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Extended report
Preference phenotypes to facilitate shared decision-making in rheumatoid arthritis
  1. Liana Fraenkel1,2,
  2. W Benjamin Nowell3,
  3. George Michel1,2,
  4. Carole Wiedmeyer3
  1. 1 School of Medicine, Yale University, New Haven, Connecticut, USA
  2. 2 VA Connecticut Healthcare System, West Haven, Connecticut, USA
  3. 3 CreakyJoints, Global Healthy Living Foundation, New York City, New York, USA
  1. Correspondence to Liana Fraenkel, Section of Rheumatology, Yale University School of Medicine, New Haven, CT 06510, USA; liana.fraenkel{at}


Objective Implementing treat-to-target (TTT) strategies requires that patients with rheumatoid arthritis (RA) and their rheumatologists decide on how best to escalate care when indicated. The objective of this study was to develop preference phenotypes to facilitate shared decision-making at the point of care for patients failing methotrexate monotherapy.

Methods We developed a conjoint analysis survey to measure the preferences of patient with RA for triple therapy, biologics and Janus kinase (JAK) inhibitors. The survey included seven attributes: administration, onset, bothersome side effects, serious infection, very rare side effects, amount of information and cost. Each choice set (n=12) included three hypothetical profiles. Preference phenotypes were identified by applying latent class analysis to the conjoint data.

Results 1273 participants completed the survey. A five-group solution was chosen based on progressively lower values of the Akaike and Bayesian information criteria. Members of the largest group (group 3: 38.4%) were most strongly impacted by the cost of the medication. The next largest group (group 1: 25.8%) was most strongly influenced by the risk of bothersome side effects. Members of group 2 (11.2%) were also risk averse, but were most concerned with the risk of very rare side effects. Group 4 (6.6%) strongly preferred oral over parenteral medications. Members of group 5 (18.0%) were most strongly and equally influenced by onset of action and the risk of serious infections.

Conclusions Treatment preferences of patients with RA can be measured and represented by distinct phenotypes. Our results underscore the variability in patients’ values and the importance of using a shared decision-making approach to implement TTT.

  • rheumatoid arthritis
  • dmards (biologic)
  • dmards (synthetic)
  • patient perspective

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  • Handling editor Josef S Smolen

  • Contributors All authors meet criteria for authorship.

  • Funding Research reported in this publication was supported by the Rheumatology Research Foundation Innovative Research Grant program and the National Institute of Arthritis and Musculoskeletal and Skin Diseases, part of the National Institutes of Health, under Award Number AR060231-06 (Fraenkel).

  • Competing interests None declared.

  • Ethics approval Yale Human Research Protection Program.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Raw deidentified will be shared once resulting manuscripts from this grant have been published.