Risk factors of symptom underestimation by physicians

Health Related Quality of Life and Cardiovascular Risk Factors

Cardiovascular diseases (CVD) is associated with deteriorating of quality of life (QOL) and exercise capacity (EC) but less is known on how EC interplays with QOL. The present study explores the relationship between quality of life and cardiovascular risk factors in people who present in cardiology clinics. A total of 153 adult presentations completed the SF-36 Health Survey and provided data for hypertension, diabetes mellitus, smoking, obesity, hyperlipidemia and history of coronary heart disease. Physical capacity was assessed by treadmill test. were correlated with the scores of the psychometric questionnaires. Participants with longer duration on treadmill exercise score higher on the scale of physical functioning. The study found that treadmill exercise intensity and duration were associated with improved scores in dimensions of the physical component summary and the physical functioning of SF-36, respectively. The presence of cardiovascular risk factors is related to a decreased quality of life. Patients with cardiovascular diseases should undergo particularly detailed analysis of the quality of life along with specific mental factors such as depersonalization and posttraumatic stress disorder.

Depressive symptoms are associated with fatigue, poorer functional status and less engagement in sports in axSpA and PsA: an analysis from the RABBIT-SpA cohort

BACKGROUND

In patients with axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA), concomitant depression might have a negative impact on the course of disease and treatment outcomes. The aims of this analysis are to determine the prevalence of depressive symptoms in axSpA and PsA patients in a real-world cohort study and to identify sociodemographic and clinical associated factors for moderate or severe depressive symptoms in both diseases.

METHODS

Patients from the RABBIT-SpA cohort with an axSpA or PsA diagnosis and a valid WHO-5 Well-Being Index score at baseline were included. A descriptive analysis of baseline and outcome parameters by category of depressive symptoms was performed and factors associated with the presence of depressive symptoms (moderate or severe) were examined in a logistic regression.

RESULTS

Two thousand four hundred seventy patients (1,245 axSpA; 1,225 PsA) were included in the analysis. In both diagnoses, the proportion of patients with moderate depressive symptoms was 8% and 21% with severe symptoms. Patients with moderate or severe depressive symptoms were less likely to engage in sports than those with no or mild depressive symptoms, had more comorbidities and higher scores for disease activity, functional limitations, fatigue, and pain and took more analgesics. In axSpA, patients with a higher disease activity, a greater functional impairment and more severe fatigue were more likely to experience depressive symptoms, while patients with more years in education and engaging in sports for at least 1 h/week were less likely to experience depressive symptoms. PsA patients with a greater functional impairment and more severe fatigue were more likely to experience depressive symptoms while those engaging in sports for at least 1 h/week were less likely to experience depressive symptoms.

CONCLUSION

We confirmed a high prevalence of depressive symptoms in both PsA and axSpA. Factors negatively associated with the presence of depressive symptoms were fatigue, not engaging in sports, and greater functional limitations. Depressive symptoms may affect the perception of disease activity / severity by patients. Thus, depressive symptoms are an important condition in axSpA and PsA that should be considered when evaluating disease activity and treatment outcomes.

Association of Patient Mental Health Status With the Level of Agreement Between Patient and Physician Ratings of Psoriasis Severity

Importance

The emerging paradigm of treat-to-target in psoriasis requires accurate monitoring of treatment response. The commonly used physician global assessment tool does not capture the patient's perception of their disease. Patient assessments facilitate shared decision-making and foster patient-centered care; however, recent research reports a discordance between patient- and physician-reported psoriasis severity. Understanding the factors underlying this discordance may improve treatment satisfaction and disease outcomes.

Objectives

To evaluate the discordance between patient- and physician-reported measures of psoriasis severity and assess the association with patient mental health status.

Design, Setting, and Participants

A cohort study using repeated cross-sectional analysis of real-world longitudinal data was conducted at a large specialist psoriasis service serving London and Southeast England. A total of 502 patients attending the psoriasis service between May 12, 2016, and November 1, 2018, were included. Data analysis was conducted July 22 to October 22, 2019.

Main Outcomes and Measures

Psoriasis severity was assessed on each visit with identical 5-point physician and patient global assessment scales (clear/nearly clear, mild, moderate, severe, and very severe). Each patient completed validated self-report screens for depression and anxiety on each visit.

Results

Longitudinal data from 502 individuals with psoriasis (1985 total observations) were available. A total of 339 patients (68%) were men, 396 (79%) were White, mean (SD) age was 47 (13) years, and 197 patients (39%) had concurrent psoriatic arthritis, 43 (9%) screened positive for depression, and 49 (10%) screened positive for anxiety. There was discordance between physician and patient measures of disease severity in 768 of 1985 office appointments (39%); on 511 visits (26%) patients rated their psoriasis as less severe and on 257 visits (13%) patients rated their psoriasis as more severe compared with their physician. Individuals who screened positive for depression or anxiety were more likely to overestimate their psoriasis severity compared with their physician (relative risk ratio: depression, 2.7; 95% CI, 1.6-4.5; anxiety, 2.1; 95% CI, 1.3-3.4). These findings remained statistically significant after adjustment for age, ethnicity, sex, body mass index, smoking, number of comorbidities, treatment modality, and presence of psoriatic arthritis.

