Zeitschrift für Rheumatologie

, Volume 78, Issue 1, pp 74–81 | Cite as

Adherence and health literacy as related to outcome of patients treated for rheumatoid arthritis

Analyses of a large-scale observational study
  • J. G. KuipersEmail author
  • M. Koller
  • F. Zeman
  • K. Müller
  • J. U. Rüffer



Disabilities in daily living and quality of life are key endpoints for evaluating the treatment outcome for rheumatoid arthritis (RA). Factors possibly contributing to good outcome are adherence and health literacy.


The survey included a representative nationwide sample of German rheumatologists and their patients with RA. The physician questionnaire included the disease activity score (DAS28) and medical prescriptions. The patient questionnaire included fatigue (EORTC QLQ-FA13), health assessment questionnaire (HAQ), quality of life (SF-12), health literacy (HELP), and patients’ listings of their medications. Adherence was operationalized as follows: patient-reported (CQR5), behavioral (concordance between physicians’ and patients’ listings of medications), physician-assessed, and a combined measure of physician rating (1 = very adherent, 0 = less adherent) and the match between physicians’ prescriptions and patients’ accounts of their medications (1 = perfect match, 0 = no perfect match) that yielded three categories of adherence: high, medium, and low. Simple and multiple linear regressions (controlling for age, sex, smoking, drinking alcohol, and sport) were calculated using adherence and health literacy as predictor variables, and disease activity and patient-reported outcomes as dependent variables.


708 pairs of patient and physician questionnaires were analyzed. The mean patient age (73% women) was 60 years (SD = 12). Multiple regression analyses showed that high adherence was significantly associated with 5/7 outcome variables and health literacy with 7/7 outcome variables.


Adherence and health literacy had weak but consistent effects on most outcomes. Thus, enhancing adherence and understanding of medical information could improve outcome, which should be investigated in future interventional studies.


Rheumatoid arthritis Therapy Adherence 

Adhärenz und Gesundheitskommunikationskompetenz in Bezug auf das Therapieergebnis bei Patienten mit rheumatoider Arthritis

Auswertungen einer großen Beobachtungsstudie



Einschränkungen in den Aktivitäten des täglichen Lebens und in der Lebensqualität sind entscheidende Endpunkte zur Beurteilung der Therapie von Patienten mit rheumatoider Arthritis (RA). Mögliche Einflussgrößen für ein positives Outcome sind Adhärenz und Gesundheitskommunikationskompetenz (GKK).


Die vorliegende Beobachtungsstudie umfasste eine deutschlandweite repräsentative Gruppe von Rheumatologen und ihren Patienten mit RA. Der Arztfragebogen umfasste den Disease Activity Score 28 (DAS28) und die verordnete Medikation. Der Patientenbogen umfasste Fragen zur Fatigue (EORTC QLQ-FA13), Funktion (HAQ), Lebensqualität (SF-12), GKK (HELP) und die vom Patienten angegebene Liste der eingenommenen Medikamente.

Adhärenz wurde wie folgt operationalisiert: standardisierter Patientenfragebogen (CQR5), verhaltensbezogen (Übereinstimmung zwischen Medikationsliste des Arztes und des Patienten), Arzteinschätzung und ein kombiniertes Verfahren aus Arzteinschätzung (1 = sehr adhärent, 0 = weniger adhärent) und der Übereinstimmung der Arztverordnungen mit der Patientenmedikationsliste (1 = perfekte, 0 = keine perfekte Übereinstimmung) mit den resultierenden möglichen Adhärenzkategorien: hoch, mittel und gering. Einfache und multiple lineare Regressionsmodelle (kontrolliert für Alter, Geschlecht, Rauchen, Alkoholkonsum und Sport) wurden berechnet unter Verwendung von Adhärenz und GKK als Prädiktoren und Krankheitsaktivität und von den Patienten angegebene Outcomes als abhängige Variablen.


Es wurden 708 Paare von Arzt- und Patientenfragebögen analysiert. Das mittlere Alter (73 % Frauen) betrug 60 Jahre (SD = 12). Multiple Regressionsanalysen zeigten, dass hohe Adhärenz signifikant assoziiert ist mit 5/7 Outcomevariablen und GKK mit 7/7 Outcomevariablen.


Adhärenz und GKK zeigen geringe, aber konsistente Effekte auf die meisten Outcomeparameter. Weitere, interventionelle Studien sind erforderlich, um zu analysieren, wie durch Steigerung der Adhärenz und Verbesserung des Verständnisses medizinischer Informationen das Outcome verbessert werden kann.


Rheumatoide Arthritis Therapie Adhärenz 



We gratefully acknowledge the support of Monika Schöll in the linguistic editing of the manuscript.


This project has been supported by an unrestricted grant by Chugai and the German Fatigue Society. Chugai did not influence the design, the performance, the analysis or the publication of the TRACE study.

Compliance with ethical guidelines

Conflict of interest

J. G. Kuipers and J. U. Rüffer report grants and personal fees from Chugai during the conduct of the study. M. Koller and F. Zeman report travel grants from the German Fatigue Society during the conduct of the study. J. G. Kuipers also reports outside the submitted work grants, personal fees and non-financial support from Abbvie, Actelion, Berlin-Chemie, Biogen, BMS, Celgene, GSK, Hexal, Hospira, Janssen-Cilag, Lilly, Medac, MSD, Mundipharma, Novartis, Pfizer, Rationpharm, Roche, Swedish Orphan Biovitrum, UCB. M. Koller also reports grants outside the submitted work from Biofrontera, Mundipharma, KFN, Roche, Janssen-Cilag. K. Müller reports travel grants from Biofrontera.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018

Authors and Affiliations

  • J. G. Kuipers
    • 1
    Email author
  • M. Koller
    • 2
  • F. Zeman
    • 2
  • K. Müller
    • 2
  • J. U. Rüffer
    • 3
  1. 1.Klinik für internistische RheumatologieRotes Kreuz Krankenhaus Bremen gGmbHBremenGermany
  2. 2.Center for Clinical StudiesUniversity Hospital RegensburgRegensburgGermany
  3. 3.German Fatigue SocietyCologneGermany

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