Are rheumatologists’ treatment decisions influenced bypatients’ age?
Objectives. The objective of this study was to determine whether physicians’ treatment preferences are influenced bypatients’ age. Methods. We mailed a survey to a random sample of rheumatologists practicing in the US. The survey included a scenariodescribing a hypothetical patient with rheumatoid arthritis (RA) on hydroxychloroquine, sulfasalazine and low-dose prednisolone,who presents with active disease during a follow-up appointment. The scenario was formulated in two versions that were
identical except for the age of the patient. After reading the scenario, respondents were asked to rate (on a 10 cm numericalrating scale) their recommendations for each of the three options: (i) increasing the dose of prednisolone, (ii) adding a newdisease-modifying anti-rheumatic drug (DMARD) and (iii) switching DMARDs. Rheumatologists who rated either adding anew DMARD or switching DMARDs higher than increasing the dose of prednisolone were classified as ‘preferring aggressivetreatment with DMARDs’, while the others were classified as ‘NOT preferring aggressive treatment with DMARDs’. Results. A total of 480 rheumatologists were mailed a questionnaire; 204 responded, giving a response rate of 42.5%.
Overall 163 (80%) respondents were classified as preferring aggressive treatment with DMARDs. Rheumatologists respondingto this survey were more likely to prefer aggressive DMARD treatment for the young RA patient vs the older RA patient(87 vs 71%, P ¼ 0.007). Conclusions. Our findings suggest that rheumatologists’ treatment recommendations may be influenced by age. Futureeducational efforts should increase physician awareness of this possible bias in order to ensure equal service delivery across ages.
KEY WORDS: Rheumatoid arthritis, Disease-modifying anti-rheumatic drugs, Decision-making.
Current treatment guidelines for patients with rheumatoid
comparable disease severity. This discrepancy in the delivery of
arthritis (RA) emphasize the need for aggressive management of
healthcare has been demonstrated in diverse areas including
active disease with one or more disease-modifying anti-rheumatic
oncology [6, 7] and cardiovascular disease [8, 9], but has not been
drugs (DMARDs) . This recommendation is based on a body of
well studied in RA. Given this background, the objective of this
literature demonstrating that aggressive treatment is associated
study was to determine whether, after controlling for other
with better long-term outcomes . There is no evidence that the
patient-related factors, rheumatologists’ treatment preferences are
overall benefits of DMARD therapy are related to patients’ age.
influenced by age. We chose to examine the influence of patients’
Yet, a large, population-based study found that the time to initiate
age on physicians’ practices using standardized scenarios because
DMARD therapy was longer, and the number of DMARDs
this method provides a controlled experimental setting in which
received was less for older vs younger patients . Similarly,
we were able to manipulate the variable of interest (i.e. age) while
Tuntucu et al.  recently found that older RA patients with
controlling for other important confounders.
disease onset after 60 yrs receive biological therapy andcombination therapy less frequently than patients with diseaseonset between ages 40 and 60 yrs (P < 0.0001). A small, single-sitestudy, however, found no differences in types of DMARDs used
Lower utilization of DMARD therapy among older patients
may be due to patients’ and/or physicians’ treatment preferences.
We mailed a survey to a random sample of rheumatologists
Regarding the former, older patients may be more risk averse
practicing adult rheumatology in the US. The random sample was
and less willing to accept the risk of drug toxicity compared with
obtained by assigning a number to consecutive rheumatologists
younger patients. Patients’ perceptions of physicians’ treatment
practicing adult rheumatology listed in the American College
recommendations have also been shown to differ with age, and
of Rheumatology Directory. From this list, a random sample
may help explain why older patients receive less aggressive care
was obtained using a random number table. The survey consisted
. Alternatively, differences in the use of DMARDs across age
of a scenario describing a hypothetical patient with RA on
groups may be due, in part, to age bias.
hydroxychloroquine, sulfasalazine and low-dose prednisolone,
Age bias refers to the observation that older patients are not
who presents with active disease during a follow-up appointment.
as likely to receive medical interventions as younger patients with
The scenario was formulated in two versions that were identical
1Department of Medicine, VA Connecticut Healthcare System, Yale University School of Medicine and 2Department of Marketing, Yale University School ofManagement, New Haven, CT, USA.
