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Psychosocial correlates of patient-physician discordance in inflammatory bowel disease
THE AMERICAN JOURNAL OF GASTROENTEROLOGY © 2002 by Am. Coll. of Gastroenterology Published by Elsevier Science Inc.
Vol. 97, No. 9, 2002 ISSN 0002-9270/02/$22.00 PII S0002-9270(02)04326-5
CLINICAL REVIEWS
Psychosocial Correlates of Patient–Physician Discordance in Inflammatory Bowel Disease Maida J. Sewitch, Ph.D., Michal Abrahamowicz, Ph.D., Alain Bitton, M.D., F.R.C.P.(C.), Donald Daly, M.D., F.R.C.P.(C.), Gary E. Wild, M.D., Ph.D., F.R.C.P.(C.), Albert Cohen, M.D., F.R.C.P.(C.), Saul Katz, M.D., F.R.C.P.(C.), Peter L. Szego, M.D., F.R.C.P.(C.), and Patricia L. Dobkin, Ph.D. Groupe de Recherche Interdisciplinaire en Sante´, University of Montre´al, Montre´al, Que´bec, Canada; Department of Epidemiology and Biostatistics, Department of Medicine, and Department of Anatomy Cell Biology, McGill University, Montre´al, Que´bec, Canada; and Division of Clinical Epidemiology, Montre´al General Hospital, Montre´al, Que´bec, Canada
OBJECTIVE: The aim of this study was to identify the independent psychosocial correlates of patient–physician discordance in adult outpatients with inflammatory bowel disease. METHODS: This cross-sectional study was conducted in three university-affiliated tertiary care settings. Psychological distress, social support, perceived stress, and negative life events were assessed, as were demographic, lifestyle, and clinical characteristics. Patient–physician discordance was assessed with 10-item questionnaires. RESULTS: Ten gastroenterologists and 200 of their patients participated. Patients and their physicians disagreed most on discussion of personal issues. Patients with Crohn’s disease had statistically significantly higher discordance on disease activity and physical limitation, as well as higher average overall discordance scores than patients with ulcerative colitis. Mean discordance levels were similar across different physicians. Higher psychological distress and more perceived stress were independently associated with higher discordance after controlling for Crohn’s disease, active disease, being with the treating physician for less than 1 yr, and recommendation for further medical investigation. Psychological distress was the most important correlate of overall discordance. CONCLUSIONS: Increased physician awareness that psychologically distressed patients have difficulty processing of clinically relevant information may lead to improved doctor–patient communication during an office visit. (Am J Gastroenterol 2002;97:2174 –2183. © 2002 by Am. Coll. of Gastroenterology)
INTRODUCTION Health perceptions impact the experience of inflammatory bowel disease (IBD) upon the individual (1). IBD is a chronic inflammatory disease of the GI tract that is characterized by periods of exacerbation and remission (2). Pa-
tients with IBD report more negative perceptions of health than do healthy subjects (3). However, although IBD patients’ perceptions of poorer health correlate with decreased functioning and greater use of health services, their perceptions do not correlate with physicians’ ratings of disease activity (4). This is not surprising given that weak associations are found among clinical symptoms, physical findings, and laboratory parameters (5). A substantial body of literature concerning various medical conditions suggests associations between greater patient–physician discordance on perceptions of health-related information and unfavorable health outcomes (6 –11), decreased patient satisfaction (12–14), decreased adherence to return appointments (11, 15), and increased use of health services (16). Patient–physician discordance is operationally defined as the difference between patient and physician ratings of the same or similar aspects of health-related information. For example, a patient and his/her physician will be asked to independently rate their own perceptions of the patient’s pain, and the degree to which the two ratings differ may be the measure of discordance. The underlying assumptions of the discordance literature are that the items assessed are essential to understanding the patient’s problem as well as to delivering appropriate treatment (10, 17), and that discordant perceptions are a result of ineffective doctor–patient communication (10, 15, 18). Physicians and patients are more likely to disagree on their perceptions of the patient’s health and the office visit when patients experience psychosocial problems (6, 7, 15, 18). In these studies, psychosocial problems have been ascertained using retrospective data from patient medical files (7, 15), questionnaires (6), and interviews (18). Some of these methods of assessment may be problematic because patients are more likely to report physical symptoms than psychosocial issues during clinical visits (19, 20), medical doctors commonly do not respond to psychosocial cues (21, 22), or recognize psychosocial issues unless they are severe (20, 23), and most doctor–patient communication focuses
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on biomedical rather than psychosocial information (24). In fact, Mitchel et al. have shown that in IBD, at least 50% of emotional problems are under-reported (25). Whereas general psychosocial concerns in the discordance studies were investigated using various indicators such as feeling depressed (18), problems with work, finances, family (7), or insufficient help from others (7), the specific patient psychosocial characteristics that may influence differences between physicians’ and patients’ perceptions have not been identified. Thus, the effects of stress (26), psychological distress (26, 27), and social support (26), which have been shown to impact physicians’ and patients’ perceptions of the patients’ health, have not been systematically studied. Furthermore, the effects of psychosocial factors on patient– physician discordance in IBD remain to be investigated. Given the link between higher discordance and unfavorable outcomes (6 –11), it may be particularly important to identify the correlates of discordance to help clinicians recognize patients at higher risk for patient–physician discrepancies. The main purpose of this study was to determine the patients’ psychosocial characteristics associated with higher discordance in IBD. Because these characteristics are potentially modifiable, elucidating the psychosocial correlates of discordance may be helpful in designing interventions that will be expected to reduce discordance, and, ultimately, improve patients’ health outcomes. In addition, by highlighting items of greater patient–physician discordance in IBD patients, these findings may indicate the specific areas to target for improved communication. Improved psychosocial functioning and better communication may lead to increased patient adherence, improved health outcomes, and more efficient use of health services (28 –34).
MATERIALS AND METHODS Study Population and Data Collection Procedures A cross-sectional study was conducted at three university hospital gastroenterology clinics in Montre´ al, Canada. Physicians affiliated with the McGill University Health Center were mailed an introductory packet of information that invited them to participate in this study. They were told that their participation would consist of completing a questionnaire on their perceptions of the patient’s health status and of the office visit immediately after a scheduled office visit with a participating patient. Intent to participate was indicated by mailing the completed survey questionnaire and consent form to the research office. Eligibility criteria for patients included age of 18 yr or older, confirmed diagnosis of Crohn’s disease or ulcerative colitis for at least 6 months, fluency in English or French, and not pregnant at recruitment. On days when the research assistant attended the clinic, IBD patients of participating physicians with scheduled appointments were approached while in the waiting room before the office visit. Written informed consent was obtained for each patient. Demographic, lifestyle, clinical, and psychosocial data were gath-
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ered before the scheduled visit. Immediately after the office visit, physicians and patients independently completed the questionnaire on perceptions. Patients provided additional information pertaining to recommended interventions such as prescription medication, scheduling of another appointment, consulting another health care professional, and medical investigation. Patients and physicians were blinded to the purpose of the study and informed that the objective was to investigate the role of psychosocial factors in the management of IBD. The research protocol was approved by the McGill University Faculty of Medicine Institutional Review Board. Instruments PATIENT–PHYSICIAN DISCORDANCE SCALE. The Patient–Physician Discordance Scale was used for assessing patient–physician discordance. The development of the new instrument and its validation are described elsewhere (35, 36). The Patient–Physician Discordance Scale is a 10-item self-report measure that uses a 10-cm visual analog scale (VAS) format for individual items. Five items assess aspects of the patient’s health status including abdominal pain, disease activity, physical functioning, psychological distress, and emotional well-being. Five other items assess aspects of the clinical visit including discussion of the main problem, discussion of personal issues, expectation of medication, expectation of further medical investigation, and patient satisfaction with the visit. The 10-item scale is completed independently by the patient and his/her physician immediately after the visit, to reflect their own perceptions of each item. Discordance is determined by calculating the difference between the patient’s and physician’s VAS ratings for each of the 10 items. Each item difference score is then standardized by dividing by the SD of the 10 patient ratings. This procedure accounts for patient “internal rating scales,” such as a preference or reluctance to endorse extreme values. Finally, the average of the absolute values of the standardized differences for the 10 items is calculated, and considered as the measure of overall discordance. This score measures the magnitude of discordance but is not influenced by whether the patient or the physician rates higher on particular items. A principal components factor analysis with orthogonal varimax rotation, which revealed that all 10 discordance items loaded above the conventional cutoff of 0.40 onto one factor, indicates a unidimensional structure of discordance (36). The Cronbach’s ␣ of 0.73 indicates satisfactory internal consistency (37). Intraclass correlation coefficients that were calculated on the 10 patient ratings ranged between 0.67 and 0.92, indicating satisfactory test–retest reliability of the patient ratings (36). For reasons of practicality, test–retest was not done for physician ratings. Disease Activity Disease activity was measured with the Harvey Bradshaw Index (38). This patient self-report scale is based upon 12
