Rheumatoid Arthritis Shared Decision Making (RAiSeD)

March 4, 2026 updated by: VA Office of Research and Development

Implementation of Shared Decision Making in Rheumatoid Arthritis: A Stepped Wedge, Cluster-randomized Trial

Shared decision making is the first overarching principle for the treat to target guidelines for rheumatoid arthritis (RA) and has been proposed as a potential mechanism to reduce health disparities, however there is little evidence to inform effective ways to implement this practice in the care of Veterans with RA. The purpose of this project is to evaluate the effectiveness of a multi-component shared decision making intervention on RA disease activity, adherence to RA medications and patient knowledge of RA. The proposed research will contribute to fundamental knowledge about how to effectively foster shared decision making across varied VA rheumatology clinical settings to improve patient disease outcomes and experience; and support clinicians to engage patients in meaningful ways with the ultimate goal to improve health, reduce disability, and eliminate disparities.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

Background: Rheumatoid arthritis (RA) impacts quality of life causing disability in up to 1% of the population and 2% of those 60 and older. Men with RA have twice the risk of death as the general population. Treatment decisions after failure with first-line methotrexate are complex, involve trade-offs in terms of harm, and require individualized decisions. In shared decision making (SDM), patients and clinicians work together to identify how to best address the patient's situation. SDM has been proposed as a way to reduce disparities, but uptake is suboptimal and no effective tools to foster SDM in a systematic way across VA exist.

Significance/Impact: Veterans with RA are disproportionately male, have more comorbidities, and higher mortality rates in comparison to the general population. SDM is the first principal of the RA treat to target guidelines. However, significant gaps in knowledge of effective interventions to support SDM exist - particularly in VA. This proposal is responsive to three VA HSR&D priority domains: 1) health care value, 2) quality of health care, and 3) health equity.

Innovation: Treatment studies in RA have focused primarily on white women, while men, who represent the VA RA population, have poorer outcomes. Targeting this subgroup to evaluate the impact of an SDM intervention on disease outcomes and adherence is novel. Use of a novel approach combining clinician training and a decision aid to recognize the unique needs of Veterans with RA is innovative.

Specific Aims: Aim 1: Evaluate the effectiveness of a multi-component SDM intervention in a stepped-wedge, cluster-randomized controlled trial on improvement in disease activity, RA knowledge, and adherence. Hypothesis 1: During SDM intervention phases, Veterans will have lower disease activity compared to during control periods and will be more likely to experience clinically important differences in a standard disease activity index. Hypothesis 2: Veterans will have greater RA knowledge and better adherence after exposure to this intervention. Exploratory Hypothesis: The SDM intervention will have a greater effect in the likelihood of lowering disease activity among racial/ethnic minorities and Veterans with limited health literacy. Aim 2: Evaluate effectiveness of a multi-component intervention to facilitate SDM. Hypothesis: An SDM intervention for Veterans with RA will result in higher uptake of SDM in enrolled clinics during the intervention phase, relative to control phase. Aim 3: Conduct a qualitative evaluation of the SDM intervention and local implementation to inform future dissemination.

Methodology: A stepped-wedge, cluster-randomized controlled trial design will be used to evaluate effectiveness of a novel SDM intervention across three sites. Participants: Veterans with RA and rheumatology clinicians; Intervention: multicomponent SDM intervention ; Control: participants at each site during the pre-intervention period; Outcomes: RA disease activity; patient-reported measures of adherence, knowledge, SDM, and an objective measure of SDM. Time: pre-intervention, intervention, and post-intervention phases for each step, measures collected over 42 months.

Implementation/Next Steps: The proposed effectiveness study has the potential to speed the translation of SDM research within VA and nationally to improve quality of care for all persons with RA.

Study Type

Interventional

Enrollment (Actual)

900

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • United States
    • California
      • San Francisco, California, United States, 94121
        • San Francisco VA Medical Center, San Francisco, CA
    • Delaware
      • Wilmington, Delaware, United States, 19805-4917
        • Wilmington VA Medical Center, Wilmington, DE
    • Oregon
      • Portland, Oregon, United States, 97207-2964
        • VA Portland Health Care System, Portland, OR
    • Pennsylvania
      • Philadelphia, Pennsylvania, United States, 19104
        • Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

14 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

Inclusion criteria for patient participants (Aims 1 & 2):

  • Meet administrative data definition of rheumatoid arthritis (see recruitment section)
  • Receive rheumatology outpatient care at participating clinics and seen at least once in prior 12 months
  • Age 18 years or older
  • English speaking
  • Moderate to high RA disease activity within 18 months prior to enrollment

Inclusion criteria for professional participants (Aims 1-3):

-Rheumatology attendings, fellows or advanced practice partners (nurse practitioners or physicians assistants) at the respective clinics

Inclusion criteria for non-clinician participants (Aim 3):

  • Have held a leadership position within their respective institution for minimum of 12 months prior to enrollment
  • Have worked in the rheumatology clinic setting at their respective institution for minimum of 12 months prior

Exclusion Criteria:

Exclusion criteria for patient participants (Aims 1 & 2):

  • Cognitive impairment
  • Inability to speak

Exclusion criteria for professional participants (Aims 1-3):

-none

Exclusion criteria for non-clinician participants (Aim 3):

  • Have held a leadership position within their respective institution for <12 months
  • Have worked in a clinic setting other than rheumatology
  • Have worked in a clinic setting <12 months