Conclusions and Relevance

The findings of this cohort study suggest that discordance between patient and physician assessments of psoriasis severity is associated with patients' mental health status. Recognition of anxiety and depression in individuals with psoriasis appears to be important when interpreting patient-reported outcome measures and informing appropriate treatment decisions.

Validity of the patient health questionnaire-2 (PHQ-2) for the detection of depression in primary care in Colombia

BACKGROUND

The PHQ-2 is a screening test for major depressive disorder (MDD) derived from PHQ-9, which has shown to be useful in the detection of cases of clinical significance in previous studies. The psychometric properties of PHQ-2 in the Colombian population are unknown.

METHODS

PHQ-2 were assessed in 243 patients in general medical consultations using the Mini-International Neuropsychiatric Interview (MINI) as the gold standard. Internal consistency, convergent validity and criterion validity were calculated by analyzing the Receptor Operating Characteristics (ROC) and the area under the curve (AUC).

RESULTS

Cronbach's alpha and McDonald's omega coefficients were 0.71. Spearman's rho coefficients for correlations with PHQ-9 and HADS-D scores were 0.63 and 0.59 (p<0.01). AUC was 0.89. The optimal cut point was ≥2 with the following indicators: sensitivity 0.87 specificity 0.74; Youden index 0.60; PPV 0.47; NPV 0.95; (LR+) 3.24; (LR-) 0.18 (95% CI 0.09-0.37). Kappa coefficient between PHQ-2 and MINI for depression was .458 and 0.46 for HADS-D.

LIMITATIONS

Since this study was done with people attending hospital, which could has implications for the prevalence of depression, affecting the validity indicators of the instrument.

CONCLUSIONS

PHQ-2 show an acceptable test performance in the context of the study. However, the test could yield a considerable amount of false positives that would require specialized evaluation to establish a reliable diagnosis.

Discordant patient-physician assessments of disease activity and its persistence adversely impact quality of life and work productivity in US Hispanics with rheumatoid arthritis

Objective

This study was designed to evaluate the determinants of patient and physician global assessments (PtGA and MDGA, respectively) of disease activity, their discordance and change over 2 years in Hispanics with rheumatoid arthritis (RA). We further examined the impact of discordance and its persistence on health-related quality of life (HRQOL) and work productivity on final visit.

Methods

We studied 536 Hispanics with established RA from a single centre. PtGA and MDGA were measured annually on 10 cm visual analogue scales and discordance was defined as absolute difference between them ≥3 cm. Associations between predictors and outcomes of interest were evaluated using multivariable regression and analysis of covariance for cross-sectional and longitudinal data, respectively.

Results

Independent predictors of baseline PtGA were pain, fatigue, depression, general health perceptions and tender joint count. MDGA was predicted by swollen joint count, tender joint count, erythrocyte sedimentation rate, fatigue and depression. Both PtGA and MDGA improved over time (all p<0.001). Discordance was observed in 43% at baseline, with fair stability over 2 years. Higher (worse) patient ratings were most prevalent; their presence at any time and increasing persistence predicted lower physical and mental HRQOL, decreased work productivity and more activity impairment at 2-year follow-up (all p<0.001).

Conclusions

Determinants of PtGA, MDGA and changes over 2 years were disparate in Hispanics with RA yielding significant discordance. Higher patient ratings at any time contributed to worse HRQOL, work productivity and activity impairment on final visit.

Irish General Practitioner referrals to psychological therapies

OBJECTIVE

General Medical Practitioners play a crucial role in the detection and referral of mental health problems in primary care. This study describes the referral patterns of Irish General Practitioners (GPs) to psychological therapies and profiles the range of psychological therapies available.

METHOD

A 21-item study-specific questionnaire exploring referral processes to psychological therapies was sent to all GPs listed by the Irish College of General Practitioners in one county in Ireland. A 19-item questionnaire exploring details of psychological therapies offered and referral pathways was sent to members of psychological therapy accrediting bodies in the same county.

RESULTS

Of 97 GP respondents (33% response rate), their estimation of the percentage of their patients who have presenting or underlying mental health issues averaged 22%. When asked to indicate which psychological therapies they consider for referrals, psychiatric referrals was the most frequent referral option (94%), followed by Counsellors (69%), Clinical psychologist (60%) and Psychotherapists (30%). GPs indicated they had some or very little knowledge of specific psychological therapies. Of 129 psychological therapists (45% response rate), self-referral and GP referral were their main referral pathways; 80% worked in private practice; highest qualification level was Undergraduate/Higher Diploma (66%), Master Level (39%) and Doctoral Level (5%).

