Background/Purpose: Discordance between patient global assessment (PGA) and physician global assessment (PhGA) regarding the disease activity of rheumatoid arthritis (RA) can be divided into three groups: positive discordance, concordance, and negative discordance. Several studies have demonstrated that the major determinants of positive discordance (PGA > PhGA) are pain and functional impairment. The clinical manifestations of negative discordance (PGA < PhGA) have not yet been fully elucidated. This study identifies determinants of this discordance using a nationwide RA database in Japan (NinJa).

Methods: The data of 13,945 patients with RA registered in NinJa in 2014 with available joint counts were analyzed. Data from patients with RA registered in both NinJa in 2014 and 2018 (n=4,923) were analyzed to study the radiographic progression of RA. The clinical variables used for the analysis included age, sex, disease duration, radiographic stage, functional class, pain visual analog scale (VAS) score, tender joint count (TJC), swollen joint count (SJC), disease activity score in 28 joints, C-reactive protein (DAS28-CRP), modified Health Assessment Questionnaire (mHAQ), and rheumatoid factor and anti-citrullinated peptide antibody (ACPA) levels. The affected joint distribution was investigated using joint indices (JI) x, y, and z, which were calculated as indices for the upper and lower joints and large joint involvement, respectively (Int J Rheum Dis 21(6):1237-45, 2018).

Results: Using a PGA-PhGA cutoff of 3 on a 10-cm scale, the numbers of patients with RA classified into positive discordance (PGA-PhGA > 3), concordance (-3 < PGA-PhGA < 3), and negative discordance (PGA-PhGA < -3) were 2,049 (14.7%), 11,785 (84.5%), and 111 (0.8％), respectively. There were no significant differences in age or disease duration between the three groups; however, the proportion of male patients was significantly higher in the negative-discordance group (19.9%, 16.5%, and 28.8%, respectively; p< 0.01). The TJC (p< 0.01), SJC (p< 0.01), and DAS28-CRP (p< 0.01) scores were higher in the negative discordance group than in the concordance group, while the PGA (p< 0.05) scores were lower in the negative discordance group than in the concordance group. JI x was significantly higher in the negative discordance group than in the other groups (p< 0.01). The proportion of patients with radiographic progression was significantly higher in the negative discordance group (33.3%) than in the concordance and positive concordance groups (13.7% and 11.5%, respectively; p< 0.01).

Conclusion: Negative discordance is prevalent in males and associated with higher disease activity, especially in the upper extremities, though the patients rated their disease activities substantially lower than their attending physicians. As negative discordance is associated with the progression of joint destruction, this rare but important discordance status can be regarded as a potential factor of poor prognosis.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/clinical-characteristics-of-patients-with-rheumatoid-arthritis-ra-who-rate-their-global-assessment-of-disease-activity-substantially-lower-than-their-physicians-negative-discordance-based-on-a-lar/