Patient-physician discordance in assessments of global disease severity in rheumatoid arthritis

Abstract

Objective: To determine the degree of discordance between patient and physician assessment of disease severity in a multiethnic cohort of adults with rheumatoid arthritis (RA), to explore predictors of discordance, and to examine the impact of discordance on the Disease Activity Score in 28 joints (DAS28).

Methods: Adults with RA (n = 223) and their rheumatologists completed a visual analog scale (VAS) for global disease severity independently. Patient demographics, the 9-item Patient Health Questionnaire (PHQ-9) depression scale score, the Health Assessment Questionnaire score, and the DAS28 were also collected. Logistic regression analyses were used to identify predictors of positive discordance, defined as a patient rating minus physician rating of >25 mm on a 100-mm VAS (considered clinically relevant). DAS28 scores stratified by level of discordance were compared using a paired t-test.

Results: Positive discordance was found in 30% of cases, with a mean +/- SD difference of 46 +/- 15. The strongest independent predictor of discordance was a 5-point increase in PHQ-9 score (adjusted odds ratio 1.61, 95% confidence interval 1.02-2.55). Higher swollen joint count and Cantonese/Mandarin language were associated with lower odds of discordance. DAS28 scores were most divergent among subjects with discordance.

Conclusion: Nearly one-third of RA patients differed from their physicians to a meaningful degree in assessment of global disease severity. Higher depressive symptoms were associated with discordance. Further investigation of the relationships between mood, disease activity, and discordance may guide interventions to improve care for adults with RA.

Figure 1

a. Side by side box plots of patient and physician global assessments for disease activity by tertile of swollen joint counts b. Side by side box plots of patient and physician globals by category of depressive symptoms on the PHQ-9 scale (0 = no depression; 1 = mild; 2 = moderate; 3 = moderate to severe; 4 = severe)

Figure 1

a. Side by side box plots of patient and physician global assessments for disease activity by tertile of swollen joint counts b. Side by side box plots of patient and physician globals by category of depressive symptoms on the PHQ-9 scale (0 = no depression; 1 = mild; 2 = moderate; 3 = moderate to severe; 4 = severe)