A novel study by researchers at the University of California, San Francisco found that nearly one-third of Rheumatoid Arthritis (RA) patients differed from their physicians in assessment of their disease severity. The disagreement between patient and doctor evaluation of RA activity was most prevalent in patients with depressive symptoms, and those who had poor overall function. Details of the study, the first to examine discordance in an ethnically diverse population, are published in the June issue of Arthritis Care & Research, a journal of the American College of Rheumatology.
According to a 2003 report from the World Health Organization (WHO) the prevalence of RA, an autoimmune disease characterized by painful swelling of the lining of the joints, varies between 0.3% and 1%. In the U.S. experts estimate roughly 1 to 2 million Americans have RA which affects twice as many women than men.
While clinicians who treat patients with diseases such as diabetes or hypertension have a gold standard diagnostic (glucose blood test or blood pressure) to accurately measure disease activity, rheumatologists rely on subjective (patient self-report) and objective measures (physician-assessed joint counts, acute-phase reactants) to determine RA disease activity. An accurate assessment of RA activity is essential in determining the severity of disease, monitoring response to treatment, and is particularly important with the advent of effective, but potentially toxic therapies. Clear patient-physician communication around symptom reporting and assessment of disease activity is central to the management of RA. While prior studies have documented discordance in RA, none have examined the possible association of patient language or mood with discordance, both of which pose barriers to communication.
"The need for patient-provider agreement in disease activity assessment is critical to the safe and effective management of RA," said Jennifer Barton, M.D., from the Department of Medicine, Rheumatology Division, at the University of California, San Francisco, and lead author of the study. The research team recruited 223 participants from the UCSF Rheumatoid Arthritis Cohort, a dual-site observational study, who were consecutively enrolled from the Rheumatoid Arthritis Clinic at San Francisco General Hospital and the UCSF Arthritis Center. Participants had a mean age of 53 (±14 years) and 88% were women. The ethnic breakdown of the study sample was 45% Latino, 27% Asian/Pacific Islander, 16% Caucasian, 10% African American, 2% American Indian or other.
Researchers gathered clinical data on each subject including rheumatoid factor, sedimentation rate, and tender and swollen joint counts, as well as the patient global assessment of disease severity as measured on a visual analog scale at each visit. Functional status was measured using the Health Assessment Questionnaire (HAQ). The 9-item Patient Health Questionnaire was used to measure depressive symptoms.
"We found clinically meaningful differences between patient and physician assessments of RA disease severity in 36% of cases," confirmed Dr. Barton. "In an overwhelming majority (85%) of these discordant pairs, the physicians' assessments underscored the patients' assessments." Researchers found that the mean VAS score for global disease severity was 46 ± 26 mm for patients and 31 ± 21 mm for physicians.
The research team also found that depressive symptoms were common with 30% of participants exhibiting major depression, and these patients had greater odds of discordance with their physicians than those who were not depressed. Researchers noted a lower level of patient-doctor discordance in those patients who had a higher swollen joint count, but discordance persisted in those patients with poorer functional status (HAQ score). "Reducing patient-doctor discordance is an important goal that can improve patient outcomes," concluded Dr. Barton. "Further investigation of the relationships between mood, disease activity, and discordance may help guide interventions that improve RA patient care."
- Jennifer L. Barton, John Imboden, Jonathan Graf, David Glidden, Edward H. Yelin, Dean Schillinger. Patient - physician discordance in assessments of global disease severity in rheumatoid arthritis. Arthritis Care & Research, 2010; DOI: 10.1002/acr.20132
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