Background Rheumatologists are the primary prescribers of methotrexate (MTX) for the treatment of rheumatoid arthritis (RA) in the United Kingdom (UK), however rheumatologists' views on their clinical practices are largely unknown. The authors conducted a qualitative study that highlighted a number of factors that contributed to their ability to discuss and commence MTX, which included how emotionally and cognitively prepared patients were to discuss treatments. The aim of this study was to further explore these themes with an online survey.
Objectives The aims of this study were:1)To establish the views of rheumatologists about MTX for the treatment of rheumatoid arthritis (RA), 2)To examine if rheumatologists' views influenced discussing or commencing MTX during the initial consultation.
Methods An online survey was designed and subsequently refined based on interviews with rheumatologists in the UK. The survey asked rheumatologists about their clinical setting, and their views and practices with respect to treating RA with MTX. Rheumatologists were asked how often specific pieces of MTX information were discussed during a consultation to commence MTX (5=Always to 1=never). They were also asked to identify the barriers to discussing these issues. The questionnaire included a factorial survey ie. two patient vignettes where we manipulated the following factors; male/female, emotionally prepared/unprepared and no/negative prior knowledge. Rheumatologists could select “information overload” as a barrier to communication with the patient. Random mixed effects models tested if these patient factors and information overload associated with 1) commencing and 2) discussing MTX.
Results Ninety-six rheumatologists seeing approximately eight (IQR:5–12) new patients a week with 15±7 years of experience completed the survey. Rheumatologists reported they often/always discussed ten (IQR 8–11) pieces of information during a consultation (Fig 1A), and information overload was identified as a communication barrier (48%); 52% of rheumatologists expected the nurse to discuss MTX therapy (Fig 1B). Sixty rheumatologists completed one, and 56 rheumatologists two vignettes (n=116). The vignette conditions and information overload significantly associated with “Commencing MTX” (X2=53.85, p <.0001, R2=.21) and discussing MTX (X2=30.9, p =.002, R2=.19). Gender* emotional preparedness (β=-4.27, 95% CI:-7.33,-1.21), and information overload*emotional preparedness (β=-3.03, 95% CI:-5.24, -.82) associated with MTX commencement, whilst only gender*emotional preparedness with discussing MTX (β=-3.86, 95% CI:-6.82, -.90).
Conclusions Currently UK rheumatologists convey a large amount of information to patients during early consultations. Almost half of rheumatologists identified the need to communicate large amounts of information in clinical consultations as a barrier to discussing MTX therapy. These data reflect the challenge clinicians face in trying to execute effective shared decision-making practices. Strategies to address patients' emotional responses to their diagnosis and being overloaded with MTX information are needed. Staggering presentation of information during clinical consultations may benefit some patients.
Disclosure of Interest None declared