Physician-Patient Discordance of Global Assessment Higher in Osteoarthritis vs Rheumatoid Arthritis

In a comparison of global health assessments by patients (PATGL) and physicians (DOCGL), researchers found more discordance in patients with osteoarthritis (OA) vs those with rheumatoid arthritis (RA), according to a report published in Rheumatology International. For both conditions, pain was the only statistically significant variable that explained such discordance between providers and patients.

Because clinical decisions in OA rely heavily on patient reports, investigators sought to determine the level of patient-physician discordance among this population, hypothesizing that it would be roughly similar to that found with RA.

Between September and December 2014, a single-center cross-sectional study compared PATGL and DOCGL assessments of patients with OA (n=243; mean age, 65.6 years; 90.1% women) and patients with RA (n=216; mean age, 56.4 years; 85.2% women), using a patient Multi-Dimensional Health Assessment Questionnaire and a physician questionnaire, both using scores from 0 to 10, where higher scores indicated poorer health. When calculating discordance using PATGL minus DOCGL, comparisons were rated as positively discordant (≥2), negatively discordant (≤-2), or concordant (absolute difference <2).

Intraclass correlations were used to evaluate agreement between PATGL and DOCGL assessments, and multivariate regression was used to calculate odds ratios (OR) in an attempt to identify variables responsible for positive discordance.

Although the mean DOCGL ratings were similar for OA and RA (4.0 vs 3.8; P =.23), mean PATGL ratings were significantly higher in OA compared with RA (5.4 vs 4.2; P =.005), resulting in a greater patient-doctor discordance for OA vs RA (mean differences, 1.35 vs 0.43; P <.001). The proportion of positive discordance was also significantly higher for patients with OA compared with patients with RA (34% vs 18%; P <.001). Negative discordance (10% vs 15%) and concordance (56% vs 67%) were seen in patients with OA vs RA, respectively.

When researchers examined agreement between assessments by patients and clinicians, the intraclass correlation was lower for OA compared with RA (0.43 vs 0.60), indicating poorer agreement in patients with OA. After multivariate logistic regression analysis, pain was found to be the only independent variable that could explain discordance in both OA (OR, 1.34; 95% CI, 1.12-1.78; P <.05) and RA (OR, 1.47; 95% CI, 1.04-2.07; P <.05).

Study strengths included the use of Multi-Dimensional Health Assessment Questionnaire across all patients, allowing for comparisons among various rheumatic diseases. Study limitations included recruitment of all participants from a single center, exclusion of those with incomplete data, possible underestimation of discordance levels for both disorders, reliance on International Classification of Diseases-9 codes that may not correlate well with American College of Rheumatology criteria, and lack of analysis of secondary OA (for patients with RA) or fibromyalgia (all patients).

“Discordance in this case may reflect deficits in physician appreciation of disease severity,” stated the authors, adding, “It is relevant to recognize discordance to improve patient care and outcomes.” They concluded by noting, “A better understanding of how discordance may affect clinical outcomes could help to develop specific interventions to improve quality of life and disease management for OA patients.”

JAB has received consulting fees from Zynerba Pharma and Glaxo SmithKline.

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Reference

Castrejon I, Shakoor N, Chua JR, Block JA. Discordance of global assessment by patients and physicians is higher in osteoarthritis than in rheumatoid arthritis: a cross-sectional study from routine care. Rheumatol Int. 2018;38:2137-2145.