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1.
PLoS Med ; 16(5): e1002800, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31067237

RESUMO

BACKGROUND: Treatment decision-making regarding immunosuppressive therapy is challenging for individuals with lupus. We assessed the effectiveness of a decision aid for immunosuppressive therapy in lupus nephritis. METHODS AND FINDINGS: In a United States multicenter, open-label, randomized controlled trial (RCT), adult women with lupus nephritis, mostly from racial/ethnic minority backgrounds with low socioeconomic status (SES), seen in in- or outpatient settings, were randomized to an individualized, culturally tailored, computerized decision aid versus American College of Rheumatology (ACR) lupus pamphlet (1:1 ratio), using computer-generated randomization. We hypothesized that the co-primary outcomes of decisional conflict and informed choice regarding immunosuppressive medications would improve more in the decision aid group. Of 301 randomized women, 298 were analyzed; 47% were African-American, 26% Hispanic, and 15% white. Mean age (standard deviation [SD]) was 37 (12) years, 57% had annual income of <$40,000, and 36% had a high school education or less. Compared with the provision of the ACR lupus pamphlet (n = 147), participants randomized to the decision aid (n = 151) had (1) a clinically meaningful and statistically significant reduction in decisional conflict, 21.8 (standard error [SE], 2.5) versus 12.7 (SE, 2.0; p = 0.005) and (2) no difference in informed choice in the main analysis, 41% versus 31% (p = 0.08), but clinically meaningful and statistically significant difference in sensitivity analysis (net values for immunosuppressives positive [in favor] versus negative [against]), 50% versus 35% (p = 0.006). Unresolved decisional conflict was lower in the decision aid versus pamphlet groups, 22% versus 44% (p < 0.001). Significantly more patients in the decision aid versus pamphlet group rated information to be excellent for understanding lupus nephritis (49% versus 33%), risk factors (43% versus 27%), medication options (50% versus 33%; p ≤ 0.003 for all); and the ease of use of materials was higher in the decision aid versus pamphlet groups (51% versus 38%; p = 0.006). Key study limitations were the exclusion of men, short follow-up, and the lack of clinical outcomes, including medication adherence. CONCLUSIONS: An individualized decision aid was more effective than usual care in reducing decisional conflict for choice of immunosuppressive medications in women with lupus nephritis. TRIAL REGISTRATION: Clinicaltrials.gov, NCT02319525.


Assuntos
Técnicas de Apoio para a Decisão , Imunossupressores/uso terapêutico , Nefrite Lúpica/tratamento farmacológico , Educação de Pacientes como Assunto , Participação do Paciente , Adulto , Comportamento de Escolha , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Alfabetização em Saúde , Humanos , Imunossupressores/efeitos adversos , Nefrite Lúpica/etnologia , Nefrite Lúpica/imunologia , Pessoa de Meia-Idade , Folhetos , Resultado do Tratamento , Estados Unidos/epidemiologia
2.
Artigo em Inglês | MEDLINE | ID: mdl-30875461

RESUMO

OBJECTIVE: In rheumatoid arthritis (RA), it is unclear if women are less likely to achieve low disease activity (LDA). We evaluated sex differences in remission and LDA, comparing different clinical and imaging measures. METHODS: We utilized data from the Veterans Affairs RA (VARA) registry and from two clinical trials. Remission and LDA were defined using composite scores, individual items (tender joints, swollen joints, ESR, CRP, evaluator/patient global assessment), and MRI. In VARA, we assessed 1) the likelihood of point remission at any time during follow-up using logistic regression, and 2) time to sustained remission (2 consecutive visits) using Cox proportional hazard models. In the clinical trials, logistic regression models evaluated the likelihood of low clinical and MRI activity at 52 weeks. RESULTS: Among 2463 patients in VARA women (10.2%) were less likely to be in DAS28-ESR remission in follow-up [OR: 0.71 (0.55, 0.91) p<0.01] and had a longer time to sustained DAS28-ESR remission. This difference was not observed for DAS28-CRP, CDAI, or RAPID3. Women were more likely to achieve favorable individual components except for an ESR <30 mm/hr [OR: 0.72 (0.57, 0.90) p<0.01]. Among 353 trial participants, (83.7% women), women had reduced rates of DAS28-ESR remission [OR: 0.39 (0.21, 0.72) p=0.003] but similar rates of low MRI synovitis and osteitis. CONCLUSION: The comparison of remission rates between men and women varies based on the disease activity measure, with sex-specific differences in ESR resulting in reliably lower rates of remission among women. There were no differences in MRI-measures. This article is protected by copyright. All rights reserved.

