Poland
| | | | - Włodzimierz Samborski
- Department of Rheumatology, Rehabilitation and Internal Medicine, University of Medical Sciences, Poznan, Poland
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Bywall KS, Esbensen BA, Heidenvall M, Erlandsson I, Lason M, Hansson M, Johansson JV. Physical function and severe side effects matter most to patients with RA (< 5 years): a discrete choice experiment assessing preferences for personalized RA treatment. BMC Rheumatol 2023; 7:17. [PMID: 37400929 DOI: 10.1186/s41927-023-00341-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 06/21/2023] [Indexed: 07/05/2023] Open
Abstract
AIM Early assessment of patient preferences has the potential to support shared decisions in personalized precision medicine for patients with rheumatoid arthritis (RA). The aim of this study was to assess treatment preferences of patients with RA (< 5 years) with previous experience of inadequate response to first-line monotherapy. METHOD Patients were recruited (March-June 2021) via four clinics in Sweden. Potential respondents (N = 933) received an invitation to answer a digital survey. The survey included an introductory part, a discrete choice experiment (DCE) and demographic questions. Each respondent answered 11 hypothetical choice questions as part of the DCE. Patient preferences and preference heterogeneity were estimated using random parameter logit models and latent class analysis models. RESULTS Patients (n = 182) assessed the most important treatment attributes out of physical functional capacity, psychosocial functional capacity, frequency of mild side effects and likelihood of severe side effects. In general, patients preferred a greater increase in functional capacity and decreased side effects. However, a substantial preference heterogeneity was identified with two underlying preference patterns. The most important attribute in the first pattern was the 'likelihood of getting a severe side effect'. Physical functional capacity was the most important attribute in the second pattern. CONCLUSION Respondents focused their decision-making mainly on increasing their physical functional capacity or decreasing the likelihood of getting a severe side effect. These results are highly relevant from a clinical perspective to strengthen communication in shared decision making by assessing patients' individual preferences for benefits and risks in treatment discussions.
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Affiliation(s)
- Karin Schölin Bywall
- School of Health, Care and Social Welfare, Division of Health and Welfare Technology, Mälardalen University, Västerås, Sweden.
- Department of Public Health and Caring Sciences, Centre for Research Ethics & Bioethics, Uppsala University, Uppsala, Sweden.
| | - Bente Appel Esbensen
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | - Mats Hansson
- Department of Public Health and Caring Sciences, Centre for Research Ethics & Bioethics, Uppsala University, Uppsala, Sweden
| | - Jennifer Viberg Johansson
- Department of Public Health and Caring Sciences, Centre for Research Ethics & Bioethics, Uppsala University, Uppsala, Sweden
- Institute for Future Studies, Stockholm, Sweden
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Bukhari RI, Alamr R, Alsindi RA, Hafiz BF, Gadah AA, Awad NA, Cheikh M, Alshaiki F, Attar SM, Attia G, Almoallim HM. Preferred Mode of Therapy Among Patients in Rheumatoid Arthritis Saudi Database: A Cross-Sectional Study. Cureus 2023; 15:e41014. [PMID: 37519580 PMCID: PMC10372554 DOI: 10.7759/cureus.41014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 08/01/2023] Open
Abstract
AIMS AND OBJECTIVES Current knowledge of patients' preferences for rheumatoid arthritis (RA) treatment is limited. Our goal was to determine the most favorable mode of therapy and the reasons behind choosing each route among RA patients in the Rheumatoid Arthritis Saudi Database (RASD). MATERIALS AND METHODS In this cross-sectional, nationwide, qualitative study, we conducted interviews with 308 RA patients to assess their preferred mode of therapy (oral, subcutaneous (SC) injection, or intravenous (IV) infusion) and to determine the reasons behind their choice. The determining factors behind patients' preferred mode of therapy were evaluated using a 10-point allocation system (1 = least important, 10 = most important). RESULTS We interviewed 308 RA patients (83.4% females, mean age, 48 years). Among all administration modes, the oral route was identified as the most preferred mode among our patients, with a percentage of 73.3%, followed by SC injection and IV infusion at 19.5% and 7.3%, respectively. Ease of drug administration was the most reported reason for patients who chose the oral route over the injection route (63.2%). Difficulty remembering to take the drug and finding it hard to swallow the pills were the highest-scored reasons for avoiding the oral route (24.9%). CONCLUSION Our study demonstrates and emphasizes the importance of shared decision-making between patients and their physicians. The oral route of therapy is, by far, the most preferred mode among our cohort of RA patients.
