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

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.     

Learning from discordance in patient and physician global assessments of systemic lupus erythematosus disease activity

OBJECTIVE: Differences have been described between patient and physician assessments of well being in several chronic illnesses, and these differences may affect outcome. Disagreement may lead to dissatisfaction and to behaviors with dangerous consequences. We describe and identify predictors of patient-physician differences on ratings of disease activity in systemic lupus erythematosus (SLE). METHODS: Data collected on 154 patients included age, education, disease duration, and patient and physician global assessments of lupus activity on a 10 cm visual analog scale (VAS), the Health Assessment Questionnaire (HAQ), the Medical Outcome Study Short-Form 36 (SF-36), the Systemic Lupus Disease Activity Index (SLEDAI), the Systemic Lupus Activity Measure (SLAM-R), and the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI). Multiple linear regression models were performed using patient VAS scores, physician VAS scores, and patient minus physician VAS scores as the dependent variables, and age, disease duration, selected SF-36 and SLAM-R subscales, and SDI as independent variables. RESULTS: Patients were 90% female and 80% Caucasian, with a mean education of 13 +/- 2.8 years and a mean age of 43.1 +/- 13.6 years. The overall mean disease duration was 10.5 +/- 7.8 years. Physicians overscored patients by 2.5 cm in 6% of the cases and patients overscored physicians in 16% of the cases. The best multivariate model to predict overall differences included SF-36 mental health and SLAM-R kidney scores. CONCLUSION: Patient-physician differences may result from a divergence in focus. Patients score lupus activity based on their psychological status, while physicians rely more heavily on the physical effect of the disease.     

A comparison of clinical assessments of disease activity in rheumatoid arthritis.

Six clinical assessments of disease activity, including a new summated change scale (SCS), have been compared in a group of 30 patients with rheumatoid arthritis seen on 8 separate occasions during their first 6 months of therapy with either D-penicillamine or hydroxychloroquine. Articular index and grip strength correlate best with erythrocyte sedimentation rate and C-reactive protein, pain score and early morning stiffness less well, and summated change score and joint circumference least well. Articular index and grip strength also correlated well with the other clinical parameters and are therefore judged to be the best clinical indices of change in treatment with these drugs.     

Activity assessments in rheumatoid arthritis

PURPOSE OF REVIEW: To describe the importance of assessing disease activity in general, aiming for significant improvement particularly low disease activity and remission, and the value of employing simplified instruments toward this end in rheumatoid arthritis RECENT FINDINGS: Various instruments have either been newly developed, validated or assessed in the recent two years. Additional insights relate to the frequency of attainment of low disease activity and remission in clinical trials and clinical practice, as well as to therapeutic strategies, which involve comprehensive and tight evaluation of disease activity in the adaptation of therapy, including biologicals. All studies assessing these instruments reveal that simplified scores perform at least similar compared with more complex indices, and often better, in the evaluation of disease activity and response to treatment. SUMMARY: Simplified indices can be routinely used in clinical practice and trials and adaptation of therapy on the basis of tight control of disease activity will lead to improved outcomes of rheumatoid arthritis.     

Measuring disease activity for rheumatoid arthritis

Rheumatoid arthritis (RA) is the most common systemic inflammatory joint disease. It can be treated effectively with disease modifying antirheumatic drugs, and the currently propagated treatment strategy is to treat RA consequently, and revise the therapeutic approach frequently on the basis of proper disease activity evaluation. In the current review, we focus on the instruments and measures used in the assessment of RA disease activity. We will first consider the so-called core set measures of activity, prividing comprehensive overviews on joint count scales, global scales, pain scales, biomarkers, and functional assessment instruments. The second part of the review focuses on the value of composite measures of disease activity; a term under which we subsume activity indices using various formulae, self-assessment tools of disease activity, and response criteria. Among the inflammatory rheumatic diseases, RA is the one for which the most intensive research is done, and usually instruments that work for RA are further tested for other joint diseases. However, there is still a research agenda for the assessment of disease activity, even for RA. One important aspect is to assess the reliability and utility of all available instruments, including the very low end of disease activity, since remission has become an achievable goal. Another focus of disease activity assessment is to derive measures that work in clinical trials and in daily practice, but are also well understood by patients and physicians.This will further improve our ability to care for patients with RA consequently.     

