Osteoarthritis Disability Is Often Underestimated By Rheumatologists
Interview with Isabel Castrejón, MD, PhD
While patients with osteoarthritis (OA) have a greater disease burden compared with patients with rheumatoid arthritis (RA), they are more likely to have the impact of their condition—including pain—underestimated by rheumatologists, according to a study presented at the annual congress of the European League Against Rheumatism (EULAR 2016), which was recently held in London.1
“Discordance of assessments between patients and their physicians occurs when both assign different values to patients’ global health estimates,” said lead author Isabel Castrejón, MD, PhD, assistant professor in the division of Rheumatology at Rush University Medical Center in Chicago. “Our study shows that patients with OA are more likely to have their clinical status underestimated by rheumatologists than are patients with RA. In both diagnoses, pain was a significant predictor of discordance, which has been associated with poorer outcomes.”
The study included 243 patients with OA and 216 patients with RA who were seen in a routine rheumatology academic setting. Physician and patient evaluation of disease severity were both based on a 0-10 visual analog scale; patient assessment included completion of a multidimensional health assessment questionnaire/routine assessment of patient index data (MDHAQ/RAPID3), which includes scores for physical function, pain and fatigue, a symptom checklist, and a self-reported joint count in addition to other variables.
Disease Severity: Underestimated In 34% of Patients
“Patient perception of disease severity was greater than physician assessment [by two units or more] in 34% of 243 patients with OA and 18% of 216 patients with RA,” Dr. Castrejón said. The assessments of severity were equivalent in just over half of OA (56%) and two-thirds (67%) of RA patients. Physician evaluation of severity was greater than patient assessment (by two units or more) in 10% of OA and 15% of RA patients.
“In most of the studies published analyzing discordance in different rheumatic diseases including RA, patient assessments of global status were more strongly associated with pain, physical function, and psychological well- being—which were regarded as ‘subjective symptoms’ by most clinicians—while physicians’ assessments were more strongly associated with other clinical findings, mainly laboratory tests,” Dr. Castrejón said.2,3
“In our study, level of pain was the strongest predictor of discordance; however, other factors such as poor physical function, anxiety, depression, and poor sleep also may be important,” Dr. Castrejón added. “Although these symptoms may be regarded as ‘subjective’, they are important to patients and may affect future outcomes. For example, physical function is a strong predictor of mortality not only in RA but also in the general population.”
Assessing Pain in OA Patients
Today, there is increased emphasis on “‘patient-centered care’ that gives due importance to patients’ perception of health and considers their priorities and preferences in making therapeutic decisions,” Dr. Castrejón said. “This ‘patient-centered care’ could be implemented using patients’ questionnaires,” she said, adding that such tools may help to decrease the level of discordance and improve future outcomes.
“In this specific study we analyze MDHAQ, which is routinely completed by all patients regardless of the diagnosis at the Division of Rheumatology at Rush University Medical Center as part of the routine care. MDHAQ includes scores for physical function and pain on a visual analog scale in addition to other relevant variables,” Dr. Castrejón said.
Although this study was performed only with rheumatologists, “discordance may be present also between other doctors [primary care physicians and orthopedic surgeons] and their patients with OA,” Dr. Castrejón said. “Physicians and patients’ concordance is desirable in shared decisions not only for rheumatologists but also for other specialties because it has been associated with greater expectations for improvement and better outcomes.”
Dr. Castrejón added that comparison of patient and physician global estimates may be useful to identify discordance, facilitate patients’ involvement in treatment decision making, and provide guidance for clinical and healthcare decisions.