# Discordance between Patient and Physician Global Assessments of Psoriatic Arthritis Activity: An Observational Study in 13 Arab Countries Running head: Patient-Physician Discordance in PsA Activity in Arab Countries

Noura Abbas, Ihsane Hmamouchi, Lina El Kibbi, Avin Maroof, Bassel Elzorkany, Nizar Abdulateef, Asal Adnan, Nabaa Ihsan, Faiq Isho Gorial, Nada Al Chama, et al.

► To cite this version:

Noura Abbas, Ihsane Hmamouchi, Lina El Kibbi, Avin Maroof, Bassel Elzorkany, et al.. Discordance between Patient and Physician Global Assessments of Psoriatic Arthritis Activity: An Observational Study in 13 Arab Countries Running head: Patient-Physician Discordance in PsA Activity in Arab Countries. Rheumatology International, 2025, 45 (4), pp.70. 10.1007/s00296-025-05819-1. hal-05001021

HAL Id: hal-05001021

https://hal.science/hal-05001021v1

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<figure><img src="image_1.png" /></figure>
# Discordance between Patient and Physician Global Assessments of Psoriatic Arthritis Activity: An Observational Study in 13 Arab Countries

Running head: Patient-Physician Discordance in PsA Activity in Arab Countries

## Patient-physician discordance in PsA activity assessment is lower in Arab countries compared to other regions

538 PsA patients

58.9% females

Age 45.5±13.2 years

PsA duration 8.8±7.3 years

<figure><img src="image_2.png" /></figure>

PGA 4.7±2.5; PhGA 4.0±2.4

Absolute difference 1.3±1.4

→ High correlation PGA & PhGA (r=0.74)

DAPSA 19.3±16.1

PsAID 3.9±2.3

HAQ 1.1±0.8

Positive FiRST 102 (19.0%)

<figure><img src="image_3.png" /></figure>

<figure><img src="image_4.png" /></figure>

<figure><img src="image_5.png" /></figure>

Discordance was low in
Arab countries (15.6%).

Positive discordance was
associated with PhGA of PsA
activity, disease activity,
fibromyalgia, and PsA impact.

<figure><img src="image_6.png" /></figure>

Discordance was primarily
identified in patients with
moderate disease activity.

Abbas N et al. Discordance between Patient and Physician Global Assessments of Psoriatic Arthritis Activity: An Observational Study in 13 Arab Countries. Arthritis Care Res (Hoboken) 2023.

Arthritis Care & Research

AMERICAN COLLEGE
of RHEUMATOLOGY
Empowering Rheumatology Professionals

## Authors

Noura Abbas MD, Ihsane Hmamouchi MD PhD, Lina El Kibbi MD, Avin Maroof MD, Bassel Elzorkany MD PhD, Nizar Abdulateef MD PhD, Asal Adnan MD, Nabaa Ihsan MD, Faiq Isho Gorial MD PhD, Nada Al Chama MD, Chafika Haouichat MD, Fatima Alnaimat MD, Suad Hannawi MD PhD, Saed Atawnah MD, Hussein Halabi MD PhD, Manal Al Mashaleh MD, Laila Aljazwi MD, Ahmed Abogamal MD PhD, Laila Ayoub MD, Elyes Bouajina MD, Rachid Bahiri MD PhD, Sahar Saad MD, Maha Sabkar MD, Krystel Aouad MD, Nelly Ziadé MD PhD*, Laure Gossec MD PhD*