3.
J Rheumatol ; 46(10): 1409-1414, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30709963

RESUMO

OBJECTIVE: The Outcome Measures in Rheumatology (OMERACT) Shared Decision Making (SDM) Working Group aims to determine the core outcome domain set for measuring the effectiveness of SDM interventions in rheumatology trials. METHODS: A white paper was developed to clarify the draft core domain set. It was then used to prepare for interviews to investigate reasons for lack of consensus on it and to suggest further improvements. RESULTS: OMERACT scientists/clinicians (n = 13) and patients (n = 10) suggested limiting the core domain set to outcome domains, removing process domains, and clarifying remaining domains. CONCLUSION: A revised core domain set will undergo further consensus-building.

4.
Clin Exp Rheumatol ; 37(3): 422-428, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30418120

RESUMO

OBJECTIVES: Obese patients with rheumatoid arthritis (RA) may be more likely to discontinue therapy than non-obese patients, possibly signifying a more refractory phenotype. The purpose of this study was to examine the association between body mass index (BMI) and discontinuation rates for different RA treatments accounting for confounding factors. METHODS: Veterans Affairs administrative databases were used to define initial courses of methotrexate (MTX), hydroxychloroquine, sulfasalazine, prednisone, and self-injectable tumour necrosis factor inhibitors (TNFi). Discontinuation was defined as a lapse in drug refill >90 days. Using overweight BMI (25-30 kg/m2) as the referent group, multivariable Cox proportional hazards models were used to evaluate associations between BMI category and time to treatment discontinuation. RESULTS: There were 46,970 initial RA treatment courses identified from 2005-2014 among 23,669 Veterans with RA. In multivariable models, severe obesity (BMI >35 kg/m2), compared to overweight BMI, was not associated with treatment discontinuation with the exception of prednisone [HR 1.10 (1.04, 1.17) p<0.001]. Patients with low (<20 kg/m2) and normal BMI (20-25 kg/m2) were more likely to discontinue MTX, TNFi, and HCQ compared to overweight patients. Other factors associated with earlier MTX and/or TNFi discontinuation included female sex, black race, greater comorbidity, depression, malignancy, congestive heart failure, current smoking, and more recent calendar year. CONCLUSIONS: Obesity was not associated with therapy discontinuation among veterans with RA after accounting for confounding factors, suggesting that obesity is not a biological mediator of more refractory disease. Conversely, low BMI, comorbidity, and depression were identified as important predictors of drug discontinuation.


Assuntos
Antirreumáticos/uso terapêutico , Artrite Reumatoide , Índice de Massa Corporal , Uso de Medicamentos/estatística & dados numéricos , Antirreumáticos/efeitos adversos , Artrite Reumatoide/tratamento farmacológico , Feminino , Humanos , Metotrexato , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Fator de Necrose Tumoral alfa
5.
J Rheumatol ; 45(12): 1636-1642, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30219761

RESUMO

OBJECTIVE: Rheumatoid arthritis (RA) patients' adherence to disease-modifying antirheumatic drugs (DMARD) is often suboptimal. We examined associations among medication beliefs, self-efficacy, and adherence to medications in RA. METHODS: Data were from a longitudinal observational cohort of persons with RA. Subjects completed telephone interviews on self-reported adherence, self-efficacy, demographics, and the Beliefs about Medicines Questionnaire (BMQ), which assesses beliefs in necessity and beliefs about taking medication. Bivariate and multivariate logistic regression identified correlates of poor adherence to synthetic DMARD and prednisone as well as to biologic therapy, including medication concerns and necessity. RESULTS: There were 362 patients who reported taking a synthetic DMARD and/or prednisone. Of these, 14% and 21% reported poor adherence to oral DMARD or prednisone, and biologics, respectively. There were 64% who reported concern about taking medicines, 81% about longterm effects, and 47% about becoming too dependent on medicines. In multivariate analyses, the BMQ necessity score was independently associated with better adherence to oral DMARD or prednisone (adjusted OR 0.61, 95% CI 0.41-0.91), while self-efficacy was associated with greater odds of poor adherence to oral medications (adjusted OR 1.23, 95% CI 1.01-1.59). Beliefs in medicines and self-efficacy were not associated with adherence to biologics. CONCLUSION: In a diverse cohort of patients with RA, stronger beliefs in the necessity of medication were associated with better adherence to oral DMARD or prednisone, while higher self-efficacy was associated with poor adherence. Providers can play important roles in eliciting patient beliefs about medications to improve adherence and ultimately health outcomes.


