AB1201 PAIN DESCRIPTORS AND DETERMINANTS OF PAIN SENSITIVITY IN KNEE OSTEOARTHRITIS: A COMMUNITY-BASED CROSS-SECTIONAL STUDY

Background

The phenomenon of heightened pain sensitivity is implicated in the pain experiences of people with OA[1]. Limited research show that pain sensitivity is associated with poor health and treatment outcomes. However, epidemiological research investigating the extent and determinants of pain sensitivity in OA is scarce. In addition, the quality of pain is poorly described. Both the assessment of quality of pain and pain sensitivity can be important to inform clinical decision-making and treatment.

Objectives

To explore pain characteristics in individuals with knee osteoarthritis (KOA), to compare pain sensitivity across individuals with KOA, chronic back pain (CBP) and pain-free individuals (NP), and to examine the relationship between clinical and pain characteristics with pain sensitivity in KOA.

Methods

Cross-sectional, community-based online survey. Two datasets were combined comprising Dutch individuals of ≥ 40 years of age, experiencing chronic knee pain (KOA, N=445; dataset 1), chronic back pain (CLP, N=504; dataset 2), or no pain (NP, N=256; dataset 2). Demographic and clinical characteristics, global health, physical activity/exercise, and pain characteristics including intensity, spreading, duration, quality (SF-MPQ), and sensitivity (PSQ) were assessed. Differences between (sub)groups were examined using analyses of variance or Chi-square tests. Regression analyses were performed to examine determinants of pain sensitivity in the KOA group.

Results

Quality of pain was most commonly described as aching, tender, and tiring-exhausting in the KOA group (Figure 1). Overall, the KOA group had higher levels of pain sensitivity compared to NP group, but lower levels than the CBP group (Table 1). Univariately, pain intensity, its temporality and spreading, global health, doing exercise, and having comorbidities were weakly related to pain sensitivity (standardized beta’s: 0.12-0.27). Symptom duration was not related to pain sensitivity. Older age, higher levels of continuous pain, lower levels of global health, and doing exercise uniquely contributed, albeit modest, to pain sensitivity (P<0.05).

Table 1.

Mean (SD) pain sensitivity scores across three groups

KOACBPNPKOA vs CBP¥KOA vs NP¥N=445N=504N=256Difference#95% CIDifference#95% CIPSQ-total, mean (SD)4.4 (1.5)4.7 (1.8)3.6 (1.4)-0.23-0.49, 0.030.680.36, 1.01PSQ-minor, mean (SD)3.2 (1.6)3.7 (2.0)2.4 (1.3)-0.32-0.60, -0.050.700.36, 1.05

Abbreviations: PSQ=Pain Sensitivity Questionnaire, KOA=Knee OA pain group, CBP=Chronic Back Pain group, NP=Non-pain group. ¥CBP: N = 487, NP: N=242. #Mean differences adjusted for sex and age.

Figure 1.

Percentage of individuals with self-reported knee OA who rated pain descriptors as moderate to severe

Note: Subgroups based on median split total score Pain Sensitivity Questionnaire. *P<0.05

Conclusion

Continuous pain such as aching and tenderness in combination with decreased physical activity may be indicative for individuals at risk for widespread pain and, ultimately, poor treatment outcomes.

References

[1]Fingleton C, Smart K, Moloney N, Fullen BM, Doody C. Pain sensitization in people with knee osteoarthritis: a systematic review and meta-analysis. Osteoarthritis Cartilage 2015;23:1043-56, doi:10.1016/j.joca.2015.02.163

Disclosure of Interests

None declared

POS0078 COMPARING METHOTREXATE MONOTHERAPY WITH METHOTREXATE PLUS LEFLUNOMIDE COMBINATION THERAPY IN PSORIATIC ARTHRITIS: A RANDOMISED, PLACEBO-CONTROLLED, DOUBLE-BLIND CLINICAL TRIAL (COMPLETE-PsA)

Background

Conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) are the cornerstone first-line treatment in psoriatic arthritis (PsA), although there is a paucity of evidence for the effectiveness of csDMARDs and especially their combination. Assessing the efficacy and safety of combinations of csDMARDs compared with csDMARD monotherapy has been prioritized on the EULAR research agenda. We hypothesized that combining csDMARDs might be more effective than csDMARD monotherapy.

