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Mental Models Highlight Discrepancies Between Rheumatologists, Patients During TTT Therapy


The developers of these models said the next step is to determine how to incorporate these patient perspectives into clinical rheumatology practice.

When it comes to treat-to-target (TTT) therapy for rheumatoid arthritis (RA), limited rheumatology care access, time constraints, patient preferences, restrictions in using disease activity scores, and insurance and cost are all potential barriers, according to a study published in ACR Open Rheumatology.

These findings were a result of rheumatologist and patient mental models developed by the study authors regarding RA treatment to better understand and develop responses to potential discrepancies in risk communication and uptake of TTT therapy, which is implemented in less than half of patients with RA.

The study interviewed 14 physicians and 30 patients with RA.

In addition to these major barriers in TTT therapy, rheumatologists noted other considerable factors.

The American College of Rheumatology 2021 guidelines strongly recommend TTT for patients who have not received either a biologic or targeted synthetic disease-modifying antirheumatic drug (DMARD) for their RA treatment, and conditionally recommended TTT therapy for patients with RA who did not adequately respond to either of these treatments.

“Although rheumatologists all acknowledged how a TTT strategy improves delivery of care in RA, several expressed concerns that the model may be too prescriptive,” the authors said. “Some rheumatologists also questioned the value of applying TTT to patients who have not responded to one or more biologic or targeted synthetic DMARDs.”

Patients also mentioned solutions that rheumatologists can implement to improve TTT therapy outcomes, including gathering data from distinct, up-to-date sources. They further added that hearing about experiences from other patients is critical in their decision-making process.

“Although the use of patient testimonials can have both positive and negative impacts on decision-making, it is important to recognize that many patients require this information to engage in the TTT process with their rheumatologist,” the authors wrote. “Therefore, rheumatologist referral to trustworthy resources may expedite TTT in some patients.”

From the patient perspective, some of them also described significant downsides to switching between DMARDs, highlighting a key discrepancy in how rheumatologists and patients weigh the benefits and drawbacks of the TTT strategy.

“Recognizing patients’ difficulty of starting a new medication with uncertain benefits and potential new side effects is a prospective target to facilitate uptake of TTT and presents a scenario in which learning from other patients’ experiences may be particularly valuable,” the authors said.

The authors also found that the physician mental model placed more of an emphasis on evaluating disease activity and patient adherence. Meanwhile, the patient mental model focused more on the impact of chronic disease weariness, medication-related fatigue, stress related to changing medications, and needing to be adequately informed by their physician throughout the TTT process.

Two major limitations are that the interview subjects were primarily female and White, and that the interviews were conducted with volunteer patients, which may hinder the generalizability of this study’s findings.

The authors said their next step is to determine how to clinically incorporate these patient views into rheumatology practice.


Hsiao B, Downs J, Lanyon M, et al. Rheumatologist and patient mental models for treatment of rheumatoid arthritis help explain low treat-to-target. ACR Open Rheumatol. Published online June 6, 2022. doi:10.1002/acr2.11443

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