Assuntos
Antirreumáticos/uso terapêutico , Artrite Reumatoide/psicologia , Produtos Biológicos/uso terapêutico , Conhecimentos, Atitudes e Prática em Saúde , Adesão à Medicação/psicologia , Autoeficácia , Adulto , Idoso , Artrite Reumatoide/tratamento farmacológico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
6.
Arthritis Care Res (Hoboken) ; 70(11): 1614-1620, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29438606

RESUMO

OBJECTIVE: Alignment of patient and clinician goals, which is central to effective patient-centered care, has been linked to improved patient experience and outcomes but has not been explored in rheumatoid arthritis (RA). The aim of this study was to analyze goal conceptualization among RA patients and clinicians. METHODS: Seven focus groups and 1 semi-structured interview were conducted with RA patients and clinicians who were recruited from 4 rheumatology clinics. An interview guide was developed to explore goal concordance related to RA treatment. Researchers utilized a concurrent deductive-inductive data analysis approach. RESULTS: Nineteen patients (mean age 55 years, 74% female, 32% non-white, and 26% Spanish-speaking) and 18 clinicians (44% trainees, 44% female, 28% non-white) participated. Across clinician and patient focus groups, the 2 identified domains were patient knowledge of RA and psychosocial dynamics (stress) in RA treatment. Within the knowledge domain, 3 themes emerged: RA knowledge for informed choice, RA knowledge to ensure adherence and medication safety, and clinician assumption of patient inability to interpret information. Within the second domain of RA and stress, 2 themes emerged: patient illness experience informs treatment context in ways that are not shared by clinicians, and the impact of patient-clinician communication and decision-making on goal concordance. CONCLUSION: Knowledge is a shared goal, but RA patients and clinicians hold divergent attitudes towards this goal. While knowledge is integral to self-management and effective shared decision-making, mismatches in attitudes may lead to suboptimal communication. Tools to support patient goal-directed RA care may promote high quality patient-centered care and result in reduced disparities.


Assuntos
Artrite Reumatoide/psicologia , Artrite Reumatoide/tratamento farmacológico , Atitude do Pessoal de Saúde , Feminino , Grupos Focais , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Relações Médico-Paciente , Pesquisa Qualitativa
7.
Rheumatol Int ; 37(10): 1765-1769, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28840348

RESUMO

The objective of this retrospective study was to evaluate the prevalence of comorbid Posttraumatic stress disorder (PTSD) and the association of PTSD with pain, disease activity, and medication use in ankylosing spondylitis (AS). Veterans with one or more visit to an outpatient rheumatology clinic at a single Veterans Affairs site during a 2-year study period were identified by ICD codes for AS and included if there was documentation of AS diagnosis by a rheumatologist. Data were collected on PTSD diagnosis, demographics, pain scores, disease activity by the Bath AS Disease Activity Index (BASDAI), and medication use. Characteristics were compared by PTSD status using t tests for continuous variables and Chi-square or Fischer's exact test for categorical variables. Of 113 Veterans with AS, 20 (18%) had a diagnosis of PTSD. Those with PTSD were significantly younger, 52 ± 17 years, as compared to those without PTSD, 59 ± 14 years (p = 0.04). BASDAI was recorded for 30% with a mean score of 4.3 ± 2.0. Those with PTSD had higher mean pain and BASDAI scores as compared to those without PTSD (p = 0.06 for both comparisons). Prescribed medications were similar for both groups in regards to synthetic disease modifying antirheumatic drugs (DMARDs), biologics, and opioids, although those with PTSD were significantly more likely to receive NSAIDs (p = 0.03). Veterans with AS and comorbid PTSD were younger and had higher reported pain and disease activity scores compared to those without PTSD in this single site study. These findings underscore the importance of identifying PTSD in patients with AS.


