Concordant and discrepant views of patients' physical functioning

Objective. Although considerable research has been done on patient-physician interaction, few studies have examined discrepancies between patients and physicians in their assessments of the patient's physical functioning. One recent study reports such discrepancies between rheumatologists and 41 % of their rheumatoid arthritis patients. This article reports data replicating that study and examining the relationships between such discrepancies and a number of other variables. Methods. This is a longitudinal study of 158 patients with rheumatoid arthritis who were interviewed 4 times over a 2-year period and who reported their levels of physical functioning on the Arthritis Impact Measurement Scales. At the time of the fourth interview, the rheumatologists rated each patient's physical functioning on the revised criteria published by the American College of Rheumatology. Results. Rheumatologists' assessments of their patients' physical functioning were discrepant with the patient's assessment for 35% of these patients. Twenty-seven patients were rated as worse than they rated themselves and 28 were rated as better. There were no differences between the concordant and the two discrepant groups in demographic or health status characteristics. Conclusions. Taken together, these data imply that it is important for physicians to verify their perceptions with the patient and that it is important for patients to verify that the physician understands them correctly.     

Arthritis patients' perceptions of rheumatologists' participatory decision-making style and communication about complementary and alternative medicine

OBJECTIVE: To examine if patients with arthritis who reported using complementary and alternative medicine (CAM) were more likely to tell their physicians about their CAM use if they rated their rheumatologist as using a more participatory decision-making style and what reasons patients gave for telling or not telling their rheumatologist about their CAM use. METHODS: A survey that asked about CAM use, health status, demographics, physician use of a participatory decision-making style, and medical skepticism was sent to individuals with arthritis who saw 23 rheumatologists at universities and private practice clinics in North Carolina. Generalized estimating equations were used to analyze the data. RESULTS: A total of 92% of patients reported using CAM for their arthritis and 54% of these patients discussed their CAM use with their rheumatologist. Women, patients who used more types of CAM, and patients who rated their rheumatologist as using a more participatory decision-making style were significantly more likely to tell their physicians about their CAM use. CONCLUSION: Our findings suggest that if rheumatologists use more participatory styles of decision making with patients and involve them when making treatment decisions, patients are more likely to tell them about their CAM use.     

Office management of fibromyalgia

The office management of fibromyalgia (FM) is best determined by two variables: (1) the severity and complexity of each patient's symptoms, and (2) the specialization and interest of the treating physician. Because there are 6 to 10 million Americans with FM, most patient visits will be to the primary care physician. Rheumatologists, physiatrists, and other musculoskeletal specialists must work with primary care physicians to foster the early diagnosis and appropriate treatment of FM. Primary care physicians are faced with enormous challenges in caring for patients with chronic pain disorders like FM. Our managed health care system insists that patient encounters be brief. Specialty referrals are often discouraged. There is little if any reimbursement for patient education. FM treatment is labor-intensive. Therefore, optimal planning and use of precious office time and resources are most important. Rheumatologists should train our primary care colleagues to recognize FM. Many patients still go months or years before this common syndrome is diagnosed. Rheumatologists should also spearhead teaching primary care physicians the basic treatment principles of FM. If the diagnosis is made early, patients with FM in community practice do very well with simple management techniques. As consultants, rheumatologists should confirm the diagnosis of FM and suggest basic FM management. Some primary care providers or other specialists will be fully capable of bypassing this consultation, especially if the patient responds to simple management suggestions. Manpower surveys have not studied the cost-effectiveness of specialty care in FM. Rheumatologists should also assume the responsibility for the management of FM patients who have not responded to basic FM management. Additionally, some rheumatologists may wish to subspecialize in FM, a major career commitment to this perplexing disorder. These situations constitute advanced FM management.     

Arthritis patients' perceptions of rheumatologists' participatory decision‐making style and communication about complementary and alternative medicine

Objective

To examine if patients with arthritis who reported using complementary and alternative medicine (CAM) were more likely to tell their physicians about their CAM use if they rated their rheumatologist as using a more participatory decision‐making style and what reasons patients gave for telling or not telling their rheumatologist about their CAM use.

Methods

A survey that asked about CAM use, health status, demographics, physician use of a participatory decision‐making style, and medical skepticism was sent to individuals with arthritis who saw 23 rheumatologists at universities and private practice clinics in North Carolina. Generalized estimating equations were used to analyze the data.

Results

A total of 92% of patients reported using CAM for their arthritis and 54% of these patients discussed their CAM use with their rheumatologist. Women, patients who used more types of CAM, and patients who rated their rheumatologist as using a more participatory decision‐making style were significantly more likely to tell their physicians about their CAM use.

