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- Title
Understanding Discordant Perceptions of Disease Severity Between Physicians and Patients With Eczema and Psoriasis Using Structural Equation Modeling.
- Authors
Long, Valencia; Chen, Zhaojin; Du, Ruochen; Chan, Yiong Huak; Yew, Yik Weng; Oon, Hazel H.; Thng, Steven; Lim, Nur Qasrina Binte Iskandar; Tan, Chris; Chandran, Nisha Suyien; Valderas, Jose M.; Phan, Phillip; Choi, Ellie
- Abstract
Key Points: Question: Why do patients and physicians assess severity differently, and why are some patients more symptomatic despite the same objective disease? Findings: In this cross-sectional study of 1053 pairs of patients with psoriasis or eczema and physicians, 487 pairs (46.3%) demonstrated discordance; physicians focused on visually objective measures, while patients heavily considered the physical, functional, and emotional consequences of disease. These disease consequences in turn differed based on the individual's resilience, self-efficacy, and tendency for negative social comparisons; physicians may also trivialize milder cases because of frequent exposure to severe diseases. Meaning: These identified factors are potential targets for cognitive-behavioral interventions to bridge differing perceptions between patients and physicians. Importance: Patients and physicians often have differing opinions on the patient's disease severity. This phenomenon, termed discordant severity grading (DSG), hinders the patient-physician relationship and is a source of frustration. Objective: To test and validate a model explaining the cognitive, behavioral, and disease factors associated with DSG. Design, Setting, and Participants: A qualitative study was first performed to derive a theoretical model. In this subsequent prospective cross-sectional quantitative study, the qualitatively derived theoretical model was validated using structural equation modeling (SEM). Recruitment was conducted between October 2021 and September 2022. This was a multicenter study in 3 Singapore outpatient tertiary dermatological centers. Dermatology patients and their attending physicians were recruited by convenience sampling. Patients were aged 18 to 99 years with psoriasis or eczema of at least 3 months' duration and recruited only once. The data were analyzed between October 2022 to May 2023. Main Outcomes and Measures: The outcome was the difference between global disease severity (0-10 numerical rating scale with a higher score indicating greater severity) as independently scored by the patient and the dermatologist. Positive discordance was defined as patient-graded severity more than 2 points higher (graded more severely) than physicians, and negative discordance if more than 2 points lower than physicians. Confirmatory factor analysis followed by SEM was used to assess the associations between preidentified patient, physician, and disease factors with the difference in severity grading. Results: Of the 1053 patients (mean [SD] age, 43.5 [17.5] years), a total of 579 (55.0%) patients were male, 802 (76.2%) had eczema, and 251 (23.8%) had psoriasis. Of 44 physicians recruited, 20 (45.5%) were male, 24 (54.5%) were aged between 31 and 40 years, 20 were senior residents or fellows, and 14 were consultants or attending physicians. The median (IQR) number of patients recruited per physician was 5 (2-18) patients. Of 1053 patient-physician pairs, 487 pairs (46.3%) demonstrated discordance (positive, 447 [42.4%]; negative, 40 [3.8%]). Agreement between patient and physician rating was poor (intraclass correlation, 0.27). The SEM analyses showed that positive discordance was associated with higher symptom expression (standardized coefficient B = 0.12; P =.02) and greater quality-of-life impairment (B = 0.31; P <.001), but not patient or physician demographics. A higher quality-of-life impairment was in turn associated with lower resilience and stability (B = −0.23; P <.001), increased negative social comparisons (B = 0.45; P <.001), lower self-efficacy (B = −0.11; P =.02), increased disease cyclicity (B = 0.47; P <.001), and greater expectation of chronicity (B = 0.18; P <.001). The model was well-fitted (Tucker-Lewis: 0.94; Root Mean Square Error of Approximation: 0.034). Conclusions and Relevance: This cross-sectional study identified various modifiable contributory factors to DSG, increased understanding of the phenomenon, and set a framework for targeted interventions to bridge this discordance. This cross-sectional study tests and validates a model explaining the cognitive, behavioral, and disease factors associated with discordant severity grading between physicians and patients with eczema and psoriasis.
- Publication
JAMA Dermatology, 2023, Vol 159, Issue 8, p811
- ISSN
2168-6068
- Publication type
Article
- DOI
10.1001/jamadermatol.2023.2008