Assuntos
Espondilite Anquilosante/complicações , Transtornos de Estresse Pós-Traumáticos/complicações , Veteranos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos Retrospectivos , Índice de Gravidade de Doença , Espondilite Anquilosante/diagnóstico
9.
J Rheumatol ; 44(11): 1727-1733, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28202740

RESUMO

OBJECTIVE: Despite advances integrating patient-centered outcomes into rheumatologic studies, concerns remain regarding their representativeness across diverse patient groups and how this affects equity. The Outcome Measures in Rheumatology (OMERACT) Equity Working Group aims to determine whether and how to address equity issues within the core outcome sets of domains and instruments. METHODS: We surveyed current and previous OMERACT meeting attendees and members of the Campbell and Cochrane Equity Group regarding whether to address equity issues within the OMERACT Filter 2.0 Core Outcome Sets and how to assess the appropriateness of domains, instruments, and measurement properties among diverse patients. At OMERACT 2016, results of the survey and a narrative review of differential psychosocial effects of rheumatoid arthritis (i.e., on men) were presented to stimulate discussion and develop a research agenda. RESULTS: We proposed 6 moments for which an equity lens could be added to the development, selection, or testing of patient-reported outcome measures (PROM): (1) recruitment, (2) domain selection, (3) feasibility in diverse settings, (4) instrument validity, (5) thresholds of meaning, and (6) consideration of statistical power of subgroup analyses for outcome reporting. CONCLUSION: There is a need to (1) conduct a systematic review to assess how equity and population characteristics have been considered in PROM development and whether these differences influence the ranking of importance of outcome domains or a patient's response to questionnaire items, and (2) conduct the same survey described above with patients representing groups experiencing health inequities.


Assuntos
Artrite/terapia , Ensaios Clínicos como Assunto , Equidade em Saúde , Medidas de Resultados Relatados pelo Paciente , Reumatologia , Humanos
10.
J Am Med Inform Assoc ; 24(1): 106-112, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27274017

RESUMO

OBJECTIVE: Patients with limited health literacy (LHL) and limited English proficiency (LEP) experience suboptimal communication and health outcomes. Electronic health record implementation in safety net clinics may affect communication with LHL and LEP patients.We investigated the associations between safety net clinician computer use and patient-provider communication for patients with LEP and LHL. MATERIALS AND METHODS: We video-recorded encounters at 5 academically affiliated US public hospital clinics between English- and Spanish-speaking patients with chronic conditions and their primary and specialty care clinicians. We analyzed changes in communication behaviors (coded with the Roter Interaction Analysis System) with each additional point on a clinician computer use score, controlling for clinician type and visit length and stratified by English proficiency and health literacy status. RESULTS: Greater clinician computer use was associated with more biomedical statements (+12.4, P = .03) and less positive affect (-0.6, P < .01) from LEP/LHL patients. In visits with patients with adequate English proficiency/health literacy, greater clinician computer use was associated with less positive patient affect (-0.9, P < .01), fewer clinician psychosocial statements (-3.5, P < .05), greater clinician verbal dominance (+0.09, P < .01), and lower ratings on quality of care and communication. CONCLUSION: Higher clinician computer use was associated with more biomedical focus with LEP/LHL patients, and clinician verbal dominance and lower ratings with patients with adequate English proficiency and health literacy. DISCUSSION: Implementation research should explore interventions to enhance relationship-centered communication for diverse patient populations in the computer era.


