The Journal of Musculoskeletal Medicine.

New Insights Into Why RA Patients and Their

Doctors Disagree
November 29, 2012
Rheumatologists and their patients with rheumatoid arthritis (RA) clearly perceive disease status
differently. Adding to a vigorous effort to define the discrepancy, new studies reported at the American
College of Rheumatology (ACR) meeting last month refined the insights from studies reported earlier
this year.
Studies reported and have both pointed to in Arthritis Care and Research in Arthritis and Rheumatism
differences in assessing pain as a chief factor in the discrepancy. In the former report, a team headed by
University of Arkansas rheumatologists added differences in perception of fatigue to the sources of
disagreement; the latter, from a team at the Medical University of Vienna, found discrepancies as to
swollen joint count (SJC).
Two further studies presented at the ACR have supplemented this information. A multicenter
US-Canada team studied information from the prospective Canadian Early Arthritis Cohort (CATCH) to
address whether the degree of discordance changes over time. The analysis involved 48 patients who
were biologic-nave at baseline, at which time they initiated DMARDs and were followed for at least a
year.
During that year, the discrepancy between patient and rheumatologist assessments decreased from 35%
to 27%. After a year, when the disease is significantly better controlled, however, pain and swollen joint
count continue to figure significantly in disagreements between doctors and their patients about disease
status. ( ) Abstract #2109
Using a different Canadian registry that follows RA patients who have begun first-line treatment with
or golimumab, a team from McMaster University and the infliximab(Drug information on infliximab)
Universities of Montreal and Victoria compared physician and self-assessments of 841 patients to
identify four significant factors that accounted for discrepancies. These included pain and swollen joint
count, as in other studies, but also morning stiffness and the health quality of life measure HAQ-DI. (
) Abstract #2108
These insights may help to develop better tools to assess disease quality, but a third study reported at
ACR may have more immediate value, helping to define those for whom standard treatment protocols
should be reconsidered. Archana Jain of the University of Alabama at Birmingham and her team
hypothesized that comorbidities such as diabetes and congestive heart failure have an important impact
The Journal of Musculoskeletal Medicine. Vol. No. November 29, 2012
http://www.musculoskeletalnetwork.com/rheumatoid-arthritis/content/article/1145622/2120451
1
on these differences in perception. At the ACR meeting they presented results of their analysis of this
question using data from the Veterans Affairs Rheumatoid Arthritis registry, involved 1305 patients
(90% of them men) linked to a decision support system. ( ) Abstract #2106
Comparing physician and patient assessments of disease status, they found no overall association of
comorbidities with discordance in assessments. However, the ratio between swollen joint count (SJC)
and tender joint count (TJC) was useful as a predictor. An SJC/TJC ratio less than 0.4 appeared to
identify patients most likely to switch biologicals, and therefore might help to identify those for whom
traditional treat-to-target strategy cutpoints may not be appropriate, they suggest.

The Journal of Musculoskeletal Medicine. Vol. No. November 29, 2012

http://www.musculoskeletalnetwork.com/rheumatoid-arthritis/content/article/1145622/2120451
2