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clinical variables that can be determined at a single outpatient visit (e.g., general well-being, abdominal pain, number of liquid stools, abdominal mass presence, and eight complications) (38). Originally designed and validated for use in Crohn’s disease, the tool has also been used to measure disease activity in ulcerative colitis (39 – 41). A cutoff of 4 and above defined active disease (40, 42, 43). In this patient sample, concurrent validity between the score on the Harvey Bradshaw Index and a VAS self-report measure of disease activity was similar for Crohn’s disease and ulcerative colitis (r ⫽ 0.60 and 0.63, respectively [41]). Psychosocial Characteristics The following validated instruments were used to measure psychological distress, social support, negative life events, and perceived stress. By using multiple psychosocial measures, it was possible to determine the independent effects of the corresponding constructs on patient–physician discordance. PSYCHOLOGICAL DISTRESS. Psychological distress was assessed with the Symptom Checklist-90R, a 90-item self-report measure that assesses a variety of symptoms of distress that occurred during the past week (44). This scale does not yield psychiatric diagnoses. Psychological distress is assessed with the Global Severity Index summary score, which combines the number and intensity of symptoms. Descriptive results are reported as normalized T-scores (normative mean score ⫽ 50, SD ⫽ 10), and clinically important distress corresponds to T-scores of 63 and greater. Test–retest coefficients, obtained from 94 psychiatric outpatients with various diagnoses, were between 0.80 and 0.90 (44). The internal consistency of the Global Severity Index in our IBD patient population was very high (Cronbach’s ␣ ⫽ 0.96). SOCIAL SUPPORT. An abbreviated version of the Social Support Questionnaire (SSQ) was used to assess size of the social support network and satisfaction with social support (45, 46). The SSQ-6 consists of six two-part questions that are divided into two subscales: six items assess the number of people in the network (SSQ-N), and six measure satisfaction with perceived available support (SSQ-S). The two subscales can be examined separately because they are only moderately intercorrelated (45). Scores on the SSQ-S subscale range from 1 to 6, with higher scores indicating greater satisfaction. SSQ-N ranges from 0 to 9, higher scores reflecting a larger social support network. Test–retest reliability, determined in 182 university undergraduates, was high with correlations of 0.84 for Number and 0.85 for Satisfaction (45). The Cronbach’s ␣s of 0.89 (SSQ-N) and 0.88 (SSQ-S) indicate high internal consistency in our IBD sample. NEGATIVE LIFE EVENTS. The Weekly Stress Inventory (WSI) is a self-report measure that assesses minor events experienced during the past week (47). Respondents are asked to check 87 items on whether the events occurred in
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the past week and to rate the intensity of resulting stress on a 7-point Likert scale. Worked late, experienced car trouble, and heard some bad news are examples of events included in the questionnaire. The WSI yields two scores: 1) the WSI-Event (WSI-E), the number of events that occurred, and 2) the WSI-Impact (WSI-I), the impact, which is derived by summing the perceived stress ratings. High scores indicate more events and greater negative impact from the events, respectively. Test–retest reliability coefficients were moderately high for the WSI-Event (r ⫽ 0.83) and the WSI-Impact (r ⫽ 0.80) when subjects were tested within the same week, but coefficients declined with the passage of time (48). The Cronbach’s ␣ was 0.96 for the WSI-I and 0.95 for the WSI-E for our patients with IBD, indicating very high internal consistency. PERCEIVED STRESS. Perceived stress was assessed with the Perceived Stress Scale, a 10-item measure of the degree to which respondents appraise stressful situations that occurred during the past month (49). The instrument was developed for use in community samples; items are scored on a 5-point scale from 0 to 4 (49). The total score provides a global measurement of the extent to which an individual feels overwhelmed by stressful situations that occurred in the past month. Total scores range from 0 to 40; higher scores indicate greater perceived stress (49). Test–retest reliability at 2 days and 6 wk was 0.85 and 0.55, respectively (50). Internal consistency in our sample was high (␣ ⫽ 0.86). Covariates Other potential correlates of discordance were assessed. Patient characteristics were ascertained before the office visit, and included age, gender, language (English/French), education, smoking status, form of IBD, level of disease activity, time since diagnosis, time under current physician’s care, duration of the visit, psychological distress, perceived stress, social support, and negative life events. Recommended interventions were assessed immediately after the visit using binary indicators for prescription medication, scheduling another appointment, consulting another health care professional, and further medical investigation. The extent to which the patient expected the prescribed medication to positively affect health was assessed after the office visit using a 100-mm VAS response format question, “how certain are you that the prescribed medication will have a positive effect on your health?” Statistical Analyses Descriptive statistics were used to characterize the study population. Demographic, clinical, and psychosocial characteristics of patients with Crohn’s disease and ulcerative colitis were compared using t tests and 2 analyses as appropriate. Multiple linear regression was used to determine whether there were statistically significant differences in mean discordance scores between physicians. A mixed model for unbalanced repeated measures analysis of variance approach was used to determine the independent cor-
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relates of discordance. This technique handles continuous dependent variables (patient–physician discordance) and accounts for 1) clustering of patients within physicians’ practices, and for 2) the unbalanced design, as the number of patients varies from physician to physician (51). We assumed that the exchangeable covariance structure of errors would account for the dependence of observations on the different patients of same physician and used the Akaike’s Information Criterion (52) for comparison with alternative covariance structures. The Akaike’s Information Criterion is one method of model selection such that the lower Akaike’s Information Criterion indicates a better fit (52). Smoking (current and past smoker compared with never smoker) was represented by two dummy variables. A priori, we decided to dichotomize time under current physician’s care at 1 yr to assess the effect of being a new patient of the treating physician. A logarithmic transformation was performed on time since diagnosis because it was not normally distributed. SSQ-S was skewed toward higher values and dichotomized at 6 (highest value), SSQ-N was dichotomized at 3 (mediansplit), and WSI-I at 105.4 (normative value). Statistical significance was set at 0.05. Statistical analyses were performed with the SAS System (SAS Institute Inc., Cary, NC) for Windows 6.12 software.
RESULTS Response Rates Ten of the 11 (90.9%) physicians invited to participate in this study agreed and provided data on at least one patient. One physician did not complete the Patient–Physician Discordance Scale questionnaires on seven patients. Two hundred of the 207 (96.1%) eligible patients approached to participate gave their consent. Two (1%) of these patients did not complete all the psychosocial questionnaires. Complete data were available for 191 (95.5%) patient–physician pairs. One physician provided 71 patients, three provided between 20 and 35, two furnished between 10 and 19, and four physicians contributed less than three patients each.
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another health care professional. At the office visit, most patients were asked to schedule a follow-up appointment and received prescriptions for pharmacotherapy. Half the patients were told they needed further medical investigation, and relatively few were advised to consult another health care professional. Patients’ psychosocial characteristics were similar for Crohn’s disease and ulcerative colitis. Pearson correlations between the psychosocial variables are presented in Table 2. With the exception of size of the support network, all variables showed statistically significantly correlations with each other. Coefficients ranged from r ⫽ 0.16 for the pairwise relationship between number of stressful events and size of the social support network to r ⫽ 0.63 for the pairwise relationship between impact and number of stressful events. Discordance Scores Descriptive statistics for the distributions of the 10 itemspecific discordance scores and overall discordance are presented in Table 3, separately for each form of IBD. Discordance was highest for discussion of personal issues and lowest for patient satisfaction. Patients with Crohn’s disease had statistically significantly higher mean discordance scores on disease activity, physical limitation, patient satisfaction, and overall discordance than those with ulcerative colitis. Pairwise correlations among the 10 item-specific discordance scores, although often statistically significant, were all below r ⫽ 0.4, indicating less than 15% of variance overlap (data not shown). Patient–physician discordance on abdominal pain was significantly correlated with all other nine discordance items, indicating that higher discordance on abdominal pain was associated with higher discordance on all other aspects of health and the clinical visit (data not shown).
Physicians’ Characteristics The median age of physicians was 47.9 yr (range 30.1– 66.6), and the majority were men. The median number of years of experience in treating patients with IBD was 16.5 yr (range 3–30). Physicians reported seeing a median of 10 (range 1–35) patients with IBD per week.
Effect of Individual Physicians on Discordance A multiple linear regression model was built to determine whether there were statistically significant differences in discordance scores between physicians. Using discordance as the outcome, there were no statistically significant differences in mean overall discordance between the six physicians who each contributed more than 10 patients (overall F ⫽ 1.30). Indeed, the mean overall discordance scores among the six physicians were very similar (p ⫽ 0.2647), ranging from 0.59 to 0.77 (data not shown).