Assuntos
Barreiras de Comunicação , Comunicação , Registros Eletrônicos de Saúde , Alfabetização em Saúde , Linguagem , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Relações Médico-Paciente , Provedores de Redes de Segurança , Estados Unidos
11.
Musculoskeletal Care ; 15(4): 295-303, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-27976535

RESUMO

OBJECTIVE: During the clinical encounter, rheumatoid arthritis (RA) patient goals for care often go unexplored. The aim of the present systematic review was to identify needs, goals and expectations of RA patients in order better to guide systematic elicitation of patient goals in clinical encounters. METHODS: An academic librarian searched MEDLINE, PsychINFO and the Cochrane Library using a specialized algorithm developed to identify articles about patient goals for RA care. Investigators screened search results according to prespecified inclusion criteria and then reviewed included articles and synthesized the evidence qualitatively, utilizing an inductive approach. RESULTS: A total of 909 titles were retrieved in the literature search, of which 871 were excluded after a title/abstract screen. Of the remaining 38, 22 papers were included in the final review. Investigators identified four major themes in the literature: (a) the bodily experience of RA; (b) achieving normalcy and maintaining wellness; (c) social connectedness and support; and (d) interpersonal and healthcare system interactions. CONCLUSION: Patients' goals when receiving care for RA are multidimensional and span several facets of everyday life. Goals for RA care should be collaboratively developed between patients and providers, with particular attention to the patient's life context and priorities.


Assuntos
Artrite Reumatoide/psicologia , Artrite Reumatoide/terapia , Metas , Humanos
13.
Arthritis Care Res (Hoboken) ; 68(7): 889-98, 2016 07.
Artigo em Inglês | MEDLINE | ID: mdl-26605752

RESUMO

OBJECTIVE: Despite innovations in treatment of rheumatoid arthritis (RA), adherence is poor and disparities persist. Shared decision making (SDM) promotes patient engagement and enhances adherence; however, few tools support SDM in RA. Our objective was to pilot a low-literacy medication guide and decision aid to facilitate patient-clinician conversations about RA medications. METHODS: RA patients were consecutively enrolled into 1 of 3 arms: 1) control; patients received existing medication guide prior to clinic visit, 2) adapted guide prior to visit, and 3) adapted guide prior to plus decision aid during visit. Outcomes were collected immediately postvisit, at 1-week, and at 3- and 6-month interviews. Eligible adults had to have failed at least 1 disease-modifying antirheumatic drug and fulfill 1 of the following: age >65 years, immigrant, non-English speaker, less than high school education, limited health literacy, and racial/ethnic minority. Primary outcomes were knowledge of RA medications, decisional conflict, and acceptability of interventions. RESULTS: The majority of 166 patients were immigrants (66%), non-English speakers (54%), and had limited health literacy (71%). Adequate RA knowledge postvisit in arm 3 was higher (78%) than arm 1 (53%; adjusted odds ratio 2.7, 95% confidence interval 1.2, 6.1). Among patients with a medication change, there was lower (better) mean decisional conflict in arms 2 and 3 (P = 0.03). There were no significant differences in acceptability. CONCLUSION: A low-literacy medication guide and decision aid was acceptable, improved knowledge, and reduced decisional conflict among vulnerable RA patients. Enhancing knowledge and patient engagement with decision support tools may lead to medication choices better aligned with RA patients' values and preferences.


Assuntos
Artrite Reumatoide , Tomada de Decisões , Técnicas de Apoio para a Decisão , Conhecimentos, Atitudes e Prática em Saúde , Alfabetização em Saúde/métodos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto
15.
J Rheumatol ; 41(7): 1290-7, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24931952

RESUMO

OBJECTIVE: Treat-to-target guidelines promote shared decision making (SDM) in rheumatoid arthritis (RA). Also, because of high cost and potential toxicity of therapies, SDM is central to patient safety. Our objective was to examine patterns of perceived communication around decision making in 2 cohorts of adults with RA. METHODS: Data were derived from patients enrolled in 1 of 2 longitudinal, observational cohorts [University of California, San Francisco (UCSF) RA Cohort and RA Panel Cohort]. Subjects completed a telephone interview in their preferred language that included a measure of patient-provider communication, including items about decision making. Measures of trust in physician, education, and language proficiency were also asked. Logistic regression was performed to identify correlates of suboptimal SDM communication. Analyses were performed on each sample separately. RESULTS: Of 509 patients across 2 cohorts, 30% and 32% reported suboptimal SDM communication. Low trust in physician was independently associated with suboptimal SDM communication in both cohorts. Older age and limited English proficiency were independently associated with suboptimal SDM in the UCSF RA Cohort, as was limited health literacy in the RA Panel Cohort. CONCLUSION: This study of over 500 adults with RA from 2 demographically distinct cohorts found that nearly one-third of subjects report suboptimal SDM communication with their clinicians, regardless of cohort. Lower trust in physician was independently associated with suboptimal SDM communication in both cohorts, as was limited English language proficiency and older age in the UCSF RA Cohort and limited health literacy in the RA Panel Cohort. These findings underscore the need to examine the influence of SDM on health outcomes in RA.


