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Are rheumatologists’ treatment decisions influenced bypatients’ age?
Objectives. The objective of this study was to determine whether physicians’ treatment preferences are influenced bypatients’ age.
Methods. We mailed a survey to a random sample of rheumatologists practicing in the US. The survey included a scenariodescribing a hypothetical patient with rheumatoid arthritis (RA) on hydroxychloroquine, sulfasalazine and low-dose prednisolone,who presents with active disease during a follow-up appointment. The scenario was formulated in two versions that were
identical except for the age of the patient. After reading the scenario, respondents were asked to rate (on a 10 cm numericalrating scale) their recommendations for each of the three options: (i) increasing the dose of prednisolone, (ii) adding a newdisease-modifying anti-rheumatic drug (DMARD) and (iii) switching DMARDs. Rheumatologists who rated either adding anew DMARD or switching DMARDs higher than increasing the dose of prednisolone were classified as ‘preferring aggressivetreatment with DMARDs’, while the others were classified as ‘NOT preferring aggressive treatment with DMARDs’.
Results. A total of 480 rheumatologists were mailed a questionnaire; 204 responded, giving a response rate of 42.5%.
Overall 163 (80%) respondents were classified as preferring aggressive treatment with DMARDs. Rheumatologists respondingto this survey were more likely to prefer aggressive DMARD treatment for the young RA patient vs the older RA patient(87 vs 71%, P ¼ 0.007).
Conclusions. Our findings suggest that rheumatologists’ treatment recommendations may be influenced by age. Futureeducational efforts should increase physician awareness of this possible bias in order to ensure equal service delivery across ages.
KEY WORDS: Rheumatoid arthritis, Disease-modifying anti-rheumatic drugs, Decision-making.
Current treatment guidelines for patients with rheumatoid
comparable disease severity. This discrepancy in the delivery of
arthritis (RA) emphasize the need for aggressive management of
healthcare has been demonstrated in diverse areas including
active disease with one or more disease-modifying anti-rheumatic
oncology [6, 7] and cardiovascular disease [8, 9], but has not been
drugs (DMARDs) . This recommendation is based on a body of
well studied in RA. Given this background, the objective of this
literature demonstrating that aggressive treatment is associated
study was to determine whether, after controlling for other
with better long-term outcomes . There is no evidence that the
patient-related factors, rheumatologists’ treatment preferences are
overall benefits of DMARD therapy are related to patients’ age.
influenced by age. We chose to examine the influence of patients’
Yet, a large, population-based study found that the time to initiate
age on physicians’ practices using standardized scenarios because
DMARD therapy was longer, and the number of DMARDs
this method provides a controlled experimental setting in which
received was less for older vs younger patients . Similarly,
we were able to manipulate the variable of interest (i.e. age) while
Tuntucu et al.  recently found that older RA patients with
controlling for other important confounders.
disease onset after 60 yrs receive biological therapy andcombination therapy less frequently than patients with diseaseonset between ages 40 and 60 yrs (P < 0.0001). A small, single-sitestudy, however, found no differences in types of DMARDs used
Lower utilization of DMARD therapy among older patients
may be due to patients’ and/or physicians’ treatment preferences.
We mailed a survey to a random sample of rheumatologists
Regarding the former, older patients may be more risk averse
practicing adult rheumatology in the US. The random sample was
and less willing to accept the risk of drug toxicity compared with
obtained by assigning a number to consecutive rheumatologists
younger patients. Patients’ perceptions of physicians’ treatment
practicing adult rheumatology listed in the American College
recommendations have also been shown to differ with age, and
of Rheumatology Directory. From this list, a random sample
may help explain why older patients receive less aggressive care
was obtained using a random number table. The survey consisted
. Alternatively, differences in the use of DMARDs across age
of a scenario describing a hypothetical patient with RA on
groups may be due, in part, to age bias.
hydroxychloroquine, sulfasalazine and low-dose prednisolone,
Age bias refers to the observation that older patients are not
who presents with active disease during a follow-up appointment.
as likely to receive medical interventions as younger patients with
The scenario was formulated in two versions that were identical
1Department of Medicine, VA Connecticut Healthcare System, Yale University School of Medicine and 2Department of Marketing, Yale University School ofManagement, New Haven, CT, USA.
Submitted 3 January 2006; revised version accepted 23 March 2006.
Correspondence to: Liana Fraenkel, Section of Rheumatology, Yale University School of Medicine, 300 Cedar ST, TAC Bldg, RM #525,
PO Box 208031, New Haven, CT 06520-8031, USA. E-mail: firstname.lastname@example.org
Published by Oxford University Press on behalf of the British Society for Rheumatology 2006.