Patients’ Characteristics Table 1 presents the demographic, lifestyle, clinical, and psychosocial characteristics of the 191 patients included in the analyses, and compares 132 Crohn’s disease with 59 ulcerative colitis patients. Mean age was 36.6 yr, and 113 (59.2%) patients were women. Patients with ulcerative colitis were more likely to be women, married, or living with a partner, and those with Crohn’s disease were more likely to have active disease, have had previous IBD-related surgery, and have received the recommendation to consult with
Bivariate Associations With Patient–Physician Discordance Crude relationships between each demographic, clinical, psychosocial, and treatment variable and discordance were evaluated using simple linear regression. As shown in Table 4, Crohn’s disease, active disease, being a new patient of the treating physician, and less certainty that medication would positively affect health, as well as recommendations for further medical investigation, pharmacotherapy, and consultation with another health care professional were associated
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Table 1. Characteristics of the Cohort and Comparison of Crohn’s Disease With Ulcerative Colitis Patients (N ⫽ 191) IBD (n ⫽ 191) N (%)
Characteristic Demographic and lifestyle Age in yr (mean, SD) Female* French speaking Education High school and less Junior college University and higher Civil status* Single Married/living with partner Widowed/divorced/separated Smoking status* Current Ex Never Clinical Median yr under doctor’s care (IQR) Median yr since diagnosis (IQR) Active disease* Previous IBD-related surgery* Duration of office visit† (min) (mean, SD) Recommended intervention Prescribed medication Further medical investigation Schedule follow-up appointment Consult another health care professional* Psychosocial Psychologically distressed Perceived stress (mean, SD) High satisfaction with social support Size of social support network (mean, SD) Number of stressful events (mean, SD) High impact of stressful events
CD (n ⫽ 132) N (%)
UC (n ⫽ 59) N (%)
36.6 (14.9) 113 (59.2) 62 (32.5)
35.4 (15.4) 69 (52.3) 43 (32.9)
39.3 (13.6) 44 (74.6) 19 (32.2)
61 (31.9) 58 (30.4) 72 (37.7)
46 (34.9) 42 (31.8) 44 (33.3)
15 (25.4) 16 (27.1) 28 (47.5)
90 (47.1) 87 (45.5) 14 (7.3)
73 (55.3) 49 (37.1) 10 (7.6)
17 (28.8) 38 (64.4) 4 (6.8)
54 (28.3) 54 (28.3) 83 (43.5)
46 (34.9) 31 (23.5) 55 (41.7)
8 (13.6) 23 (39.0) 28 (47.5)
3.0 (1.5–6) 8.4 (4.1–15.9) 105 (55.0) 89 (46.6) 16.6 (11.0)
3.0 (1.5–6) 8.4 (4.1–15.9) 82 (62.1) 84 (63.6) 16.4 (11.0)
3.0 (1–7) 7.2 (4.4–14.0) 23 (39.0) 5 (8.5) 17.0 (10.9)
158 (82.7) 106 (55.8) 150 (78.5) 35 (18.4)
106 (80.3) 71 (54.2) 104 (78.8) 32 (24.4)
52 (88.1) 35 (59.3) 46 (78.0) 3 (5.1)
73 (38.2) 17.3 (7.1) 64 (33.5) 3.4 (1.8) 26.5 (16.2) 43 (22.5)
48 (36.4) 16.9 (7.4) 43 (32.6) 3.3 (1.8) 25.8 (15.8) 29 (22.0)
25 (42.4) 18.3 (6.6) 21 (35.6) 3.6 (1.8) 23.5 (17.0) 14 (23.7)
CD ⫽ Crohn’s disease; IQR ⫽ interquartile range; UC ⫽ ulcerative colitis. * p ⬍ 0.05 for comparison between CD and UC patients based on unequal groups; t test for continuous and 2 test for categorical variables. † Visit duration based on the patient’s perception, which was moderately correlated (r ⫽ 0.52, p ⫽ 0.0001) with the physician’s perception of the visit (mean ⫽ 16.3, SD ⫽ 6.4).
with statistically significantly higher patient–physician discordance because the corresponding 95% confidence intervals excluded 0. There were also statistically significant associations between higher psychological distress, more perceived stress, lower satisfaction with social support, and greater number and impact of stressful life events, and higher discordance. However, given the complex problem of intercorrelations between different psychosocial vari-
ables, these crude associations might have been affected by confounding bias (53). Independent Associations With Patient–Physician Discordance To identify the independent correlates of patient–physician discordance, we used a mixed linear models approach for clustered data. As shown in Table 5, higher psychological
Table 2. Pearson Correlations Between Psychosocial Variables (N ⫽ 191) 1 1. 2. 3. 4. 5. 6.
Psychological distress Perceived stress High satisfaction with social support Size of social support network Number of stressful events High impact of stressful events
* p ⬎ 0.05. † p ⬎ 0.01. ‡ p ⬎ 0.001.
0.61‡ ⫺0.28‡ ⫺0.03 0.56‡ 0.60‡
2
⫺0.16* ⫺0.11 0.27† 0.33‡
3
0.08 ⫺0.34‡ ⫺0.22*
4
5
0.16* 0.05
0.63‡
6
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Table 3. Descriptive Statistics for Item Discordance Scores for PPDS and Comparison of Means for CD and UC Using Wilcoxon Rank Sum Testing PPDS
IBD (N ⫽ 191)
Items and Total
Mean (SD)
Median
Abdominal pain Disease activity† Physical limitation* Psychological distress Emotional well-being Problem discussed Personal issues discussed Expect medication Expect testing Patient satisfaction* Overall discordance†
0.51 (0.69) 0.63 (0.62) 0.66 (0.66) 0.74 (0.65) 0.69 (0.63) 0.55 (0.63) 1.07 (0.85) 0.82 (0.95) 0.94 (1.02) 0.44 (0.46) 0.70 (0.39)
0.25 0.43 0.44 0.54 0.53 0.32 0.89 0.41 0.62 0.31 0.64
CD (N ⫽ 132)
UC (N ⫽ 59)
Range
Mean (SD)
Mean (SD)
0–4.07 0–2.62 0–2.95 0–3.38 0–3.51 0–3.71 0–3.32 0–5.28 0–5.61 0–2.51 0.04–2.65
0.51 (0.67) 0.70 (0.62) 0.69 (0.66) 0.76 (0.69) 0.71 (0.64) 0.58 (0.67) 1.14 (0.83) 0.90 (1.01) 1.01 (1.08) 0.49 (0.49) 0.75 (0.39)
0.43 (0.63) 0.46 (0.58) 0.55 (0.65) 0.68 (0.57) 0.61 (0.52) 0.47 (0.51) 0.93 (0.86) 0.60 (0.75) 0.81 (0.88) 0.34 (0.36) 0.59 (0.34)
CD ⫽ Crohn’s disease; PPDS ⫽ Patient–Physician Discordance Scale; UC ⫽ ulcerative colitis. Each item on the PPDS is measured on a 10-cm visual analog scale (VAS) and the theoretical range of discordance scores, calculated as (patient VAS–physician VAS) ratings is ⫺10.0 to ⫹10.0. Overall discordance is calculated as the mean of the sum of the 10 VAS ratings. * p ⬍ 0.05. † p ⬍ 0.01 for the comparison of CD vs UC patients based on the Wilcoxon rank sum tests.
distress, higher perceived stress, Crohn’s disease, active disease, being a new patient of the treating physician, and recommendations for further medical investigation had statistically significant independent effects on patient–physician discordance, and each was associated with higher discordance. A multiple linear regression model indicated that of all of these variables, psychological distress explained the highest proportion of variance in discordance (12.5%) (data not shown). In contrast to the unadjusted bivariate analyses,
social support and stressful events were not independently associated with discordance, once adjusted for psychological distress and perceived stress.
DISCUSSION The study findings support a relationship between patient psychosocial characteristics and discordance in IBD. Higher psychological distress and higher perceived stress were in-
Table 4. Results of Selected Separate Bivariate Linear Regression Models for Patient–Physician Discordance Bivariate Models Demographic and lifestyle Age Female French speaking Clinical Active disease (Yes/No)* Crohn’s disease (Yes/No)* Yr since diagnosis New patient of treating physician*† Certain that medication will have positive effect (n ⫽ 172)* Psychosocial Psychological distress* Perceived stress* Low satisfaction with social support* Social support network size Number of stress events* High impact of stress events* Recommended intervention Prescribed medication* Further medical investigation* Schedule follow-up appointment Consult another health professional*

95% CI
⫺0.002 0.034 0.101
(⫺0.006–0.001) (⫺0.145–0.076) (⫺0.009–0.221)
0.230 0.158 ⫺0.019 0.148 ⫺0.003
(0.126–0.334) (0.043–0.274) (⫺0.078–0.040) (0.021–0.275) (⫺0.005–⫺0.001)
0.304 0.016 0.135 0.055 0.005 0.250
(0.190–0.418) (0.009–0.023) (0.021–0.248) (⫺0.053–0.164) (0.001–0.008) (0.125–0.375)
0.159 0.120 0.125 0.184
(0.015–0.303) (0.011–0.230) (⫺0.006–0.256) (0.046–0.322)
 represents the estimated difference in discordance scores between the two categories of a binary variable or a change in discordance associated with a unit increase in the quantitative variables, adjusted for all other variables listed above. * Statistically significant (p ⬍ 0.05). † New patient defined as being with the current physician for 1 yr or less (N ⫽ 46).
