Purpose: American College of Rheumatology guidelines “strongly recommend” aggressive care with disease modifying anti-rheumatic drugs (DMARDs) in order to achieve and maintain tight control in rheumatoid arthritis (RA). Despite the widespread endorsement of this approach, data suggest that many patients are not effectively treated. There are currently no proven mechanisms to effectively inform patients and enable them to process the complex information involving decisions related to escalating care. The objective of this study is to develop a decision tool to effectively inform and “nudge” RA patients with active disease to accept additional therapy.
Methods: We first performed a systematic review to generate the outcome data and risk estimates required for the tool. A Delphi panel of experts was used to determine which AEs should be represented to all subjects to ensure informed consent. Additional information can be accessed through links for those desiring additional information. Probabilistic information is presented using theoretically motivated manipulations; e.g.: bar graphs to emphasize relative benefits and pie charts to emphasize the denominator. Participants perform a Best-Worst scaling exercise after viewing the informational content to clarify their priorities. We conducted a pre-post test pilot study to assess the feasibility, acceptability, and preliminary evidence of the tool’s efficacy in improving informed choice.
Results: We interviewed104 subjects; mean age (SD) = 62 (12); 84% female, 86% White; median duration of RA =13 years (range 1-61). Knowledge (sum of correct responses to 20 questions) and willingness to take a biologic (11-point numeric rating scale) significantly improved after viewing the tool (mean differences 3.1 and 1.4 respectively, both p < 0.0001). Decisional conflict (informed and value subscales) also significantly decreased (mean differences 20.4 and 20.7, both p<0.001). Increased willingness to take a biologic was greater among younger adults and those with a college education. Improvement in knowledge was seen across ages and educational backgrounds. Over 90% of participants ratings; related to the quality and quantity of information were very good or excellent. 89% found the tool to be very helpful and all would recommend it for patients with RA.
Conclusion: A tool designed based on the principles of Fuzzy Trace theory to nudge patients towards accepting “strong recommendations” increased knowledge, decreased decisional conflict, and increased patient willingness to escalate care in a pre-post test setting.