## Affiliations

<table><thead><tr><td>Author</td><td>Affiliation</td><td>Email</td></tr></thead><tbody><tr><td>Noura Abbas, MD</td><td>Saint-Joseph University and Hotel-Dieu de France Hospital, Beirut, Lebanon</td><td>noura.abbas@hotmail.com</td></tr><tr><td>Ihsane Hmamouchi, MD PhD</td><td>International University of Rabat (UIR), Faculty of Medicine, Health Sciences Research Center (CReSS), Rabat, Morocco; Rheumatology Unit, Temara Provincial Hospital, Temara, Morocco.</td><td>ihsane.hmamouchi@gmail.com</td></tr><tr><td>Lina El Kibbi, MD</td><td>Division of Rheumatology, Department of Internal Medicine, Specialized Medical Centre, Riyadh, Saudi</td><td>linakibbe@gmail.com</td></tr></tbody></table>
<table><tr><td>Avin Maroof, MD</td><td>Arabia<br/>University of Kurdistan-Hewler (UKH) School of Medicine; and Rizgary Hospital Erbil, Iraq</td><td>avinmaroof@gmail.com</td></tr><tr><td>Bassel Elzorkany, MD PhD</td><td>Rheumatology Department, Cairo University, Egypt</td><td>basselelzorkany@gmail.com</td></tr><tr><td>Nizar Abdulateef, MD PhD</td><td>Rheumatology Unit, Department of Medicine, College of Medicine, University of Baghdad, Baghdad, Iraq</td><td>nazarlateef@yahoo.com</td></tr><tr><td>Asal Adnan, MD</td><td>Baghdad Teaching Hospital, Baghdad Medical City, Baghdad, Iraq</td><td>asaladnan1987@gmail.com</td></tr><tr><td>Nabaa Ihsan, MD</td><td>Baghdad Teaching Hospital, Baghdad Medical City, Baghdad, Iraq.</td><td>dr.nabaaihsan@yahoo.com</td></tr><tr><td>Faiq Isho Gorial, MD PhD</td><td>Rheumatology Unit, Department of Medicine, College of Medicine, University of Baghdad, Baghdad, Iraq</td><td>faiqig@gmail.com</td></tr><tr><td>Nada Al Chama, MD</td><td>Rheumatology Department, Ibn Al-Nafees Hospital, Damascus, Syria</td><td>nada_alshamaa@yahoo.com</td></tr><tr><td>Chafika Haouichat, MD</td><td>Rheumatology Department, Djilali Bounaama University Hospital, Khemis Miliana, Douera, Algiers. Faculty of Medicine El Mahdi Si Ahmed. Blida, Algeria</td><td>chaouichat@yahoo.fr</td></tr><tr><td>Fatima Alnaimat, MD</td><td>Division of Rheumatology, Department of Medicine, The University of Jordan, Amman, Jordan</td><td>falnaimat@yahoo.com</td></tr><tr><td>Suad Hannawi, MD PhD</td><td>Rheumatology Department, Emirates Health Services, Ministry of Health and Prevention, Dubai, United Arab Emirates, UAE</td><td>suadhannawi@gmail.com</td></tr><tr><td>Saed Atawnah, MD</td><td>Al-Quds University, Al-Ahli Hospital, Hebron, Palestine</td><td>atawnahsaed@gmail.com</td></tr><tr><td>Hussein Halabi, MD PhD</td><td>Section of Rheumatology, Department of Internal Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia</td><td>mfasel@gmail.com</td></tr><tr><td>Manal Al Mashaleh, MD</td><td>Rheumatology Division of Internal Medicine, King Hussein Medical Centre, Royal Medical Services. Jordan Armed Forces, Jordan</td><td>manal_mashaleh@yahoo.com</td></tr><tr><td>Laila Aljazwi, MD</td><td>Tripoli Central Hospital, Tripoli, Libya</td><td>aljazye.lm30@gmail.com</td></tr><tr><td>Ahmed Abogamal, MD PhD</td><td>Dr Sulaiman Al Habib Hospital, Al-Azhar Faculty of Medicine, Dubai, UAE</td><td>ahmedfathy15@yahoo.com</td></tr><tr><td>Laila Ayoub, MD</td><td>Rheumatology Unit, Department of Internal Medicine, Tripoli Central Hospital. Faculty of Medicine, University of Tripoli, Libya</td><td>laila_ayoub21@yahoo.ca</td></tr><tr><td>Elyes Bouajina, MD</td><td>Farhat Hached Hospital of Sousse, Tunisia</td><td>elyes.bouajina@rns.tn</td></tr><tr><td>Rachid Bahiri, MD PhD</td><td>El Ayachi Hospital, Medical University Hospital, Rabat, Morocco</td><td>bahirirachid@yahoo.fr</td></tr><tr><td>Sahar Saad, MD</td><td>King Hamad University Hospital Bahrain, Assiut Medical School of Egypt</td><td>saharsaad68@gmail.com</td></tr></table>
<table><tr><td>Maha Sabkar, MD</td><td>King Hamad University Hospital, Bahrain</td><td>maha.sabkar@khuh.org.bh</td></tr><tr><td>Krystel Aouad, MD</td><td>Saint George Hospital University Medical Centre, Saint George University of Beirut, Lebanon</td><td>krystel.aouad@hotmail.com</td></tr><tr><td>Nelly Ziadé, MD PhD</td><td>Saint-Joseph University and Hotel-Dieu de France Hospital, Beirut, Lebanon</td><td>nellziade@yahoo.fr</td></tr><tr><td>Laure Gossec, MD PhD</td><td>1. Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France<br>2. AP-HP, Pitié-Salpêtrière Hospital, Rheumatology Department, Paris, France</td><td>laure.gossec@aphp.fr</td></tr></table>