Objectives

We aimed to investigate whether a combination of methotrexate (MTX) and leflunomide (LEF) is superior to MTX monotherapy on improvement in disease activity in patients with PsA.

Methods

Patients with a clinical diagnosis of PsA and active disease (≥2 swollen joints) were included in this randomised, placebo-controlled, double-blind trial. Patients were randomised (1:1) to MTX plus LEF or MTX plus placebo. Patients received MTX 15 mg/week for four weeks and thereafter 25 mg/week, combined with two LEF 10 mg tablets or two placebo tablets daily. The primary outcome was the difference between the MTX plus LEF group and the MTX plus placebo group on the psoriatic arthritis disease activity score (PASDAS) at week 16 adjusted for baseline PASDAS. Key secondary outcomes included safety and the achievement of minimal disease activity (MDA) criteria and PASDAS low disease activity (LDA) (≤3.2).

Results

A total of 78 PsA patients (MTX + LEF n=39; MTX + placebo n=39) were included. The mean age was 53.1 (SD=12.8) years and 36% (n=28) of the patients were female. The mean PASDAS at baseline was 4.9 (SD=1) in both treatment groups. Table 1 shows that MTX plus LEF was superior to MTX plus placebo at week 16 (PASDAS 3.1, SD=1.4 vs 3.7, SD=1.3; treatment difference= -0.6, 90% CI -1.0 to -0.1, one-sided P-value=0.025). Similar and significant results were found for achievement of MDA criteria (59% vs 33%, one-sided P-value=0.013) and PASDAS LDA (59% vs 35%, one-sided P-value=0.019) (Figure 1 and Table 1). Other favorable and significant outcomes for the MTX plus LEF group included -among others- the improvement in swollen joint count (SJC) (median [IQR] = -3 [-5, -2] vs -2 [-4, 0], one-sided P-value=0.039) and the proportion of patients with active psoriasis (i.e. body surface area score >0) at week 16 (44% vs 68%, one-sided P-value=0.014). Generally mild adverse events and treatment discontinuation (MTX+LEF n/N=10/39; MTX + placebo n/N=3/39) occurred more frequently in the MTX plus LEF group.

Table 1.

Primary and secondary outcomes at week 16

MTX + LEF(N=39)MTX + placebo (N=38)*Absolute difference [90% CI]P-valueOne-sidedPrimary endpointPASDAS at week 163.1 (1.4)3.7 (1.3)-0.6 [-1.0, -0.1]0.025Selected secondary endpointsFulfilling PASDAS LDA, N (%)23 (59)13 (35)24% [6, 42]0.019Fulfilling MDA criteria, N (%)23 (59)12 (33)26% [7, 44]0.013SJC66, change from baseline, median (Q1, Q3)-3 (-5, -2)-2 (-4, 0)..0.039TJC68, change from baseline, median (Q1, Q3)-2 (-4, 0)-2 (-5, 0)..0.457VAS physician global, change from baseline, mean (SD)-22.0 (21.9)-12.2 (19.7)-9.8 [-17.7, -1.9]0.021VAS patient global, change from baseline, mean (SD)-20.9 (24.4)-13.9 (28.3)-7.0 [-17.0, 3.0]0.124Active psoriasis, N (%)17 (44)26 (68)-25% [-43, -7]0.014

* One patient in the MTX + LEF group was excluded from the efficacy analysis due to change of diagnosis.

Figure 1.

Proportion of patients meeting different PsA responder criteria for low disease activity at week 16

* = one-sided P-value <0.05

DAPSA = Disease Activity in Psoriatic Arthritis

Conclusion

MTX plus LEF combination therapy resulted in a significantly greater improvement in disease activity according to PASDAS and MDA than treatment with MTX monotherapy in patients with PsA after 16 weeks. In addition, a greater improvement in psoriasis was found for the combination group. However, there are indications that MTX plus LEF combination is less well tolerated than MTX monotherapy.

Acknowledgements

We would like to thank all the patients that participated in this study; all rheumatologists from the Sint Maartenskliniek that helped with the patient inclusion; our patient partners and especially R. van den Griend; Dr. E. Mahler for her suggestions and advice with regard to the study design; Dr. C. Popa and Dr. D. Telgt for being members of our data safety monitoring board and the rheumatology nurses of our center for their assistance with collecting the data.