Assuntos
Artrite Reumatoide/terapia , Tomada de Decisões , Alfabetização em Saúde , Linguagem , Participação do Paciente , Relações Médico-Paciente , Confiança , Adulto , Idoso , Comunicação , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade
16.
BMC Med Inform Decis Mak ; 14: 104, 2014 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-25649726

RESUMO

BACKGROUND: Shared decision-making in rheumatoid arthritis (RA) care is a priority among policy makers, clinicians and patients both nationally and internationally. Demands on patients to have basic knowledge of RA, treatment options, and details of risk and benefit when making medication decisions with clinicians can be overwhelming, especially for those with limited literacy or limited English language proficiency. The objective of this study is to describe the development of a medication choice decision aid for patients with rheumatoid arthritis (RA) in three languages using low literacy principles. METHODS: Based on the development of a diabetes decision aid, the RA decision aid (RA Choice) was developed through a collaborative process involving patients, clinicians, designers, decision-aid and health literacy experts. A combination of evidence synthesis and direct observation of clinician-patient interactions generated content and guided an iterative process of prototype development. RESULTS: Three iterations of RA Choice were developed and field-tested before completion. The final tool organized data using icons and plain language for 12 RA medications across 5 issues: frequency of administration, time to onset, cost, side effects, and special considerations. The tool successfully created a conversation between clinician and patient, and garnered high acceptability from clinicians. CONCLUSIONS: The process of collaboratively developing an RA decision aid designed to promote shared decision making resulted in a graphically-enhanced, low literacy tool. The use of RA Choice in the clinical encounter has the potential to enhance communication for RA patients, including those with limited health literacy and limited English language proficiency.


Assuntos
Artrite Reumatoide , Tomada de Decisões , Técnicas de Apoio para a Decisão , Alfabetização em Saúde , Adulto , Artrite Reumatoide/tratamento farmacológico , Humanos
17.
J Health Care Poor Underserved ; 24(4): 1542-51, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24185151

RESUMO

Electronic health record (EHR) implementation may affect patient-clinician communication for diverse safety-net populations. We conducted a cross-sectional survey of English-, Spanish-, and Cantonese-speaking patients in a public hospital clinic with a basic EHR. We examined multivariate associations of patient race/ethnicity, language, and education with perceptions of primary-care provider (PCP) computer use. Among 399 respondents, 25% had less than a high school education, 22% preferred Spanish, and 17% Cantonese. Asian (AOR 3.1), non-English-speakers (AOR 3.6) were more likely to report that PCPs used the computer half or more of the visit. Asians were more likely to report that computers helped PCPs remember patient concerns (AOR 5.6). Non-English-speakers had lower odds of reporting that PCPs listened less carefully to them because of computers (AOR 0.3). Patients at risk for communication barriers may perceive advantages of PCP computer use. Safety-net clinics should consider EHR impact on communication disparities.


Assuntos
Grupos de Populações Continentais/estatística & dados numéricos , Registros Eletrônicos de Saúde , Relações Médico-Paciente , Atenção Primária à Saúde , Atitude Frente aos Computadores , Estudos Transversais , Registros Eletrônicos de Saúde/estatística & dados numéricos , Feminino , Hospitais Públicos , Humanos , Masculino , Pessoa de Meia-Idade , Provedores de Redes de Segurança , São Francisco , Inquéritos e Questionários , População Urbana
18.
Arthritis Res Ther ; 15(5): R157, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-24432366

