Abstract: Determinants of Discordance Between Patients and Physicians in Their Assessment of Lupus Disease Activity

Determinants of Discordance Between Patients and Physicians in Their Assessment of Lupus Disease Activity

JIM C. YEN, MICHAL ABRAHAMOWICZ, PATRICIA L. DOBKIN, ANN E. CLARKE, RENALDO N. BATTISTA, and PAUL R. FORTIN

ABSTRACT.

Objective. We evaluated different methods for quantifying patient-physician discordance and identified factors associated with discordance in the assessment of lupus disease activity.

Methods. Data from 208 female patients who had a comprehensive annual examination were extracted from the Montreal General Hospital Lupus Registry. Discordance was measured by the difference between the patient self-reported 10 cm visual analog scale (VAS) and the physician VAS for global disease activity (VASDIFF). Multiple linear regression was used to identify the correlates of discordance, e.g., SF-36^TM scales, Systemic Lupus Activity Measure (SLAM) components, etc. Four regression models were estimated using: (1) all patients; (2) only patients who evaluated disease activity higher than their physician's assessment; (3) only patients who evaluated disease activity lower than their physician's assessment; and (4) all patients, with the absolute value of VASDIFF as the dependent variable.

Results. Of the 208 observations, 150 (72%) of the VASDIFF scores were within ± 2.5 cm on a 10 cm scale, indicating absence of marked discordance; 43 (20.7%) were from patients overscoring and 15 (7.2%) from patients underscoring their physician by at least 2.5 cm. Higher SF-36 role physical score, more bodily pain, and lower role emotional score in addition to the SLAM-skin component were independently associated with higher discordance. SF-36 social function and mental health scores as well as SLAM-neurological and kidney components were correlated with discordance in some subanalyses. Bodily pain was the most important variable for predicting "clinically relevant" discordance, followed by SLAM-skin and kidney components.

Conclusion. Discordance between patients and physicians may result from patients scoring their disease activity based on their psychological and physical well-being, whereas physicians score disease activity based on the clinical and physical signs and symptoms of lupus. (J Rheumatol 2003;30:1967-76)

Key Indexing Terms:

PATIENT-PHYSICIAN RELATIONSHIP
DISCORDANCE
LUPUS
DISEASE ACTIVITY

From the Division of Clinical Epidemiology, The McGill University Health Centre; Department of Epidemiology and Biostatistics, McGill University; Faculty of Medicine, McGill University; Division of Clinical Immunology and Allergy, The McGill University Health Centre; Agence d'Évaluation des Technologies et des Modes d'Intervention en Santé (AÉTMIS), Montreal, Quebec; and Division of Rheumatology, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.

Dr. Abrahamowicz is a James McGill Professor and a Scientist of the Canadian Institutes of Health Research (CIHR). Dr. Dobkin is a Senior Scientist of the Fonds de la Recherche en Santé de Québec. Dr. Clarke is a Canadian Institutes of Health Research (CIHR) Investigator. Dr. Fortin is a Senior Research Scholar of The Arthritis Society and Director of Clinical Research, Arthritis Centre of Excellence, University Health Network.

J.C. Yen, BScPhm, PhD, Division of Clinical Epidemiology, The McGill University Health Centre; M. Abrahamowicz, PhD, Division of Clinical Epidemiology, The McGill University Health Centre, Department of Epidemiology and Biostatistics, McGill University; P.L. Dobkin, PhD, Division of Clinical Epidemiology, The McGill University Health Centre, Faculty of Medicine, McGill University; A.E. Clarke, MD, MSc, Division of Clinical Epidemiology, Division of Clinical Immunology and Allergy, The McGill University Health Centre; R.N. Battista, MD, ScD, Department of Epidemiology and Biostatistics, McGill University, Agence d'Évaluation des Technologies et des Modes d'Intervention en Santé; P.R. Fortin, MD, MPH, Division of Rheumatology, Toronto Western Hospital, University Health Network.

Address reprint requests to Dr. P. Fortin, Division of Rheumatology, Room MP-10-304 Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada.

Submitted June 25, 2002; revision accepted February 24, 2003.