CONCLUSION

GPs refer patients presenting with mental health problems to psychiatrists with significantly lower percentages referring to other types of psychological therapists. Findings demonstrate that there is a need for greater education and information-sharing between GPs and providers of accredited psychological therapies to increase knowledge on specific therapies and their evidence base.

Case finding and screening clinical utility of the Patient Health Questionnaire (PHQ-9 and PHQ-2) for depression in primary care: a diagnostic meta-analysis of 40 studies

BACKGROUND

The Patient Health Questionnaire (PHQ) is the most commonly used measure to screen for depression in primary care but there is still lack of clarity about its accuracy and optimal scoring method.

AIMS

To determine via meta-analysis the diagnostic accuracy of the PHQ-9-linear, PHQ-9-algorithm and PHQ-2 questions to detect major depressive disorder (MDD) among adults.

METHOD

We systematically searched major electronic databases from inception until June 2015. Articles were included that reported the accuracy of PHQ-9 or PHQ-2 questions for diagnosing MDD in primary care defined according to standard classification systems. We carried out a meta-analysis, meta-regression, moderator and sensitivity analysis.

RESULTS

Overall, 26 publications reporting on 40 individual studies were included representing 26 902 people (median 502, s.d.=693.7) including 14 760 unique adults of whom 14.3% had MDD. The methodological quality of the included articles was acceptable. The meta-analytic area under the receiver operating characteristic curve of the PHQ-9-linear and the PHQ-2 was significantly higher than the PHQ-9-algorithm, a difference that was maintained in head-to-head meta-analysis of studies. Our best estimates of sensitivity and specificity were 81.3% (95% CI 71.6-89.3) and 85.3% (95% CI 81.0-89.1), 56.8% (95% CI 41.2-71.8) and 93.3% (95% CI 87.5-97.3) and 89.3% (95% CI 81.5-95.1) and 75.9% (95% CI 70.1-81.3) for the PHQ-9-linear, PHQ-9-algorithm and PHQ-2 respectively. For case finding (ruling in a diagnosis), none of the methods were suitable but for screening (ruling out non-cases), all methods were encouraging with good clinical utility, although the cut-off threshold must be carefully chosen.

CONCLUSIONS

The PHQ can be used as an initial first step assessment in primary care and the PHQ-2 is adequate for this purpose with good acceptability. However, neither the PHQ-2 nor the PHQ-9 can be used to confirm a clinical diagnosis (case finding).

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

A geriatric assessment in general practice: prevalence, location, impact and doctor-patient perceptions of pain

BACKGROUND

To investigate what a geriatric assessment in general practice adds towards previous findings of prevalence, location, impact and the dyadic doctor-patient perception of pain in this age group.

METHODS

Cross-sectional study. Consecutive patients aged 70 and over underwent a comprehensive geriatric assessment in general practice that included a basic pain assessment (severity, sites and impact). Patients with pain and their doctors then independently rated its importance. Pain was correlated with further findings from the assessment, such as overall health, physical impairments, everyday function, falls, mood, health related lifestyle, social circumstances, using bivariate and multivariate statistics. Patient-doctor agreement on the importance of pain was calculated using kappa statistics.

RESULTS

219 out of 297 patients (73.7 %) reported pain at any location. Pain was generally located at multiple sites. It was most often present at the knee (33.9%), the lumbar spine (33.5%) as well as the hip (13.8%) and correlated with specific impairments such as restrictions of daily living (knee) or sleep problems (spine). Patients with pain and their physicians poorly agreed on the importance of the pain problem.

CONCLUSIONS

A basic pain assessment can identify older patients with pain in general practice. It has resulted in a high prevalence exceeding that determined by encounters in consultations. It has been shown that a geriatric assessment provides an opportunity to address pain in a way that is adapted to older patients' needs - addressing all sites, its specific impact on life, and the patients' perceived importance of pain. Since there is little doctor-patient agreement, this seems a valuable strategy to optimize concrete treatment decisions and patient centered care.

TRIAL REGISTRATION

This study is registered in the German Clinical Trial Register ( DRKS00000792 ).

Patient-physician discordance in global assessment in early spondyloarthritis and its change over time: the DESIR cohort

Objective

To assess patient-physician discordance in global assessment of disease activity in early axial spondyloarthritis (axSpA) over time and determinants of discordance.

Methods

DESIR (Devenir des Spondyloarthropathies Indifférenciées Récentes) is a French, multicentre, longitudinal cohort of patients with early inflammatory back pain suggestive of axSpA. Patient global assessment (PGA) and physician global assessment (PhGA) were rated with a 0–10 numerical rating scale, every 6 months during 2 years then at 3 years. Discordance was defined by the absolute difference |PGA–PhGA|≥3 (range 0–10) and was analysed at each visit. Determinants of (PGA−PhGA) were assessed at the visit level by a generalised linear mixed model.