Conclusion

Our findings suggest that if rheumatologists use more participatory styles of decision making with patients and involve them when making treatment decisions, patients are more likely to tell them about their CAM use.     

Frustrating patients

Objective:To identify differences between patients viewed as frustrating by their physicians and those considered typical and satisfying. Design:This cross-sectional observational study focused on psychologically distressed high users of medical services. Frustrating patients were compared with typical and satisfying patients, using data from patient questionnaires, physician assessments, structured psychiatric interviews, and computerized utilization records. Setting:Group Health Cooperative of Puget Sound, a large health maintenance organization. Patients/participants:Study patients were in the top decile for ambulatory visits, and had elevated scores for anxiety, depression, and somatization. Among the 339 patients invited to participate in the study, 251 agreed, and 228 were rated by their physicians. Main results:A substantial proportion (37%) of the high users were viewed as frustrating by their physicians. Physicians’ ratings of physical disease severity did not differ among the groups, but frustrating patients rated their own health status less favorably and reported more somatic symptoms and disabilities. The frustrating group utilized more medical services than did other distressed high utilizers. All three groups had a high prevalence of mental disorders. However, frustrating patients had higher rates of somatization and generalized anxiety disorder. Conclusions:Physicians and their frustrating patients had contrasting views of the patients’ illnesses. The best predictors of physician frustration were somatization and increased medical service utilization. There is need for further research and clinical attention concerning optimal clinical management for patients with somatization. Supported by grant MH41739-02 from the National Institute of Mental Health, Rockville, Maryland.     

Unsaid but not forgotten: patients' unvoiced desires in office visits

OBJECTIVES: To examine patient, physician, and health care system characteristics associated with unvoiced desires for action, as well as the consequences of these unspoken requests. PATIENTS AND METHODS: Patient surveys were administered before, immediately after, and 2 weeks after outpatient visits in the practices of 45 family practice, internal medicine, and cardiology physicians working in a multispecialty group practice or group model health maintenance organization. Data were collected at the index visit from 909 patients, of whom 97.6% were surveyed 2 weeks after the outpatient visit. Before the visit, patients rated their trust in the physician, health concerns, and health status. After the visit, patients reported on various types of unexpressed desires and rated their visit satisfaction. At follow-up, patients rated their satisfaction, health concerns, and health status, and also described their postvisit health care use. Evaluations of the visit were also obtained from physicians. RESULTS: Approximately 9% of the patients had 1 or more unvoiced desire(s). Desires for referrals (16.5% of desiring patients) and physical therapy (8.2%) were least likely to be communicated. Patients with unexpressed desires tended to be young, undereducated, and unmarried and were less likely to trust their physician. Patients with unvoiced desires evaluated the physician and visit less positively; these encounters were evaluated by physicians as requiring more effort. Holding an unvoiced desire was associated with less symptom improvement, but did not affect postvisit health care use. CONCLUSIONS: Patients' unvoiced needs affect patients' and physicians' visit evaluations and patients' subjective perceptions of improvement. Implications of these findings for clinical practice are examined.     

Health care and burden of illness in systemic lupus erythematosus compared to rheumatoid arthritis: results from the National Database of the German Collaborative Arthritis Centres

During the past 20 years, outcome studies in the rheumatic diseases have, on the one hand, given increasing evidence of the unfavourable long-term prognosis of rheumatoid arthritis (RA) and on the other hand determined continuous improvement of prognosis in systemic lupus erythematosus (SLE). The aim of the study was to investigate how this translates into the current spectrum of patients with rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) seen by rheumatologists in Germany and to compare aspects of the burden of disease, disease outcomes and treatment between these two important rheumatic diseases using a large clinical database. Current health care was analysed with data from the German rheumatological database of 10 068 patients with RA and 1248 patients with SLE seen by rheumatologists in 2001. In addition, of a total of 3546 patients with SLE and 24 969 patients with RA seen at the German Collaborative Arthritis Centres between 1994 and 2001, 3465 cases of SLE were matched by age, sex, disease duration and referral status with a corresponding RA case. There were considerable differences in treatment of patients before referral to a rheumatologist and in rheumatologic care. In 2001, patients with SLE were treated by their rheumatologists mainly with antimalarials (AM, 37%), azathioprine (29%) and nonselective NSAIDs (16%). Of them, 61% received at least one immunosuppressive drug (including AM) plus glucocorticoids. In RA, methotrexate was the predominant medication (63%), and 56% received at least one immunosuppressive drug plus glucocorticoids. Matched pairs analysis showed that SLE patients with a short disease duration were almost equally burdened by pain, functional limitations and reduced health status as RA patients. After a disease duration of >10 years, however, patients with RA showed poorer outcomes than those with SLE: RA patients reported significantly more often severe pain (30% in RA versus 17% in SLE) and poor global health status (52 versus 38%), and their disease activity as well as severity was rated higher by the rheumatologists. In conclusion, comparing large groups of RA and SLE patients we found a similar burden in early but not in late disease. Taking into account limitations as to the generalizability of the results (recruitment in rheumatologic care, cross-sectional data, underestimation of SLE-specific outcomes), the discrepancy between the high increase in disease-related negative outcomes with longer disease duration in RA but not in SLE indicates a better long-term prognosis in SLE concerning the items observed. The great disparity in treatment intensity between rheumatologists and nonrheumatologists shows that the involvement of a specialist is needed equally in both diseases.     

