Patient-Physician Discordance in Assessments of Global Disease Severity in Rheumatoid Arthritis

Department of Medicine, Division of Rheumatology, University of California, San Francisco, CA 94143, USA.
Arthritis care & research 06/2010; 62(6):857-64. DOI: 10.1002/acr.20132
Source: PubMed


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).
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.
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.
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.

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Available from: Edward H Yelin, Aug 10, 2015
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    • "Moreover, it is obvious that patients are involved in their treatment decision making process. Previous studies have shown that discordance exists between the patients' and rheumatologists' rating of disease activity [29,30] and that they approach the decision to intensify medication differently [31,32]. Moreover, patients may be reluctant to change medications frequently and fear side effects. "
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    ABSTRACT: Introduction Clinical trials have demonstrated that treatment-to-target (T2T) is effective in achieving remission in early rheumatoid arthritis (RA). However, the concept of T2T has not been fully implemented yet and the question is whether a T2T strategy is feasible in daily clinical practice. The objective of the study was to evaluate the adherence to a T2T strategy aiming at remission (Disease Activity Score in 28 joints (DAS28) < 2.6) in early RA in daily practice. The recommendations regarding T2T included regular assessment of the DAS28 and advice regarding DAS28-driven treatment adjustments. Methods A medical chart review was performed among a random sample of 100 RA patients of the DREAM remission induction cohort. At all scheduled visits, it was determined whether the clinical decisions were compliant to the T2T recommendations. Results The 100 patients contributed to a total of 1,115 visits. The DAS28 was available in 97.9% (1,092/1,115) of the visits, of which the DAS28 was assessed at a frequency of at least every three months in 88.3% (964/1,092). Adherence to the treatment advice was observed in 69.3% (757/1,092) of the visits. In case of non-adherence when remission was present (19.5%, 108/553), most frequently medication was tapered off or discontinued when it should have been continued (7.2%, 40/553) or treatment was continued when it should have been tapered off or discontinued (6.2%, 34/553). In case of non-adherence when remission was absent (42.1%, 227/539), most frequently medication was not intensified when an intensification step should have been taken (34.9%, 188/539). The main reason for non-adherence was discordance between disease activity status according to the rheumatologist and DAS28. Conclusions The recommendations regarding T2T were successfully implemented and high adherence was observed. This demonstrates that a T2T strategy is feasible in RA in daily clinical practice.
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    • "To give an example, it has been suggested that the implementation of a treat-to-target strategy, based on treatment escalation if goal Juvenile Arthritis Disease Activity Score (JADAS) [20,21] is not reached, in clinical practice may improve disease outcome [22]. Furthermore, it is widely agreed that integration of parent- and child-reported outcomes in daily care may facilitate concordance with physician’s choices and compliance with therapeutic prescriptions [23-25]. To reach this goal, there is a need for outcome measures that are simple and easy to apply. "
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    • "Since self-report questionnaires are regarded as the primary method of assessing HRQoL, the self-assessment was arbitrarily set as the reference point. Similar to other studies [11,34,35] and according to the usual definition of a clinically important difference in the health-related quality of life, self-assessment and parental assessment were rated as "in agreement" when the absolute difference was less than or equal to half the standard deviation of the child's values [36]. This distribution based method was also recommended in [37]. "
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