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Differing Views on Disease Severity Linked to Worse Symptoms, QOL in Psoriasis, Eczema

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By identifying modifiable factors that contribute to differing opinions between patients and physicians regarding the patient’s disease severity, a phenomenon known as discordant severity grading (DSG), researchers found that positive discordance was associated with higher symptom expression and greater quality of life (QOL) impairment among individuals who have psoriasis and eczema.

This cross-sectional study is published in JAMA Dermatology.

“Measures of behavioral, cognitive, and psychological factors are not routinely collected and are thus less readily available,” wrote the study researchers. “However, many of these factors are modifiable and provide a framework for subsequent intervention.”

In the study, the researchers aimed to gain a better understanding of the factors that contribute to differing perceptions on disease severity between patients and physicians and provide direction for the implementation of cognitive behavior interventions that could bridge this discordance. They tested and validated a model with the objective of explaining the cognitive, behavioral, and disease factors associated with DSG. The qualitative theoretical model was validated using structural equation modeling (SEM).

Patients (n = 1057) and their attending physicians (n = 44) were recruited from 3 outpatient dermatological centers in Singapore between October 2021 and September 2022. These patients were aged 18 to 99 years and had been living with psoriasis or eczema for at least 3 months. The data for these patients were analyzed from October 2022 to May 2023.

The primary outcome of the study was a difference in global disease severity scores, which are measured on a scale from 0 to 10—with higher scores indicating greater severity—between the patient and the dermatologist. Positive discordance was defined as a patient-graded severity of 2 points higher than that of the physician, and negative discordance was if a patient's ratng was 2 points lower than the physician.

Of the total patients enrolled, 4 withdrew from the study, leaving 1053 patient-physician pairs available for analysis, in which the mean (SD) age of patients was 43.5 (17.5) years. Additionally, 579 (55%) were male, 802 (76.2%) had eczema, and 251 (23.8%) had psoriasis.

Of the physicians enrolled, 20 (45.5%) were male, 24 (54.5%) were aged 31 to 40 years, 20 (45.5%) were senior residents or fellows, and 14 (31.8%) were consultants or attending physicians. Additionally, the median (IQR) number of patients recruited was 5 (2-18) patients per physician.

A positive discordance was associated with higher symptom expression (standardized coefficient B = 0.12; P = .02) and greater QOL impairment (B = 0.31; P < .001), but not patient or physician demographics.

Furthermore, higher QOL was associated with lower resilience and stability (B = -0.23; P = .02), 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 researchers acknowledged some limitations to the study, including potential sampling bias and having no existing scale for measuring or defining DGS. Despite these limitations, the researchers believe the study highlights the importance of recognizing and understanding the multivariable factors that contribute to discordance in perceptions of disease severity among physicians and patients with psoriasis and eczema.

“This study brings to the surface key lessons for dermatologists—that many reasons for discordance are, in fact, modifiable,” wrote the researchers. "This paves the way for further interventional work in this area and should be points of focus for the practicing physician.”


Long V, Chen Z, Du R, et al. Understanding discordant perceptions of disease severity between physicians and patients with eczema and psoriasis using structural equation modeling. JAMA Dermatology. 2023;159(8):811-819. doi:10.1001/jamadermatol.2023.2008

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Schedule15 Jun 2024