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Affiliation(s)
- Rahaf I Bukhari
- Department of Medicine, Faculty of Medicine, Umm Al-Qura University, Makkah, SAU
| | - Rasha Alamr
- Department of Medicine, Umm Al-Qura University, Makkah, SAU
| | | | - Bayan F Hafiz
- Department of Medicine, Faculty of Medicine, Umm Al-Qura University, Makkah, SAU
| | - Aziza A Gadah
- Department of Medicine, Umm Al-Qura University, Makkah, SAU
| | - Nermeen A Awad
- Department of Medicine, Dr. Soliman Fakeeh Hospital, Jeddah, SAU
| | - Mohamed Cheikh
- Department of Rheumatology, Dr. Soliman Fakeeh Hospital, Jeddah, SAU
| | - Fatma Alshaiki
- Department of Rheumatology, East Jeddah Hospital, Jeddah, SAU
| | - Suzan M Attar
- Department of Medicine, Faculty of Medicine/Rheumatology, King Abdulaziz University, Jeddah, SAU
| | - Gamal Attia
- Department of Medicine, Faculty of Medicine/Rheumatology, Al-Azhar University, Cairo, EGY
| | - Hani M Almoallim
- Department of Medicine, Faculty of Medicine/Rheumatology, Umm Al-Qura University, Makkah, SAU
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EL Masri H, McGuire TM, van Driel ML, Benham H, Hollingworth SA. Dynamics of Patient-Based Benefit-Risk Assessment of Medicines in Chronic Diseases: A Systematic Review. Patient Prefer Adherence 2022; 16:2609-2637. [PMID: 36164323 PMCID: PMC9508999 DOI: 10.2147/ppa.s375062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/25/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A critical gap exits in understanding the dynamics of patient-based benefit-risk assessment (BRA) of medicines in chronic diseases during the disease journey. PURPOSE To systematically review and synthesize current evidence on the changes of patients' preferences about the benefits and risks of medicines during their disease journey including the influence of disease duration and severity, and previous treatment experience. METHODS A systematic review of studies identified in PubMed and Embase, from inception to November 2020, was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Articles were eligible if they analyzed adult patient-based BRA of medicines with a chronic disease, based on at least one of the pre-specified dimensions: disease severity, disease duration, or previous treatment experience. RESULTS A total of 26,228 articles were identified and 105 were eligible for inclusion. Of these, 85 detected a variation in patient-based BRA of medicines with at least one of the pre-specified criteria. Patients with higher disease severity and more treatment experience have increased risk tolerance. It remains inconclusive whether disease duration directly affects the relative importance of a patient's preference. CONCLUSION Factors important for patients' BRA of their medicines during a chronic disease journey vary more with their clinical situation and previous treatment experience than with time since diagnosis. Due to the importance of these factors on patients' perspectives and potential impact on their decision-making and eventually their clinical outcomes, there is a need for more studies to assess the dynamics of patients' BRA in every disease.
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Affiliation(s)
- Hiba EL Masri
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
- Correspondence: Hiba EL Masri, School of Pharmacy, The University of Queensland, 20 Cornwall St, Woolloongabba, Brisbane, Queensland, 4102, Australia, Tel +61 478512234, Email
| | - Treasure M McGuire
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
- Mater Pharmacy, Mater Health, Brisbane, Queensland, Australia
| | - Mieke L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Helen Benham
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Rheumatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Functional capacity vs side effects: treatment attributes to consider when individualising treatment for patients with rheumatoid arthritis. Clin Rheumatol 2021; 41:695-704. [PMID: 34655004 PMCID: PMC8873051 DOI: 10.1007/s10067-021-05961-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 12/21/2022]
Abstract
Introduction Individualisation of rheumatoid arthritis (RA) treatment needs to take account of individual patients’ preferences to increase patient-centeredness in treatment decisions. The aim of this study was to identify patient-relevant treatment attributes to consider when individualising treatment for patients with RA. Method Patients with RA in Sweden were invited to rank the most important treatment attributes in an online survey (April to May 2020). Semi-structured interviews were conducted (October to November 2020) to further identify and frame potential attributes for shared decision-making. The interviews were audio-recorded, transcribed and analysed using thematic framework analysis. Patient research partners and rheumatologists supported the selection and framing of the treatment attributes across the assessment. Results The highest ranked attributes (N = 184) were improved functional capacity, reduced inflammation, reduced pain and fatigue and the risk of getting a severe side effect. The framework analysis revealed two overarching themes for further exploration: treatment goals and side effects. ‘Treatment goals’ emerged from functional capacity, revealing two dimensions: physical functional capacity and psychosocial functional capacity. ‘Side effects’ revealed that mild and severe side effects were the most important to discuss in shared decision-making. Conclusions Functional capacity (physical and psychosocial) and potential side effects (mild and severe) are important treatment attributes to consider when individualising RA treatment. Future research should assess how patients with RA weigh benefits and risks against each other, in order to increase patient-centeredness early on the treatment trajectory.
