SOCIAL NORMATIVE BELIEFS ARE CENTRAL TO PATIENT CHOICE TO INTENSIFY THERAPY IN RHEUMATOID ARTHRITIS

Purpose:

To compare the effects of two forms of decision support: a pharmaceutical industry FDA endorsed decision guide (Pharm Booklet) and International Patient Decision Aids Standard (IPDAS) compliant patient decision aids (PtDA) on patient medication beliefs and choice to intensify therapy.

Methods:

We conducted a mail survey of 797 biologic naïve rheumatoid arthritis (RA) patients in a community rheumatology practice. Patients were presented with a hypothetical decision scenario where they were asked to consider adding Enbrel^TM (etanercept) to their current regimen. Each patient was randomized to review 1 of 3 forms of etanercept specific decision supports: a long PtDA (LONG DA), a short PtDA (SHORT DA), or the manufacture’s FDA endorsed Enbrel^™ decision guide (Pharm Booklet). Each subject was evaluated for: their decision to intensify therapy, beliefs about etanercept viewed through the Integrated Model of Behavioral Prediction, pre and post intervention etanercept related knowledge, and decisional conflict.

Results:

402 biologic naïve RA patients participated (response rate 52%). 30.6% of patients randomized to Pharm Booklet elected to initiate etanercept. Only 14.6% and 14.0% of patients who reviewed the LONG DA or SHORT DA choose to take etanercept (χ²=15.7; P<.001). There was no difference in decisional conflict between groups. A binary logistic regression model explained 44.2% (R²= .442) of patient choice to intensify therapy by initiating etanercept. The strongest predictors of choice to intensify therapy were beliefs about etanercept: Improve Symptoms (OR = 2.55 95% CI:1.71, 3.80), Social Normative Beliefs about intensifying therapy with etanercept (OR = 2.24, 95% CI: 1.49, 3.35), and risk of Adverse Event (AE) (OR= 0.59 95% CI: 0.39, 0.89). The LONG and SHORT DA produced a significantly greater increase in relevant knowledge, but the increased knowledge and feeling of being informed did not impact patient beliefs about etanercept, decisional conflict or their choice to intensify therapy.

Conclusion:

Patients supported by the Pharm Booklet were twice as likely to choose to intensify therapy. Our study suggests that the choice architecture and persuasive content in the PHARM Booklet communicates a descriptive norm regarding initiation of etanercept. The descriptive norm increases patient belief of effectiveness and likelihood to follow a physician recommendation to intensify therapy.