Assessing physician/patient perceptions in rheumatoid arthritis. A vital component in patient education

Patient education surveys were completed by 101 patients with rheumatoid arthritis and by 28 rheumatologists to assess and compare patients' reports with physicians' perceptions of patients' needs regarding content, provider, and education program delivery methods. Both groups agreed on the importance of patients' education about arthritis, especially on the topics of medication, physician/patient communication, quackery, and maintaining ambulation. A higher proportion of physicians reported that patient education was needed in psychosocial areas, activities of daily living, sexual concerns, and community resources. Patients sought more education in disease process, diagnostic procedures, and nutrition. Patients rated pharmacists and nutritionists significantly more important as educational sources than did physicians. Both groups reported individual patient/practitioner meetings as the preferred delivery method. Physicians reported group education to be valuable for some psychosocial topics; patients disagreed significantly. Despite considerable consensus, disagreements were evident in the psychosocial area and in the role of allied health professionals. Clarification, understanding, and resolution of these differences should be sought before implementing patient education programs.     

Systemic lupus erythematosus in three ethnic groups. XI. Sources of discrepancy in perception of disease activity: a comparison of physician and patient visual analog scale scores

OBJECTIVE: To compare patient's and physician's assessment of disease activity in a multiethnic (Hispanic, African American, and Caucasian) cohort of systemic lupus erythematosus (SLE) patients. METHODS: Three hundred patients with SLE from the LUMINA (Lupus in Minority populations: Nature versus nurture) cohort were included. Disease activity was assessed with the Systemic Lupus Activity Measure (SLAM); patients and physicians assessed disease activity using a 10-cm anchored visual analog scale (VAS). The difference between VAS scores was termed discrepancy (>1 cm was considered a priori clinically relevant). Selected sociodemographic, clinical, behavioral, and psychological variables were examined in relation to discrepancy in univariable and multivariable models adjusting for the physician global VAS score in order to eliminate ceiling and floor effects. RESULTS: A discrepancy was exhibited by 58% of the patients. Abnormal laboratory findings were negatively associated with discrepancy, and poor self-perceived functioning and joint involvement were positively associated with discrepancy. Ethnicity did not account for discrepant perception of disease activity. CONCLUSION: Patients and physicians rate disease activity in SLE differently. Physicians appear to place more emphasis on laboratory features while patients place more emphasis on function.     

Established rheumatoid arthritis: clinical assessments

Clinical assessment of established rheumatoid arthritis (RA) can have several purposes. It can be used to evaluate prognosis, disease course or interventions at both the individual and the group level (i.e. in a clinical trial), over the short or long term. The instruments used for the different purposes are not always the same. For example, information on prognosis is very useful when assessing the risk:benefit ratio of early aggressive pharmacotherapy; however, established prognostic factors are currently of limited use in individual patients with established RA. As, at the individual patient level, disease activity, disability and joint damage have variable courses, the course of the disease should be evaluated regularly both with process (i.e. erythrocyte sedimentation rate, joint counts) and with outcome (i.e. radiological progression, sum of past process) measures. For the evaluation of interventions, 'core sets' of valid measures to assess disease activity, outcome and specific criteria for improvement are used; these can, to some extent, be useful in clinical practice.     