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Choi IA, Kim JH, Hae Chang S, Song R, Ha YJ, Won Kim H, Seok Lee J, Choi B, Oh YJ, Moon KW. Patient perspectives on biological treatments for inflammatory arthritis: A multi-center study in Korea. Arch Rheumatol 2021; 36:499-509. [PMID: 35382362 PMCID: PMC8957778 DOI: 10.46497/archrheumatol.2021.8524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/11/2020] [Indexed: 12/24/2022] Open
Abstract
Objectives: The aim of this study was to evaluate the patient’s perception of the use of biological disease-modifying anti-rheumatic drugs (bDMARDs) and provide a basis for physicians to understand the patient’s perspective.
Patients and methods: Between December 2018 and June 2019, a total of 307 patients (162 males, 145 females; mean age: 48 years; range, 18 to 81 years) were included in this investigator-initiated, multi-center, observational, and cross-sectional study in six rheumatology centers. We asked patients using bDMARDs to treat rheumatoid arthritis (RA) or ankylosing spondylitis (AS) to complete a questionnaire regarding major considerations and satisfaction with bDMARDs, preferred administration route, knowledge about bDMARDs, experiences of adverse events, non-adherence, and expectations of their healthcare provider. The satisfaction of physician and clinical information on the patient's disease and treatment were also collected.
Results: Of the patients, 139 had RA and 168 had AS. Median disease duration was six years in RA and five years in AS. A total of 80.1% of the patients and 77.1% of the physicians indicated being satisfied or very satisfied with the therapeutic effect of the current bDMARD. Most patients were open to intravenous or subcutaneous injection, with the most preferred route of administration being subcutaneous (41.3%), followed by intravenous (32.0%), and oral (26.7%). The patients considered therapeutic effect to be more important than cost or convenience while choosing a bDMARD (69.3%), and most were willing to be educated about therapeutic effects (46.1%). Only 35.2% of the patients reported well and/or very well knowledge about the therapeutic effects, side effects, and administration methods of their current bDMARD, and 86.6% cited their physician as the primary source of information about biological treatment.
Conclusion: Patients value therapeutic effect more than cost or convenience while selecting a bDMARD, and consider their physicians to be the primary information source. Therefore, it is important for physicians to provide appropriate education and encourage patients to cooperate actively with treatment.
