Patient‐Physician Discordance in Global Assessment in Rheumatoid Arthritis: A Systematic Literature Review With Meta‐Analysis

Abstract

(249 words)Objective: The integration of the patient in therapeutic decision-making is important in the management of rheumatoid arthritis (RA); but the patient opinion regarding disease status may differ from the physician's opinion. The aim of this study was to assess in the published literature the frequency and drivers of patient-physician discordance in global assessment in RA.Method: Systematic literature review by 2 investigators of all papers published up to January 2015 in Medline or EMBASE, reporting discordance in RA. Discordance was defined based on the absolute difference of patient global and physician global assessments (PGA/PhGA) on 0-10cm scales. The frequency of discordance and its predictors were collected in each study. Frequencies of discordance were pooled by metaanalysis using random effect. Results:In all, 12 studies were selected (i.e.,11,879 patients): weighted mean age 55.1±13.9 years, weighted mean disease duration 10.4±9.3 years, 80.7% were women. The value of the difference |PGA-PhGA| defining discordance varied between ≥0.5cm (N=2 studies) to ≥3cm (N=5 studies); the weighted mean value was 2.7cm. The pooled percentage of patients with discordance was 43% (95% confidence interval 36%-51%, range: 25%-76%). PGA was usually higher than PhGA. The drivers of PGA were pain and functional incapacity, whereas drivers of PhGA were joint counts and acute phase reactants. Conclusion:Discordance in global assessment was most frequently defined as a difference of 3 points or more; even with such a stringent definition, up to half the patients were found to be discordant. The long-term consequences of this discordance remain to be determined.

Determinants of Patient’s Global Assessment of Disease Activity and Physician’s Global Assessment of Disease Activity in patients with rheumatoid arthritis: A post hoc analysis of overall and Japanese results from phase 3 clinical trials

“…This finding is supported by the result of a survey involving 301 rheumatologists in Japan, in which 83.4% rheumatologists considered relief of joint pain as their treatment targets when treating patients with RA [19]. Other observational studies (carried out in multiple countries, including Europe, Russia, Latin America, and North America) have also identified joint counts [7,[11][12][13][14] and CRP [12] as important determinants of PhGA in patients with RA. In contrast, pain was not found to be a determinant of PhGA in studies examining discordance, and was not an important determinant of PhGA in an Austrian observational study of patients with RA [14], suggesting this may be a characteristic specific to Japanese physicians.…”

“…Both these measures are assessed as part of three commonly used measures of disease activity in clinical trials, the American College of Rheumatology Core Data Set, Simplified Disease Activity Index, and Clinical Disease Activity Index (CDAI) [10]. Patient-physician discordance in global assessment has been widely reported for studies conducted in many countries around the world, including Japan, with PtGA typically being higher than PhGA [3][4][5][6][7][8][9]11]. For instance, studies carried out in many countries around the world have reported positive discordance (PtGA > PhGA) ranging from 23.7% to 71.3% and negative discordance (PtGA < PhGA) ranging from 0% to 27.5% [4][5][6][7][8][9].…”

Determinants of Patient‐Physician Discordance in Global Assessment in Psoriatic Arthritis: A Multicenter European Study

“…In the literature, discordance is usually defined as a difference in ratings of global assessment of 3 points or more on a 0–10 scale . Up to half the patients with rheumatoid arthritis (RA) appear discordant with their physician in global assessment of disease, and in a recent study, 28.8% of early axial spondyloarthritis patients were discordant with their physician .…”

“…Most published analysis of patient‐physician discordance identified pain, physical function, and health‐related quality of life as potential predictive factors of discordance in RA . Psychological aspects, and to a lesser degree, fatigue, remain rarely reported in clinical trials and cohorts of PsA .…”

The Patient Global Assessment of Disease Activity in Rheumatoid Arthritis: Identification of Underlying Latent Factors

“…Recent work has revealed that 30% of patients with RA suffer from persistent undifferentiated symptoms of pain, fatigue, and functional disability despite seeming attainment of low inflammatory disease activity [9]. This discordance in assessments of disease activity between patients and their providers is a critical issue, so addressing factors that influence patients’ assessments of disease activity is necessary to narrow this gap and improve patient outcomes.…”