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Arthritis Care Res (Hoboken). 2018 Oct 28. doi: 10.1002/acr.23801. [Epub ahead of print]

A Qualitative Exploration of Triangulated Shared Decision Making in Rheumatoid Arthritis.

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Yale University School of Medicine, Internal Medicine (Rheumatology), 333 Cedar Street, New Haven, CT, 60510.



Treat-to-target implementation in rheumatoid arthritis (RA) requires a shared decision making (SDM) process. However, ability to pay is a major determinant of patient choice, but how this factor affects SDM is under explored.


Visits at four RA clinics during which patients faced a decision to change their treatment were audiotaped between May 2016 and June 2017. Audiotapes were transcribed verbatim and analyzed using qualitative Framework Analysis.


156 visits were analyzed. Most RA patients, except those with effective insurance coverage, had deliberations disrupted or sidelined by third-party insurance providers having power to authorize the preferred DMARD choice. This triangulated SDM complicated efficiency in deliberations and timely treatment, and was a barrier to shared engagement about health risks and symptom improvement typically found in patient-provider dyads.


Rheumatology care providers should aim to incorporate treatment costs and ability to pay into their deliberations so individualized out-of-pocket estimates can be considered during triangulated SDM at point-of-care. This article is protected by copyright. All rights reserved.


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