Submitted 3 January 2006; revised version accepted 23 March 2006.
Correspondence to: Liana Fraenkel, Section of Rheumatology, Yale University School of Medicine, 300 Cedar ST, TAC Bldg, RM #525,
PO Box 208031, New Haven, CT 06520-8031, USA. E-mail: [email protected]
Published by Oxford University Press on behalf of the British Society for Rheumatology 2006. Continue Increase treatment prednisone
FIG. 1. Example of rating scale used.
except for the age of the patient. Each rheumatologist was mailed
TABLE 1. Demographic characteristics of study sample vs larger survey of
one version of the scenario. Scenarios were classified by version
(i.e. young vs older RA patient), and assignment of scenarios wasdetermined using a computer-generated randomization sequence
Half the respondents received a scenario containing the
‘Mr. T is an 82-yr old man with rheumatoid factor-positive
RA diagnosed approximately 15 months ago. His disease has been
well controlled with low dose prednisolone and the combination
of hydroxychloroquine and sulfasalazine (2 g BID) . He does
not take NSAIDs because they upset his stomach. Today, duringa routine follow-up visit, he complains of increased pain inhis finger joints. The review of symptoms is otherwise negative
apart from increased morning stiffness lasting up to 1.5 hours
care, 20% were based at academic centers, and the median
(baseline ¼ 20–30 minutes). General physical examination is
number of years in practice was 18 (range 2–53). Because
unremarkable except for moderate synovitis involving the 2nd
questionnaires were returned anonymously, we do not have any
and 3rd MCPs (metacarpophalangeal joints) bilaterally. Lab tests
information on the non-responders. However, a comparison
from this morning: normal CBC, SMA7, LFT, TSH, ESR ¼ 45.’
of the demographic characteristics of this study sample with
The remaining rheumatologists received the same scenario
that of a larger recently published survey on biological drug use
except that the patient’s age was 28 yrs. Photographs of an older
adult and young man sitting with the same physician were inserted
The median (interquartile range) willingness to increase
into the old- and young-patient scenarios, respectively.
the dose of prednisolone was 2 (0–7), to prescribe an additional
After reading the scenario, respondents were asked to rate
DMARD was 5 (0–9) and to switch DMARDS was 6 (1–9).
(on a 10 cm numerical rating scale ) their recommendations for
Overall, 163 (80%) of respondents were classified as preferring
each of the three options: (i) increasing the dose of prednisolone,
(ii) adding a new DMARD, and (iii) switching DMARDs.
In bivariate analyses, rheumatologists responding to this survey
An example of the scale used is provided in Fig. 1.
were more likely to prefer aggressive DMARD treatment for the
Respondents were also asked to indicate the number of years in
young vs old RA patient (87 vs 71%, P ¼ 0.007). In addition
practice their gender, their type of practice and how they spend
to patients’ age, physician gender and number of years in practice
the majority of their time. No reminders were sent, and each
were also associated with preference for aggressive therapy in
rheumatologist received only one mailing. Surveys were returned
bivariate analyses. About 94% (n ¼ 50) of the female rheumatol-
anonymously in pre-addressed, stamped envelopes.
ogists preferred aggressive DMARD treatment compared with74% (n ¼ 109) of the male physicians (P ¼ 0.002). The median
number of years in practice was less among physicians preferringaggressive DMARD therapy compared with those not preferring
We used descriptive statistics to describe the physicians’ char-
aggressive therapy (17 vs 23 yrs, P < 0.05).
acteristics. Median values and ranges are presented because the
In a logistic regression model evaluating the preceding
distributions of preferences were not normally distributed.