Awareness and knowledge of fibromyalgia among French rheumatologists and general practitioners

OBJECTIVES: Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain and fatigue. Its prevalence is estimated to be at 3.4% in women and 0.5% in men. It is a major cause of morbidity. Our objective was to evaluate, using a self-questionnaire sent by mail, the level of knowledge of French physicians, general practitioners, and rheumatologists on fibromyalgia and to analyse their therapeutic approach. METHODS: The demographic characteristics of a sample of general practitioners and rheumatologists were compared to those of the overall data available. This comparison demonstrated the good representativeness of our sample. RESULTS: Fibromyalgia was considered as a disease by 23% of rheumatologists and 33% of general practitioners. While on average, each rheumatologist followed 30 fibromyalgia patients, each general practitioner followed 6.1 patients (i.e., 2 to 5% of their practice's patient base). Among rheumatologists, 6.4% made no distinction between this disease and depression vs. 13.1% of general practitioners. The diagnosis of fibromyalgia was made based on tenderness that occurs in precise, localized areas of the body (trigger points) by 94% of rheumatologists and 79.1% of general practitioners. Of general practitioners and rheumatologists, 93.7% and 73.7% respectively, have not received any medical school training on fibromyalgia or chronic fatigue syndrome. CONCLUSION: Given the lack of medical school training and continuing professional education concerning fibromyalgia (rare use of pain rating scales, confusion in the classification of rheumatic diseases), there is an urgent need to initiate an explicit teaching effort on chronic pain, and on fibromyalgia in particular.     

The public neglect of rheumatic diseases: insights from analyses of attendees in a musculoskeletal disease awareness activity

OBJECTIVES: To obtain data on the care received by individuals counselled during a public health awareness campaign on painful musculoskeletal conditions (MSC). METHODS: Easy non-formal access to rheumatologists/pain specialists was offered using a mobile unit (Rheuma-Bus) at widely accessible sites. Clients were asked to assess their severity of pain using a 100 mm visual analogue scale (VAS). Age, gender, disease duration, diagnosis if known, current and previous treatment as well as tentative diagnoses assigned and recommendations given to each individual by the counselling physicians were recorded. RESULTS: Average (SD) VAS pain rating was 59 (20.6) mm. Approximately 40% of clients had never consulted a physician for their condition before, but had lower pain scores than those who had seen a physician. Patients with inflammatory MSC had higher pain scores than those with non-inflammatory conditions. More than 2% of the clients had a newly detected inflammatory rheumatic disease. CONCLUSIONS: Many individuals having painful MSC seek medical help only when a very high threshold of pain is reached. Even while under treatment, the high mean pain scores suggest neglect of MSC that are not adequately recognised as important contributors to disability and decreased quality of life.     

第二次全国风湿免疫专科医师调查报告

目的调查中国风湿病医师从业现状,为中国风湿病学科发展提供依据。方法由中国医师协会风湿免疫病专科医师分会组织实施,以各省、直辖市、自治区为单位进行调查。采用统一编制的调查问卷登记的方式进行统计。结果共调查1013家医院,设立风湿专科503个(42.9%),非风湿专科669个(57.1%)。共纳入风湿病医师4515人,男1790人,女2725人,男女比例为1:1.52;平均年龄为3 8.6岁,≤30岁人数最多,为1090人(24.1%)。所有调查医师中主任医师887人(19.7%),副主任医师1044人(23.1%),主治医师1301人(28.8%),住院医师1283人(28.4%)。4515名调查医师中,2799人(62.0%)为风湿病免疫专科医师,教育背景以本科人数最多(2180人,48.3%);1773人(39.3%)接受过国内风湿专科继续教育,200人(4.4%)接受过国外风湿专科学习;2009至2011年共有2050人(45.4%)曾在国内专业期刊发表科研论文,共计发表论文6948篇;401人(8.9%)在国外专业期刊发表科研论文,共计814篇。     

