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Title: Investigating adherence to methotrexate in patients with rheumatoid arthritis
Author: Hope, Holly
ISNI:       0000 0004 7971 1410
Awarding Body: University of Manchester
Current Institution: University of Manchester
Date of Award: 2018
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Background: Methotrexate (MTX) is the first-line treatment for rheumatoid arthritis (RA), yet response is not universal and patient non-adherence may partially explain this. Given that achieving remission remains a priority for rheumatologists, very little is known about their views and clinical approach when prescribing MTX. Aims: The aims of the Thesis were; 1) to quantify the rate of adherence to MTX in the UK, 2) to identify the reasons for non-adherence and 3) to investigate the predictors of non-adherence; from the patient and rheumatologist perspectives. Methods: The Rheumatoid Arthritis Medication Study is a prospective cohort of patients with RA who are incident MTX users, followed over their first year of MTX therapy. MTX adherence and reasons for non-adherence were quantified utilising patient diaries that captured weekly MTX use from baseline to six months. The multivariable effects of baseline characteristics on the odds of being ever nonadherent at six months were calculated. In a subsample, positive, negative and uncertain illness appraisals were coded from free text contained in patient diaries. The MTX related appraisals made during therapy of adherent and non-adherent (100% versus < 90% adherence) were compared. In depth qualitative interviews were conducted with rheumatologists' (n=16) to identify salient themes. These themes were further explored in an online survey using patient vignettes that simulated a clinical consultation. Random effects models tested the main and interaction effects of gender*emotional preparedness*prior knowledge* information overload on clinicians' decision to discuss and commence MTX. Results: Of those who returned their diary (n=606) the rate of adherence was very high (98%), (26%) were ever non-adherent. Non-adherence was mainly intentional (71%) and related to side effect concerns. The multivariable model included age, gender, DAS28, fatigue, ≥2 co-morbidities and high medication concerns despite need, but it was only modestly better than chance at predicting ever nonadherence (AUC=0.63). There were marked differences between those who did and did not return a diary. Adherent patients made more positive and certain appraisals about MTX during therapy than non-adherent patients. Information overload*emotional preparedness and gender*emotional preparedness associated with clinical decisions (n=116) to discuss and commence MTX. Discussion: Early MTX is apparently good, but these data indicate those who did not return a diary may have been non-adherent. Rheumatologists (unconsciously) tailor consultations in response to perceived cognitive and emotional unpreparedness, and this tailoring may be more evident with female patients. The potential impact of such tailoring on patient trust, shared decision making and adherence has implications for clinical practice and requires further investigation.
Supervisor: Cordingley, Mary ; Hyrich, Kimme ; Verstappen, Suzanne Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available
Keywords: Methotrexate ; Shared decision making ; Clinical practice ; Clinician beliefs ; Illness beliefs ; Mixed methods ; Patients ; Anti-rheumatic medication ; Arthritis ; Adherence ; Health beliefs