covariates (patients’ age, physician gender and number of years
Rheumatologists who rated either adding a new DMARD or
in practice), patient’s age [adjusted odds ratio (95% confidence
switching DMARDs higher than increasing the dose of pred-
interval) ¼ 3.0 (1.4–6.2)] and physician gender [adjusted odds ratio
nisolone were classified as ‘preferring aggressive treatment with
(95% confidence interval) ¼ 5.4 (1.5–19.2)] remained associated
DMARDs’, while the others were classified as ‘NOT preferring
with preference for aggressive DMARD therapy.
aggressive treatment with DMARDs’. The association of treat-ment preference with age was ascertained using the chi-squarestatistic. We also examined the association of treatment preferencewith physicians’ characteristics using the chi-square statistic and
the Mann–Whitney test for categorical and non-parametric data,respectively. Multi-variate analyses were subsequently performed
In this study, we found that rheumatologists were more likely
using multiple logistic regression. This protocol was approved by
to recommend aggressive treatment for a young RA patient
the Human Investigations Committee at our institution.
compared with an older RA patient with the same disease activityand comorbidities. These results may help explain why Kremerset al.  and Tuntucu et al.  found that older adults with RAwere less aggressively treated compared with their younger
counterparts. Our results also suggest that age bias may be
A total of 480 rheumatologists were mailed a questionnaire; 204
stronger among male physicians. This finding is consistent with
responded, giving a response rate of 42.5%. Ninety-one scenarios
some studies demonstrating that women tend to have fewer
describing the older patient and 113 scenarios describing the
systematic biases towards the elderly than do men . As in a
younger patient were returned. About 74% of the respondents
study by Gruppen et al. , we also found that younger
were male; 84% spent the majority of their time in adult patient
physicians were more likely to favour ‘aggressive’ treatment for
Ageism in rheumatologists’ recommendations
older adults. This result did not reach statistical significance when
6. Woodard S, Nadella PC, Kotur L, Wilson J, Burak WE, Shapiro CL.
controlled for other covariates, perhaps because of small numbers.
Older women with breast carcinoma are less likely to receive adjuvant
This study does have important limitations. First, we chose not
chemotherapy: evidence of possible age bias? Cancer 2003;98:1141–9.
to send reminders and second mailings in order to respect
7. Alibhai SM, Krahn MD, Cohen MM, Fleshner NE, Tomlinson GA,
physicians’ right to refuse participation, and as a result, achieved
Naglie G. Is there age bias in the treatment of localized prostate
a participation rate of 42.5%. This response rate, however,
is consistent with [12, 15], or better than , previous surveys of
8. Gurwitz JH, Osganian V, Goldberg RJ, Chen ZY, Gore JM,
rheumatologists in the US. In addition, because the questionnaires
Alpert JS. Diagnostic testing in acute myocardial infarction:
were returned anonymously, we do not have any information
does patient age influence utilization patterns? Am J Epidemol
on the non-respondents. Nonetheless, some demographic char-
acteristics of the respondents are similar to a recent, large survey
9. Yarzebski J, Goldberg RJ, Gore JM, Alpert JS. Temporal trends and
conducted on the same population .
factors associated with pulmonary artery catheterization in patients
In order to limit the number of potential influences on
with acute myocardial infarction. Chest 1994;105:1003–8.
physician behaviour, we did not vary patient gender in the
10. O’Dell JR, Haire CE, Erikson N et al. Treatment of rheumatoid
scenarios. However, gender has been shown to affect healthcare
arthritis with methotrexate alone, sulfasalazine and hydroxychloro-
in other fields [17, 18]. In addition, we did not have a large
quine, or a combination of all three medications. N Engl J Med
physicians’ characteristics and age bias. In practice, efforts to
11. Hollen PJ, Gralla RJ, Kris MG, McCoy S, Donaldson GW,
reduce age bias in rheumatologists would most likely be directed
Moinpour CM. A comparison of visual analogue and numerical
at a general population of practicing clinicians and not specific
rating scale formats for the Lung Cancer Symptom Scale (LCSS):
does format affect patient ratings of symptoms and quality of life?
