Background/Purpose

Discordance between patients’ and physicians’ global assessments of disease activity occurs in up to a third of clinical evaluations for rheumatoid arthritis (RA).  In this study, we sought to determine the association between the presence of patient-physician discordance at baseline and clinical disease activity after the 24 weeks of disease-modifying therapy.

Methods

We conducted an observational study of consecutive patients with newly diagnosed RA recruited between July 2008 and December 2010.  RA was defined by the Leiden early RA prediction rule.  The primary rheumatologist prescribed disease-modifying therapy, which did not follow any study protocol.  Standard disease activity assessments were performed by a single joint assessor, who was independent of treatment decision-making, at baseline and at 24 weeks of follow-up, including tender and swollen joint counts, patient and physician global assessments of disease activity (0 – 100 mm visual analog scales), and the C-reactive protein.  Discordance was defined by ≥25-mm difference between the patient and physician global assessments.  A higher patient-than-physician global assessment defined positive discordance, and a higher physician-than-patient global assessment defined negative discordance.  The outcome variable of interest for this analysis was the Disease Activity Score in 28 joints, 3-variable version (which excludes the patient global assessment), using the C-reactive protein (DAS28-CRP).  The association between discordance and DAS28-CRP at 24 weeks was determined using linear regression models, adjusting for multiple study covariates.

Results

A total of 66 patients were included in this study.  The mean age was 56.4 years, and 66% was female.  As initial treatment, 51% of patients received methotrexate, 25% hydroxychloroquine, and 58% prednisone.  Patient-physician discordance was present at 27% of the baseline visits, 10% with positive discordance (i.e., patient high) and 17% with negative discordance (i.e., physician high).  The presence of positive discordance was predictive of higher DAS28-CRP after 24 weeks of disease-modifying therapy (β coefficient = 1.58; p = 0.017) whereas negative discordance was not predictive (β coefficient = 0.65; p = 0.091), after adjusting for age, sex, disease duration, rheumatoid factor, anti-CCP antibodies, baseline tender joint count, baseline swollen joint count, baseline CRP, initial DMARD, prednisone use, and smoking status. 

Conclusion

In conclusion, discordance in which patient’s assessment of disease activity is higher than the physician’s assessment is predictive of significantly higher DAS28-CRP after 24-weeks of disease-modifying therapy.  Further research is necessary to explicate factors underlying patient-physician discordance and to develop strategies for managing these factors.  This work is anticipated to improve treatment outcomes for patients with RA.

---

« Back to 2014 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/patient-physician-discordance-of-disease-activity-assessments-predicts-inadequate-treatment-response-in-early-rheumatoid-arthritis/