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Health Services Research
  • Allocation: Randomized
  • Interventional Model: Sequential Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
No Intervention: Control
Usual care
Experimental: Intervention
Intervention phase
Behavioral: Clinician communication training
The clinician training is a generic, skills- and attitude-based approach for clinicians to acknowledge their decision making conversations with patients that 1) there is more than one option, and 2) patient's views matter in deciding what to do next. This tools-free approach can be used on the spot when needed and is termed fostering choice awareness (FCA). The one-hour training consists of 4 parts: 1) a knowledge session on evidence and guidelines on effective conversations and SDM, 2) video-review of behaviors which foster or hinder choice awareness, 3) clinical simulations in which clinicians practice fostering choice awareness behaviors, and 4) a reminder card for use in future clinic visits. Video clips will be of patient-clinician conversations around treatment decision making to prompt and probe clinicians' experiences, improve understanding, and improve practice.
Other Names:
  • fostering choice awareness
Behavioral: Patient activation
The patient activation component consists of three questions patients can ask their clinician to help them become more involved: "1. What are my options?; 2. What are the possible benefits and harms of those options?; 3. How likely are each of those benefits and harms to happen to me?" These questions have been used in studies to promote improved communication in a number of conditions including cardiovascular disease, cancer, and women's health.
Other Names:
  • AskShareKnow
Behavioral: RA Medication summary guide and RA Choice
RA Choice presents information on FDA-approved RA treatments in a set of cards, which can be used alone or in combination based on a patient's preference, values, and the clinician's experience. The RA medication summary guide describes options for medication, physical therapy, occupational therapy, and ways to stay healthy with diet and exercise. Tool development followed key principles of creating low literacy materials that featured icons, short phrases written in plain language, and included topics of interest to RA patients faced with a medication decision. For the proposed study, we will include a paper-based version of the tool, or a web-based version available for telephone or VA Video Connect (VVC) visits. The tools will be updated to include new FDA-approved therapies (e.g., JAK inhibitors).

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Disease activity
Time Frame: through study completion (up to 4 years), on average 3 times per year
RA disease activity will be measured using composite score: the Clinical Disease Activity Index (range 0-76) or CDAI. This is a composite score of clinician assessed swollen and tender joints counts, clinician global assessment and patient global assessment of disease activity. Higher score is indicative of higher disease activity.
through study completion (up to 4 years), on average 3 times per year

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Change in rheumatoid arthritis knowledge
Time Frame: measured at baseline, 6 months and 12 months on a subset
Patient general knowledge of RA and RA medications will be measured using a 8-item self-reported survey. This measure is designed to capture rudimentary knowledge of RA and RA medications. A score of 7 out of 8 correct answers is considered adequate RA knowledge. One or more missed dose per week is considered poor adherence.
measured at baseline, 6 months and 12 months on a subset
Change in adherence
Time Frame: measured at baseline, 6 months and 12 months on a subset
Patient-reported RA medication adherence will be assessed using a validated single-item measure: "How many times do you think you may have missed taking your pills in the last week?". A response of 1 or greater is considered nonadherent. Among participants taking a biologic therapy (self-injection or infusion), adherence will be measured asking, "How many times do you think you have missed your RA injection or infusion in the past month?" Adherence will be dichotomized into either poor or adequate adherence, with poor adherence defined as missing 1 RA pills over the past week or 1 RA injections in the past month.
measured at baseline, 6 months and 12 months on a subset
CollaboRATE questionnaire
Time Frame: through study completion (up to 4 years), on average 3 times per year
CollaboRATE is a brief, validated patient-reported 3-item measure to assess the process of shared decision making. Each item represents a dimension of shared decision making (explanation or the health issue, elicitation of patient preferences, and Integration of patient preferences). The questions are each rated on a 10-point anchored scale from 1 (no effort was made) to 10 (every effort was made). Higher scores indicate a better shared decision making experience.
through study completion (up to 4 years), on average 3 times per year
Change in OPTION-5 (objective measure of shared decision making)
Time Frame: through study completion (up to 4 years), on average 1 time per year
OPTION-5 is a measure of direct observation (audio-taped recordings) of shared decision making. The measure contains 5 items scored from 0 (absence of shared decision making) to 4 (optimal performance). A trained external observer will score the clinician on the extent to which they involve the patient in decision making, scores are summed and scaled to fall between 0-100 for ease of interpretation. Higher scores indicate greater uptake of shared decision making.
through study completion (up to 4 years), on average 1 time per year
SURE questionnaire
Time Frame: through study completion (up to 4 years), on average 3 times per year
SURE is a brief, validated patient-reported 4-item measure to assess patient uncertainty about treatment choice including uncertainty about benefits and risks, what matters most to the patient, support in making the choice, and feeling sure about the best choice. Patients rate each item true or false and scores can range from 0-4. A score below 4 is indicates decisional conflict and a score of 3 or less is considered clinically relevant decisional conflict.
through study completion (up to 4 years), on average 3 times per year

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

VA Office of Research and Development

Investigators

  • Principal Investigator: Jennifer Barton, MD, VA Portland Health Care System, Portland, OR

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

September 19, 2022

Primary Completion (Actual)

February 23, 2026

Study Completion (Actual)

February 23, 2026

Study Registration Dates

First Submitted

July 21, 2022

First Submitted That Met QC Criteria

September 1, 2022

First Posted (Actual)

September 7, 2022

Study Record Updates

Last Update Posted (Actual)

March 6, 2026

Last Update Submitted That Met QC Criteria

March 4, 2026

Last Verified

March 1, 2026

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • IIR 20-162

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

product manufactured in and exported from the U.S.

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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