Results

A total of 702 patients were analysed at baseline (401 with complete data over 3 years): mean age 33.8±8.6 years, 379 (54.0%) female, mean symptom duration 18.1±10.5 months. Mean PGA values were always higher than mean PhGA values with a mean absolute difference of 1.8 points. At baseline, 202 (28.8%) patients had discordance mainly by PGA>PhGA; over 3 years the frequency of discordance was stable (range 25.5–28.8%). Discordance was not stable at the patient level, 118 (29.4%) patients were discordant once and 88 (22.0%) twice, and only 92 (22.9%) more than twice. Determinants of (PGA−PhGA) were spine pain (β=0.24, p<0.001) and fatigue (β=0.13, p<0.001).

Conclusions

Discordance concerned a quarter of patients with early axSpA. Over 3 years of follow-up, discordance did not decrease (no ‘reference shift’). Discordance was not a stable trait, indicating discordance is not a patient characteristic.

Real-world disparities between patient- and clinician-reported outcomes: results from a disease-specific program in depression and anxiety

PURPOSE

The purpose of this study was to identify potential discordance between physician and patient rated measures of depression used by primary care physicians and psychiatrists.

PRIMARY PRACTICE SETTING

This study collected data from primary care physicians and psychiatrists in the United States between October and December 2009.

METHODOLOGY AND SAMPLE

A real-world, cross-sectional study was conducted using the Neuroses Disease-Specific Programme (Adelphi Real World, Macclesfield, United Kingdom). Treatment practice data were collected by 180 physicians (100 primary care and 80 psychiatrists) who were asked to provide information for the next 15 outpatients presenting prospectively with symptoms of anxiety and/or depression (n = 2,704 patients). The primary outcome measures were the Clinical Global Impressions-and Patient Global Impressions-Improvement scales, completed by both physicians and their matched patients, respectively. Cohen's kappa coefficient (κ) was calculated to assess the level of agreement between the Clinical Global Impressions-and Patient Global Impressions-Improvement scale responses.

RESULTS

Physician- and patient-rated overall improvement in illness was 82% and 89%, respectively. Results of the kappa analysis demonstrated fair agreement between patients and physicians regarding overall improvement in illness (44% agreement; κ= 0.23). Physician ratings of patient improvement progressively decreased with increased severity of illness.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

These real-world data suggest that the degree of reduction in symptoms of anxiety and/or depression may be estimated differently by physicians when compared with their patients. Understanding the potential for disparities between physician- and patient-rated measures in reviewing patient care, particularly in patients with more severe depressive symptoms, can help ensure that treatment plans are aligned with patient needs.

Mitigating the risk of opioid abuse through a balanced undergraduate pain medicine curriculum

Chronic pain is highly prevalent in the United States and Canada, occurring in an estimated 30% of the adult population. Despite its high prevalence, US and Canadian medical schools provide very little training in pain management, including training in the safe and effective use of potent analgesics, most notably opioids. In 2005, the International Association for the Study of Pain published recommendations for a core undergraduate pain management curriculum, and several universities have implemented pilot programs based on this curriculum. However, when outcomes have been formally assessed, these initiatives have resulted in only modest improvements in physician knowledge about chronic pain and its treatment. This article discusses strategies to improve undergraduate pain management curricula and proposes areas in which those efforts can be augmented. Emphasis is placed on opioids, which have great potency as analgesics but also substantial risks in terms of adverse events and the risk of abuse and addiction. The authors conclude that the most important element of an undergraduate pain curriculum is clinical experience under mentors who are capable of reinforcing didactic learning by modeling best practices.

Predictors of discordance between physicians' and patients' appraisals of health-related quality of life in atrial fibrillation patients: findings from the Angiotensin II Antagonist in Paroxysmal Atrial Fibrillation Trial

BACKGROUND

Assessing health status is fundamental when weighing treatment options for atrial fibrillation (AF) patients. Most health-related quality-of-life (HRQoL) data stem from self-ratings, whereas treatment decisions are based upon physicians' estimations.

METHODS

The degree of congruence between patients' and physicians' assessments of the patients' subjective health status was used as an indicator of good communication and shared understanding. A total of 334 patients with paroxysmal AF without significant concomitant heart diseases and their physicians were asked in a prospective blinded study to rate the patients' HRQoL. The Short Form-12 was used for self-ratings; the Short Form-8, for physician ratings. Using baseline data, intraclass correlations and Bland-Altman graphs were used to assess concordance; cross-sectional multivariate regression analyses assessed patient characteristics associated with discordance.

RESULTS

On average, physicians rated their patients' HRQoL higher than patients did (∆mental component score [MCS] = -3.23, P < .0001, and ∆physical component score [PCS] = -2.21, P = .0001). Intraclass correlations and Bland-Altman graphs showed unsatisfactory concordance. Physical inactivity (∆ = 4.84) had the greatest bivariate effect on PCS discordance, and major depressive disorder (∆ = 7.01), on MCS discordance. In the regression analyses, depression was significantly associated with discord in the MCS (β = -0.94, P < .001) and the PCS (β = -0.37, P < .002). Sleeping disorder was associated with discord in the MCS (β = -4.13, P < .002), and physical inactivity, with discord in the PCS (β = -1.47, P = .006).

