Use of Low-Literacy Decision Aid to Enhance Knowledge and Reduce Decisional Conflict Among a Diverse Population of Adults With Rheumatoid Arthritis: Results of a Pilot Study.

In the last two decades, patients with rheumatoid arthritis (RA) have witnessed an expansion in the number and nature of treatment options available. The FDA has approved more than 10 new disease modifying anti-rheumatic drugs (DMARDs) since the late 1990s. These innovations and treat-to-target strategies have improved the likelihood of achieving remission, and, perhaps, improved survival (1). This progress, however, has introduced high complexity for patients and clinicians with respect to deciding which agents to use. Technical approaches to the selection of DMARDs such as guidelines appear inadequate, as they may not align with patient expectations, goals, and preferences for treatment or with personal and social contexts. This may lead to poor adherence, which, like many other chronic diseases, is inadequate in RA: adherence rates for biologic DMARDs are often less than 60% (2). Such alignment of guidelines with patient goals and preferences is only possible with patient involvement in the decision making process, a national and international policy priority (3–6). We have found that nearly one-third of adults with RA report suboptimal shared decision-making (SDM) communication with their clinicians (7), and patients with lower education, limited health literacy, lower trust in physician, and limited English language proficiency are more likely to report suboptimal SDM. Thus, lack of clear communication in these conversations may contribute to health disparities (8, 9). In particular, RA patients who are non-white, immigrants, or who have limited English language proficiency have higher disease activity and poorer function despite access to effective therapies (10). Limited health literacy has also been associated with greater disability in RA (11). SDM requires that patients and clinicians share information about safety, efficacy, and treatment burden of available options. Central to SDM is ensuring that patients have basic knowledge of RA and its treatment, which has been shown to be suboptimal in vulnerable populations (12). Clinicians are called upon to communicate this information in environments often constrained by time and competing tasks. In addition, they must make special effort to reach those with barriers to communication. Thus, efforts to improve RA outcomes may involve imparting knowledge and promoting patient engagement using efficient, low literacy approaches that reduce, rather than exacerbate, disparities in care. Given increasing demands on patients and clinicians, evidence of suboptimal SDM, and gaps in patient knowledge, we designed a literacy appropriate medication guide and decision aid (RA Choice). RA Choice was created to facilitate conversation between patients and clinicians about RA medications (13) and support SDM with patients who experienced an inadequate response to methotrexate monotherapy. Developed in three languages, the tools are aimed at populations with barriers to communication. We then performed a pilot study to assess feasibility and acceptability and the tools’ impact on knowledge of RA medications and decisional conflict among a diverse population in two urban rheumatology clinics.