Disclosure of Interests

Michelle L.M. Mulder: None declared, Johanna E. Vriezekolk Speakers bureau: Eli Lilly Netherlands BV and Galapagos Biopharma Netherlands BV, Tamara van Hal Speakers bureau: Eli Lilly and Novartis, Grant/research support from: support for attending meetings from UCB (personal funding), Lieke Nieboer: None declared, Nathan den Broeder: None declared, E.M.G.J. de Jong Speakers bureau: AbbVie, Almirall, Janssen Pharmaceutica, Novartis, Lily, Celgene, Leo Pharma, Sanofi, UCB and Galapagos (all funding is not personal but goes to the independent research fund of the department of dermatology of Radboud university medical centre Nijmegen, the Netherlands), Consultant of: AbbVie, Almirall, Janssen Pharmaceutica, Novartis, Lily, Celgene, Leo Pharma, Sanofi, UCB and Galapagos (all funding is not personal but goes to the independent research fund of the department of dermatology of Radboud university medical centre Nijmegen, the Netherlands), Grant/research support from: AbbVie, Novartis, Janssen Pharmaceutica, Leo Pharma and UCB for research on psoriasis, Alfons den Broeder: None declared, Frank van den Hoogen: None declared, Philip Helliwell Speakers bureau: Pfizer, Abbvie, Novartis and Janssen, Consultant of: Eli Lilly, Mark Wenink: None declared

POS1561-HPR HEALTH CARE PROVIDERS’ PERSPECTIVE ON CONTINUATION VERSUS TEMPORARY INTERRUPTION OF IMMUNOMODULATORY AGENTS IN CASE OF AN INFECTION: AN INTERVIEW STUDY

Background

Immunomodulatory agents (IA) are often used in the treatment of immune mediated inflammatory diseases (IMIDs). The use of some of these IA is associated with a slightly increased infection risk (1), which raises concerns especially during the current COVID-19 pandemic. It is however unknown whether it is best to continue or temporary interrupt IA in case of an infection, and what the views of health care providers are on this subject.

Objectives

To obtain insight in the health care providers’ perspective regarding continuation and temporary interruption in case of an infection and to assess barriers and facilitators for both treatment strategies.

Methods

Health care providers, involved in the pharmacological treatment of different IMID patients, were interviewed by phone or face-to-face using semi-structured interviews. Recruitment was done using purposive sampling based on age, gender, function, specialty and affinity with the topic. Interviews were conducted until data saturation and analyzed by two researchers using inductive thematic analysis.

Results

Thirteen health care providers with three different functions (medical specialist, physician assistant, resident in training) from three different medical specialties (rheumatology, gastroenterology and dermatology) were interviewed. Mean age was 49 years (range 34 to 66) and the majority was female (69%). Ten main themes were constructed, yielding 77 barriers and facilitators across the two treatment strategies (see Table 1 for themes and a selection of barriers/facilitators). Health care providers mentioned that the choice between continuation and temporary interruption is often about balancing infection severity, IMID severity (e.g. risk of flare) and patient characteristics (comorbidities/vulnerability). They struggled with the lack of evidence on these two treatment strategies, which leads to choices being made based on previous experiences or intuition.

Table 1.

Identified themes

ThemeExample of barrier/facilitator1. IMID characteristicsLow disease activity (facilitator for interruption)2. IA characteristicsLarge administration intervals: interruption not possible (barrier for interruption)3. Effects of IA on infection / immune systemBelief on positive effect (facilitator for continuation)4. Patient characteristicsPatients with comorbidities / history of previous infections (facilitator for interruption)5. Infection characteristicsMild infection (facilitator for continuation)6. Guidelines / current practiceCurrent practice = interruption of IA during infection (barrier for continuation)7. Health care provider characteristicsPeer influence (facilitator for interruption; health care providers state that they would interrupt IA if for example an infectious diseases specialist would recommend so)8. FinancialHigher costs (barrier for continuation)9. Stopping IA in generalChance to stop/taper IA (facilitator for interruption)10. Interruption characteristicsShort duration: no impact on disease activity (facilitator for interruption)

Conclusion

A wide variety of barriers and facilitators for temporary interruption and continuation of IA during infection were identified. These perceived barriers and facilitators –together with emerging evidence on the risk and benefits of IA use during infections (2)– will aid implementation of the most optimal strategy regarding IMIDs, IA and infections.