CONCLUSIONS

In patients with AF, even in the absence of significant concomitant cardiac diseases, depression, followed by sleeping disorder and physical inactivity, was significantly associated with discordance. These findings should be considered by physicians when choosing treatment strategies.

[Treatment of mental and psychosomatic complaints - how the general population in Germany gets treatment, and what it expects and knows about treatment alternatives]

OBJECTIVES

The healthcare sector provides a wide range of services with various treatment approaches for mental or psychosomatic complaints. The present study assesses treatment preferences and knowledge within the general population in Germany.

METHODS

In 2011, a total of n = 2555 individuals aged 14-97 years were interviewed as part of a representative population survey. Using a structured interview, we examined the retrospective, current, and prospective utilization of outpatient psychotherapy, treatment preferences, and knowledge of the alternatives.

RESULTS

Outpatient psychotherapy was currently or in the past used by 7.1 % of respondents, inpatient psychotherapy by 3.2 %. Medical psychotherapists were consulted by 12.5 %, psychological psychotherapists by 8.8 %o f the respondents. Future treatment expectations were directed more frequently towards medical than psychological psychotherapists. The primary care physician continues to play a pivotal role in the treatment of mental/psychosomatic disorders. Treatment expectations were largely independent of the type of disorder. Women were nearly twice as likely as men to utilize or have utilized outpatient psychotherapy (9.1 % vs. 4.8 %).

DISCUSSION

The existing outpatient care for patients with mental or psychosomatic complaints is well accepted among large parts of the population. For mental or psychosomatic problems, the majority of respondents prefer a medical psychotherapist. Further research needs to clarify which factors determine this preference.

Patient-physician concordance and discordance in gynecology: do physicians identify patients' reasons for visit and do patients understand physicians' actions?

OBJECTIVE

To assess physician-patient concordance on reasons for consultation and actions taken during consultation in five different gynecological practices, and to investigate patient and physician factors influencing discordance in reporting.

METHODS

1667 post-encounter questionnaires completed by patients and physicians were compared in terms of reasons for consultation and actions taken during consultation. Patient-physician concordance was assessed using kappa statistics. Multivariable regression analyses served to identify determinants of discordance.

RESULTS

A moderate to high level of patient-physician concordance on reasons for consultation and actions taken during the consultation was found. Discordance regarding reasons for consultation was associated with patient and practice characteristics, discordance regarding actions taken during the consultation only with practice characteristics. Counseling emerged as a particular source of patient-physician discordance.

CONCLUSION

In gynecological practices, discordance depends on the reason or action assessed, but is particularly pronounced when it comes to counseling. The influence of physician characteristics on patient-physician concordance needs more attention in research.

PRACTICE IMPLICATIONS

Gynecologists need to establish a mutual understanding with their patients about the reason of the consultation and the actions taken in the consultation, in particular with regard to counseling.

Comparison of expectations of physicians and patients with rheumatoid arthritis for rheumatology clinic visits: a pilot, multicenter, international study

AIM

To describe and compare expectations of patients with rheumatoid arthritis (RA) and their physicians with regard to what is most important to achieve during a rheumatology clinic visit.

METHODS

Subjects were RA patients enrolled in four centers from China, one from Japan and one from the USA, and rheumatologists at those centers. The questionnaires were provided at clinics and patients were asked to list their three top priorities for the rheumatology clinic visit. Physicians were contacted separately and asked to give three general expectations, not for specific visits. We classified clinical expectations into a series of 24 terms for patients and 17 for physicians. We compared physicians' to patients' responses, compared expectations among centers in China, Japan and the USA, and evaluated relationships between patients' responses and age, gender, nationality, disease duration and DAS-28 (Disease Activity Score-28).

RESULTS

Patients' clinical expectations for visits focused primarily on control of pain (63.7%), improvement of function (49.3%) and discussion of effects of medication (38.1%). Physicians also included control of pain (59.5%), but also emphasized inquiry about drug side-effects (47.8%) and objective assessment of disease activity (41.4%). We found no differences related to patients' gender, disease duration and DAS-28, but there were some differences related to age and nationality.

CONCLUSION

We found some agreement and some discordance of clinical expectations between RA patients and physicians. There appear to be some different expectations in different countries. Findings from this pilot survey may help physicians consider patients' expectations in planning rheumatology clinic visits and may lead to further hypothesis-driven studies.

Agreement between self-report and medical records on signs and symptoms of respiratory illness

BACKGROUND

Information on patient symptoms can be obtained by patient self-report or medical records review. Both methods have limitations.

AIMS

To assess the agreement between self-report and documentation in the medical records of signs/symptoms of respiratory illness (fever, cough, runny nose, sore throat, headache, sinus problems, muscle aches, fatigue, earache, and chills).

