Shared decision making in standard rheumatology practice: from policy to practice

NMUH Staff Publications

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<span style="font-size: 10pt;">Background: Shared decision making (SDM) is based on setting up a good relationship between the patient and the treating doctor. To accomplish this, we adopted a SDM model based on 3 pillars: a)Presenting choice, b) defining options, and c) supporting patients discover preferences and make decisions. The model is centered on respecting "what matters most" to the patients and respecting their "informed choice" Objectives: To assess 1. The patients' perception and impact of SDM on drug compliance in RA patients. 2. the cost effectiveness of shared decision making in standard practice. Methods: A double-blind randomized controlled study which included early arthritis patients diagnosed according to ACR/EULAR criteria. The patients were randomly stratified into: Active group (69 patients) who were given a Shared Decision aid to read whilst waiting outside the clinic room, entailing their choices and treatment options. The patient was then reviewed in the clinic where decision talk phase was carried out towards making a decision regarding the preferred treatment. The control group included 68 patients. The standard drug information leaflets were given to the patient prior to having a thorough discussion in the clinic. Disease activity status and DMARDs therapy were monitored over 1-year period during which PROMs, compliance to medications and co-morbidity scores 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 questionnaire completed by every patient in both the active group and control group 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 no significant difference on comparing the disease activity parameters in both groups whereas there was significant improvement of the patients' adherence to anti-rheumatic therapy (p<0.01) in favour of the active group. Medication compliance in the active group was significantly (P<0.01) correlated with changes in PROMs parameters with significant less contact to the advice line in comparison to the control group. Stopping the DMARDs therapy because of intolerance 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. There was no significant difference on comparing the time taken for discussion with the patient to explain their DMARDs therapy and options available. Conclusions: SDM did facilitate a longer term positive impact on the patients' management. SDM was cost effective as it led to reduced health service use over a 1-year period as well as better patients' adherence to therapy and less number of sick leaves. Furthermore, SDM was not found to be time consuming. The shared partnership had a direct impact on the patients' management as it allowed the patients to have a better attitude toward their management, self-efficacy/self-confidence which were both correlated with improved clinical outcomes. </span>