Treatment Satisfaction with Rheumatoid Arthritis in Patients with Different Disease Severity and Financial Burden: A Subgroup Analysis of a Nationwide Survey in China
Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by joint inflammation, pain, and progressive disability. Despite significant advancements in RA treatments, achieving optimal disease outcomes remains a challenge. Patient satisfaction with treatment is a critical factor influencing adherence, compliance, and overall disease management. This study aimed to analyze treatment satisfaction among Chinese RA patients, focusing on the impact of disease severity and financial burden. The findings provide valuable insights into the unmet needs of RA patients and highlight areas for improvement in treatment strategies.
Background and Objectives
The treat-to-target (T2T) strategy has been widely recommended for RA management, aiming to achieve deep clinical remission and improve long-term quality of life. However, studies indicate that the implementation of T2T in China is still in its developmental stages, with significant gaps in diagnosis and treatment. Despite the availability of effective therapies, issues such as safety concerns, therapeutic regimens, remission duration, and patient compliance persist. Dissatisfaction with treatment can lead to poor adherence, negatively impacting disease outcomes. Therefore, understanding the factors influencing patient satisfaction is essential for optimizing RA management.
This study sought to evaluate treatment satisfaction among Chinese RA patients, focusing on two key factors: self-assessed disease severity and the proportion of treatment costs relative to household income. By analyzing these factors, the study aimed to identify barriers to satisfaction and provide evidence-based recommendations for improving RA care in China.
Methods
This study was a subgroup analysis of a cross-sectional survey conducted between March 2018 and April 2018 in 12 hospitals across 11 provinces, municipalities, and autonomous regions in China. The survey included RA patients and their physicians, all of whom were part of the Chinese Registry of Rheumatoid Arthritis (CREDIT). Eligible participants were aged 18 or older, had been diagnosed with RA for more than six months according to the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria, and had received RA treatment. Patients with comprehension barriers or those who had not yet started treatment were excluded.
Participants were divided into subgroups based on their self-assessed disease severity (severe, moderate, mild, and extremely mild) and the proportion of treatment costs relative to household income (50%). The Treatment Satisfaction Questionnaire for Medication version II (TSQM-II) was used to assess patient satisfaction across four domains: effectiveness, side effects, convenience, and global satisfaction. Scores ranged from 0 (extremely dissatisfied) to 100 (extremely satisfied). The questionnaire was administered for all medications and specifically for biological disease-modifying anti-rheumatic drugs (bDMARDs).
Results
Baseline Characteristics
The study included 1,237 RA patients, with 230 classified as severe, 543 as moderate, 425 as mild, and 39 as extremely mild based on self-assessed disease severity. Patients with severe RA were older, had lower education levels, longer disease durations, and higher treatment costs compared to those with milder disease. Specifically, 43% of severe RA patients spent more than 50% of their household income on treatment, compared to only 11.1% of mild RA patients. Additionally, severe RA patients were more likely to use glucocorticoids and bDMARDs.
When subgrouped by treatment cost proportion, patients with higher financial burdens (>50% of income) had lower education levels, longer disease durations, and more severe self-assessed disease. They also reported higher use of conventional synthetic DMARDs (csDMARDs), glucocorticoids, and bDMARDs.
Treatment Satisfaction by Disease Severity
Patients with severe and moderate RA reported lower satisfaction scores across multiple domains compared to those with mild or extremely mild disease. For all medications, effectiveness, convenience, and global satisfaction scores were significantly lower in the severe and moderate subgroups (all P < 0.001). For bDMARDs, effectiveness and convenience scores were lower in the severe RA subgroup compared to the extremely mild subgroup (both P < 0.05). However, there were no significant differences in side effects scores across subgroups.
Treatment Satisfaction by Financial Burden
Patients with lower financial burdens (<10% of income) reported higher satisfaction scores across all domains compared to those with higher financial burdens. For all medications, effectiveness, side effects, and convenience scores were significantly higher in the 50% subgroup (all P < 0.05). Global satisfaction scores were also higher in the <10% subgroup compared to the 31–50% subgroup (P = 0.004). For bDMARDs, convenience scores were higher in the 50% subgroups (P = 0.005), and global satisfaction scores were higher in the <10% subgroup compared to the 31–50% subgroup (P = 0.032).
Discussion
The study highlights the significant impact of disease severity and financial burden on treatment satisfaction among Chinese RA patients. Patients with severe RA and those with higher treatment costs relative to their income reported lower satisfaction across multiple domains, including effectiveness, convenience, and global satisfaction. These findings underscore the need for more effective and convenient treatment options, particularly for patients with severe disease and those facing financial challenges.
The association between disease severity and treatment satisfaction is consistent with previous studies. Patients with severe RA often experience more significant symptoms and disability, leading to higher expectations for treatment effectiveness. When these expectations are not met, satisfaction declines. Additionally, the use of more complex treatment regimens, such as bDMARDs, may contribute to lower convenience scores among severe RA patients.
Financial burden emerged as a critical factor influencing treatment satisfaction. Patients who spent a larger proportion of their income on treatment reported lower satisfaction, likely due to the stress and economic strain associated with high treatment costs. This finding aligns with global research showing that financial barriers negatively impact adherence and outcomes in chronic diseases. In China, where out-of-pocket healthcare expenses are significant, addressing the financial burden of RA treatment is essential for improving patient satisfaction and compliance.
The study also revealed that early diagnosis and treatment are associated with better outcomes and lower financial burdens. Patients with extremely mild RA had shorter disease durations and lower treatment costs, highlighting the importance of early intervention in RA management. However, the majority of patients in the study had moderate to severe disease, suggesting delays in diagnosis and treatment. Improving disease awareness and access to healthcare resources, particularly in rural areas, could help reduce the severity of RA at diagnosis and improve long-term outcomes.
Limitations
While this study provides valuable insights, it has several limitations. First, the sample size, though substantial, may not fully represent the diverse RA population in China. Second, disease severity and treatment cost proportions were self-reported, introducing potential subjective biases. Objective measures such as the Health Assessment Questionnaire (HAQ) or Sharp scores were not included. Third, the cross-sectional design limits the ability to assess changes in satisfaction over time. Fourth, the study focused exclusively on RA and did not account for comorbidities that could influence satisfaction. Finally, the reliability and validity of the Chinese version of the TSQM-II were not assessed, and the study did not evaluate satisfaction with csDMARDs or glucocorticoids.
Conclusion
This study demonstrates that higher disease severity and greater financial burden are associated with lower treatment satisfaction among Chinese RA patients. Addressing these factors is essential for improving adherence, compliance, and overall disease outcomes. Strategies to enhance treatment effectiveness and convenience, particularly for severe RA patients, and measures to reduce the financial burden of RA treatment are urgently needed. Early diagnosis and intervention, along with improved access to healthcare resources, can help mitigate the severity of RA and reduce treatment costs. By focusing on patient satisfaction, healthcare providers can optimize RA management and improve the quality of life for patients in China.
doi.org/10.1097/CM9.0000000000000749
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