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Rheumatologists, patients share common barriers to controlling RA
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Rheumatologists and patients share several reported barriers to achieving disease control in rheumatoid arthritis, including a perceived medication risk aversion, suboptimal treatment adherence and a lack of effective communication regarding the benefits of RA disease control, according to recent findings in Arthritis Care & Research.
“A recent study found that patients with RA were unaware of the goals of the T2T strategy, prioritized symptom relief and ensuring function over decreasing disease activity or preventing disease progression,” Justin K. Owensby, PharmD, PhD, of the University of Alabama at Birmingham, and colleagues wrote. “Patients may decline treatment escalation recommended by professional guidelines because they fear worsening symptoms with switching therapies, a concern that outweighs their optimism for improvement with therapy escalation.”
“Moreover, while tight control of disease activity hinges on adherence to prescribed medications, only two-thirds of patients with RA are adherent to their prescribed DMARDs, for various reasons including competing comorbid conditions, medication cost, adverse events and side effects, as well as trust in their provider,” the researchers added. “Thus, while multiple physician and patient factors influence adherence to T2T strategy, the rheumatology community lacks a deep understanding of the challenges that rheumatologists and patients face when attempting to achieve better RA control.”
To identify and analyze patient- and rheumatologist-reported barriers to RA disease control, Owensby and colleagues surveyed individuals included in the Consortium of Rheumatology Researchers of North America (Corrona) registry. The registry features more than 750 physicians and more than 50,000 patients diagnosed with RA. Via email, researchers invited the rheumatologists and patients in Corrona to participate in hour-long nominal group sessions, which included an introduction and explanation, silent generation of ideas, sharing ideas, group discussion, and voting and ranking.
The researchers conducted three nominal group sessions with rheumatologists, totaling 25 participants, and four patient group sessions totaling 37 participants. Further, 1,528 random patients with RA from the Corrona registry were asked to rank their top three barriers to disease control in an online survey. Five hundred patients responded within three weeks, of whom 450 were included in the final analysis.
According to the researchers, the financial aspects of RA care ranked first among both rheumatologist and patient nominal groups regarding important barriers to RA disease control. Medication risk aversion ranked second among rheumatologists and third among patients. Meanwhile, among the 450 patient survey responders, 77% considered RA a top health priority, and 51% reported being aware of the treattotarget strategy for RA care. The three most important barriers to achieving disease control among these patients were RA prognosis uncertainty, medication risk aversion and care-related financial and administrative burdens.
“In addition, our results indicated patients were not aware of the guideline-recommended T2T approach. Thus, we believe that a behavioral intervention could help patients become better informed and engaged about evidence-based RA care,” Owensby and colleagues wrote. “Moreover, such an intervention addressing perceived obstacles to achieving disease control may facilitate meaningful conversations and shared decision making between patients and physicians, improve adherence to goal-directed RA care espoused by the T2T strategy, and thus result in improved quality of life of patients with RA.” – by Jason Laday
Disclosures: Owensby reports no relevant financial disclosures. Please see the full study for additional author disclosures.
Perspective
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David A. McLain, MD, FACP, FACR
Why do patients with rheumatoid arthritis fail to reach target in the Treat to Target (T2T) protocol? This study uses a novel nominal group process to identify the barriers that the authors describe as “organic” rather than selecting from a pre-determined list — I think the authors results match the reasons we see in the clinic every day.
The authors asked the patients, “From your perspective, what obstacles make it hard for you to control your rheumatoid arthritis?” while the physicians were asked, “What are some of the challenges you face in achieving T2T goals for your RA patients?”
The most common barrier to achieving T2T identified by the rheumatologists were treatment-related cost and administrative issues (such as prior authorization), which has been a major problem in my practice, particularly in the Medicare patients who had elected to join an “Advantage” plan. One patient on an “Advantage” plan related to me that his biologic was approved and the specialty pharmacy needed an address to ship it. He said, “Before you ship, what do I owe?” The answer was “$600 a month”, which he declined. A new issue for patients with commercial insurance are copay accumulator plans.
The second physician-identified barrier in this study was patient medication risk aversion; this again is a common reason why I am not able to achieve T2T. We see patients with active synovitis, a high CRP, a high CDAI, and/or a high VECTRA, but they will say “I’m doing fine, Doc, with my current treatment. Those other medications have a lot of side effects. That cancer risk really scares me.” Their present RA regimen may be only prednisone and/or prednisone and a pain medication, an NSAID alone, or a non-biologic DMARD. We know this is not doing the job and their rheumatoid arthritis will progress, but we have to “sell” them that it will progress if they don’t start a more effective treatment. Some take months to come around to accept more aggressive treatment.
The third most common barrier identified by physicians was the concern with the reliability of the measurements of disease activity. Some of this was related to fibromyalgia causing an increase in the RAPID-3, which many of us use in practice.
From the patient perspective, financial burden and comorbidities were the two highest ranked themes. The patient co-pays for biologics and even some DMARDs makes the patient unable to take them or puts a financial burden on them. The comorbidities of diabetes, infection, and active cancer can make treatment decisions difficult for the patient and their provider.
One novel finding in this study was the difference in responses between the RA patients who had received biologics and those who had not. Those who had received biologics were more concerned with the financial aspects of treatment. A major concern I see in my practice is the patient nearing Medicare age, who have done well for years on a biologic but wonder what will happen when they go onto Medicare.
With the “Advantage” plans, patients are often told that their biologics will be “covered”. However, the insurance salesperson “forgets” to tell the patient that their co-pay will be 20% of the retail price of the medication, an amount that few patients are willing — and most unable — to spend. Similarly, you could tell your child “I will ‘cover’ your new Mercedes — I will pay $100 per month.” This study helps to put statistics to issues most of us are dealing with every day as we try to implement T2T.
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