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Table 5. Results of Multivariable Mixed Model for Unbalanced Repeated Measures Analysis of Variance for Independent Correlates of Patient-Physician Discordance Variable

95% CI
p
Active disease Crohn’s disease New patient of treating physician* Psychological distress Perceived stress Further medical investigation Intercept
0.141 0.165 0.139 0.158 0.010 0.108 0.691
(0.039–0.244) (0.058–0.272) (0.024–0.253) (0.014–0.302) (0.001–0.018) (0.010–0.206) (0.414–0.967)
0.0072 0.0028 0.0178 0.0323 0.0264 0.0317 0.0003
 represents the estimated difference in discordance scores between the two categories of a binary variable or a change in discordance associated with a unit increase in the quantitative variables, adjusted for all other variables listed above. * New patient defined as being with the current physician for 1 yr or less.
dependently associated with higher patient–physician discordance even after controlling for clinical variables. The independent contributions of psychological distress and perceived stress found in the present study indicate that they affect discordance through different mechanisms. These results provide evidence that the relationship between psychosocial problems and greater discordance that has been reported in other clinical settings (7, 15) occurs also in IBD. By directly assessing patients’ levels of psychological distress, perceived stress, social support, and negative life events and employing multivariable statistical analyses, we were able to evaluate the effect of each variable for its independent association with patient–physician discordance, while reducing the risk of confounding bias. Further, by restricting the clinical population to patients with IBD, an association between disease severity and discordance was found, which was not distorted by the heterogeneous grouping together of patients with various medical conditions, a situation that likely influenced the results of other discordance studies that were conducted mainly in primary care settings (6 –9, 13, 15–18, 54, 55). Discussion of personal issues showed the highest average discordance of all 10-scale items. We found that, compared to their IBD patients, physicians, on average, overestimated the extent to which personal issues were discussed. This was not surprising given that under-reporting (6, 19, 23) and underdetecting (20, 23) of psychosocial issues are consistently reported in the literature. Indeed, Mitchel et al. (25) reported that patients with IBD do not voluntarily admit psychosocial problems. Yet, the average visit duration reported in the present study, 16.6 min, may not be sufficient for adequate discussion of psychosocial issues. As suggested by Robinson and Roter (56) in their study in primary care, visits during which psychosocial issues were disclosed and counseled took, on average, more time (mean ⫽ 18.9 min) than visits with disclosure of psychosocial problems (mean ⫽ 16.5 min) and visits without disclosure (mean ⫽ 12.6 min). Although the average discordance score on abdominal pain was not high, agreement on this item may be critical to establishing similar patient–physician perceptions because discordance on abdominal pain was significantly related to discordance on the other nine items. Our results partially corroborate with those of other in-
vestigators. Similar to Lieberman et al. (14), who studied patients with other medical conditions, we found associations between greater patient–physician discordance and increased disease severity. Similar to investigators who studied different clinical populations, no links were found between discordance and patient demographic characteristics (54), patient education (54), other socioeconomic variables (15), or a continuous variable representing the duration under the care of a given physician (54). However, the binary indicator of new versus established patient status was found to be associated with higher discordance, indicating that patients seen by the current physician for less than 1 yr were at risk of higher discordance than were patients with more established relationships. Intuitively, most of the psychosocial variables included in this study were a priori expected to be related to patient– physician discordance. Indeed, the bivariate analyses indicated that higher discordance was statistically significantly related to increased psychological distress, greater perceived stress, lower satisfaction with social support, and increased number and impact of negative life events. However, intercorrelations between different psychosocial variables might have biased the results of some of these unadjusted analyses by creating spurious associations (53). Indeed, in the multivariable model, only perceived stress and psychological distress remained statistically significant independent correlates of discordance, with psychological distress being the single most important explanatory variable. It may be that stressful events and social support lose their effects after adjustment for psychological distress and perceived stress because what matters most are the subjective perceptions rather than the objective events. The clinical implication is that it may be beneficial for physicians to detect psychological distress in their patients with IBD because psychologically distressed patients seem to have difficulty processing information. Physicians need to spend more time explaining disease and treatment-related issues to these patients and getting their feedback in an attempt to reduce discordance, and, thus, possibly improve treatment adherence and ultimate clinical outcomes. Neither physicians nor patients in this study could be considered a truly random sample. For practical reasons, patient recruitment occurred only on the days when the
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research assistant attended the clinic, and patients who visited their physicians more often were more likely to have been included in the study. If frequent attenders were more in agreement with their physicians, this may have resulted in an underestimate of the level of discordance. However, it is unlikely to have affected our results, which pertained to correlates of discordance. Language may have potentially affected our results given that discordance was evaluated in English and French and that discordance was assumed to result from doctor–patient communication. However, variability in language was restricted to patients, as French was the mother tongue of only one of the six physicians who contributed more than one patient to this study. Patient language was accounted for during the model-building stages and was not found to be statistically significantly related to discordance. Therefore, the effect of patient language on level of discordance appears to be minimal. Given the lack of a single measure of disease activity that has been validated for both Crohn’s disease and ulcerative colitis, there were several concerns regarding the appropriate measure. The major concern was that it is inappropriate to use different measures of disease activity for different subgroups of patients (e.g., ulcerative colitis and Crohn’s disease) in one statistical analysis. The Harvey Bradshaw Index was considered the necessary, albeit, imperfect way for measuring disease activity for all patients, regardless of the form of IBD, for several reasons. Firstly, the Crohn’s Disease Activity Index requires completion of a 7-day diary (57), and it would have been impossible to obtain a measurement of disease activity at the time of patient recruitment. Secondly, we have previously demonstrated that three symptoms on the Crohn’s Disease Activity Index and the Harvey Bradshaw (e.g., well-being, frequency of stools, and abdominal pain) contribute most heavily to disease activity in both ulcerative colitis and Crohn’s disease patients (41). Third, data from both external sources (40) and from this study sample (41), which suggest that the concurrent validity of the Harvey Bradshaw measure of disease activity for ulcerative colitis is approximately the same as for Crohn’s disease, supported the use of the Harvey Bradshaw in patients with both forms of IBD. Thus, data derived both externally and internally support the use of the Harvey Bradshaw in patients with both forms of IBD. A second drawback inherent in the present study is the cross-sectional study design in which all of the variables were assessed at the index visit. This precludes determining the direction of causality because it is difficult to separate cause and effect when assessments of exposure and outcome are performed at the same time (58). Nevertheless, with the exception of social support, the psychosocial variables were measured based on questions about feelings or events experienced during the past week or month. Because patient– physician discordance was assessed subsequent to measuring patient psychosocial characteristics and is a product of the clinical visit, and given that both patients and physicians
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were blinded to the study hypothesis, the influence of information bias was minimized. Therefore, the current study corroborates the hypothesis that the patient’s psychosocial characteristics influence the level of patient–physician discordance. One of the strengths of this study is the assessment of global patient–physician discordance. Prior research, which had been hampered by the absence of a standardized and validated measure (6 –10, 13–18, 54, 55, 59), evaluated discordance on various single items, which may have limited comparability and relevance of the results. Future discordance research may evaluate ways in which discordance might be used to improve health outcomes. The effectiveness of an intervention aimed at improving, for example, patient adherence through improved communication with physicians, in which patients with higher discordance scores are contacted soon after an office visit in an attempt to reduce discrepancies, could be tested in a randomized clinical trial. Future research may also include determining the relationship between discordance and resource use given that discordance beyond a particular level may lead to doctor shopping.
CONCLUSION In conclusion, increased psychological distress and higher perceived stress are associated with higher patient–physician discordance in IBD. On the one hand, these results corroborate the associations between patient psychosocial variables and higher discordance that are found in other medical conditions. On the other hand, these findings may help clinicians who treat patients with IBD to identify specific psychosocial characteristics most likely to be found in patients at higher risk of discordance. Higher psychological distress was the most important correlate of higher discordance after controlling for active disease, new patient status and Crohn’s disease. The suggestion that psychologically distressed patients have difficulty processing information may raise physicians’ awareness of the importance of detecting psychological distress in their patients, and, ultimately, lead to improved communication during an office visit.
ACKNOWLEDGMENTS This study was done at the Division of Clinical Epidemiology, Montre´ al General Hospital, Montre´ al, Que´ bec, Canada. This study has come out in the Department of Epidemiology and Biostatistics of McGill University, as a part of the Ph.D. research of the first author. This research was made possible through financial support from the McGill University Social Sciences and Humanities Committee and the Montre´ al General Hospital Research Institute. Maida J. Sewitch, Ph.D., is currently supported as a postdoctoral fellow by the Canadian Institutes of Health
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Research. During this study, she was supported by Health Canada through a National Health Research and Development Program Ph.D. research training fellowship and by the Fonds de Recherche en Sante´ du Que´ bec (FRSQ) through a Ph.D. health professional training fellowship. Michal Abrahamowicz, Ph.D., is supported as a Scientist by the Canadian Institutes of Health Research. Alain Bitton, M.D., F.R.C.P.(C), is supported as a Junior Clinician Researcher by the FRSQ. Gary E. Wild, M.D., Ph.D., F.R.C.P.(C), is supported as a Senior Clinician Scientist by the FRSQ. Patricia L. Dobkin, Ph.D., is a FRSQ Senior Career Awardee. Reprint requests and correspondence: Maida J. Sewitch, Ph.D., Groupe de Recherche Interdisciplinaire en Sante´ , Faculty of Medicine, University of Montre´ al, C.P. 6128, succ. Centre-ville, Montre´ al, Que´ bec, Canada, H3C 3J7. Received Nov. 6, 2001; accepted Apr. 2, 2002.
