George Karpouzas, MD, on Predictors of RA Treatment Adherence


In this podcast, George Karpouzas, MD, talks about his study that evaluated the unique and interactive roles of patient beliefs about the necessity of rheumatoid arthritis medications and concerns about them in predicting adherence to prescribed treatments.

Additional Resource:


George A. Karpouzas, MD, is a professor of medicine at the University of California, Los Angeles, and chief of rheumatology at The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center in Los Angeles, California.



Amanda Balbi: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator Amanda Balbi with Consultant360 Specialty Network.

Medication adherence is instrumental for the successful management of rheumatoid arthritis to a goal of remission. Awareness of medication necessity and concerns regarding its use influence adherence and respectively foster or undermine the achievement of treatment goals.

In a new study, a research team explored the unique and interactive roles of patient beliefs about the necessity of RA medications as well as concerns about them in predicting adherence to prescribed medications.

Today I’m speaking with the lead author of the study, Dr George A. Karpouzas, MD, who is a professor of medicine at UCLA and chief of rheumatology at The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center in Los Angeles, California.

Thank you for joining us today, Dr Karpouzas. Let’s dive into your study.

So to start, can you tell us how were necessity and concerns about medications evaluated? And what were patients’ concerns about RA medications?

George Karpouzas: In order to evaluate the necessity and concern beliefs about medication in patients with rheumatoid arthritis, we use the standardized brief medication questionnaire and that, as I mentioned, is a standardized questionnaire that has 2 separate domains. It has a necessity domain and a concern domain, and each of those domains has 5 statements.

Patients grade those statements from a scale of 1 through 5, based on the degree of disagreement or agreement with what the statement expresses. Each of those statements are measured from 1 to 5, and the total range of scores in each of the 2 domains is from 5 to 25.

To make this a bit more concrete, some of the questions on concerns, for example, have to do with whether having to take medication worries the patient. Another thing is “I sometimes worry about long-term effects of my medications” or “My medications, for example, disrupt my life” or worries about becoming too dependent on those types of medications.

As I mentioned, patients will grade these statements from a scale of 1 to 5, based on the level of agreement or disagreement with that statement. The final score is basically utilized in the analysis.

Amanda Balbi: And how did necessity and concerns individually contribute to adherence? And how did they interact?

George Karpouzas: That's a very good question. So, necessity and concern had independent and opposing contributions to adherence. This was even after adjustments for age, gender, and disease duration were made.

That means that obviously higher necessity was associated with fostering adherence, whereas higher concerns were associated with disincentivizing patients from adhering to their medications.

In terms of interaction, there was a significant interaction between necessity and concerns on adherence. To put this into perspective, at low levels of concerns, there was no significant association between necessity and adherence. Most patients generally seem to be largely adherent to their medications if they had very few concerns about them.

However, when patients had a lot of concerts, high levels of concerns about medication, the higher their necessity perception was, then the higher the adherence to those medications were.

In order to actually gain a bit more insight about how this interaction worked, we did this latent profile analysis in which we basically derived patient profiles, by virtue of how patients fell under necessity and concern evaluations. This analysis yielded 4 latent patient groups.

The first was the low-necessity low-concern group, which was the smallest group. Those were the “indifferent” patients, so they didn't really have much engagement, didn't have many concerns, didn't also see much necessity in taking their medications.

The second group, which was the second-least populace group, was the low-necessity high-concern group—or the so-called “skeptical” group. The third group was the high-necessity and high-concern group—or “ambivalent” group. And the fourth group was the high-necessity and low-concern group, which was the “accepting” group. Thankfully, this was the most populous of all, with 121 patients.

Obviously, those 4 distinct groups displayed significant differences across disease impact and burden—for example, erosive presence or patient assessment of disease activity, also significant differences in physical and mental function, mood, and most certainly adherence.

To make this more concrete, adherence, as I mentioned, varied across those groups, even after adjusting for significant differences. It appeared to be highest in the “accepting” group, which is the group that had the high-necessity and low-concern feature. Obviously, it was lowest in the “skeptical” group, which was the group with the low-necessity and high-concern characteristics.

Amanda Balbi: So how can your findings help clinicians improve patients’ adherence to RA medications?

George Karpouzas: I think that a message that is basically generated is that if you aim at reducing concerns that may be more effective in the ambivalent group—this is the group that has high-necessity and high-concern—whereas emphasizing medication necessity may be more relevant to the “skeptical” group, which is the group that has low-necessity appreciation high-concerns.

Truncating your message differently in those different groups may make you more efficient in convincing and incentivizing patients to comply with their therapy and, therefore, experience its full effect.

Amanda Balbi: What are the key take-home messages for rheumatologists?

George Karpouzas: The relationship between necessity and concern beliefs regarding RA medications significantly influence adherence and direct physicians in effectively targeting their education efforts—I think that's the main thing.

The second thing is that a balanced discussion with the patient addressing each of those domains provides the safest platform for adherence.

Third, as I mentioned earlier, a message and a concerted effort targeted at reducing concerns might be more effective in the “ambivalent” group, whereas impressing upon necessity of medical treatment towards goal optimization in patients with residual concerns may further promoted here in particularly in the “skeptical” group.

Amanda Balbi: Absolutely. Thank you again for speaking with me today about your study.

George Karpouzas: Thank you very much, Amanda, for this opportunity to communicate our findings to the broader rheumatology audience.