WILLINGNESS TO CHANGE TREATMENT SHOULD BE ASSESSED AT MULTIPLE TIME POINTS

Purpose: Patient unwillingness to change their current treatment can adversely affects treatment outcomes. A key finding among rheumatoid arthritis (RA) patients is that willingness to change is weakly related to disease activity (DA). Unwillingness has been assessed principally by cross-sectional studies. However, for many patients with chronic conditions, disease severity fluctuates over time. The objective of this study was to examine if the trajectory of disease activity influences willingness to change treatment.

Methods: We interviewed 156 patients actively engaged in treatment for RA at four regular intervals over a six month period. DA was assessed with a validated 40-point self-report measure. A standard procedure was used to rescale this rating to 10 points. We hypothesized that patients would recognize a 10% (1-point) change in their DA. The recognition hypothesis was tested by examining DA scores against a 10-point scale that measured discrepancy between patients' current and desired health states. Further, we hypothesized that the trajectory of DA over six months in combination with DA at each time point is significantly associated with willingness to change. Willingness was assessed on an 11-point scale. Patients whose DA ratings varied by less than 1 point were classified as having a stable trajectory; a variation of 1 point or more was classified as changing. Hypotheses were tested using linear mixed effects models.

Results: Of the 142 participants who completed at least two interviews, 95 had a changing trajectory. As displayed in Figure 1, there is a significant linear relationship between mean recognition ratings and DA scores (t=9.1, df=371.4, p<.001), which supports the hypothesis that patients recognize a 10% change in their DA. The trajectory main effect is non-significant, while the interaction between trajectory and DA is significant (F=7.7, df=2/239.2, p<.001). The relationship between DA and willingness is significant (F=4.8, df=5/422, p<.001), but the interaction model has a better fit and the relationship is linear only for patients with a changing trajectory (t=4.1, df=308.3, p<.001).

Conclusions: DA fluctuates over time and fluctuations influence patients' willingness to change their current treatment. Findings suggest that for at least some patients who have a chronic condition, willingness to change is dynamic and should be measured at multiple time points.