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CLINICAL REVIEWS
Psychosocial Correlates of Patient–Physician Discordance in Inflammatory Bowel Disease Maida J. Sewitch, Ph.D., Michal Abrahamowicz, Ph.D., Alain Bitton, M.D., F.R.C.P.(C.), Donald Daly, M.D., F.R.C.P.(C.), Gary E. Wild, M.D., Ph.D., F.R.C.P.(C.), Albert Cohen, M.D., F.R.C.P.(C.), Saul Katz, M.D., F.R.C.P.(C.), Peter L. Szego, M.D., F.R.C.P.(C.), and Patricia L. Dobkin, Ph.D. Groupe de Recherche Interdisciplinaire en Sante´, University of Montre´al, Montre´al, Que´bec, Canada; Department of Epidemiology and Biostatistics, Department of Medicine, and Department of Anatomy Cell Biology, McGill University, Montre´al, Que´bec, Canada; and Division of Clinical Epidemiology, Montre´al General Hospital, Montre´al, Que´bec, Canada
OBJECTIVE: The aim of this study was to identify the independent psychosocial correlates of patient–physician discordance in adult outpatients with inflammatory bowel disease. METHODS: This cross-sectional study was conducted in three university-affiliated tertiary care settings. Psychological distress, social support, perceived stress, and negative life events were assessed, as were demographic, lifestyle, and clinical characteristics. Patient–physician discordance was assessed with 10-item questionnaires. RESULTS: Ten gastroenterologists and 200 of their patients participated. Patients and their physicians disagreed most on discussion of personal issues. Patients with Crohn’s disease had statistically significantly higher discordance on disease activity and physical limitation, as well as higher average overall discordance scores than patients with ulcerative colitis. Mean discordance levels were similar across different physicians. Higher psychological distress and more perceived stress were independently associated with higher discordance after controlling for Crohn’s disease, active disease, being with the treating physician for less than 1 yr, and recommendation for further medical investigation. Psychological distress was the most important correlate of overall discordance. CONCLUSIONS: Increased physician awareness that psychologically distressed patients have difficulty processing of clinically relevant information may lead to improved doctor–patient communication during an office visit. (Am J Gastroenterol 2002;97:2174 –2183. © 2002 by Am. Coll. of Gastroenterology)
INTRODUCTION Health perceptions impact the experience of inflammatory bowel disease (IBD) upon the individual (1). IBD is a chronic inflammatory disease of the GI tract that is characterized by periods of exacerbation and remission (2). Pa-
tients with IBD report more negative perceptions of health than do healthy subjects (3). However, although IBD patients’ perceptions of poorer health correlate with decreased functioning and greater use of health services, their perceptions do not correlate with physicians’ ratings of disease activity (4). This is not surprising given that weak associations are found among clinical symptoms, physical findings, and laboratory parameters (5). A substantial body of literature concerning various medical conditions suggests associations between greater patient–physician discordance on perceptions of health-related information and unfavorable health outcomes (6 –11), decreased patient satisfaction (12–14), decreased adherence to return appointments (11, 15), and increased use of health services (16). Patient–physician discordance is operationally defined as the difference between patient and physician ratings of the same or similar aspects of health-related information. For example, a patient and his/her physician will be asked to independently rate their own perceptions of the patient’s pain, and the degree to which the two ratings differ may be the measure of discordance. The underlying assumptions of the discordance literature are that the items assessed are essential to understanding the patient’s problem as well as to delivering appropriate treatment (10, 17), and that discordant perceptions are a result of ineffective doctor–patient communication (10, 15, 18). Physicians and patients are more likely to disagree on their perceptions of the patient’s health and the office visit when patients experience psychosocial problems (6, 7, 15, 18). In these studies, psychosocial problems have been ascertained using retrospective data from patient medical files (7, 15), questionnaires (6), and interviews (18). Some of these methods of assessment may be problematic because patients are more likely to report physical symptoms than psychosocial issues during clinical visits (19, 20), medical doctors commonly do not respond to psychosocial cues (21, 22), or recognize psychosocial issues unless they are severe (20, 23), and most doctor–patient communication focuses
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on biomedical rather than psychosocial information (24). In fact, Mitchel et al. have shown that in IBD, at least 50% of emotional problems are under-reported (25). Whereas general psychosocial concerns in the discordance studies were investigated using various indicators such as feeling depressed (18), problems with work, finances, family (7), or insufficient help from others (7), the specific patient psychosocial characteristics that may influence differences between physicians’ and patients’ perceptions have not been identified. Thus, the effects of stress (26), psychological distress (26, 27), and social support (26), which have been shown to impact physicians’ and patients’ perceptions of the patients’ health, have not been systematically studied. Furthermore, the effects of psychosocial factors on patient– physician discordance in IBD remain to be investigated. Given the link between higher discordance and unfavorable outcomes (6 –11), it may be particularly important to identify the correlates of discordance to help clinicians recognize patients at higher risk for patient–physician discrepancies. The main purpose of this study was to determine the patients’ psychosocial characteristics associated with higher discordance in IBD. Because these characteristics are potentially modifiable, elucidating the psychosocial correlates of discordance may be helpful in designing interventions that will be expected to reduce discordance, and, ultimately, improve patients’ health outcomes. In addition, by highlighting items of greater patient–physician discordance in IBD patients, these findings may indicate the specific areas to target for improved communication. Improved psychosocial functioning and better communication may lead to increased patient adherence, improved health outcomes, and more efficient use of health services (28 –34).
MATERIALS AND METHODS Study Population and Data Collection Procedures A cross-sectional study was conducted at three university hospital gastroenterology clinics in Montre´ al, Canada. Physicians affiliated with the McGill University Health Center were mailed an introductory packet of information that invited them to participate in this study. They were told that their participation would consist of completing a questionnaire on their perceptions of the patient’s health status and of the office visit immediately after a scheduled office visit with a participating patient. Intent to participate was indicated by mailing the completed survey questionnaire and consent form to the research office. Eligibility criteria for patients included age of 18 yr or older, confirmed diagnosis of Crohn’s disease or ulcerative colitis for at least 6 months, fluency in English or French, and not pregnant at recruitment. On days when the research assistant attended the clinic, IBD patients of participating physicians with scheduled appointments were approached while in the waiting room before the office visit. Written informed consent was obtained for each patient. Demographic, lifestyle, clinical, and psychosocial data were gath-
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ered before the scheduled visit. Immediately after the office visit, physicians and patients independently completed the questionnaire on perceptions. Patients provided additional information pertaining to recommended interventions such as prescription medication, scheduling of another appointment, consulting another health care professional, and medical investigation. Patients and physicians were blinded to the purpose of the study and informed that the objective was to investigate the role of psychosocial factors in the management of IBD. The research protocol was approved by the McGill University Faculty of Medicine Institutional Review Board. Instruments PATIENT–PHYSICIAN DISCORDANCE SCALE. The Patient–Physician Discordance Scale was used for assessing patient–physician discordance. The development of the new instrument and its validation are described elsewhere (35, 36). The Patient–Physician Discordance Scale is a 10-item self-report measure that uses a 10-cm visual analog scale (VAS) format for individual items. Five items assess aspects of the patient’s health status including abdominal pain, disease activity, physical functioning, psychological distress, and emotional well-being. Five other items assess aspects of the clinical visit including discussion of the main problem, discussion of personal issues, expectation of medication, expectation of further medical investigation, and patient satisfaction with the visit. The 10-item scale is completed independently by the patient and his/her physician immediately after the visit, to reflect their own perceptions of each item. Discordance is determined by calculating the difference between the patient’s and physician’s VAS ratings for each of the 10 items. Each item difference score is then standardized by dividing by the SD of the 10 patient ratings. This procedure accounts for patient “internal rating scales,” such as a preference or reluctance to endorse extreme values. Finally, the average of the absolute values of the standardized differences for the 10 items is calculated, and considered as the measure of overall discordance. This score measures the magnitude of discordance but is not influenced by whether the patient or the physician rates higher on particular items. A principal components factor analysis with orthogonal varimax rotation, which revealed that all 10 discordance items loaded above the conventional cutoff of 0.40 onto one factor, indicates a unidimensional structure of discordance (36). The Cronbach’s ␣ of 0.73 indicates satisfactory internal consistency (37). Intraclass correlation coefficients that were calculated on the 10 patient ratings ranged between 0.67 and 0.92, indicating satisfactory test–retest reliability of the patient ratings (36). For reasons of practicality, test–retest was not done for physician ratings. Disease Activity Disease activity was measured with the Harvey Bradshaw Index (38). This patient self-report scale is based upon 12
