It is widely recommended that rheumatologists use validated measures to monitor disease activity and adjust medication accordingly. Despite the widespread endorsement that treatment should be escalated in patients with moderate or high disease activity, data suggests that this approach is frequently not followed in daily clinical practice. In order to improve quality of care in RA in daily clinical practice, it is important to understand the factors which influence both patients' and physicians' decisions on whether or not to escalate DMARDs in case of active disease.
Five focus groups were held (3 with RA patients and 2 with rheumatologists) to examine which factors influence rheumatologists' and patients' decisions related to escalation of DMARDs in patients who continue to have moderate to severe disease activity despite treatment with DMARDs. The focus groups were recorded and transcribed verbatim. The transcripts were analyzed on the basis of the grounded theory with Atlas.ti 6.0.11. Two analysts (LvH and WK) independently coded the transcripts. The independent codings were reviewed by the analysts. Codes were redefined until consensus was reached. Categories were derived from the final list of codes.
Disease activity plays a role in the decision to escalate DMARDs for both RA patients as well as rheumatologists. RA patients emphasized that pain and fatigue were important in their decision. In contrast, rheumatologists emphasized the importance of objective disease activity parameters (e.g. joint swelling) in deciding whether or not to escalate DMARDs.
Both physicians and patients discussed the role of numerous additional factors which we divided into 4 categories: rheumatologist-related, patient-related, medication-related and organisational-related (see Figure 1). Rheumatologists felt, for example, that patient willingness to change, coping behaviour, age and patients' experiences with medication changes in the past, were important in their decision. RA patients emphasized that the route of administration, side effect profile and the availability of other options to relieve symptoms were important in their decision. The complete list of factors discussed in the focus groups is illustrated in Figure 1.
Besides disease activity there are many other reasons influencing the decision whether or not to escalate DMARDs which were described by 5 categories. RA patients and rheumatologists consider different factors in their decision. These findings are a first attempt to explain why medication is often not escalated in patients with moderate or high disease activity and will guide future quantitative methods to improve quality of care in RA in daily clinical practice.
Figure 1. Overview of considerations regarding escalation of DMARDs