* NZ and LG were co-senior authors and contributed equally to this work.

Corresponding author: Noura Abbas

Address: Saint-Joseph University and Hotel-Dieu de France Hospital, Beirut, Lebanon

Phone number: +961 71 867 169

E-mail address: [noura.abbas@hotmail.com](mailto:noura.abbas@hotmail.com)
ORCID IDs

<table><thead><tr><td>Author</td><td>ORCID-ID</td></tr></thead><tbody><tr><td>Noura Abbas</td><td>0000-0003-2894-4524</td></tr><tr><td>Ihsane Hmamouchi</td><td>0000-0003-4402-5034</td></tr><tr><td>Lina El Kibbi</td><td>0000-0003-1710-9996</td></tr><tr><td>Avin Maroof</td><td>0000-0002-6554-5314</td></tr><tr><td>Bassel Elzorkany</td><td>0000-0003-2704-9712</td></tr><tr><td>Nizar Abdulateef</td><td>0000-0003-0659-8130</td></tr><tr><td>Asal Adnan</td><td>0000-0001-9140-5860</td></tr><tr><td>Nabaa Ihsan</td><td>0000-0002-7634-0146</td></tr><tr><td>Faiq Isho Gorial</td><td>0000-0002-2760-5566</td></tr><tr><td>Nada Al Chama</td><td>0000-0001-6305-4581</td></tr><tr><td>Chafika Haouichat</td><td>0000-0002-3779-8576</td></tr><tr><td>Fatima Alnaimat</td><td>0000-0002-5574-2939</td></tr><tr><td>Suad Hannawi</td><td>0000-0002-5689-6710</td></tr><tr><td>Saed Atawnah</td><td></td></tr><tr><td>Hussein Halabi</td><td>0000-0002-5174-8292</td></tr><tr><td>Manal Al Mashaleh</td><td>0000-0002-8286-6531</td></tr><tr><td>Laila Aljazwi</td><td>0000-0002-5349-2964</td></tr><tr><td>Ahmed Abogamal</td><td>0000-0002-5236-424X</td></tr><tr><td>Laila Ayoub</td><td>0000-0003-0381-2197</td></tr><tr><td>Elyes Bouajina</td><td></td></tr><tr><td>Rachid Bahiri</td><td>0000-0001-5677-1750</td></tr><tr><td>Sahar Saad</td><td></td></tr><tr><td>Maha Sabkar</td><td></td></tr><tr><td>Krystel Aouad</td><td>0000-0001-8708-9324</td></tr><tr><td>Nelly Ziade</td><td>0000-0002-4479-7678</td></tr><tr><td>Laure Gossec</td><td>0000-0002-4528-310X</td></tr></tbody></table>

**Conflict of interest:** The authors declare that they have no competing interest to disclose in relation to this study.