Contribution of rheumatoid arthritis disease activity and disability to rheumatoid cachexia

This cross-sectional study was done to show how nutritional indices influence each other and the contributions made by inflammation to the development of rheumatoid cachexia. We studied 295 female patients with rheumatoid arthritis (RA). We chose five nutritional indices: body mass index (BMI), arm muscle area (AMA), triceps skinfold thickness (TSF), which were obtained via anthropometric measurements, and serum albumin and cholesterol. Clinical indicators of RA included disease duration, C-reactive protein (CRP) and Disease Activity Score 28 (DAS28). We performed a bivariate correlation test between the nutritional indices and multiple regression analysis for each nutritional index. Mean AMA was low, 87.3% of the normal value, whereas TSF was not different. Muscle protein expressed by AMA decreased according to RA duration, whereas visceral protein indicated by serum albumin decreased with an increase in RA activity. The continuation of inflammation appears to be essential for a decrease in muscle protein in rheumatoid cachexia. DAS28 showed a positive contribution to BMI in the regression model, and the increase in RA disease activity causes an increase in BMI via an accumulation of tissue fat.     

Platelet count and disease activity in juvenile rheumatoid arthritis

Blood samples from 41 children with juvenile rheumatoid arthritis (JRA) were studied. The platelet count was tested for possible relationship and correlation with a number of clinical and laboratory parameters. High platelet count was associated with active disease, presence of secondary amyloidosis, and poor functional capacity. The platelet count was positively correlated with the erythrocyte sedimentation rate, anemia, and granulocytosis. The platelet count thus seems to provide an additional parameter of disease activity in patients with JRA.     

Contribution of rheumatoid arthritis disease activity and disability to rheumatoid cachexia

Abstract

This cross-sectional study was done to show how nutritional indices influence each other and the contributions made by inflammation to the development of rheumatoid cachexia. We studied 295 female patients with rheumatoid arthritis (RA). We chose five nutritional indices: body mass index (BMI), arm muscle area (AMA), triceps skinfold thickness (TSF), which were obtained via anthropometric measurements, and serum albumin and cholesterol. Clinical indicators of RA included disease duration, C-reactive protein (CRP) and Disease Activity Score 28 (DAS28). We performed a bivariate correlation test between the nutritional indices and multiple regression analysis for each nutritional index. Mean AMA was low, 87.3% of the normal value, whereas TSF was not different. Muscle protein expressed by AMA decreased according to RA duration, whereas visceral protein indicated by serum albumin decreased with an increase in RA activity. The continuation of inflammation appears to be essential for a decrease in muscle protein in rheumatoid cachexia. DAS28 showed a positive contribution to BMI in the regression model, and the increase in RA disease activity causes an increase in BMI via an accumulation of tissue fat.     

Interplay between patient global assessment,pain, and fatigue and influence of other clinical disease activity measures in patients with active rheumatoid arthritis

The interplay between patient-reported outcome measures in rheumatology is not well clarified. The objective of the study was to examine associations on the group level and concordance on the individual patient level between patient global assessment (PaGl), pain, and fatigue as scored on visual analog scales (VAS) in the daily clinic by patients with active rheumatoid arthritis (RA). Associations with other measures of disease activity were also examined. Traditional disease activity data on 221 RA patients with active disease planned to initiate biological treatment were extracted from the Danish DANBIO registry. Associations between VAS PaGl, pain, and fatigue (0–100) were examined using multiple regression analysis. Concordance between the VAS scores was expressed as the bias (mean difference between intra-individual scores) and the 95 % lower and upper limits of agreement (LLoA; ULoA) according to the Bland-Altman method. Mean age was 57?±?14 years, mean Disease Activity Score (DAS28-CRP4) 5.0?±?0.9, and mean PaGl 63.6?±?22.6. PaGl was most strongly predicted by pain and fatigue, pain by PaGl and fatigue, and fatigue by PaGl and pain (beta ranging from 0.17 to 0.69, p?<?0.01–0.0001). More objective measures were not or far less predictive. LLoA;ULoA [bias] for PaGl vs. pain was ?19.1; 29.5 [5.2], for PaGl vs. fatigue ?22.8; 28.6 [2.9], and for fatigue vs. pain ?29.2; 33.8 [2.3]. In conclusion, PaGl, pain, and fatigue were most strongly explained by each other, not by more objective clinical measures of disease activity and were nearly identical on the group level. On the individual patient level, however, differences between the scores varied considerably. The findings highlight the challenge of understanding and dealing with traditional patient-reported VAS measures when it comes to individual RA patients in the daily clinic.