Patients and Physicians Disagree on Disease Activity in Three Quarters of Cases
According to the authors, Paul Studenic and Daniel Aletaha, MD, both of the Department of Internal Medicine and the Medical University of Vienna in Austria, patients typically use the patient global assessment (PGA) to rate their disease activity, whereas physicians use the evaluator global assessment (EGA). What this means is that patients and physicians differed in their ratings of rheumatoid arthritis disease activity in 76% of the cases, which would have major ramifications in terms of increasing, decreasing, or otherwise changing treatment for rheumatoid arthritis. This disconnect between patients’ rating of their disease activity and physicians can have a serious effect on the relationship between doctor and patient, leading to problems with trust, respect, and adherence to treatment.
Inflammation and Pain Cause Patient-Physician Discord
The patients whose data was used in this study were assessed at an initial baseline visit, at which point methotrexate treatment was initiated, followed by a second assessment two to seven months later. In 61% of patients the PGA score was higher than EGA, and 15% had higher EGA than PGA. Around a quarter (24%) had similar PGA and EGA scores, indicating a concordance between physician and patient assessment of the activity of rheumatoid arthritis in these cases. Swollen joint count (SJC) was the only variable found to to have an inverse correlation with the theory proposed that more joint swelling indicated higher disease activity to physicians, In contrast, all other variables had a positive correlation, suggesting that patients’ pain perceptions were worse than physicians’.
Opinions Divide as RA Pain Worsens
After starting methotrexate treatment 41% of patients and 46% of their physicians considered disease activity to have improved, 37% of patients and 27% found no change in disease activity, and 21% of patients and 28% of physicians thought that the patients’ rheumatoid arthritis had worsened since baseline. Patients and physicians were more likely to agree that disease activity had improved whereas those felt to have worsened had less concordance between patient and physician opinion.
Patient-Doctor Relationship Vital in RA Management
This research suggests that physicians need to have a better awareness of moments in the patient-doctor relationship where the shared decision-making process could break down. In the case of rheumatoid arthritis this appears to be most likely when patients feel their pain has worsened but the physician evaluates joint swelling as having lowered or remained the same as baseline. Patients may feel that therapy needs to change or medications need to be increased, creating a challenge for physicians to appear both authoritative and sympathetic. Conversely, patients may feel that low pain in rheumatoid arthritis means that treatment is working and there is no need to change medications whereas the physician may evaluate joint swelling as having increased and need to carefully explain why it is likely beneficial to modify treatment.
Pain Management in RA
A key indication from this research is that more attention needs to be paid to pain management in rheumatoid arthritis treatment as it appears that physicians are too focused on inflammation and not enough on patients’ reports of pain. For patients with rheumatoid arthritis symptoms such as neck pain, joint pain, fatigue, and joint stiffness it is important to establish a trusting relationship with your physician so that suggestions for treatment changes are made with respect to the values of both parties. The findings of this latest study shows that patients rate rheumatoid arthritis disease activity worse than physicians on the basis of pain, meaning that some serious work needs doing to re-engender trust when treating RA.
Studenic, P., Radner, H., Smolen, J.S., Aletaha, D., (2012), Discrepancies between patients and physicians in the perception of rheumatoid arthritis disease activity, Arthritis Rheum. Published online July 18, 2012.