1. Improving Decision-Making for Medications in Rheumatoid Arthritis Edward Yelin, Ph.D. Jennifer Barton, M.D. Laura Trupin, M.P.H. Gina Evans-Young University of California, San Francisco

2. Evidence-based consensus that early treatment with disease-modifying agents (DMARDs), including new biological agents, results in improved outcomes for RA Evidence-based consensus that early treatment with disease-modifying agents (DMARDs), including new biological agents, results in improved outcomes for RA Project 2008-2010 to describe prevalence of problems in patient-physician communication in RA for vulnerable populations Project 2008-2010 to describe prevalence of problems in patient-physician communication in RA for vulnerable populations Conducted at two UCSF sites: public hospital and tertiary hospital clinics Conducted at two UCSF sites: public hospital and tertiary hospital clinics Observed clinically meaningful discordance between patients and physicians in assessment of disease severity Observed clinically meaningful discordance between patients and physicians in assessment of disease severity Found clinically and statistically significant differences in shared decision- making about treatments, disease severity, and functional status by race/ethnicity, language, and immigration status Found clinically and statistically significant differences in shared decision- making about treatments, disease severity, and functional status by race/ethnicity, language, and immigration status Background to Project-1

3. Disparities in outcomes differed by site Disparities in outcomes differed by site Pronounced disparities at tertiary care setting, but almost none at public hospital clinic setting Pronounced disparities at tertiary care setting, but almost none at public hospital clinic setting Suggests the hypothesis that select features of public hospital clinic reduce disparities in communication, decision-making, treatments, and ultimately outcomes Suggests the hypothesis that select features of public hospital clinic reduce disparities in communication, decision-making, treatments, and ultimately outcomes Features include … Features include … Translation services Translation services Clinicians and staff with experience in multicultural care (including language) Clinicians and staff with experience in multicultural care (including language) Clinicians and staff with experience in “working the system” for access to contemporary medications Clinicians and staff with experience in “working the system” for access to contemporary medications Background to Project-2

4. Examining Room as One Source of Disparity (But Not Only Source) Examining Room as One Source of Disparity (But Not Only Source)

5. Accumulating evidence that public sector clinical settings may improve treatment choices for vulnerable populations Accumulating evidence that public sector clinical settings may improve treatment choices for vulnerable populations Investigators found that quality of care for systemic lupus erythematosus may be substantially better in public managed care organizations Investigators found that quality of care for systemic lupus erythematosus may be substantially better in public managed care organizations Trial designed to test one aspect of public hospital clinic’s service mix for RA: communication about medication choices Trial designed to test one aspect of public hospital clinic’s service mix for RA: communication about medication choices Three arms: Three arms: Existing RA Medication summary guide (from AHRQ) Existing RA Medication summary guide (from AHRQ) New RA Medication summary guide modified in consultation with members of vulnerable populations and rheumatologists New RA Medication summary guide modified in consultation with members of vulnerable populations and rheumatologists New RA medication summary guide plus decision aid tool to be used in clinical encounters New RA medication summary guide plus decision aid tool to be used in clinical encounters Background to Project-3

6. Outcomes assessed in trial … Outcomes assessed in trial … Primary Primary Knowledge about medications Knowledge about medications Decisional conflict about medications Decisional conflict about medications Secondary Secondary Assessment of interpersonal processes of care (“objective”) and satisfaction with providers (“subjective”) Assessment of interpersonal processes of care (“objective”) and satisfaction with providers (“subjective”) Treatment uptake for disease-modifying agents and side-effect profile Treatment uptake for disease-modifying agents and side-effect profile Disease activity and functional status at six months Disease activity and functional status at six months Trial began last week with goal of 75 persons with RA in each arm Trial began last week with goal of 75 persons with RA in each arm Criteria for enrollment Criteria for enrollment Member of vulnerable population based on one or more of following: Member of vulnerable population based on one or more of following: low health literacy, immigrant, elder, non-English speaker, non-white low health literacy, immigrant, elder, non-English speaker, non-white Currently taking at least one disease-modifying agent Currently taking at least one disease-modifying agent Currently active disease Currently active disease Background to Project-4

7. Reach Reach All participants will be in targeted population (but we will monitor participation rate by category of vulnerability) All participants will be in targeted population (but we will monitor participation rate by category of vulnerability) Trial is really designed to see if health delivery system can overcome vulnerabilities brought to the ambulatory setting Trial is really designed to see if health delivery system can overcome vulnerabilities brought to the ambulatory setting Effectiveness Effectiveness Secondary goal of trial is to assess impact of summary guide and decision aid on outcomes (outcomes are multi-dimensional) Secondary goal of trial is to assess impact of summary guide and decision aid on outcomes (outcomes are multi-dimensional) Adoption, implementation Adoption, implementation Will achieve adoption by FIAT given trial Will achieve adoption by FIAT given trial Implementation snafus will be closely observed despite trial Implementation snafus will be closely observed despite trial Maintenance Maintenance Will measure outcomes at six months (but not primary outcomes of knowledge of and decisional conflict about medications) Will measure outcomes at six months (but not primary outcomes of knowledge of and decisional conflict about medications) RA Treatment Trial and Framework for Evaluating iAdapt Projects

8. Prior project treated the two UCSF clinics as black boxes and found that one clinic was able to reduce disparities in access and outcomes Prior project treated the two UCSF clinics as black boxes and found that one clinic was able to reduce disparities in access and outcomes Current project “breaks into” the black box to test whether ability to communicate effectively about treatment choices is key element in improving outcomes in vulnerable populations Current project “breaks into” the black box to test whether ability to communicate effectively about treatment choices is key element in improving outcomes in vulnerable populations We will monitor implementation, but basically assume that we are operating in a lab, that is a clinic with an unnaturally small number of snafus dealt with in advance We will monitor implementation, but basically assume that we are operating in a lab, that is a clinic with an unnaturally small number of snafus dealt with in advance RA may be good test of attempt to improve process of care since role of timely use of DMARDs has been proven effective and made the basis of treatment guidelines RA may be good test of attempt to improve process of care since role of timely use of DMARDs has been proven effective and made the basis of treatment guidelines Can You Bottle the Essence of a Clinic Focused on Vulnerable Populations?