References

[1]Singh JA, Cameron C, Noorbaloochi S, Cullis T, Tucker M, Christensen R, et al. Risk of serious infection in biological treatment of patients with rheumatoid arthritis: a systematic review and meta-analysis. Lancet. 2015;386(9990):258-65.

[2]COntinuation Versus Interruption of Immunomodulating Drugs in case of an Infectious disease in IMID patients (COVID I2 study), with special attention for COVID 19: a pragmatic, explorative randomized controlled trial. [Internet]. [cited 2021 Jan 21]. Available from: https://www.trialregister.nl/trial/8922.

Disclosure of Interests

Merel Opdam: None declared, Johanna E. Vriezekolk: None declared, Alfons den Broeder Grant/research support from: Grants for quality of care projects and research outside the current study from Abbvie, Galapagos, Pfizer, Novartis, Lilly, Sanofi, Gilead (to the institution/rheumatology department), L.M. Verhoef: None declared

OP0210-HPR THE OCCURRENCE OF OVERWHELMING FATIGUE IN INDIVIDUALS WITH KNEE OSTEOARTHRITIS: A DAILY DIARY STUDY

Background

Cross sectional research shows that nearly half of the individuals with osteoarthritis (OA) experience fatigue and over one third experience severe fatigue (1). However, few studies have addressed the unpredictable and fluctuating course of fatigue in OA including the occurrence of overwhelming fatigue as evidenced from qualitative research (2). In-depth understanding of the course of fatigue and its determinants may inform clinical decision making and treatment.

Objectives

To explore 1) the occurrence of overwhelming fatigue and its determinants and 2) the variability of daily experienced fatigue in individuals with knee OA.

Methods

A daily diary design. 73 participants with a self-reported diagnosis of knee OA aged >40 years and in possession of a Smartphone completed a baseline questionnaire on demographics, health status (EQ5D-VAS), and self-efficacy (Arthritis Self-Efficacy Scale (ASES)). This was followed by daily assessments with regard to overwhelming fatigue, fatigue severity, pain, sleep, and perceived exertion of physical activities (PEPA) over a 7 day period. A yes/no format was used to assess overwhelming fatigue and a numeric rating scale (NRS, 0-10) was used to assess fatigue severity, pain, sleep, and PEPA. The variability of fatigue was assessed by calculating the standard deviation (SD) per participant over this 7 day period. Comparisons between participants with and without overwhelming fatigue were conducted by unpaired t-tests and Pearson’s chi-square tests where appropriate.

Results

47 participants were included in the analysis. Overwhelming fatigue occurred at least once in 26 (55%) participants with mean= 2.7 (SD= 1.4) over a 7 day period. Differences of participants with and without overwhelming fatigue are displayed in Table 1.

Table 1.

Characteristics of participants (n=47) included in the analysis.

Characteristics*All participants (n=47)Participants with overwhelming fatigue (n=26)Participants without overwhelming fatigue (n=21)Difference (95% CI)p-valueAge63.4 (8.6)61.7 (8.5)65.5 (8.5)-3.8 (-8.8; 1.2)0.13Female (n (%))39 (83%)23 (88%)16 (76%)0.47BMI27.4 (4.6)28.0 (5.1)26.5 (3.8)1.5 (-1.1; 4.1)0.25Health status67.5 (13.8)66.0 (13.5)69.5 (14.2)-3.5 (-11.7; 4.7)0.39ASES pain2.9 (1.0)3.2 (0.8)2.5 (1.1)0.7 (0.1; 1.3)0.02ASES os2.5 (0.8)2.7 (0.8)2.2 (0.7)0.5 (0.1; 1.0)0.02Fatigue severity4.9 (1.7)5.5 (1.5)4.1 (1.6)1.3 (0.4; 2.3)0.01Pain4.2 (1.9)4.8 (1.6)3.4 (2.0)1.4 (0.3; 2.5)0.01Sleep5.9 (1.6)5.5 (1.7)6.4 (1.4)-0.9 (-1.8; -0.0)0.05PEPA4.9 (1.2)5.0 (1.2)4.8 (1.3)0.2 (-0.6; 0.9)0.64

ASES, Arthritis Self-Efficacy Scale; ASES os, other symptoms; PEPA, perceived exertion of physical activities. For health status, ASES pain, ASES os, and sleep, higher scores reflect better outcomes; for PEPA, higher scores reflect more PEPA; for fatigue severity and pain, higher scores reflect higher levels. *mean (SD) unless otherwise statedg.