The prevalence and impact of managed care for persons with rheumatoid arthritis in 1994 and 1999

OBJECTIVES: To estimate the proportion of persons with rheumatoid arthritis (RA) in managed care and fee-for-service settings in 1994 and 1999, to ascertain whether there are differences in utilization between persons in the 2 systems of care in the 2 years, and to determine whether 1994 managed care status or change between 1994 and 1999 in managed care status affects outcomes. METHODS: The present study uses data from the University of California, San Francisco RA Panel Study, in which 310 patients with RA from a random sample of Northern California rheumatologists were interviewed annually between 1994 and 1999 using a structured survey instrument. We use linear and logistic regression to compare the health care utilization and outcomes of persons in managed care and fee-for-service after adjusting for differences in demographic and health characteristics. RESULTS: The proportion of respondents in managed care increased from 60% to 79% between 1994 and 1999, including an increase from 37% to 68% among persons eligible for Medicare and an increase from 74% to 92% among persons ineligible for Medicare. With the exception of physical therapy visits in 1999, patients with RA in managed care did not report significantly different utilization of any service for RA than those in fee-for-service in either 1994 and 1999, including hospital admissions and joint replacement surgery. Managed care status in 1994, and change in managed care status between 1994 and 1999, were not associated with significantly different outcomes in 1999. CONCLUSION: Despite the growth in the proportion of patients with RA in managed care, those in managed care did not differ from those in fee-for-service settings in utilization or outcomes.     

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.     

Does physician gender affect satisfaction of men and women visiting the emergency department?

OBJECTIVE: To assess the association of physician gender with patient ratings of physician care. DESIGN: Interviewer-administered survey and follow-up interviews 1 week after emergency department (ED) visit. SETTING: Public hospital ED. PATIENTS/PARTICIPANTS: English- and Spanish-speaking adults presenting for care of nonemergent problems; of 852 patients interviewed in the ED who were eligible for follow-up, 727 (85%) completed a second interview. MEASUREMENTS AND MAIN RESULTS: We conducted separate ordered logistic regressions for women and men to determine the unique association of physician gender with patient ratings of 5 interpersonal aspects of care, their trust of the physician, and their overall ratings of the physician, controlling for patient age, health status, language and interpreter status, literacy level, and expected satisfaction. Female patients trusted female physicians more (P =.003) than male physicians and rated female physicians more positively on the amount of time spent (P =.01), on concern shown (P =.04), and overall (P =.03). Differences in ratings by female patients of male and female physicians in terms of friendliness (P =.13), respect shown (P =.74), and the extent to which the physician made them feel comfortable (P =.10) did not differ significantly. Male patients rated male and female physicians similarly on all dimensions of care (overall, P =.74; friendliness, P =.75; time spent, P =.30; concern shown, P =.62; making them feel comfortable, P =.75; respect shown, P =.13; trust, P =.92). CONCLUSIONS: Having a female physician was positively associated with women's satisfaction, but physician gender was not associated with men's satisfaction. Further studies are needed to identify reasons for physician gender differences in interpersonal care delivered to women. KEY WORDS: patient satisfaction; gender; physician-patient relations; delivery of care; health care quality.     

Assessment of family physicians' knowledge about fibromyalgia in Egypt

Aim of the workTo assess knowledge of Egyptian family physicians about the diagnostic criteria and treatment modalities of fibromyalgia.Subjects and methodsA questionnaire and an informed consent were sent by email to family physicians working in primary health care centers in Egypt. The questionnaire assessed 3 areas: sociodemographic and professional data; knowledge about diagnosis; and knowledge about treatment modalities. Scoring system was used to categorize levels of knowledge into very low, low, moderate, high and very high.ResultsA total of 108 family physicians responded, with a response rate of 60%.The respondents were 27 consultants, 54 specialists and 27 residents, with a median age of 33 years and a median experience of 12 years. Very low, low and moderate levels of familiarity with fibromyalgia were perceived by 28.7%, 30.6% and 28% respectively. Close to half of participants (46.2%) gained their knowledge about fibromyalgia through self-study. According to the scoring system, 39.8% had low level of knowledge about clinical presentation and 37% had the same level of knowledge about treatment modalities. About three quarters (76%) of participants agreed that patients with fibromyalgia should be referred to rheumatologists. The most common selected clinical presentations were widespread pain (94.4%) and excessive fatigue (91.7%), while the most selected treatment modalities were non-steroidal anti-inflammatory drugs (89.8%) and selective serotonin reuptake inhibitors (47.2%).ConclusionKnowledge about clinical presentation and treatment modalities of fibromyalgia among Egyptian family physicians is low. Continuing medical education about fibromyalgia is needed to improve quality of health care.     