RESUMO

INTRODUCTION: Our objective was to determine rheumatoid arthritis (RA) patients' understanding of methotrexate and assess whether knowledge varies by age, education, English language proficiency, or other disease-related factors. METHODS: Adults with RA (n = 135) who were enrollees of an observational cohort completed a structured telephone interview in their preferred language between August 2007 and July 2009. All subjects who reported taking methotrexate were asked 11 questions about the medication in addition to demographics, education level, and language proficiency. Primary outcome was a total score below the 50th percentile (considered inadequate methotrexate knowledge). Bivariable and multivariable logistic regressions were performed. Covariates included demographics, language proficiency, education, and disease characteristics. RESULTS: Of 135 subjects, 83% were female, with a mean age of 55 ± 14 years. The majority spoke English (64%), followed by 22% Spanish and 14% Cantonese or Mandarin. Limited English language proficiency (LEP) was reported in 42%. Mean methotrexate knowledge score was 5.4 ± 2.6 (range, 0 to 10); 73 (54%) had a score lower than 5 (of 10). Age older than 55, less than high school education, LEP, better function, and biologic use were independently associated with poor knowledge. CONCLUSIONS: In a diverse RA cohort, overall methotrexate knowledge was poor. Older age and limited proficiency in English were significant correlates of poor knowledge. Identification of language barriers and improved clinician-patient communication around methotrexate dosing and side effects may lead to improved safety and enhanced benefits of this commonly used RA medication.


Assuntos
Artrite Reumatoide/tratamento farmacológico , Conhecimentos, Atitudes e Prática em Saúde , Entrevistas como Assunto , Metotrexato/uso terapêutico , Adulto , Fatores Etários , Idoso , Antirreumáticos/uso terapêutico , Estudos de Coortes , Barreiras de Comunicação , Escolaridade , Feminino , Humanos , Linguagem , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Multilinguismo , Análise Multivariada , Estudos Observacionais como Assunto
19.
Arthritis Care Res (Hoboken) ; 62(6): 857-64, 2010 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-20535797

RESUMO

OBJECTIVE: To determine the degree of discordance between patient and physician assessment of disease severity in a multiethnic cohort of adults with rheumatoid arthritis (RA), to explore predictors of discordance, and to examine the impact of discordance on the Disease Activity Score in 28 joints (DAS28). METHODS: Adults with RA (n = 223) and their rheumatologists completed a visual analog scale (VAS) for global disease severity independently. Patient demographics, the 9-item Patient Health Questionnaire (PHQ-9) depression scale score, the Health Assessment Questionnaire score, and the DAS28 were also collected. Logistic regression analyses were used to identify predictors of positive discordance, defined as a patient rating minus physician rating of >25 mm on a 100-mm VAS (considered clinically relevant). DAS28 scores stratified by level of discordance were compared using a paired t-test. RESULTS: Positive discordance was found in 30% of cases, with a mean +/- SD difference of 46 +/- 15. The strongest independent predictor of discordance was a 5-point increase in PHQ-9 score (adjusted odds ratio 1.61, 95% confidence interval 1.02-2.55). Higher swollen joint count and Cantonese/Mandarin language were associated with lower odds of discordance. DAS28 scores were most divergent among subjects with discordance. CONCLUSION: Nearly one-third of RA patients differed from their physicians to a meaningful degree in assessment of global disease severity. Higher depressive symptoms were associated with discordance. Further investigation of the relationships between mood, disease activity, and discordance may guide interventions to improve care for adults with RA.


Assuntos
Artrite Reumatoide/diagnóstico , Artrite Reumatoide/psicologia , Medição da Dor/psicologia , Relações Médico-Paciente , Índice de Gravidade de Doença , Adulto , Idoso , Estudos de Coortes , Depressão/diagnóstico , Depressão/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos
20.
Patient Prefer Adherence ; 3: 335-44, 2009 Nov 29.
Artigo em Inglês | MEDLINE | ID: mdl-20016797

RESUMO

Significant advances in the treatment of rheumatoid arthritis (RA) have been made over the past 10 years with the introduction of biologic therapies, such as the TNF inhibitors. With these medications, many patients with RA have seen significant improvement in symptoms, function, and quality of life. However, with the introduction of the biologics, decision-making for this chronic disease that affects up to 1% of the population has become even more complex. Patient preferences for mode and frequency of administration, and for certain risks vs benefits as well as medication beliefs are central to uptake and adherence to these medications. This review examines the current literature on patient satisfaction, adherence, and preference for biologic therapy in RA.

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