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clinical variables that can be determined at a single outpatient visit (e.g., general well-being, abdominal pain, number of liquid stools, abdominal mass presence, and eight complications) (38). Originally designed and validated for use in Crohn’s disease, the tool has also been used to measure disease activity in ulcerative colitis (39 – 41). A cutoff of 4 and above defined active disease (40, 42, 43). In this patient sample, concurrent validity between the score on the Harvey Bradshaw Index and a VAS self-report measure of disease activity was similar for Crohn’s disease and ulcerative colitis (r ⫽ 0.60 and 0.63, respectively [41]). Psychosocial Characteristics The following validated instruments were used to measure psychological distress, social support, negative life events, and perceived stress. By using multiple psychosocial measures, it was possible to determine the independent effects of the corresponding constructs on patient–physician discordance. PSYCHOLOGICAL DISTRESS. Psychological distress was assessed with the Symptom Checklist-90R, a 90-item self-report measure that assesses a variety of symptoms of distress that occurred during the past week (44). This scale does not yield psychiatric diagnoses. Psychological distress is assessed with the Global Severity Index summary score, which combines the number and intensity of symptoms. Descriptive results are reported as normalized T-scores (normative mean score ⫽ 50, SD ⫽ 10), and clinically important distress corresponds to T-scores of 63 and greater. Test–retest coefficients, obtained from 94 psychiatric outpatients with various diagnoses, were between 0.80 and 0.90 (44). The internal consistency of the Global Severity Index in our IBD patient population was very high (Cronbach’s ␣ ⫽ 0.96). SOCIAL SUPPORT. An abbreviated version of the Social Support Questionnaire (SSQ) was used to assess size of the social support network and satisfaction with social support (45, 46). The SSQ-6 consists of six two-part questions that are divided into two subscales: six items assess the number of people in the network (SSQ-N), and six measure satisfaction with perceived available support (SSQ-S). The two subscales can be examined separately because they are only moderately intercorrelated (45). Scores on the SSQ-S subscale range from 1 to 6, with higher scores indicating greater satisfaction. SSQ-N ranges from 0 to 9, higher scores reflecting a larger social support network. Test–retest reliability, determined in 182 university undergraduates, was high with correlations of 0.84 for Number and 0.85 for Satisfaction (45). The Cronbach’s ␣s of 0.89 (SSQ-N) and 0.88 (SSQ-S) indicate high internal consistency in our IBD sample. NEGATIVE LIFE EVENTS. The Weekly Stress Inventory (WSI) is a self-report measure that assesses minor events experienced during the past week (47). Respondents are asked to check 87 items on whether the events occurred in
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the past week and to rate the intensity of resulting stress on a 7-point Likert scale. Worked late, experienced car trouble, and heard some bad news are examples of events included in the questionnaire. The WSI yields two scores: 1) the WSI-Event (WSI-E), the number of events that occurred, and 2) the WSI-Impact (WSI-I), the impact, which is derived by summing the perceived stress ratings. High scores indicate more events and greater negative impact from the events, respectively. Test–retest reliability coefficients were moderately high for the WSI-Event (r ⫽ 0.83) and the WSI-Impact (r ⫽ 0.80) when subjects were tested within the same week, but coefficients declined with the passage of time (48). The Cronbach’s ␣ was 0.96 for the WSI-I and 0.95 for the WSI-E for our patients with IBD, indicating very high internal consistency. PERCEIVED STRESS. Perceived stress was assessed with the Perceived Stress Scale, a 10-item measure of the degree to which respondents appraise stressful situations that occurred during the past month (49). The instrument was developed for use in community samples; items are scored on a 5-point scale from 0 to 4 (49). The total score provides a global measurement of the extent to which an individual feels overwhelmed by stressful situations that occurred in the past month. Total scores range from 0 to 40; higher scores indicate greater perceived stress (49). Test–retest reliability at 2 days and 6 wk was 0.85 and 0.55, respectively (50). Internal consistency in our sample was high (␣ ⫽ 0.86). Covariates Other potential correlates of discordance were assessed. Patient characteristics were ascertained before the office visit, and included age, gender, language (English/French), education, smoking status, form of IBD, level of disease activity, time since diagnosis, time under current physician’s care, duration of the visit, psychological distress, perceived stress, social support, and negative life events. Recommended interventions were assessed immediately after the visit using binary indicators for prescription medication, scheduling another appointment, consulting another health care professional, and further medical investigation. The extent to which the patient expected the prescribed medication to positively affect health was assessed after the office visit using a 100-mm VAS response format question, “how certain are you that the prescribed medication will have a positive effect on your health?” Statistical Analyses Descriptive statistics were used to characterize the study population. Demographic, clinical, and psychosocial characteristics of patients with Crohn’s disease and ulcerative colitis were compared using t tests and 2 analyses as appropriate. Multiple linear regression was used to determine whether there were statistically significant differences in mean discordance scores between physicians. A mixed model for unbalanced repeated measures analysis of variance approach was used to determine the independent cor-
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relates of discordance. This technique handles continuous dependent variables (patient–physician discordance) and accounts for 1) clustering of patients within physicians’ practices, and for 2) the unbalanced design, as the number of patients varies from physician to physician (51). We assumed that the exchangeable covariance structure of errors would account for the dependence of observations on the different patients of same physician and used the Akaike’s Information Criterion (52) for comparison with alternative covariance structures. The Akaike’s Information Criterion is one method of model selection such that the lower Akaike’s Information Criterion indicates a better fit (52). Smoking (current and past smoker compared with never smoker) was represented by two dummy variables. A priori, we decided to dichotomize time under current physician’s care at 1 yr to assess the effect of being a new patient of the treating physician. A logarithmic transformation was performed on time since diagnosis because it was not normally distributed. SSQ-S was skewed toward higher values and dichotomized at 6 (highest value), SSQ-N was dichotomized at 3 (mediansplit), and WSI-I at 105.4 (normative value). Statistical significance was set at 0.05. Statistical analyses were performed with the SAS System (SAS Institute Inc., Cary, NC) for Windows 6.12 software.
RESULTS Response Rates Ten of the 11 (90.9%) physicians invited to participate in this study agreed and provided data on at least one patient. One physician did not complete the Patient–Physician Discordance Scale questionnaires on seven patients. Two hundred of the 207 (96.1%) eligible patients approached to participate gave their consent. Two (1%) of these patients did not complete all the psychosocial questionnaires. Complete data were available for 191 (95.5%) patient–physician pairs. One physician provided 71 patients, three provided between 20 and 35, two furnished between 10 and 19, and four physicians contributed less than three patients each.
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another health care professional. At the office visit, most patients were asked to schedule a follow-up appointment and received prescriptions for pharmacotherapy. Half the patients were told they needed further medical investigation, and relatively few were advised to consult another health care professional. Patients’ psychosocial characteristics were similar for Crohn’s disease and ulcerative colitis. Pearson correlations between the psychosocial variables are presented in Table 2. With the exception of size of the support network, all variables showed statistically significantly correlations with each other. Coefficients ranged from r ⫽ 0.16 for the pairwise relationship between number of stressful events and size of the social support network to r ⫽ 0.63 for the pairwise relationship between impact and number of stressful events. Discordance Scores Descriptive statistics for the distributions of the 10 itemspecific discordance scores and overall discordance are presented in Table 3, separately for each form of IBD. Discordance was highest for discussion of personal issues and lowest for patient satisfaction. Patients with Crohn’s disease had statistically significantly higher mean discordance scores on disease activity, physical limitation, patient satisfaction, and overall discordance than those with ulcerative colitis. Pairwise correlations among the 10 item-specific discordance scores, although often statistically significant, were all below r ⫽ 0.4, indicating less than 15% of variance overlap (data not shown). Patient–physician discordance on abdominal pain was significantly correlated with all other nine discordance items, indicating that higher discordance on abdominal pain was associated with higher discordance on all other aspects of health and the clinical visit (data not shown).
Physicians’ Characteristics The median age of physicians was 47.9 yr (range 30.1– 66.6), and the majority were men. The median number of years of experience in treating patients with IBD was 16.5 yr (range 3–30). Physicians reported seeing a median of 10 (range 1–35) patients with IBD per week.
Effect of Individual Physicians on Discordance A multiple linear regression model was built to determine whether there were statistically significant differences in discordance scores between physicians. Using discordance as the outcome, there were no statistically significant differences in mean overall discordance between the six physicians who each contributed more than 10 patients (overall F ⫽ 1.30). Indeed, the mean overall discordance scores among the six physicians were very similar (p ⫽ 0.2647), ranging from 0.59 to 0.77 (data not shown).