Influence of patient education on profiles of physician practices

BACKGROUND: Few data are available about the effect of patient socioeconomic status on profiles of physician practices. OBJECTIVE: To determine the ways in which adjustment for patients' level of education (as a measure of socioeconomic status) changes profiles of physician practices. DESIGN: Cross-sectional survey of patients in physician practices. SETTING: Managed care organization in western New York State. PARTICIPANTS: A random sample of 100 primary care physicians and 50 consecutive patients seen by each physician. MEASUREMENTS: Ranks of physicians for patient physical and mental health (Short Form 12-Item Health Survey) and satisfaction (Patient Satisfaction Questionnaire), adjusted for patient age, sex, morbidity, and education. RESULTS: Physicians whose patients had a lower mean level of education had significantly better ranks for patient physical and mental health status after adjustment for patients' level of education level than they did before adjustment (P < 0.001); this result was not seen for patient satisfaction. After adjustment for patients' level of education, each 1-year decrease in mean educational level was associated with a rank that improved by 8.1 (95% CI, 6.6 to 9.6) for patient physical health status and by 4.9 (CI, 3.9 to 5.9) for patient mental health status. Adjustment for education had similar effects for practices with more educated patients and those with less educated patients. CONCLUSIONS: Profiles of physician practices that base ratings of physician performance on patients' physical and mental health status are substantially affected by patients' level of education. However, these results do not suggest that physicians who care for less educated patients provide worse care. Physician profiling should account for differences in patients' level of education.     

Biologikatherapie der juvenilen idiopathische Arthritis im jungen Erwachsenenalter

Background

The majority of patients with juvenile idiopathic arthritis (JIA) need specialized care when they enter adulthood. An increasing number of these patients take biologic disease modifying antirheumatic drugs (DMARDs) at the time of transition. The biologic register BiKeR provides information about the health status and healthcare situation of JIA patients during childhood and adolescence and with their entrance into adulthood these patients are systematically transferred to JuMBO, the follow-up register for young adults with JIA treated with biologics and nonbiologic DMARDs.

Objective

The aim of this study was to investigate the healthcare situation of patients with JIA during transition from pediatric to adult care.

Methods

The current analyses included patients who were successfully transferred from the BiKeR to JuMBO registers. The DMARD treatment and patient-reported outcome (i.e. disease activity, pain and functional ability) were assessed at the last documentation in BikeR and at the first as well as the last documentation in JuMBO.

Results

During the transition period 1 in 10 JIA patients stopped DMARD therapy and 1 in 20 patients did not visit a physician for adults. Three-quarters of the adult JIA patients included in JuMBO (N?=?811) reached adult rheumatology care. Adult rheumatologists usually continued therapy with biologics in these patients. Every second patient was still being treated with etanercept, 5 years after the start of the first treatment with biologics. Adult rheumatologists changed the biologic substance in every fourth patient, mainly because of treatment failure. In comparison to patients in regular adult rheumatology care, those who did not remain in specialized care had a higher discontinuation rate of biologics. Moreover, patients with sporadic use of medical care had a significantly poorer health status than those with a regular use of medical care at least every 6 months.

Conclusion

The data show that there is a need for improving healthcare during the period of transition from pediatric to adult rheumatology.     

Pain syndromes, disability, and chronic disease in childhood.

Childhood disability and chronic disease are common, and their prevalence is increasing as children survive with conditions that were previously fatal. It is important that physicians in training learn about disability and handicap, and the functioning of multidisciplinary teams to manage these problems. Chronic ill-health is often very expensive to manage, and some serious and creative thinking about the best way to fund such health care is urgently needed. Pediatric rheumatologists are involved with the care of many children with chronic and recurrent musculoskeletal pain; however, they have not perhaps focused enough research effort on the investigation of pain and its management. Whether reflex neurovascular dystrophy, fibromyalgia, and chronic fatigue syndrome are part of a disease continuum is unclear, but it seems probable that psychosocial problems are often important contributing factors in all three conditions. Immunoglobulin subclass deficiencies are being increasingly delineated, occurring in chronic fatigue syndrome as well as many other disease states. Their clinical relevance still remains, for the most part, uncertain. Short stature occurs in many chronic illnesses, and the role of growth hormone treatment in these conditions is beginning to be investigated.