Background/Purpose

Healthcare must be patient-centered to achieve optimal outcomes and quality of life.  From this perspective, it is significant that patients with rheumatoid arthritis (RA) sometimes rate their disease activity as much higher than their rheumatologists.  This ‘discordance’ is mediated in part by patient-reported pain.  In this study, our objective was to characterize the qualities of pain reported by patients in the context of patient-physician discordance.

Methods

We conducted an observational study of consecutive patients with RA recruited between July 2008 and December 2010.  A physician joint assessor, who was independent from treatment decision-making, performed a standardized clinical evaluation.  Positive discordance was defined as the patient global assessment being ≥25-mm higher than the physician global assessment of disease activity.  Patients completed the pain visual analog scale (VAS; range: 0 – 100 mm) and the Short Form McGill Pain Questionnaire (SF-MPQ), including the sensory (range: 0 – 33) and affective (range: 0 – 12) scales.  Examples of sensory characteristics are “sharp, aching or throbbing,” and examples of affective characteristics are “sickening, fear-causing, or punishing-cruel.”  We abstracted electronic medical records to collect demographics, laboratory data, smoking status, and body mass index (kg/m²).  Correlations between explanatory variables and the presence of positive discordance were determined using Spearman methods, adjusting for RA characteristics.

Results

A total of 127 patients with RA were recruited (mean age 55.6 years; mean disease duration 6.8 months; 63% female).  The mean (SD) pain VAS was 47 (26) mm.  The median (range) scores for the SF-MPQ sensory and affective scales were 10 (0 to 29) and 2 (0 to 9).  Positive discordance (i.e., patient high) was associated with higher pain (r = 0.37, p = <0.001) and fatigue (r = 0.32, p<0.001).  The SF-MPQ data showed that positive discordance was more strongly associated with affective characteristics of pain (r = 0.30, p <0.001) than sensory characteristics of pain (r = 0.23, p = 0.013).  The association of positive discordance with SF-MPQ affective pain was independent of age, sex, rheumatoid factor, anti-CCP antibodies, body mass index, smoking status, and use of prednisone or disease-modifying drugs. 

Conclusion

The significance of this study is that in the context of positive discordance, patients are more likely to describe their pain using words that have affective or emotional connotations.  This finding could reflect activation of pain, mood, and fear networks in the brain.  Future research should evaluate the connectivity between these brain networks in the setting of patient-physician discordance and determine their relationship to subclinical immune/inflammatory status.  The positive impact could be the development of new approaches that better alleviate pain and improve quality of life in our patients.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/pain-characteristics-among-patients-with-rheumatoid-arthritis-in-the-context-of-patient-physician-discordance-in-disease-activity-assessments/