Age bias in medicine is a well-recognized problem in heathcare
delivery and has received considerable attention in fields such as
12. Cush JJ. Biological drug: US perspectives on indications and
oncology and cardiovascular disease, but has not been well-
monitoring. Ann Rheum Dis 2005;64:iv18–23.
studied in rheumatology [6–9, 19–24]. The results of this study,
13. Rupp DE, Vodanocih SJ, Crede M. The multidimensional nature
along with other evidence [2, 3], suggest that underutilization of
of ageism: construct validity and group differences. J Soc Psychol
DMARDs in older adults may be partially explained by age bias.
Examining this bias as an influence on physicians’ treatment
14. Gruppen LD, Wolf FM, Van Voorhees C, S JK. The influence
recommendations is particularly important in RA given that the
of general and case-related experience on primary care treatment
incidence of RA increases with age and the proportion of older
decision making. Arch Intern Med 1988;148:2657–63.
adults is steadily growing. Future educational efforts should
15. Yazici Y, Erkan D, Paget SA. Monitoring by rheumatologists
increase physician awareness of this possible bias in order to
for methotrexate, etanercept, infliximab, and anakinra-associated
ensure equal service delivery across ages.
adverse effects. Arthritis Rheum 2003;48:2769–72.
16. Wolfe F, Albert DA, Pincus T. A survey of United States
rheumatologists concerning effectiveness of disease modifying anti-
rheumatic drugs and prednisone in the treatment of rheumatoidarthritis. Arthritis Care Res 1998;11:375–81.
We would like to thank all participants for their time and effort.
17. Blum M, Slade M, Boden D, Cabin H, Caulin-Glaser T. Examination
L.F. is supported by the K23 Award AR048826-01 A1.
of gender bias in the evaluation and treatment of angina pectorisby cardiologists. Am J Cardiol 2004;93:765–7.
The authors have declared no conflicts of interest.
18. Lauer M, Pashkow F, Snader C, Harvey S, Thomas J, Marwick T.
Gender and referral for coronary angiography after treadmill thalliumtesting. Am J Cardiol 1996;78:278–83.
19. Witt JD. Age bias and choice of intervention for treatment of
avascular necrosis. J Bone Jt Surg 2000;82-A(12):1805–6.
1. O’Dell JR. Therapeutic strategies for rheumatoid arthritis. N Engl J
20. Williams D, Bennett K, Feely J. Evidence for an age and gender bias
in the secondary prevention of ischaemic heart disease in primary
2. Kremers HM, Nicola P, Crowson CS, O’Fallon WM, Gabriel SE.
care. Br J Clin Pharmacol 2003;55:604–8.
Therapeutic strategies in rheumatoid arthritis over a 40-yr period.
21. Madan AK, Aliabadi-Wahle S, Beech DJ. Age bias: a cause of
underutilization of breast conservation treatment. J Cancer Educ
3. Tutuncu Z, Reed G, Kremer J, Kavanaugh A. Do patients with older
onset rheumatoid arthritis receive less aggressive treatment than
22. Madan AK, Aliabadi-Wahle S, Beech DJ. Ageism in medical
younger patients? Ann Rheum Dis 2006; [Epub ahead of print]
students’ treatment recommendations: the example of breast-
conserving procedures. Acad Med 2001;76:282–4.
4. Harrison MJ, Kim CA, Silverberg M, Paget SA. Does age bias the
23. Plaisier BR, Blostein PA, Hurt KJ, Malangoni MA. Withholding/
aggressive treatment of elderly patients with rheumatoid arthritis?
withdrawal of life support in trauma patients: is there an age bias?
5. Johnson MF, Lin M, Mangalik S, Murphy DJ, Kramer AM. Patients’
24. Rybarczyk B, Haut A, Lacey RF, Fogg LF, Nicholas JJ.
perceptions of physicians’ recommendations for comfort care differ by
A multifactorial study of age bias among rehabilitation professionals.
patient age and gender. J Gen Intern Med 2000;15:248–55.
Arch Phys Med Rehab 2001;82:625–32.
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