METHODS

Respondents were 176 research participants in the Hutterite Influenza Prevention Study during the 2008-2009 influenza season with information about the presence or absence of signs/symptoms from both self-report and primary care medical records.

RESULTS

Compared with medical records, lower proportions of self-reported fever, sore throat, earache, cough, and sinus problems were found. Total agreements between self-report and medical report of symptoms ranged from 61% (for sore throat) to 88% (for muscle aches and earache), with kappa estimates varying from 0.05 (for chills) to 0.41 (for cough) and 0.51 (for earache). Negative agreement was considerably higher (from 68% for sore throat to 93% for muscle aches and earache) than positive agreement (from 13% for chills to 58% for earache) for each symptom except cough where positive agreement (77%) was higher than negative agreement (64%). Agreements varied by age group. We found better agreement for earache (kappa = 0.62) and lower agreements for headache, sinus problems, muscle aches, fatigue, and chills in older children (aged >5 years) and adults.

CONCLUSIONS

Agreements were variable depending on the specific symptom. Contrary to research in other patient populations which suggests that clinicians report fewer symptoms than patients, we found that the medical record captured more symptoms than selfreport. Symptom agreement and disagreement may be affected by the perspectives of the person experiencing them, the observer, the symptoms themselves, measurement error, the setting in which the symptoms were observed and recorded, and the broader community and cultural context of patients.

Determinants of discordance in patients' and physicians' rating of rheumatoid arthritis disease activity

OBJECTIVE

To assess the determinants of patients' (PTGL) and physicians' (MDGL) global assessment of rheumatoid arthritis (RA) activity and factors associated with discordance among them.

METHODS

A total of 7,028 patients in the Quantitative Standard Monitoring of Patients with RA study had PTGL and MDGL assessed at the same clinic visit on a 0-10-cm visual analog scale (VAS). Three patient groups were defined: concordant rating group (PTGL and MDGL within ±2 cm), higher patient rating group (PTGL exceeding MDGL by >2 cm), and lower patient rating group (PTGL less than MDGL by >2 cm). Multivariable regression analysis was used to identify determinants of PTGL and MDGL and their discordance.

RESULTS

The mean ± SD VAS scores for PTGL and MDGL were 4.01 ± 2.70 and 2.91 ± 2.37, respectively. Pain was overwhelmingly the single most important determinant of PTGL, followed by fatigue. In contrast, MDGL was most influenced by swollen joint count (SJC), followed by erythrocyte sedimentation rate (ESR) and tender joint count (TJC). A total of 4,454 (63.4%), 2,106 (30%), and 468 (6.6%) patients were in the concordant, higher, and lower patient rating groups, respectively. Odds of higher patient rating increased with higher pain, fatigue, psychological distress, age, and morning stiffness, and decreased with higher SJC, TJC, and ESR. Lower patient rating odds increased with higher SJC, TJC, and ESR, and decreased with lower fatigue levels.

CONCLUSION

Nearly 36% of patients had discordance in RA activity assessment from their physicians. Sensitivity to the "disease experience" of patients, particularly pain and fatigue, is warranted for effective care of RA.

Do general practitioners overestimate the health of their patients with lower education?

This study sought to ascertain whether disagreement between patients and physicians on the patients' health status varies according to patients' education level. INTERMEDE is a cross-sectional multicentre study. Data were collected from both patients and doctors via pre- and post consultation questionnaires at the GP's office over a two-week period in October 2007 in 3 regions of France. The sample consists of 585 eligible patients (61% women) and 27 GPs. A significant association between agreement/disagreement between GP and patient on the patient's health status and patient's education level was observed: 75% of patients with a high education level agreed with their GP compared to 50% of patients with a low level of education. Patients and GPs disagreed where patients with the lowest education level said that their health was worse relative to their doctor's evaluation 37% of the time, versus 16% and 14% for those with a medium or high education level respectively. A multilevel multivariate analysis revealed that patients with a low educational level and medium educational level respectively were at higher risk of being overestimated by GP's in respect of self-reported health even if controlling for confounders. These findings suggest that people with a lower education level who consider themselves to have poor health are less reliably identified as such in the primary care system. This could potentially result in lack of advice and treatment for these patients and ultimately the maintenance of health inequalities.

The incremental value of self-reported mental health measures in predicting functional outcomes of veterans

Research on patient-centered care supports use of patient/consumer self-report measures in monitoring health outcomes. This study examined the incremental value of self-report mental health measures relative to a clinician-rated measure in predicting functional outcomes among mental health service recipients. Participants (n = 446) completed the Behavior and Symptom Identification Scale, the Brief Symptom Inventory, and the Veterans/Rand Short Form-36 at enrollment in the study (T1) and 3 months later (T2). Global Assessment of Functioning (GAF) ratings, mental health service utilization, and psychiatric diagnoses were obtained from administrative data files. Controlling for demographic and clinical variables, results indicated that improvement based on the self-report measures significantly predicted one or more functional outcomes (i.e., decreased likelihood of post-enrollment psychiatric hospitalization and increased likelihood of paid employment), above and beyond the predictive value of the GAF. Inclusion of self-report measures may be a useful addition to performance measurement efforts.

