Longitudinal Occurrence and Predictors of Patient‐Provider Discordance Between Global Assessments of Disease Activity in Rheumatoid Arthritis: A Case–Control Study

Abstract

Objective:The objective was to identify longitudinal predictors of discordance between patients with rheumatoid arthritis (RA) and their health care providers, where patient global assessment of disease activity is substantially higher than provider global assessment. Methods:This retrospective case-control study included 102 cases with positive discordance (ie, ≥25 mm between patient and provider global assessments) and 102 controls without discordance who were matched for age, sex, RA duration, and Clinical Disease Activity Index (CDAI). Data were collected at the baseline visit (date of diagnosis or earliest available visit), the index visit (participation in a previous cross-sectional study), and at up to 11 additional visits before the index visit. Data included patient characteristics, disease activity measures, disease activity score in 28 joints for C-reactive protein with the 3-variable version (DAS28-CRP[3]), and medications. Data were analyzed by using linear and logistic regression models with smoothing splines for nonlinear trends.Results: Overall, the mean age was 63 years, 75% were female, and mean RA duration was 10 years. Compared with controls, cases had higher rates of discordant visits during the 4 years before the index visit, and they had higher CDAI and DAS28-CRP(3) earlier in the disease course. Cases more frequently had antinuclear antibodies, nonerosive disease, prior depression, or prior use of antidepressants or fibromyalgia medications. Disease-modifying medication use was not different between cases and controls. Conclusion:The findings inform new hypotheses about the relationships of disease activity and antinuclear antibodies to the later occurrence of positive discordance among patients with RA.

Clinical variables, including novel joint index, associated with future patient‐physician discordance in global assessment of rheumatoid arthritis (RA) disease activity based on a large RA database in Japan

“…Previous cross‐sectional studies have demonstrated that positive discordance in RA (ie, higher PGA of RA activity as compared to PhGA) is associated with pain, functional disability, and various other impairments, such as fatigue, anxiety, and sleep disturbance 5–8,12–16 . In contrast, only few studies have investigated the transition of PGA‐PhGA discordance over time 9,18,19 . In this study, we investigated the clinical variables predictive of future positive discordance based on the nationwide NinJa RA database in Japan.…”

“…First, it had a retrospective design, indicating that significant but unrecognized biases could have affected the selection of patients with RA with positive discordance or concordance. The second limitation was the lack of data that would potentially be relevant to PGA‐PhGA discordance, such as fatigue and complications due to depression or fibromyalgia 9,11,12,18 . The lack of a control group for comparison is the third limitation.…”

“…[5][6][7][8][12][13][14][15][16] In contrast, only few studies have investigated the transition of PGA-PhGA discordance over time. 9,18,19 As for the cutoff value for discordance in global assessment of disease activity, we used 3 cm as a cutoff in the present study, since a systematic literature review by Desthieux et al demonstrated that a difference of ≥3 cm on a 10-cm VAS scale was most frequently used to define discordance. 5 In addition, we used 3 ± 1 cm (2, 3, and 4 cm) as the cutoff value in our previous report investigating the determinants of PGA-PhGA discordance in NinJa 2015 and demonstrated that the determinants were not affected even when cutoff values other than 3 cm were used.…”

“…The second limitation was the lack of data that would potentially be relevant to PGA-PhGA discordance, such as fatigue and complications due to depression or fibromyalgia. 9,11,12,18 The lack of a control group for comparison is the third limitation. Desthieux et al suggested that the positive discordance in patients with early axial spondylarthritis is not a stable trait but presumably a visit-specific characteristic.…”

“…[5][6][7][12][13][14][15][16][17] However, few longitudinal studies have investigated the shift in PGA-PhGA discordance over time in patients with RA. 9,18,19 Karpouzas et al investigated this shift over 2 years in 536 Hispanic patients with established RA and demonstrated that positive discordance was stable over time and that its presence at baseline increased the likelihood of positive discordance at subsequent visits. 9 This stability of positive discordance suggests that positive discordance in RA in fact represents a patient-specific characteristic.…”