High disease activity may not be sufficient to escalate care

Rheumatoid arthritis (RA) treatment regimens are not adjusted in response to active disease as frequently as indicated. The objective of this study was to examine how disease activity and patients' illness beliefs combine to predict future treatment changes in patients who are currently under the care of a rheumatologist.

We interviewed RA patients at baseline and at 2, 4, and 6 months. We examined the association of disease activity (Routine Assessment of Patient Index Data 4) and 5 specific illness beliefs (consequences, treatment control, symptom burden, concern, and emotional impact) with future escalation of treatment using logistic regression. Analyses were adjusted for age, current biologic agent use, and disease duration. Disease activity and illness beliefs were dichotomized at the median to create 4 dummy variables (e.g., low disease activity + high illness belief) in order to examine the combined impact of disease activity and illness beliefs on escalation.

Twenty-nine percent of the participants (n = 41 of 142) had an escalation of treatment during the followup period. When examined separately, disease activity and 4 of the illness beliefs (consequences, symptom burden, concern, and emotional impact) were associated with future escalation. High disease activity was predictive of future escalation only when combined with high levels of consequences, concern, and emotional impact. The combinations of high disease activity and high consequences, concern, and emotional impact were much stronger predictors of future escalation than either factor in isolation.

The findings suggest that patients' illness beliefs are an important determinant of treatment decisions, which are not fully captured by disease activity measures alone.