Self-reported side effects in buprenorphine and methadone patients receiving antiretroviral therapy: results from the MANIF 2000 cohort study

AIMS

The aim of the study was to investigate the relationship between methadone and buprenorphine treatment and self-reported symptoms in HIV-infected opioid dependent individuals receiving antiretroviral therapy (ART).

DESIGN

Longitudinal study.

SETTING

The French MANIF2000 cohort was used to compare self-reported symptoms in buprenorphine and methadone patients also receiving ART.

PARTICIPANTS

We selected individuals receiving ART and OAT (342 visits among 106 patients).

MEASUREMENTS

Symptoms were self-reported using a list of 14 symptoms (e.g. nausea, fatigue, fever) perceived during the previous 4 weeks, including three painful symptoms (abdominal or muscular pain, headaches). A two-step Heckman approach enabled us to account for the non-random assignment of OAT: a probit model identified predictors of starting either buprenorphine or methadone. A Poisson regression based on generalized estimating equations (GEE) was then used to identify predictors of the number of symptoms while adjusting for the non-random assignment of OAT.

FINDINGS

The median (interquartile range) number of symptoms was 4 (1-6) and 2 (1-6) among buprenorphine and methadone patients, respectively. After adjustment for non-random assignment of OAT type, depressive and opioid withdrawal symptoms, anxiolytics consumption and daily cannabis use, methadone patients were more likely to report a lower number of symptoms than those receiving buprenorphine.

CONCLUSIONS

Methadone patients on ART report fewer symptoms than buprenorphine patients on ART under current treatment conditions in France. Further experimental research is still needed to identify an OAT-ART strategy which would minimize the burden of self-reported symptoms and potential interactions, while assuring sustainability and response to both treatments.

Identification of patient-reported distress by clinical nurse specialists in routine oncology practice: a multicentre UK study

BACKGROUND

There is uncertainty regarding how well clinical nurse specialists are able to identify distress in cancer settings.

METHODS

We examined recognition of patient-reported distress by nurse specialists across three sites in the East Midlands (UK). Clinicians were asked to report on their clinical opinion regarding the presence of distress or any mental health complication after routine assessment of 401 mixed cancer patients. Patient-reported distress was defined by the distress thermometer at a cut-off of 4 or higher.

RESULTS

We found that the prevalence of patient-reported distress was 45.4%. The rates for mild, moderate and severe distress were: 23.4, 13.7 and 8.2, respectively. When looking for distress (or any mental health complication) nurse practitioners had a detection sensitivity of 50.5% and specificity 80.0%. Cohen's kappa suggested fair agreement between staff and patients. Examining predictors of distress, clinicians were better able to recognise higher severities of distress (adjusted R(2) =0.87 P=0.001). There was lower sensitivity in palliative stages but no differences according to the type of cancer. There was also higher sensitivity but lower specificity in those clinicians with high self-rated confidence.

CONCLUSIONS

Nurses working in cancer settings have difficulty identifying distress using their routine clinical judgement and tend to make more false-negative than false-positive errors. Evidence-based strategies that improve detection of mild and moderate distress are required in routine cancer care.

Patient-physician discordance in assessments of global disease severity in rheumatoid arthritis

OBJECTIVE

To determine the degree of discordance between patient and physician assessment of disease severity in a multiethnic cohort of adults with rheumatoid arthritis (RA), to explore predictors of discordance, and to examine the impact of discordance on the Disease Activity Score in 28 joints (DAS28).

METHODS

Adults with RA (n = 223) and their rheumatologists completed a visual analog scale (VAS) for global disease severity independently. Patient demographics, the 9-item Patient Health Questionnaire (PHQ-9) depression scale score, the Health Assessment Questionnaire score, and the DAS28 were also collected. Logistic regression analyses were used to identify predictors of positive discordance, defined as a patient rating minus physician rating of >25 mm on a 100-mm VAS (considered clinically relevant). DAS28 scores stratified by level of discordance were compared using a paired t-test.

RESULTS

Positive discordance was found in 30% of cases, with a mean +/- SD difference of 46 +/- 15. The strongest independent predictor of discordance was a 5-point increase in PHQ-9 score (adjusted odds ratio 1.61, 95% confidence interval 1.02-2.55). Higher swollen joint count and Cantonese/Mandarin language were associated with lower odds of discordance. DAS28 scores were most divergent among subjects with discordance.

CONCLUSION

Nearly one-third of RA patients differed from their physicians to a meaningful degree in assessment of global disease severity. Higher depressive symptoms were associated with discordance. Further investigation of the relationships between mood, disease activity, and discordance may guide interventions to improve care for adults with RA.

