Understanding how patients (vs physicians) approach the decision to escalate treatment: a proposed conceptual model

UMMS Affiliation

Departmen of Quantitative Health Sciences

Publication Date


Document Type



Health Services Administration | Health Services Research | Musculoskeletal Diseases | Rheumatology


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.

CONCLUSION: 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. British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.


decision making, patient preference, quality of care, rheumatoid arthritis, treat to target

DOI of Published Version



Rheumatology (Oxford). 2015 Feb;54(2):278-85. doi: 10.1093/rheumatology/keu324. Epub 2014 Aug 28. Link to article on publisher's site.

Journal/Book/Conference Title

Rheumatology (Oxford, England)

Related Resources

Link to Article in PubMed

PubMed ID