Decision making about medications in rheumatoid arthritisShaw, Yomei (2017) Decision making about medications in rheumatoid arthritis. Doctoral Dissertation, University of Pittsburgh. (Unpublished)
AbstractUnderstanding the issues surrounding decision making about medication treatments has important implications for public health, including improving the quality of care for patients with chronic conditions. This dissertation examines medication decisions in one chronic condition, rheumatoid arthritis (RA). Chapter one introduces the context of decision making about medications in RA. Guidelines recommend treating RA to the target (T2T) of low disease activity (LDAS) with disease-modifying antirheumatic drugs (DMARDs). T2T requires regularly monitoring for moderate/high disease activity (MHDAS), and adjusting DMARDs at least every 3 months until the patient reaches LDAS. The chapter provides background on the challenges of implementing T2T, and summarizes chapters two through four. Chapter two addresses delays in DMARD adjustment for patients with MHDAS. Survival analysis is used to examine the extent of delays in DMARD adjustments and whether delayed DMARD adjustment leads to delayed LDAS. Forty percent of RA patients with persistent MHDAS wait longer than 3 months to receive DMARD adjustment, and timely DMARD adjustment is associated with reaching LDAS sooner. There may be a need to reduce delays in DMARD therapy adjustment for many patients. Chapter three examines patients’ perspectives on medication decisions, exploring how feelings in response to events and information motivate decisions to accept or resist medications. Patients’ feelings towards the benefits and dangers of medications, their identity as an ill person, the act of taking medication, and the decision process itself affect willingness to accept medications. Awareness of feelings motivating resistance to taking medications may allow physicians to better support patients confronting threatening information and difficult treatment decisions. Chapter four compares patient joint assessments with physician joint assessments to examine their suitability for disease activity monitoring between visits. Although agreement on joint assessment items is modest, agreement on detection of MHDAS is better. Patient joint assessments may be useful for disease monitoring between visits, potentially reducing delays to DMARD adjustment. This dissertation provides a multi-level view of treatment guideline implementation in RA. Understanding the interdependency of patient, provider, and system level factors in medication decisions is valuable for improving the quality of care for patients with chronic conditions. Share
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