Background/Purpose: A great challenge in managing rheumatoid arthritis (RA) is the scenario of patient-physician discordance, in which despite seeming control of inflammation, patients suffer from undifferentiated symptoms of pain, fatigue, psychosocial distress, and functional disability. Our aim was to explicate the etiologic domains underlying patient-physician discordance.

Methods: We identified consecutive patients with RA fulfilling the ACR/EULAR 2010 criteria from our outpatient practice. Patients with ≥25-mm difference between patient and provider global assessments (0-100) of disease activity were identified. We abstracted electronic records for RA disease characteristics and comorbidities. Disease activity was classified according to Clinical Disease Activity Index (CDAI). In a sub-study, 50 discordant and 20 concordant patients (10 each with CDAI ≤10 and >10) completed several validated health status instruments (e.g., pain visual analog scale (VAS), Health Assessment Questionnaire II (HAQ-II), Fibromyalgia Research Survey, and the Patient-Reported Outcome Measures Information System (PROMIS) Pain Interference and Ability to Participate surveys) and underwent grayscale (GS) and power Doppler (PD) ultrasonography of the dominant hand, wrist and foot. Differences between discordant and concordant groups were evaluated using chi-square and rank sum tests.

Results: Patient-physician discordance affected 118 (34%) of 351 consecutive visits. The study cohort included 141 of these patients (mean age 61 years, 73% female), with discordant global assessments in 68 (48%). Of the discordant patients, 63 (93%) rated their disease activity as greater than their provider, with median (range) patient global assessment of 57 (2-87) and provider global assessment of 15 (0-80). Discordance was associated with seronegativity (p=0.008 for rheumatoid factor and p=0.035 for anti-cyclic citrullinated peptide (anti-CCP) antibodies), lack of joint erosions (p=0.013), and the presence of comorbid osteoarthritis (p=0.005), depression (p=0.004), and fibromyalgia (p=0.011). The proportion of patients with CDAI >10 was significantly higher in the discordant than concordant group (50% vs. 33%, p<0.001). While usage of RA therapies was similar between groups, discordant patients had greater usage of opioids (p=0.015), antidepressants (p<0.001), and fibromyalgia medications (p=0.018). In the sub-study, higher values for the pain VAS, HAQ-II disability, Fibromyalgia widespread pain index, PROMIS Pain Interference, and PROMIS Ability to Participate questionnaires distinguished the discordant group. On sonographic examination, the discordant group had 66% GS synovitis ≥2 and 38% PD synovitis ≥1.

Conclusion: Our findings demonstrate that a comprehensive framework for evaluation of patient-physician discordance should include domains of seronegativity, fibromyalgia, depression, comorbid osteoarthritis, and persistent synovitis. Further work is necessary to develop a standardized approach for patient-centered evaluation and shared decision-making to improve outcomes for patients with RA in the setting of patient-physician discordance.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/towards-patient-centeredness-of-the-treat-to-target-paradigm-development-of-a-framework-for-evaluation-of-patients-with-rheumatoid-arthritis-in-the-setting-of-patient-physician-discordance/