The variability of daily experienced fatigue per participant ranged from SD= 0.2 to 2.9 (Figure 1). This was not significantly different between participants with and without overwhelming fatigue.

Figure 1.

Standard deviations of average fatigue severity over a 7 day period per participant (n=47).

Conclusion

Our findings suggest that more than half of the participants experienced at least one episode of overwhelming fatigue and that this is related to self-efficacy, fatigue severity, pain, and sleep. Fatigue remained fairly stable over time by the majority of participants.

References

[1]Overman CL, Kool MB, da Silva JAP, Geenen R. The prevalence of severe fatigue in rheumatic diseases: an international study. Clin Rheumatol. 2016;35:409–15.

[2]Power JD, Badley EM, French MR, Wall AJ, Hawker GA. Fatigue in osteoarthritis: A qualitative study. BMC Musculoskeletal Disorders. 2008;9:63.

Acknowledgements

We would like to thank Yvonne Peters for her involvement in the study design and data collection.

Disclosure of Interests

None declared

OP0118-HPR GAMING FOR ADHERENCE TO MEDICATION USING E-HEALTH IN RHEUMATOID ARTHRITIS (GAMER) STUDY – A RANDOMISED CLINICAL TRIAL

Background

Effectiveness of pharmacological therapy in rheumatoid arthritis (RA) is limited by inadequate medication adherence. Medication adherence can be influenced by implicit attitudes of personal medication needs and concerns about adverse consequences. We targeted these implicit attitudes using a serious puzzle game.

Objectives

To assess the effectiveness of a serious game compared to usual care to improve adherence to disease modifying anti-rheumatic drugs (DMARDs) in patients with rheumatoid arthritis (RA).

Methods

A multicentre randomised clinical trial was performed with a 3 month follow-up period.[1] Inclusion criteria were adulthood, RA diagnosis, use of DMARDs and possession of a smartphone/tablet. All participants received usual care. In addition, intervention participants were invited to play the serious puzzle game at will. The game was designed to influence players’ attitudes toward medication.[2] Collected data consisted of serious game play data, Compliance Questionnaire in Rheumatology (CQR), Beliefs about Medication Questionnaire (BMQ), Health Assessment Questionnaire (HAQ) and Rheumatoid Arthritis Disease Activity Index (RADAI).

Primary outcome was DMARD implementation adherence at three months assessed as the difference in proportion of non-adherent patients (<80% taking adherence) between intervention and control group using the discriminant function of the CQR using the Chi-squared test.

Two sample t-tests and Wilcoxon rank-sum test were performed to test for differences on secondary outcomes between study groups where appropriate.

Results

229 participants were randomised and 186 participants completed the study. Of the 85 intervention participants, 70 (82%) played the serious game for at least one hour. The serious game was played a median of 36 sessions with an average playtime of 25 minutes leading to a median overall playtime of 9.7 hours. A total of 59 (69%) intervention participants showed at least 40 days of gaming activity. Control group adherence (54%) and intervention group adherence (63%) based on the dichotomised CQR-score did not differ at three months (p = 0.26) (see Table 1). Neither was there a significant difference in CQR continuous score (p = 0.20), beliefs about medication differential score (p = 0.43) or clinical outcomes (HAQ: p = 0.97; RADAI: p = 0.90) (see Table 1).

Table 1.

Study outcomes at end-point (3 months)

Control group (n=101)Intervention group (n=85)p-valuePrimary outcomeAdherent no. (%)*55 (54)52 (63)0.26Secondary medication outcomesCQR continuous mean ± SD75 ± 1273 ± 110.20BMQ-Specific NCD score mean ± SD4.8 ± 4.25.3 ± 4.70.43Secondary clinical outcomesRADAI score median [IQR]2.5 [1.2 – 4.0]2.5 [1.5 – 4.2]0.90HAQ score median [IQR]0.8 [0.3 – 1.4]0.6 [0.3 – 1.4]0.97

Abbreviations: no. – number; SD – standard deviation; CQR – Compliance Questionnaire on Rheumatology; BMQ – Beliefs about Medication questionnaire; IQR – interquartile range

* Percentage of the total number of participants excluding missing data.