Patients’ Characteristics Table 1 presents the demographic, lifestyle, clinical, and psychosocial characteristics of the 191 patients included in the analyses, and compares 132 Crohn’s disease with 59 ulcerative colitis patients. Mean age was 36.6 yr, and 113 (59.2%) patients were women. Patients with ulcerative colitis were more likely to be women, married, or living with a partner, and those with Crohn’s disease were more likely to have active disease, have had previous IBD-related surgery, and have received the recommendation to consult with
Bivariate Associations With Patient–Physician Discordance Crude relationships between each demographic, clinical, psychosocial, and treatment variable and discordance were evaluated using simple linear regression. As shown in Table 4, Crohn’s disease, active disease, being a new patient of the treating physician, and less certainty that medication would positively affect health, as well as recommendations for further medical investigation, pharmacotherapy, and consultation with another health care professional were associated
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Table 1. Characteristics of the Cohort and Comparison of Crohn’s Disease With Ulcerative Colitis Patients (N ⫽ 191) IBD (n ⫽ 191) N (%)
Characteristic Demographic and lifestyle Age in yr (mean, SD) Female* French speaking Education High school and less Junior college University and higher Civil status* Single Married/living with partner Widowed/divorced/separated Smoking status* Current Ex Never Clinical Median yr under doctor’s care (IQR) Median yr since diagnosis (IQR) Active disease* Previous IBD-related surgery* Duration of office visit† (min) (mean, SD) Recommended intervention Prescribed medication Further medical investigation Schedule follow-up appointment Consult another health care professional* Psychosocial Psychologically distressed Perceived stress (mean, SD) High satisfaction with social support Size of social support network (mean, SD) Number of stressful events (mean, SD) High impact of stressful events
CD (n ⫽ 132) N (%)
UC (n ⫽ 59) N (%)
36.6 (14.9) 113 (59.2) 62 (32.5)
35.4 (15.4) 69 (52.3) 43 (32.9)
39.3 (13.6) 44 (74.6) 19 (32.2)
61 (31.9) 58 (30.4) 72 (37.7)
46 (34.9) 42 (31.8) 44 (33.3)
15 (25.4) 16 (27.1) 28 (47.5)
90 (47.1) 87 (45.5) 14 (7.3)
73 (55.3) 49 (37.1) 10 (7.6)
17 (28.8) 38 (64.4) 4 (6.8)
54 (28.3) 54 (28.3) 83 (43.5)
46 (34.9) 31 (23.5) 55 (41.7)
8 (13.6) 23 (39.0) 28 (47.5)
3.0 (1.5–6) 8.4 (4.1–15.9) 105 (55.0) 89 (46.6) 16.6 (11.0)
3.0 (1.5–6) 8.4 (4.1–15.9) 82 (62.1) 84 (63.6) 16.4 (11.0)
3.0 (1–7) 7.2 (4.4–14.0) 23 (39.0) 5 (8.5) 17.0 (10.9)
158 (82.7) 106 (55.8) 150 (78.5) 35 (18.4)
106 (80.3) 71 (54.2) 104 (78.8) 32 (24.4)
52 (88.1) 35 (59.3) 46 (78.0) 3 (5.1)
73 (38.2) 17.3 (7.1) 64 (33.5) 3.4 (1.8) 26.5 (16.2) 43 (22.5)
48 (36.4) 16.9 (7.4) 43 (32.6) 3.3 (1.8) 25.8 (15.8) 29 (22.0)
25 (42.4) 18.3 (6.6) 21 (35.6) 3.6 (1.8) 23.5 (17.0) 14 (23.7)
CD ⫽ Crohn’s disease; IQR ⫽ interquartile range; UC ⫽ ulcerative colitis. * p ⬍ 0.05 for comparison between CD and UC patients based on unequal groups; t test for continuous and 2 test for categorical variables. † Visit duration based on the patient’s perception, which was moderately correlated (r ⫽ 0.52, p ⫽ 0.0001) with the physician’s perception of the visit (mean ⫽ 16.3, SD ⫽ 6.4).
with statistically significantly higher patient–physician discordance because the corresponding 95% confidence intervals excluded 0. There were also statistically significant associations between higher psychological distress, more perceived stress, lower satisfaction with social support, and greater number and impact of stressful life events, and higher discordance. However, given the complex problem of intercorrelations between different psychosocial vari-
ables, these crude associations might have been affected by confounding bias (53). Independent Associations With Patient–Physician Discordance To identify the independent correlates of patient–physician discordance, we used a mixed linear models approach for clustered data. As shown in Table 5, higher psychological
Table 2. Pearson Correlations Between Psychosocial Variables (N ⫽ 191) 1 1. 2. 3. 4. 5. 6.
Psychological distress Perceived stress High satisfaction with social support Size of social support network Number of stressful events High impact of stressful events
* p ⬎ 0.05. † p ⬎ 0.01. ‡ p ⬎ 0.001.
0.61‡ ⫺0.28‡ ⫺0.03 0.56‡ 0.60‡
2
⫺0.16* ⫺0.11 0.27† 0.33‡
3
0.08 ⫺0.34‡ ⫺0.22*
4
5
0.16* 0.05
0.63‡
6
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Table 3. Descriptive Statistics for Item Discordance Scores for PPDS and Comparison of Means for CD and UC Using Wilcoxon Rank Sum Testing PPDS
IBD (N ⫽ 191)
Items and Total
Mean (SD)
Median
Abdominal pain Disease activity† Physical limitation* Psychological distress Emotional well-being Problem discussed Personal issues discussed Expect medication Expect testing Patient satisfaction* Overall discordance†
0.51 (0.69) 0.63 (0.62) 0.66 (0.66) 0.74 (0.65) 0.69 (0.63) 0.55 (0.63) 1.07 (0.85) 0.82 (0.95) 0.94 (1.02) 0.44 (0.46) 0.70 (0.39)
0.25 0.43 0.44 0.54 0.53 0.32 0.89 0.41 0.62 0.31 0.64
CD (N ⫽ 132)
UC (N ⫽ 59)
Range
Mean (SD)
Mean (SD)
0–4.07 0–2.62 0–2.95 0–3.38 0–3.51 0–3.71 0–3.32 0–5.28 0–5.61 0–2.51 0.04–2.65
0.51 (0.67) 0.70 (0.62) 0.69 (0.66) 0.76 (0.69) 0.71 (0.64) 0.58 (0.67) 1.14 (0.83) 0.90 (1.01) 1.01 (1.08) 0.49 (0.49) 0.75 (0.39)
0.43 (0.63) 0.46 (0.58) 0.55 (0.65) 0.68 (0.57) 0.61 (0.52) 0.47 (0.51) 0.93 (0.86) 0.60 (0.75) 0.81 (0.88) 0.34 (0.36) 0.59 (0.34)
CD ⫽ Crohn’s disease; PPDS ⫽ Patient–Physician Discordance Scale; UC ⫽ ulcerative colitis. Each item on the PPDS is measured on a 10-cm visual analog scale (VAS) and the theoretical range of discordance scores, calculated as (patient VAS–physician VAS) ratings is ⫺10.0 to ⫹10.0. Overall discordance is calculated as the mean of the sum of the 10 VAS ratings. * p ⬍ 0.05. † p ⬍ 0.01 for the comparison of CD vs UC patients based on the Wilcoxon rank sum tests.
distress, higher perceived stress, Crohn’s disease, active disease, being a new patient of the treating physician, and recommendations for further medical investigation had statistically significant independent effects on patient–physician discordance, and each was associated with higher discordance. A multiple linear regression model indicated that of all of these variables, psychological distress explained the highest proportion of variance in discordance (12.5%) (data not shown). In contrast to the unadjusted bivariate analyses,
social support and stressful events were not independently associated with discordance, once adjusted for psychological distress and perceived stress.
DISCUSSION The study findings support a relationship between patient psychosocial characteristics and discordance in IBD. Higher psychological distress and higher perceived stress were in-
Table 4. Results of Selected Separate Bivariate Linear Regression Models for Patient–Physician Discordance Bivariate Models Demographic and lifestyle Age Female French speaking Clinical Active disease (Yes/No)* Crohn’s disease (Yes/No)* Yr since diagnosis New patient of treating physician*† Certain that medication will have positive effect (n ⫽ 172)* Psychosocial Psychological distress* Perceived stress* Low satisfaction with social support* Social support network size Number of stress events* High impact of stress events* Recommended intervention Prescribed medication* Further medical investigation* Schedule follow-up appointment Consult another health professional*

95% CI
⫺0.002 0.034 0.101
(⫺0.006–0.001) (⫺0.145–0.076) (⫺0.009–0.221)
0.230 0.158 ⫺0.019 0.148 ⫺0.003
(0.126–0.334) (0.043–0.274) (⫺0.078–0.040) (0.021–0.275) (⫺0.005–⫺0.001)
0.304 0.016 0.135 0.055 0.005 0.250
(0.190–0.418) (0.009–0.023) (0.021–0.248) (⫺0.053–0.164) (0.001–0.008) (0.125–0.375)
0.159 0.120 0.125 0.184
(0.015–0.303) (0.011–0.230) (⫺0.006–0.256) (0.046–0.322)
 represents the estimated difference in discordance scores between the two categories of a binary variable or a change in discordance associated with a unit increase in the quantitative variables, adjusted for all other variables listed above. * Statistically significant (p ⬍ 0.05). † New patient defined as being with the current physician for 1 yr or less (N ⫽ 46).
