Division of Rheumatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.
Department of Physical Medicine and Rehabilitation, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.
Arthritis Res Ther. 2017 Sep 26;19(1):212. doi: 10.1186/s13075-017-1419-5.
Discordance between patients with rheumatoid arthritis (RA) and their rheumatology health care providers is a common and important problem. The objective of this study was to perform a comprehensive clinical evaluation of patient-provider discordance in RA.
A cross-sectional observational study was conducted of consecutive RA patients in a regional practice with an absolute difference of ≥ 25 points between patient and provider global assessments (possible points, 0-100). Data were collected for disease activity measures, clinical characteristics, comorbidities, and medications. In a prospective substudy, participants completed patient-reported outcome measures and underwent ultrasonographic assessment of synovial inflammation. Differences between the discordant and concordant groups were tested using χ and rank sum tests. Multivariable logistic regression was used to develop a clinical model of discordance.
Patient-provider discordance affected 114 (32.5%) of 350 consecutive patients. Of the total population, 103 patients (29.5%) rated disease activity higher than their providers (i.e., 'positive' discordance); only 11 (3.1%) rated disease activity lower than their providers and were excluded from further analysis. Positive discordance correlated with negative rheumatoid factor and anticyclic citrullinated peptide antibodies, lack of joint erosions, presence of comorbid fibromyalgia or depression, and use of opioids, antidepressants, or anxiolytics, or fibromyalgia medications. In the prospective study, the group with positive discordance was distinguished by higher pain intensity, neuropathic type pain, chronic widespread pain and associated polysymptomatic distress, and limited functional health status. Depression was found to be an important mediator of positive discordance in low disease activity whereas the widespread pain index was an important mediator of positive discordance in moderate-to-high disease activity states. Ultrasonography scores did not reveal significant differences in synovial inflammation between discordant and concordant groups.
The findings provide a deeper understanding of patient-provider discordance than previously known. New insights from this study include the evidence that positive discordance is not associated with unrecognized joint inflammation by ultrasonography and that depression and fibromyalgia appear to play distinct roles in determining positive discordance. Further work is necessary to develop a comprehensive framework for patient-centered evaluation and management of RA and associated comorbidities in patients in the scenario of patient-provider discordance.
类风湿关节炎（RA）患者与风湿病医生之间的意见分歧是一个常见且重要的问题。本研究的目的是对 RA 患者与医生之间的意见分歧进行全面的临床评估。
对一家区域诊所中连续的 RA 患者进行横断面观察性研究，这些患者的患者与医生的总体评估存在≥25 分的绝对差异（可能的分数为 0-100 分）。收集疾病活动度指标、临床特征、合并症和药物的数据。在一项前瞻性亚研究中，参与者完成了患者报告的结局测量，并接受了滑膜炎的超声评估。使用 χ 检验和秩和检验比较了不一致和一致组之间的差异。使用多变量逻辑回归建立意见分歧的临床模型。
114 例（32.5%）350 例连续患者存在患者与医生之间的意见分歧。在总人群中，有 103 例（29.5%）患者对疾病活动度的评估高于其医生（即“阳性”意见分歧）；仅有 11 例（3.1%）患者对疾病活动度的评估低于其医生，且被排除在进一步分析之外。阳性意见分歧与阴性类风湿因子和抗环瓜氨酸肽抗体、无关节侵蚀、合并纤维肌痛或抑郁、使用阿片类药物、抗抑郁药或抗焦虑药或纤维肌痛药物有关。在前瞻性研究中，阳性意见分歧组的疼痛强度较高、神经病理性疼痛、慢性广泛疼痛和相关的多症状困扰、以及有限的功能健康状况有区别。在疾病活动度较低的情况下，抑郁被认为是阳性意见分歧的重要中介因素，而在疾病活动度中度至高度的情况下，广泛疼痛指数是阳性意见分歧的重要中介因素。超声评分未显示意见不一致和一致组之间滑膜炎的显著差异。
本研究提供了比以往研究更深入的对患者与医生之间意见分歧的理解。本研究的新发现包括以下证据：阳性意见分歧与超声检查未发现的关节炎症不相关，抑郁和纤维肌痛似乎在确定阳性意见分歧方面发挥了不同的作用。需要进一步的工作来制定一个全面的框架，用于在患者与医生意见分歧的情况下对 RA 及其相关合并症进行以患者为中心的评估和管理。