Clinical diagnosis of depression in primary care: a meta-analysis

BACKGROUND

Depression is a major burden for the health-care system worldwide. Most care for depression is delivered by general practitioners (GPs). We assessed the rate of true positives and negatives, and false positives and negatives in primary care when GPs make routine diagnoses of depression.

METHODS

We undertook a meta-analysis of 118 studies that assessed the accuracy of unassisted diagnoses of depression by GPs. 41 of these studies were included because they had a robust outcome standard of a structured or semi-structured interview.

FINDINGS

50 371 patients were pooled across 41 studies and examined. GPs correctly identified depression in 47.3% (95% CI 41.7% to 53.0%) of cases and recorded depression in their notes in 33.6% (22.4% to 45.7%). 19 studies assessed both rule-in and rule-out accuracy; from these studies, the weighted sensitivity was 50.1% (41.3% to 59.0%) and specificity was 81.3% (74.5% to 87.3%). At a rate of 21.9%, the positive predictive value was 42.0% (39.6% to 44.3%) and the negative predictive value was 85.8% (84.8% to 86.7%). This finding suggests that for every 100 unselected cases seen in primary care, there are more false positives (n=15) than either missed (n=10) or identified cases (n=10). Accuracy was improved with prospective examination over an extended period (3-12 months) rather than relying on a one-off assessment or case-note records.

INTERPRETATION

GPs can rule out depression in most people who are not depressed; however, the modest prevalence of depression in primary care means that misidentifications outnumber missed cases. Diagnosis could be improved by re-assessment of individuals who might have depression.

FUNDING

None.

Depressive symptoms and perceived doctor-patient communication in the Heart and Soul study

BACKGROUND

Doctor-patient communication is an important marker of health-care quality. Little is known about the extent to which medical comorbidities, disease severity and depressive symptoms influence perceptions of doctor-patient communication in patients with chronic disease.

METHODS

In a cross-sectional study of 703 outpatients with chronic coronary disease, we evaluated the extent to which patient reports of doctor-patient communication were influenced by medical comorbidities, disease severity and depressive symptoms. We assessed patient reports of doctor-patient communication using the Explanations of Condition and Responsiveness to Patient Preferences subscales from the "Interpersonal Processes of Care" instrument. Poor doctor-patient communication was defined as a score of <4 (range 1 to 5) on either subscale. All patients completed the nine-item Patient Health Questionnaire (PHQ) for measurement of depressive symptoms and underwent an extensive evaluation of medical comorbidities and cardiac function.

RESULTS

In univariate analyses, the following patient characteristics were associated with poor reported doctor-patient communication on one or both subscales: female sex, white or Asian race and depressive symptoms. After adjusting for demographic factors, medical comorbidities and disease severity, each standard deviation (5.4-point) increase in depressive symptom score was associated with a 50% greater odds of poor reported explanations of condition (OR 1.5, 95% CI, 1.2-1.8; p < 0.001) and a 30% greater odds of poor reported responsiveness to patient preferences (OR 1.3, 95% CI, 1.1-1.5; p = 0.01). In contrast, objective measures of disease severity (left ventricular ejection fraction, exercise capacity, inducible ischemia) and medical comorbidities (hypertension, diabetes, myocardial infarction) were not associated with reports of doctor-patient communication.

CONCLUSIONS

In outpatients with chronic coronary heart disease, depressive symptoms are associated with perceived deficits in doctor-patient communication, while medical comorbidities and disease severity are not. These findings suggest that patient reports of doctor-patient communication may partly reflect the psychological state of the patient.

Impact of doctor-patient communication on preoperative anxiety: Study at industrial township, Pimpri, Pune

BACKGROUND

Anxiety may not be recognized by physicians though they affect a large number of patients awaiting surgery as reported in some studies. Good doctor-patient communication may have an impact on preoperative anxiety.

AIM

To find out the incidence of anxiety in patients awaiting surgery and its association with good doctor-patient communication.

MATERIALS AND METHODS

The study was undertaken in a medical college hospital situated in an industrial township, for the duration of two months. It was a cross-sectional study. The study included 79 patients admitted to various surgical wards of a teaching hospital. Data was collected on a pretested questionnaire, which included a set of questions on various aspects of doctor-patient communication. The level of anxiety was assessed using the Hospital Anxiety and Depression Scale (HADS). Statistical analysis was carried out using the WHO/CDC package EPI INFO 2002. Though preoperative anxiety was collected on an ordinal scale, later during analysis, it was collapsed to give a categorical scale. Aspects of doctor-patient communication associated with preoperative anxiety were explored by Chi square tests.

RESULTS

Out of the total 79 patients, 26.5% reported definite anxiety levels. Good doctor-patient communication was found to be inversely associated with anxiety levels in the preoperative period.

CONCLUSIONS

Preoperative anxiety is a common phenomenon among indoor surgical patients. A lot can be done to alleviate this anxiety by improving doctor-patient communication.