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Table 5. Results of Multivariable Mixed Model for Unbalanced Repeated Measures Analysis of Variance for Independent Correlates of Patient-Physician Discordance Variable

95% CI
p
Active disease Crohn’s disease New patient of treating physician* Psychological distress Perceived stress Further medical investigation Intercept
0.141 0.165 0.139 0.158 0.010 0.108 0.691
(0.039–0.244) (0.058–0.272) (0.024–0.253) (0.014–0.302) (0.001–0.018) (0.010–0.206) (0.414–0.967)
0.0072 0.0028 0.0178 0.0323 0.0264 0.0317 0.0003
 represents the estimated difference in discordance scores between the two categories of a binary variable or a change in discordance associated with a unit increase in the quantitative variables, adjusted for all other variables listed above. * New patient defined as being with the current physician for 1 yr or less.
dependently associated with higher patient–physician discordance even after controlling for clinical variables. The independent contributions of psychological distress and perceived stress found in the present study indicate that they affect discordance through different mechanisms. These results provide evidence that the relationship between psychosocial problems and greater discordance that has been reported in other clinical settings (7, 15) occurs also in IBD. By directly assessing patients’ levels of psychological distress, perceived stress, social support, and negative life events and employing multivariable statistical analyses, we were able to evaluate the effect of each variable for its independent association with patient–physician discordance, while reducing the risk of confounding bias. Further, by restricting the clinical population to patients with IBD, an association between disease severity and discordance was found, which was not distorted by the heterogeneous grouping together of patients with various medical conditions, a situation that likely influenced the results of other discordance studies that were conducted mainly in primary care settings (6 –9, 13, 15–18, 54, 55). Discussion of personal issues showed the highest average discordance of all 10-scale items. We found that, compared to their IBD patients, physicians, on average, overestimated the extent to which personal issues were discussed. This was not surprising given that under-reporting (6, 19, 23) and underdetecting (20, 23) of psychosocial issues are consistently reported in the literature. Indeed, Mitchel et al. (25) reported that patients with IBD do not voluntarily admit psychosocial problems. Yet, the average visit duration reported in the present study, 16.6 min, may not be sufficient for adequate discussion of psychosocial issues. As suggested by Robinson and Roter (56) in their study in primary care, visits during which psychosocial issues were disclosed and counseled took, on average, more time (mean ⫽ 18.9 min) than visits with disclosure of psychosocial problems (mean ⫽ 16.5 min) and visits without disclosure (mean ⫽ 12.6 min). Although the average discordance score on abdominal pain was not high, agreement on this item may be critical to establishing similar patient–physician perceptions because discordance on abdominal pain was significantly related to discordance on the other nine items. Our results partially corroborate with those of other in-
vestigators. Similar to Lieberman et al. (14), who studied patients with other medical conditions, we found associations between greater patient–physician discordance and increased disease severity. Similar to investigators who studied different clinical populations, no links were found between discordance and patient demographic characteristics (54), patient education (54), other socioeconomic variables (15), or a continuous variable representing the duration under the care of a given physician (54). However, the binary indicator of new versus established patient status was found to be associated with higher discordance, indicating that patients seen by the current physician for less than 1 yr were at risk of higher discordance than were patients with more established relationships. Intuitively, most of the psychosocial variables included in this study were a priori expected to be related to patient– physician discordance. Indeed, the bivariate analyses indicated that higher discordance was statistically significantly related to increased psychological distress, greater perceived stress, lower satisfaction with social support, and increased number and impact of negative life events. However, intercorrelations between different psychosocial variables might have biased the results of some of these unadjusted analyses by creating spurious associations (53). Indeed, in the multivariable model, only perceived stress and psychological distress remained statistically significant independent correlates of discordance, with psychological distress being the single most important explanatory variable. It may be that stressful events and social support lose their effects after adjustment for psychological distress and perceived stress because what matters most are the subjective perceptions rather than the objective events. The clinical implication is that it may be beneficial for physicians to detect psychological distress in their patients with IBD because psychologically distressed patients seem to have difficulty processing information. Physicians need to spend more time explaining disease and treatment-related issues to these patients and getting their feedback in an attempt to reduce discordance, and, thus, possibly improve treatment adherence and ultimate clinical outcomes. Neither physicians nor patients in this study could be considered a truly random sample. For practical reasons, patient recruitment occurred only on the days when the
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research assistant attended the clinic, and patients who visited their physicians more often were more likely to have been included in the study. If frequent attenders were more in agreement with their physicians, this may have resulted in an underestimate of the level of discordance. However, it is unlikely to have affected our results, which pertained to correlates of discordance. Language may have potentially affected our results given that discordance was evaluated in English and French and that discordance was assumed to result from doctor–patient communication. However, variability in language was restricted to patients, as French was the mother tongue of only one of the six physicians who contributed more than one patient to this study. Patient language was accounted for during the model-building stages and was not found to be statistically significantly related to discordance. Therefore, the effect of patient language on level of discordance appears to be minimal. Given the lack of a single measure of disease activity that has been validated for both Crohn’s disease and ulcerative colitis, there were several concerns regarding the appropriate measure. The major concern was that it is inappropriate to use different measures of disease activity for different subgroups of patients (e.g., ulcerative colitis and Crohn’s disease) in one statistical analysis. The Harvey Bradshaw Index was considered the necessary, albeit, imperfect way for measuring disease activity for all patients, regardless of the form of IBD, for several reasons. Firstly, the Crohn’s Disease Activity Index requires completion of a 7-day diary (57), and it would have been impossible to obtain a measurement of disease activity at the time of patient recruitment. Secondly, we have previously demonstrated that three symptoms on the Crohn’s Disease Activity Index and the Harvey Bradshaw (e.g., well-being, frequency of stools, and abdominal pain) contribute most heavily to disease activity in both ulcerative colitis and Crohn’s disease patients (41). Third, data from both external sources (40) and from this study sample (41), which suggest that the concurrent validity of the Harvey Bradshaw measure of disease activity for ulcerative colitis is approximately the same as for Crohn’s disease, supported the use of the Harvey Bradshaw in patients with both forms of IBD. Thus, data derived both externally and internally support the use of the Harvey Bradshaw in patients with both forms of IBD. A second drawback inherent in the present study is the cross-sectional study design in which all of the variables were assessed at the index visit. This precludes determining the direction of causality because it is difficult to separate cause and effect when assessments of exposure and outcome are performed at the same time (58). Nevertheless, with the exception of social support, the psychosocial variables were measured based on questions about feelings or events experienced during the past week or month. Because patient– physician discordance was assessed subsequent to measuring patient psychosocial characteristics and is a product of the clinical visit, and given that both patients and physicians
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were blinded to the study hypothesis, the influence of information bias was minimized. Therefore, the current study corroborates the hypothesis that the patient’s psychosocial characteristics influence the level of patient–physician discordance. One of the strengths of this study is the assessment of global patient–physician discordance. Prior research, which had been hampered by the absence of a standardized and validated measure (6 –10, 13–18, 54, 55, 59), evaluated discordance on various single items, which may have limited comparability and relevance of the results. Future discordance research may evaluate ways in which discordance might be used to improve health outcomes. The effectiveness of an intervention aimed at improving, for example, patient adherence through improved communication with physicians, in which patients with higher discordance scores are contacted soon after an office visit in an attempt to reduce discrepancies, could be tested in a randomized clinical trial. Future research may also include determining the relationship between discordance and resource use given that discordance beyond a particular level may lead to doctor shopping.
CONCLUSION In conclusion, increased psychological distress and higher perceived stress are associated with higher patient–physician discordance in IBD. On the one hand, these results corroborate the associations between patient psychosocial variables and higher discordance that are found in other medical conditions. On the other hand, these findings may help clinicians who treat patients with IBD to identify specific psychosocial characteristics most likely to be found in patients at higher risk of discordance. Higher psychological distress was the most important correlate of higher discordance after controlling for active disease, new patient status and Crohn’s disease. The suggestion that psychologically distressed patients have difficulty processing information may raise physicians’ awareness of the importance of detecting psychological distress in their patients, and, ultimately, lead to improved communication during an office visit.
ACKNOWLEDGMENTS This study was done at the Division of Clinical Epidemiology, Montre´ al General Hospital, Montre´ al, Que´ bec, Canada. This study has come out in the Department of Epidemiology and Biostatistics of McGill University, as a part of the Ph.D. research of the first author. This research was made possible through financial support from the McGill University Social Sciences and Humanities Committee and the Montre´ al General Hospital Research Institute. Maida J. Sewitch, Ph.D., is currently supported as a postdoctoral fellow by the Canadian Institutes of Health
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Research. During this study, she was supported by Health Canada through a National Health Research and Development Program Ph.D. research training fellowship and by the Fonds de Recherche en Sante´ du Que´ bec (FRSQ) through a Ph.D. health professional training fellowship. Michal Abrahamowicz, Ph.D., is supported as a Scientist by the Canadian Institutes of Health Research. Alain Bitton, M.D., F.R.C.P.(C), is supported as a Junior Clinician Researcher by the FRSQ. Gary E. Wild, M.D., Ph.D., F.R.C.P.(C), is supported as a Senior Clinician Scientist by the FRSQ. Patricia L. Dobkin, Ph.D., is a FRSQ Senior Career Awardee. Reprint requests and correspondence: Maida J. Sewitch, Ph.D., Groupe de Recherche Interdisciplinaire en Sante´ , Faculty of Medicine, University of Montre´ al, C.P. 6128, succ. Centre-ville, Montre´ al, Que´ bec, Canada, H3C 3J7. Received Nov. 6, 2001; accepted Apr. 2, 2002.
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