title: Understanding how patients (vs physicians) approach the decision to escalate treatment: a proposed conceptual model.
abstract: OBJECTIVE
  We performed a qualitative study to better understand how patients with RA approach risk-benefit trade-offs inherent in the choice of remaining with their current treatment vs escalating care.
  
  
  METHODS
  We used a think-aloud protocol to examine how patients with RA approach risk-benefit trade-offs inherent in the choice of remaining with their current treatment vs adding a biologic. The data emerging from the protocols were used to develop a conceptual model describing how patients approach the decision to escalate care.
  
  
  RESULTS
  Participants who were strongly impacted by their disease were not open to considering alternative options. For some patients, being highly impacted by their disease results in a strong preference to escalate care. For others, the same level of distress is reason to unconditionally refuse additional medications. In contrast, those who were moderately impacted were more open to consider treatment options. Among these participants, however, subjects' risk-benefit trade-offs were consistently modified by factors unrelated to medication, including sociodemographic characteristics, role responsibilities and the quality of the patient-physician relationship.
  
  
  CONCLUSIONS
  The conceptual model indicates that patients approach the decision to escalate care differently from physicians. In order to improve care in RA, it is important to recognize that many patients with moderate to high disease activity are not open to alternative treatments, which is a prerequisite to engaging in decision making. Routine clinical encounters should enable health care providers to identify these patients in order to tailor education prior to recommending treatment escalation.
authors.affiliation: Department of Medicine, Yale University School of Medicine, Yale University, New Haven, Department of Medicine, VA Connecticut Health Care System, West Haven, CT, Department of Psychology, Yeshiva University, New York, NY and Department of Research, VA Central Western Massachusetts, North Hampton, MA, USA. Department of Medicine, Yale University School of Medicine, Yale University, New Haven, Department of Medicine, VA Connecticut Health Care System, West Haven, CT, Department of Psychology, Yeshiva University, New York, NY and Department of Research, VA Central Western Massachusetts, North Hampton, MA, USA. liana.fraenkel@yale.edu.
authors.forename: Liana
authors.initials: L
authors.lastname: Fraenkel
authors.affiliation: Department of Medicine, Yale University School of Medicine, Yale University, New Haven, Department of Medicine, VA Connecticut Health Care System, West Haven, CT, Department of Psychology, Yeshiva University, New York, NY and Department of Research, VA Central Western Massachusetts, North Hampton, MA, USA.
authors.forename: Elizabeth K
authors.initials: EK
authors.lastname: Seng
authors.affiliation: Department of Medicine, Yale University School of Medicine, Yale University, New Haven, Department of Medicine, VA Connecticut Health Care System, West Haven, CT, Department of Psychology, Yeshiva University, New York, NY and Department of Research, VA Central Western Massachusetts, North Hampton, MA, USA.
authors.forename: Meaghan
authors.initials: M
authors.lastname: Cunningham
authors.affiliation: Department of Medicine, Yale University School of Medicine, Yale University, New Haven, Department of Medicine, VA Connecticut Health Care System, West Haven, CT, Department of Psychology, Yeshiva University, New York, NY and Department of Research, VA Central Western Massachusetts, North Hampton, MA, USA.
authors.forename: Kristin
authors.initials: K
authors.lastname: Mattocks
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000523:psychology; D001685:Biological Factors / Q000627:therapeutic use*; D003657:Decision Making; D057915:Drug Substitution; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010358:Patient Participation; D057240:Patient Preference; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians'; D055815:Young Adult
chemical_list: D018501:Antirheumatic Agents; D001685:Biological Factors
keywords: decision making; patient preference; quality of care; rheumatoid arthritis; treat to target