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Affiliation(s)
- In Ah Choi
- Department of Internal Medicine, Division of Rheumatology, Chungbuk National University Hospital, Cheongju, South Korea
- Department of Internal Medicine, College of Medicine, Chungbuk National University, Cheongu, South Korea
| | - Ji Hyoun Kim
- Department of Internal Medicine, Division of Rheumatology, Chungbuk National University Hospital, Cheongju, South Korea
| | - Sung Hae Chang
- Department of Internal Medicine, Division of Rheumatology, Soonchunhyang University Hospital, Cheonan, South Korea
| | - Ran Song
- Department of Internal Medicine, Division of Rheumatology, Kyung Hee University, Seoul, South Korea
| | - You-Jung Ha
- Department of Internal Medicine, Division of Rheumatology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hye Won Kim
- Department of Internal Medicine, Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jeong Seok Lee
- Korea Advanced Institute of Science and Technology, Graduate School of Medical Science and Engineering, Daejeon, South Korea
| | - Byoongyong Choi
- Department of Internal Medicine, Division of Rheumatology, Seoul Metropolitan Seoul Medical Center, Seoul, South Korea
| | - Yoon-Jeong Oh
- Department of Internal Medicine, Division of Rheumatology, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Ki Won Moon
- Department of Internal Medicine, Division of Rheumatology, Kangwon National University School of Medicine, Chuncheon, South Korea
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Nash P, Lim I, Marabani M. A comparison of Janus kinase inhibitor safety in rheumatoid arthritis. Int J Rheum Dis 2021. [DOI: 10.1111/1756-185x.14127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Peter Nash
- School of Medicine Griffith University Brisbane QLD Australia
| | | | - Mona Marabani
- Department of Medicine Arthritis and Osteoporosis Centre Canterbury Hospital Sydney NSW Australia
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Taylor PC, Ancuta C, Nagy O, de la Vega MC, Gordeev A, Janková R, Kalyoncu U, Lagunes-Galindo I, Morović-Vergles J, de Souza MPGUES, Rojkovich B, Sidiropoulos P, Kawakami A. Treatment Satisfaction, Patient Preferences, and the Impact of Suboptimal Disease Control in a Large International Rheumatoid Arthritis Cohort: SENSE Study. Patient Prefer Adherence 2021; 15:359-373. [PMID: 33633444 PMCID: PMC7900444 DOI: 10.2147/ppa.s289692] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 12/25/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Patients' needs and perspectives are important determinants of treatment success in rheumatoid arthritis (RA). Assessing patients' perspectives can help identify unmet needs and enhance the understanding of treatment benefits. OBJECTIVE The SENSE study assessed the impact of inadequate response to disease-modifying antirheumatic drugs (DMARDs) on treatment satisfaction, disease outcomes, and patient perspectives related to RA disease management. METHODS SENSE was a noninterventional, cross-sectional study conducted in 18 countries across Europe, Asia, and South America. Adult patients with poorly controlled RA of moderate/high disease activity were eligible. Patient satisfaction was assessed by the Treatment Satisfaction Questionnaire for Medication (TSQM v1.4). Treatment adherence, healthcare resource utilization (HRU), quality of life (QoL), work ability, digital health literacy (DHL), patient preference information, and treatment strategy were also assessed. RESULTS A total of 1624 patients were included in the study: most were female (84.2%) and middle-aged, and mean disease duration was 10.5 years. Mean TSQM global satisfaction subscore was 60.9, with only 13.5% of patients reporting good treatment satisfaction (TSQM global ≥80). The strongest predictor of good treatment satisfaction was treatment with advanced therapies. Most patients (87.4%) reported good treatment adherence. In general, patients had impaired QoL and work ability, high HRU, and 67.4% had poor DHL. Leading treatment expectations were "general improvement of arthritis" and "less joint pain". Most patients preferred oral RA medications (60.7%) and rapid (≤1 week) onset of action (71.1%). "Increased risk for malignancies" and "increased risk for cardiovascular disease" were the least acceptable side effects. Despite suboptimal control, advanced therapies were only used in a minority of patients, and DMARD switches were planned for only half of the patients. CONCLUSION Suboptimal disease control negatively impacts treatment satisfaction, work ability, QoL, and HRU. Data collected on patient perspectives may inform shared decision-making and optimize treat-to-target strategies for improving patient outcomes in RA.
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Affiliation(s)
- Peter C Taylor
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Correspondence: Peter C Taylor Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UKTel +44 1865 227323 Email
| | - Codrina Ancuta
- Department of Rheumatology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
| | | | | | - Andrey Gordeev
- V.A. Nasonova Research Institute of Rheumatology, Moscow, Russian Federation
| | - Radka Janková
- Department of Pediatric and Adult Rheumatology, Faculty Hospital Motol, Prague, Czech Republic
| | - Umut Kalyoncu
- Department of Internal Medicine, Division of Rheumatology, Hacettepe University, Ankara, Turkey
| | | | - Jadranka Morović-Vergles
- Department of Internal Medicine, Division of Clinical Immunology, Allergology and Rheumatology, Dubrava University Hospital, University of Zagreb School of Medicine, Zagreb, Croatia
| | | | - Bernadette Rojkovich
- Department of Rheumatology and Physiotherapy, Polyclinic of the Hospitaller Brothers of St. John of God, Semmelweis University, Budapest, Hungary
| | | | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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