Conclusion

This multicentre randomised clinical trial showed that a serious puzzle game aimed at reinforcing a positive attitude towards DMARDs was frequently played during three months. Playing the game did not improve medication adherence nor influenced beliefs about medication or clinical outcomes in RA patients.

References

[1]https://www.trialregister.nl/trial/7217

[2]Pouls B, Bekker CL, van Dulmen S, Vriezekolk JE, van den Bemt BJF. A serious puzzle game to enhance adherence to anti-rheumatic drugs in rheumatoid arthritis patients: systematic development using Intervention Mapping. JMIR Serious Games. 06/11/2021:31570 (forthcoming/in press)

Disclosure of Interests

Bart Pouls: None declared, Charlotte Bekker: None declared, Johanna E. Vriezekolk: None declared, Sandra van Dulmen: None declared, Bart van den Bemt Speakers bureau: UCB, Pfizer, Sanofi-Aventis, Galapagos, Amgen en Eli Lilly

Quality of knee osteoarthritis care in the Netherlands: a survey on the perspective of people with osteoarthritis

Background

Quality indicators (QIs) are used to monitor quality of care and adherence to osteoarthritis (OA) standards of care. Patient reported QIs can identify the most important gaps in quality of care and the most vulnerable patient groups. The aim of this study was to capture the perspective of people with knee OA (KOA) in the Netherlands on the quality of care received, and explore determinants related to lower achievement rates.

Methods

We sent an online survey to all members of The Dutch Knee Panel (n = 622) of the Sint Maartenskliniek Nijmegen, the Netherlands between September and October 2019. The survey consisted of a slightly adapted version of the “OsteoArthritis Quality Indicator” (OA-QI) questionnaire (18 items; yes, no, N/A); a rating of quality of KOA care on a 10-point scale; a question on whether or not one wanted to see change in the care for KOA; and an open-ended question asking recommendations for improvement of OA care. Furthermore, sociodemographic and disease related characteristics were collected. Pass rates for separate QIs and pass rates on patient level were calculated by dividing the number of times the indicator was achieved by the number of eligible persons for that particular indicator.

Results

A total of 434 participants (70%) completed the survey. The mean (SD) pass rate (those answering “Yes”) for separate QIs was 49% (20%); ranging from 15% for receiving referral for weight reduction to 75% for patient education on how to manage knee OA. The mean (SD) pass rate on patient level was 52% (23%). Presence of OA in other joints, comorbidities, and having a knee replacement were associated with higher pass rates. On average, a score of 6.5 (1.6) was given for the quality of care received, and the majority of respondents (59%) wanted change in the care for KOA. Of 231 recommendations made, most often mentioned were the need for tailoring of care (14%), more education (13%), and more empathy and support from healthcare providers (12%).

Conclusion

This study found patients are only moderately satisfied with the OA care received, and showed substantial gaps between perceived quality of care for OA and internationally accepted standards. Future research should focus on the underlying reasons and provide strategies to bridge these gaps.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08014-1.

Healthcare professionals’ perceptions on barriers and facilitators to DMARD use in rheumatoid arthritis

Background

Disease-modifying anti-rheumatic drugs (DMARDs) are the cornerstone of rheumatoid arthritis (RA) treatment. However, the full benefits of DMARDs are often not realized because many patients are sub-optimally adherent to their medication. In order to optimize adherence, it is essential that healthcare professionals (HCPs) understand patients’ barriers and facilitators for medication use. Insight in these barriers and facilitators may foster the dialogue about adequate medication use between HCPs and patients. What HCPs perceive as barriers and facilitators has, so far, scarcely been investigated. This study aimed to identify the perceptions of HCPs on patients’ barriers and facilitators that might influence their adherence.

Methods

This qualitative study was performed using semi structured in-depth interviews with HCPs. An interview guide was used, based on an adjusted version of the Theoretical Domains Framework (TDF). Thematic analysis was conducted to identify factors that influence barriers and facilitators to DMARD use according to HCPs.

