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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) [1]. 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 [1]. 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 [2]. Similarly, we were able to manipulate the variable of interest (i.e. age) while Tuntucu et al. [3] 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 [5]. 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: liana.fraenkel@yale.edu Published by Oxford University Press on behalf of the British Society for Rheumatology 2006.
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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) [10]. 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 [11]) 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. [2] and Tuntucu et al. [3] 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 [13]. As in a younger patient were returned. About 74% of the respondents study by Gruppen et al. [14], 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 older adults. This result did not reach statistical significance when 6. Woodard S, Nadella PC, Kotur L, Wilson J, Burak WE, Shapiro CL.
controlled for other covariates, perhaps because of small numbers.
Older women with breast carcinoma are less likely to receive adjuvant This study does have important limitations. First, we chose not chemotherapy: evidence of possible age bias? Cancer 2003;98:1141–9.
to send reminders and second mailings in order to respect 7. Alibhai SM, Krahn MD, Cohen MM, Fleshner NE, Tomlinson GA, physicians’ right to refuse participation, and as a result, achieved Naglie G. Is there age bias in the treatment of localized prostate a participation rate of 42.5%. This response rate, however, is consistent with [12, 15], or better than [16], previous surveys of 8. Gurwitz JH, Osganian V, Goldberg RJ, Chen ZY, Gore JM, rheumatologists in the US. In addition, because the questionnaires Alpert JS. Diagnostic testing in acute myocardial infarction: were returned anonymously, we do not have any information does patient age influence utilization patterns? Am J Epidemol on the non-respondents. Nonetheless, some demographic char- acteristics of the respondents are similar to a recent, large survey 9. Yarzebski J, Goldberg RJ, Gore JM, Alpert JS. Temporal trends and conducted on the same population [12].
factors associated with pulmonary artery catheterization in patients In order to limit the number of potential influences on with acute myocardial infarction. Chest 1994;105:1003–8.
physician behaviour, we did not vary patient gender in the 10. O’Dell JR, Haire CE, Erikson N et al. Treatment of rheumatoid scenarios. However, gender has been shown to affect healthcare arthritis with methotrexate alone, sulfasalazine and hydroxychloro- in other fields [17, 18]. In addition, we did not have a large quine, or a combination of all three medications. N Engl J Med physicians’ characteristics and age bias. In practice, efforts to 11. Hollen PJ, Gralla RJ, Kris MG, McCoy S, Donaldson GW, reduce age bias in rheumatologists would most likely be directed Moinpour CM. A comparison of visual analogue and numerical at a general population of practicing clinicians and not specific rating scale formats for the Lung Cancer Symptom Scale (LCSS): does format affect patient ratings of symptoms and quality of life? Age bias in medicine is a well-recognized problem in heathcare delivery and has received considerable attention in fields such as 12. Cush JJ. Biological drug: US perspectives on indications and oncology and cardiovascular disease, but has not been well- monitoring. Ann Rheum Dis 2005;64:iv18–23.
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Examining this bias as an influence on physicians’ treatment 14. Gruppen LD, Wolf FM, Van Voorhees C, S JK. The influence recommendations is particularly important in RA given that the of general and case-related experience on primary care treatment incidence of RA increases with age and the proportion of older decision making. Arch Intern Med 1988;148:2657–63.
adults is steadily growing. Future educational efforts should 15. Yazici Y, Erkan D, Paget SA. Monitoring by rheumatologists increase physician awareness of this possible bias in order to for methotrexate, etanercept, infliximab, and anakinra-associated ensure equal service delivery across ages.
adverse effects. Arthritis Rheum 2003;48:2769–72.
16. Wolfe F, Albert DA, Pincus T. A survey of United States rheumatologists concerning effectiveness of disease modifying anti- rheumatic drugs and prednisone in the treatment of rheumatoidarthritis. Arthritis Care Res 1998;11:375–81.
We would like to thank all participants for their time and effort.
17. Blum M, Slade M, Boden D, Cabin H, Caulin-Glaser T. Examination L.F. is supported by the K23 Award AR048826-01 A1.
of gender bias in the evaluation and treatment of angina pectorisby cardiologists. Am J Cardiol 2004;93:765–7.
The authors have declared no conflicts of interest.
18. Lauer M, Pashkow F, Snader C, Harvey S, Thomas J, Marwick T.
Gender and referral for coronary angiography after treadmill thalliumtesting. Am J Cardiol 1996;78:278–83.
19. Witt JD. Age bias and choice of intervention for treatment of avascular necrosis. J Bone Jt Surg 2000;82-A(12):1805–6.
1. O’Dell JR. Therapeutic strategies for rheumatoid arthritis. N Engl J 20. Williams D, Bennett K, Feely J. Evidence for an age and gender bias in the secondary prevention of ischaemic heart disease in primary 2. Kremers HM, Nicola P, Crowson CS, O’Fallon WM, Gabriel SE.
care. Br J Clin Pharmacol 2003;55:604–8.
Therapeutic strategies in rheumatoid arthritis over a 40-yr period.
21. Madan AK, Aliabadi-Wahle S, Beech DJ. Age bias: a cause of underutilization of breast conservation treatment. J Cancer Educ 3. Tutuncu Z, Reed G, Kremer J, Kavanaugh A. Do patients with older onset rheumatoid arthritis receive less aggressive treatment than 22. Madan AK, Aliabadi-Wahle S, Beech DJ. Ageism in medical younger patients? Ann Rheum Dis 2006; [Epub ahead of print] students’ treatment recommendations: the example of breast- conserving procedures. Acad Med 2001;76:282–4.
4. Harrison MJ, Kim CA, Silverberg M, Paget SA. Does age bias the 23. Plaisier BR, Blostein PA, Hurt KJ, Malangoni MA. Withholding/ aggressive treatment of elderly patients with rheumatoid arthritis? withdrawal of life support in trauma patients: is there an age bias? 5. Johnson MF, Lin M, Mangalik S, Murphy DJ, Kramer AM. Patients’ 24. Rybarczyk B, Haut A, Lacey RF, Fogg LF, Nicholas JJ.
perceptions of physicians’ recommendations for comfort care differ by A multifactorial study of age bias among rehabilitation professionals.
patient age and gender. J Gen Intern Med 2000;15:248–55.
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Source: http://faculty.som.yale.edu/ravidhar/documents/AreRheumatologistsTreatmentDecisionsInfluencedbyPatientsAge.pdf

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