Rheumatoid Arthritis Patients, Providers Often Differ

One-third of patients who have rheumatoid arthritis disagree with their provider as to the severity of their disease.

Close to one-third (29%) think their disease severity is worse than their doctor thinks it is.

Patients with rheumatoid arthritis who have fibromyalgia, depression, or nonerosive disease are most likely to have disagreements with their provider as to the severity of their disease.

Discordance or disagreement between patients with rheumatoid arthritis and their health care providers has been well described. Most often, patient reports of disease activity on global assessment tools are higher than those on provider global assessments.

Divya Challa and fellow researchers at the Mayo Clinic pointed out that patient-provider discordance in rheumatoid arthritis contributes to decreased work productivity, reduced likelihood of remission, and the possibility of increased radiographic joint damage.

The authors sought to uncover the clinical correlates of patient-provider discordance and published their findings in a recent Arthritis Research & Therapy article.

The study

With an observational, cross-sectional design, the study looked at 350 consecutive patients at the Mayo Clinic who had a diagnosis of rheumatoid arthritis.

Disease activity was measured with the Disease Activity Score 28 using C-reactive protein and was also classified by the Clinical Disease Activity Index into 1 of 4 groups: remission (DAS, < 2.8), low disease activity (DAS, ≥ 2.8 to < 10.0), moderate disease activity (DAS, ≥ 10.0 to < 22.0), and high disease activity (DAS, ≥ 22.0).

Subjects filled out health questionnaires and joints were examined with ultrasound to determine perceived and clinical disease activity.

The results

• Patient-provider discordance occurred in 32.5% of subjects.

• Global assessments were rated higher than provider assessments by 29.4% of subjects.

• At their most recent visit, 68% of subjects saw a nurse practitioner or physician assistant and 33% saw a physician.

• There was no difference in discordance between physician and nonphysician visits.

• The discordant subjects had a higher median global assessment of disease activity when compared to those in the concordant group (p<0.001).

• The median global assessment of disease activity was higher in the discordant subjects than in the concordant group (p<0.001).

• Provider global assessments did not differ between concordant and discordant subjects.

• In the discordant and concordant groups, 2% and 33% of patients, respectively, were in remission.

• More patients in the discordant group had low disease activity (50% vs 33%) and moderate disease activity (37% vs 22%) than in the concordant group (P<.001).

• Numbers of patients with high disease activity were similar between groups.

• Subjects in the discordant group reported higher pain scores (p<.001).

• Subjects in the discordant group were more likely to have negative rheumatoid factor and anticyclic citrullinated peptide antibodies and lack radiographic joint erosions and more than 2 tender joints.

• Patients with fibromyalgia and depression were significantly associated with discordance (P<0.001 and P=0.02, respectively).

• Discordant patients used opioids, fibromyalgia medications, antidepressants, and sleep aids at a significantly higher rate than concordant subjects.

• Pharmacologic treatment for rheumatoid arthritis was similar between groups.

Implications for physicians

• Discordance between disease activity perception among patients with rheumatoid arthritis and their health care provider is widespread.

• Physicians and other health care providers should ask their patients how they feel about their rheumatoid arthritis even if objective measures categorize them in low disease activity states.

• Pain is the discordant state most frequently reported by patients who have rheumatoid arthritis.

• Patients with rheumatoid arthritis and comorbid fibromyalgia or depression should be screened for deficits in perception relating to their comfort and disease activity.

Disclosures:

Financial support for this study was provided by the Larry and Ruth Eaton Family Career Development Fund and the National Center for Advancing Translational Science.

References:

Challa DN, Kvrgic Z, Cheville AL, et al. “Patient-provider discordance between global assessments of disease activity in rheumatoid arthritis: a comprehensive clinical evaluation.” Arthritis Res Ther. 2017;19:212. doi: 10.1186/s13075-017-1419-5.