Patient-provider discordance between global assessments of disease activity in rheumatoid arthritis: a comprehensive clinical evaluation

Abstract

BackgroundDiscordance between patients with rheumatoid arthritis (RA) and their rheumatology health care providers is a common and important problem. The objective of this study was to perform a comprehensive clinical evaluation of patient-provider discordance in RA.MethodsA cross-sectional observational study was conducted of consecutive RA patients in a regional practice with an absolute difference of ≥ 25 points between patient and provider global assessments (possible points, 0–100). Data were collected for disease activity measures, clinical characteristics, comorbidities, and medications. In a prospective substudy, participants completed patient-reported outcome measures and underwent ultrasonographic assessment of synovial inflammation. Differences between the discordant and concordant groups were tested using χ2 and rank sum tests. Multivariable logistic regression was used to develop a clinical model of discordance.ResultsPatient-provider discordance affected 114 (32.5%) of 350 consecutive patients. Of the total population, 103 patients (29.5%) rated disease activity higher than their providers (i.e., ‘positive’ discordance); only 11 (3.1%) rated disease activity lower than their providers and were excluded from further analysis. Positive discordance correlated with negative rheumatoid factor and anticyclic citrullinated peptide antibodies, lack of joint erosions, presence of comorbid fibromyalgia or depression, and use of opioids, antidepressants, or anxiolytics, or fibromyalgia medications. In the prospective study, the group with positive discordance was distinguished by higher pain intensity, neuropathic type pain, chronic widespread pain and associated polysymptomatic distress, and limited functional health status. Depression was found to be an important mediator of positive discordance in low disease activity whereas the widespread pain index was an important mediator of positive discordance in moderate-to-high disease activity states. Ultrasonography scores did not reveal significant differences in synovial inflammation between discordant and concordant groups.ConclusionsThe findings provide a deeper understanding of patient-provider discordance than previously known. New insights from this study include the evidence that positive discordance is not associated with unrecognized joint inflammation by ultrasonography and that depression and fibromyalgia appear to play distinct roles in determining positive discordance. Further work is necessary to develop a comprehensive framework for patient-centered evaluation and management of RA and associated comorbidities in patients in the scenario of patient-provider discordance.

A cross‐sectional study on factors associated with patient–physician discordance in global assessment of patients with axial spondyloarthritis: an Asian perspective

“…Comorbidities such as chronic pain syndromes and mood disorders, which include fibromyalgia and depression, respectively, have been known to coexist with axSpA and may contribute to overestimation of patient‐reported symptoms such as pain scores, hence influencing discordance . Several studies in patients with spondyloarthritis suggest that factors associated with discordance were psychological rather than physical domains of health . In our study, none of the patients had chronic pain syndromes, so we were not able to determine if discordance between PGA and PhGA was affected by chronic pain syndromes.…”

Treatment patterns and achievement of the treat-to-target goals in a real-life rheumatoid arthritis patient cohort: data from 1317 patients

“…For example, rheumatologists in the CORRONA registry were more reluctant to initiate bDMARDs in older patients 22 as was the case in our study. Other factors, such as patients' preferences, concerns for potential treatment-related complications or patient-physician discordances in disease activity assessment 23 could also play a role.…”

Discordance between the patient’s and physician’s global assessment in rheumatoid arthritis: Data from the REAL study—Brazil

“…This distance between points of view was also found in several other studies. In general, pain and/or physical function were associated with poorer patient assessment in the vast majority of studies [3,8,10,11,13,[23][24][25][26][27][28][29], whereas NSJ and/or abnormal acute inflammation tests were more frequent determinants of worse physician's assessments [8][9][10][11]13,26,27,29]. Numerous potential causes for this discordance have been identified, particularly pain due to inflammatory and non-inflammatory processes different from RA, fatigue, functional disability, depression, psychological stress, low health literacy, and patient-physician communication problems [6,9,10,26].…”