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PsA severity: When physicians’ assessment does not agree with patients’

Jairia Dela Cruz
29 Apr 2019

Physicians are likely to underestimate the severity of psoriatic arthritis (PsA) in patients who are older, show higher fatigue levels, complain of greater pain or have poorer mental health, according to a Singapore study. In contrast, overestimation of disease severity by physicians tends to occur in the presence of higher swollen joint counts.

“To our knowledge, this is the first study to identify factors associated with [patient-physician] discordance in an Asian [PsA] population [and] identify mental health as a factor associated with discordance,” the authors said.

Discordance between patients’ and physicians’ perception of disease severity has important clinical implications, as it hampers shared decision‐making, which may in turn affect long‐term outcomes, they added.

The study included 142 PsA patients (mean age, 51.1 years; 51.4 percent male; 66.2 percent Chinese) with a mean illness duration of 27.5 months who were recruited from a single centre in Singapore.

Patients evaluated their disease severity on a 100-mm visual analogue scale. Physicians, on the other hand, used an 11-point numeric rating scale (NRS) to assess patients’ disease severity.

Patient‐physician global assessment (PGA‐PhGA) discordance was computed by first standardizing PhGA in NRS to 0–100 and then PhGA was subtracted from PGA. A difference of 20 or more indicated that physicians were underestimating patients’ perceptions of disease activity (positive discordance), whereas a difference of –20 or less indicated overestimation (negative discordance).

Disease severity was underestimated by physicians in 17.6 percent of patients and overestimated in 20.4 percent of patients. Positive discordance was documented in patients with significantly higher scores for pain and fatigue severity, whereas negative discordance in patients with shorter duration of illness and significantly higher tender/swollen joint counts. [Int J Rheum Dis 2019;doi:10.1111/1756-185X.13568]

Furthermore, positive discordance was more likely to occur for non-Chinese patients and negative discordance in Chinese patients, although the differences were not statistically significant.

On multivariable analysis, age, fatigue level and pain score were positively associated with patient‐physician discordance, while swollen joint count and mental health were negatively associated.

“In this study, we revealed the importance of mental health in influencing discordance. Psychological factors such as mental health status and emotional well‐being play an important role in a patient's assessment of disease activity,” the authors said.

They explained that PsA patients have higher scores for anxiety and depression relative to healthy controls, with both conditions associated with pain and fatigue.

“[Mental health] could be an area that the physician underestimates. It is therefore an important area for physicians to focus on in the daily management of PsA,” they added.

Given that discordance between physicians’ and patients’ perception of disease severity may prevent remission achievement and reduce work productivity, identifying factors associated with discordance may provide pertinent information to facilitate shared decision‐making, optimize treatment outcomes, improve functional status and reduce healthcare costs, according to the authors.

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