Towards a "tipping point" in rheumatology practice: implementing an integrative model of electronic shared decision making in the standard rheumatology outpatient setting

NMUH Staff Publications

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<span style="font-size: 10pt;">Background: The principles of shared decision making (SDM) are well documented; however, there is a lack of guidance and tools about how to implement this approach in routine clinical practice. Objectives: To assess 1. The implementation of electronic (e-SDM) model in standard clinical practice, 2. the impact of e-SDM on drug compliance in RA patients. 3. The patients' perception and satisfaction about e-SDM as an aid tool. Methods: A double-blind randomized controlled study which included 61 RA patients who have been referred to the pre-biologic therapy assessment clinic. Prior to clinic assessment, every patient was posted a PROMs questionnaire as well as an e-shared decision aid regarding biologic therapy. On the assessment day, after clinical examination and disease activity assessment, discussion was opened regarding the appropriate biologic therapy based on the SDM aid. The control group included 63 RA patients referred to the same clinic. All patients were asked to arrive 30 minutes earlier than their scheduled appointment. Every patient completed a PROMs questionnaire prior to the clinical assessment. The standard drug information leaflet(s) were also given to the patient. Treatment options were discussed in the clinic after clinical assessment. All the patients included in this work met the ACR/EULAR criteria. Disease activity status and DMARDs/ biologic therapy were monitored over 1-year period during which PROMs and compliance to medications were also recorded. Primary outcome was the patients' adherence to their medications; change in disease activity score (DAS-28) and PROMs after 1-year of management. Secondary outcomes were: 1. the outcome of a copy of SURE Test completed by every patient in both groups at time zero and at 1-year of treatment to rate the patient's perspective regarding their condition and treatment. 2. Time taken by each patient in the clinic to discuss their queries regarding the DMARDs medication. Results: There was significant improvement of the patients' adherence to the biologic as well as DMARDs therapy (p<0.01) in favour of the active group. Medication compliance was significantly correlated with changes in PROMs parameters with significant less contact to the advice line in comparison to the control group. After excluding treatment cessation for allergic reactions, stopping the biologic therapy for intolerance or lack of response was significantly less in the active group. The improvement of disease activity parameters was associated with improvement in functional disability and quality of life scores as well as less absence days from work. The answers to "SURE" questions were significantly higher in the active group. The discussion time recorded per patient in the active group was significantly less (p<0.05) in comparison to the control group. Conclusions: Patients participation in the decision making process was associated with higher satisfaction and better adherence to therapy. Results provided evidence that the electronic format of the tool provided firmer foundation for partnership and helped to save time in comparison to standard policies. Involvement in decision making is a key facet of patient participation in health care and rheumatologists are urged to adopt SDM in every treatment decision. [Conference abstract]</span>