FIG. 1. Example of rating scale used.
except for the age of the patient. Each rheumatologist was mailed
TABLE 1. Demographic characteristics of study sample vs larger survey of
one version of the scenario. Scenarios were classified by version
(i.e. young vs older RA patient), and assignment of scenarios wasdetermined using a computer-generated randomization sequence
Half the respondents received a scenario containing the
‘Mr. T is an 82-yr old man with rheumatoid factor-positive
RA diagnosed approximately 15 months ago. His disease has been
well controlled with low dose prednisolone and the combination
of hydroxychloroquine and sulfasalazine (2 g BID) . He does
not take NSAIDs because they upset his stomach. Today, duringa routine follow-up visit, he complains of increased pain inhis finger joints. The review of symptoms is otherwise negative
apart from increased morning stiffness lasting up to 1.5 hours
care, 20% were based at academic centers, and the median
(baseline ¼ 20–30 minutes). General physical examination is
number of years in practice was 18 (range 2–53). Because
unremarkable except for moderate synovitis involving the 2nd
questionnaires were returned anonymously, we do not have any
and 3rd MCPs (metacarpophalangeal joints) bilaterally. Lab tests
information on the non-responders. However, a comparison
from this morning: normal CBC, SMA7, LFT, TSH, ESR ¼ 45.’
of the demographic characteristics of this study sample with
The remaining rheumatologists received the same scenario
that of a larger recently published survey on biological drug use
except that the patient’s age was 28 yrs. Photographs of an older
adult and young man sitting with the same physician were inserted
The median (interquartile range) willingness to increase
into the old- and young-patient scenarios, respectively.
the dose of prednisolone was 2 (0–7), to prescribe an additional
After reading the scenario, respondents were asked to rate
DMARD was 5 (0–9) and to switch DMARDS was 6 (1–9).
(on a 10 cm numerical rating scale ) their recommendations for
Overall, 163 (80%) of respondents were classified as preferring
each of the three options: (i) increasing the dose of prednisolone,
(ii) adding a new DMARD, and (iii) switching DMARDs.
In bivariate analyses, rheumatologists responding to this survey
An example of the scale used is provided in Fig. 1.
were more likely to prefer aggressive DMARD treatment for the
Respondents were also asked to indicate the number of years in
young vs old RA patient (87 vs 71%, P ¼ 0.007). In addition
practice their gender, their type of practice and how they spend
to patients’ age, physician gender and number of years in practice
the majority of their time. No reminders were sent, and each
were also associated with preference for aggressive therapy in
rheumatologist received only one mailing. Surveys were returned
bivariate analyses. About 94% (n ¼ 50) of the female rheumatol-
anonymously in pre-addressed, stamped envelopes.
ogists preferred aggressive DMARD treatment compared with74% (n ¼ 109) of the male physicians (P ¼ 0.002). The median
number of years in practice was less among physicians preferringaggressive DMARD therapy compared with those not preferring
We used descriptive statistics to describe the physicians’ char-
aggressive therapy (17 vs 23 yrs, P < 0.05).
acteristics. Median values and ranges are presented because the
In a logistic regression model evaluating the preceding
distributions of preferences were not normally distributed.
covariates (patients’ age, physician gender and number of years
Rheumatologists who rated either adding a new DMARD or
in practice), patient’s age [adjusted odds ratio (95% confidence
switching DMARDs higher than increasing the dose of pred-
interval) ¼ 3.0 (1.4–6.2)] and physician gender [adjusted odds ratio
nisolone were classified as ‘preferring aggressive treatment with
(95% confidence interval) ¼ 5.4 (1.5–19.2)] remained associated
DMARDs’, while the others were classified as ‘NOT preferring
with preference for aggressive DMARD therapy.
aggressive treatment with DMARDs’. The association of treat-ment preference with age was ascertained using the chi-squarestatistic. We also examined the association of treatment preferencewith physicians’ characteristics using the chi-square statistic and
the Mann–Whitney test for categorical and non-parametric data,respectively. Multi-variate analyses were subsequently performed
In this study, we found that rheumatologists were more likely
using multiple logistic regression. This protocol was approved by
to recommend aggressive treatment for a young RA patient
the Human Investigations Committee at our institution.
compared with an older RA patient with the same disease activityand comorbidities. These results may help explain why Kremerset al.  and Tuntucu et al.  found that older adults with RAwere less aggressively treated compared with their younger
counterparts. Our results also suggest that age bias may be
A total of 480 rheumatologists were mailed a questionnaire; 204
stronger among male physicians. This finding is consistent with
responded, giving a response rate of 42.5%. Ninety-one scenarios
some studies demonstrating that women tend to have fewer
describing the older patient and 113 scenarios describing the
systematic biases towards the elderly than do men . As in a
younger patient were returned. About 74% of the respondents
study by Gruppen et al. , we also found that younger
were male; 84% spent the majority of their time in adult patient
physicians were more likely to favour ‘aggressive’ treatment for
Ageism in rheumatologists’ recommendations
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We would like to thank all participants for their time and effort.
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L.F. is supported by the K23 Award AR048826-01 A1.
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The authors have declared no conflicts of interest.
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