Translating research into clinical practice: quality improvement to halve non-adherence to methotrexate.
OBJECTIVE
MTX remains the cornerstone for therapy for RA, yet research shows that non-adherence is significant and correlates with response to therapy. This study aimed to halve self-reported non-adherence to MTX at the Kellgren Centre for Rheumatology.


METHODS
An anonymous self-report adherence questionnaire was developed and data collected for 3 months prior to the introduction of interventions, and then regularly for the subsequent 2.5 years. A series of interventions were implemented, including motivational interviewing training, consistent information about MTX and development of a summary bookmark. Information on clinic times was collected for consultations with and without motivational interviewing. Surveys were conducted to ascertain consistency of messages about MTX. A biochemical assay was used to test MTX serum levels in patients at two time points: before and 2.8 years following introduction of the changes. Remission rates at 6 and 12 months post-MTX initiation were retrieved from patient notes and cost savings estimated by comparing actual numbers of new biologic starters compared with expected numbers based on the numbers of consultants employed at the two time points.


RESULTS
Between June and August 2016, self-reported non-adherence to MTX was 24.7%. Following introduction of the interventions, self-reported non-adherence rates reduced to an average of 7.4% between April 2018 and August 2019. Clinic times were not significantly increased when motivational interviewing was employed. Consistency of messages by staff across three key areas (benefits of MTX, alcohol guidance and importance of adherence) improved from 64% in September 2016 to 94% in January 2018. Biochemical non-adherence reduced from 56% (September 2016) to 17% (June 2019), whilst remission rates 6 months post-initiation of MTX improved from 13% in 2014/15 to 37% in 2017/18, resulting is estimated cost savings of £30 000 per year.


CONCLUSION
Non-adherence to MTX can be improved using simple measures including focussing on the adherence and the benefits of treatment, and providing consistent information across departments.
['Barton|Anne|A|', 'Jani|Meghna|M|', 'Bundy|Christine|C|', 'Bluett|James|J|', 'McDonald|Stephen|S|', 'Keevil|Brian|B|', 'Dastagir|Faraz|F|', 'Aris|Melissa|M|', 'Bruce|Ian|I|', 'Ho|Pauline|P|', 'McCarthy|Eoghan|E|', 'Bruce|Ellen|E|', 'Parker|Ben|B|', 'Hyrich|Kimme|K|', 'Gorodkin|Rachel|R|']
D018501:Antirheumatic Agents D001172:Arthritis, Rheumatoid D001688:Biological Products D003253:Consultants D017046:Cost Savings D006801:Humans D055118:Medication Adherence D008727:Methotrexate D062405:Motivational Interviewing D010353:Patient Education as Topic D058996:Quality Improvement D012074:Remission Induction D057566:Self Report D011795:Surveys and Questionnaires D013997:Time Factors
quality improvement methotrexate adherence motivational interviewing