Results

Fifteen HCPs (5 rheumatologists, 5 nurses and 5 pharmacists) were interviewed. They mentioned a variety of factors that, according to their perceptions, influence DMARD adherence in patients with RA. Besides therapy-related factors, such as (onset of) medication effectiveness and side-effects, most variation was found within patient-related factors and reflected patients’ beliefs, ways of coping, and (self-management) skills toward medication and their condition. In addition, factors related to the condition (e.g., level of disease activity), healthcare team and system (e.g., trust in HCP), and social and economic context (e.g. support, work shifts) were reported.

Conclusions

This study provided insights in HCPs’ perceptions of the barriers and facilitators to DMARD use patients with RA. Most factors that were mentioned were patient-related and potentially modifiable. When physicians understand patients’ perceptions on medication use, adherence to DMARDs can probably be optimized in patients with RA leading to more effectiveness of treatment outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07459-0.

Ranking facilitators and barriers of medication adherence by patients with inflammatory arthritis: a maximum difference scaling exercise

Introduction

Facilitators and barriers of adherence to disease-modifying anti-rheumatic drugs (DMARDs) have been identified by patients with inflammatory arthritis earlier. However, the relative importance from the patients’ perspective of these factors is unknown. Knowledge on this ranking might guide the development of interventions and may facilitate targeted communication on adherence. This study aims to examine 1) the relative importance patients attach to facilitators and barriers for DMARDs adherence, and 2) the relationship between patient characteristics and ranking of these factors.

Methods

One hundred twenty-eight outpatients with inflammatory arthritis; (60% female, mean age 62 years (SD = 12), median disease duration 15 years, IQR (7, 23) participated in a Maximum Difference scaling exercise and ranked 35 items based upon previously identified facilitators and barriers to medication adherence. Hierarchical Bayes estimation was used to compute mean Rescaled Probability Scores (RPS; 0–100) (i.e. relative importance score). Kendall’s coefficient of concordance was used to examine a possible association between patients’ characteristics (i.e. age, sex and educational level) and ranking of the items.

Results

The three most important items ranked by patients were: Reduction of symptoms formulated as “Arthritis medications help to reduce my symptoms” (RPS = 7.30, CI 7.17–7.44), maintaining independence formulated as “I can maintain my independence as much as possible” (RPS = 6.76, CI 6.54–6.97) and Shared decision making formulated as “I can decide –together with my physician- about my arthritis medications” (RPS = 6.48, CI 6.24–6.72). No associations between patient characteristics and ranking of factors were found.

Conclusions

Reducing symptoms, maintaining independency and shared decision making are patients’ most important factors for DMARDs adherence. This knowledge might guide the development of interventions and may facilitate communication between health professionals and their patients on medication adherence.

Choosing wisely in daily practice: a mixed methods study on determinants of antinuclear antibody testing by rheumatologists

OBJECTIVES

To explore the relationship between antinuclear antibody (ANA) overuse and rheumatologist-related factors before and after an intervention aimed at reducing ANA overuse.

METHOD

In this mixed methods study we performed surveys among rheumatologists (n = 20) before and after the ANA intervention (education and feedback). We identified clinician-related determinants of ANA overuse (demographic characteristics, cognitive bias, numeracy, personality, thinking styles, and knowledge) by multivariate analysis. Two focus group meetings with rheumatologists were held 6 months after the intervention to explore self-reported determinants.

RESULTS

Questionnaires were completed by all rheumatologists and eight participated in the focus groups. Rheumatologists with more work experience and a less extravert personality ordered more ANA tests before the intervention [β = 0.01, 95% confidence interval (CI) 0.003 to 0.02, p = 0.01 and β = -0.11, 95% CI -0.21 to -0.01, p = 0.04, respectively; R² = 47%]. After the intervention, female rheumatologists changed less than their male colleagues with regard to the number of ANA tests ordered (β = 0.15, 95% CI 0.03-0.26, p = 0.02; R^{2 =} 25%). During the focus groups, seven themes were identified that influenced improvement in ANA overuse: determinants related to the intervention and the study, individual health professionals, patients, professional interactions, incentives and resources, capacity for organizational change, and social, political, and legal factors.

CONCLUSIONS

We identified several determinants that together explained a sizable part of the variance observed in the ANA outcomes at baseline and in the change in ANA outcomes afterwards. Furthermore, the focus groups yielded additional factors suggesting a complex interplay of determinants influencing rheumatologists' ANA ordering behaviour.