**Funding:** No specific funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out the work described in this article.

Word count: 3215

**Abstract (word count: 250)**

**Objective:** Discordance between physicians and patients in assessing psoriatic arthritis (PsA) activity is common and might impact treatment adherence and decision-making. Cultural and belief systems may influence this discordance. This study aimed to assess the extent of patient-physician discordance in PsA in Arab countries and its association with demographic and disease characteristics.

**Methods:** The TACTIC study was a cross-sectional observational study across 13 Arab countries in 2022. Patient and physician global assessments (PGA, PhGA) of disease activity (0-10 scale) were collected, along with demographic and disease data, Disease Activity in Psoriatic Arthritis (DAPSA), and Psoriatic
Arthritis Impact of Disease (PsAID). Discordance was defined as an absolute difference of |PGA-PhGA|>2. Its association with patient characteristics was analyzed through multivariable multinomial logistic regression.

**Results:** In 538 patients (317 females, 58.9%), with a mean age of 45.5±13.2 years and PsA duration of 8.8±7.3 years, the disease was moderately active (mean DAPSA 19.3±16.1; mean PsAID 3.86±2.33). Mean PGA was higher than mean PhGA (4.7±2.5 versus 4.0±2.4, p<0.001) with a high correlation between global assessments (r=0.74). Discordance was infrequent (84 patients, 15.6%) and mostly due to higher PGA (70/84, 83.3%). Discordance (one-point increase) was associated with lower PhGA (Odds ratio (OR) 3.03 [95%CI 2.18-4.22]), positive fibromyalgia screening (OR 1.28 [95%CI 1.03-1.58]), higher DAPSA (OR 1.16 [95%CI 1.03-1.09]), and higher PsAID scores (OR 2.63 [95%CI 1.96-3.54]), and was primarily identified in patients with moderate disease activity.

**Conclusion:** Discordance between PGA and PhGA was infrequent in Arab countries, suggesting strong patient-physician alignment. Expectations may play a role in this discordance.

**Keywords:** Psoriatic Arthritis; Patient Reported Outcome Measures; Patient Global Assessment; Physician Global Assessment; Arab World; Patient-Physician Discordance; Disease activity; Psoriatic Arthritis Impact of Disease (PsAID)

**Significance and Innovations:**

* Patient-physician discordance in PsA activity assessment is lower in Arab countries (15.6%) compared to previous studies in other settings.

* Positive discordance was associated with PhGA of PsA activity, disease activity, fibromyalgia, and PsA impact.

* Discordance was primarily observed in patients with moderate disease activity; for these patients, closer evaluation is warranted.
# 1. Introduction

Psoriatic arthritis (PsA) is a chronic inflammatory disease that affects up to 30% of patients with psoriasis. It presents with a range of manifestations, including peripheral arthritis, spondylitis, enthesitis, dactylitis, psoriatic skin, and nail disease (1). The complexity and heterogeneity of PsA make its diagnosis, treatment, and assessment particularly challenging.

PsA has a significant multidimensional impact on patients’ lives and can be associated with several comorbidities (2). Treatment selection depends on multiple factors, including the severity of the disease, the presence of comorbidities or extra-musculoskeletal manifestations (EMMs), the patient's preference, and previous treatments (1,3). It aims to reduce disease impact, improve the patient’s quality of life, and achieve minimal disease activity through a treat-to-target approach. Standardized outcome measures are used to assess PsA activity and its impact on patients, evaluate treatment efficacy, and guide therapeutic decisions. However, these tools predominantly reflect healthcare professionals’ assessments (4). Consequently, there has been an increased emphasis on using patient-reported outcome measures (PROMs), which incorporate the patient’s perspective on symptoms, functional status, and health-related quality of life (5). Patient empowerment and shared decision-making are important aspects of rheumatic disease management. Nevertheless, the patient’s experience may differ from the physician’s assessment, and this disagreement may lead to patient dissatisfaction regarding treatment decisions, poor adherence to treatment, negative impact on disease progression and outcomes, and added healthcare costs for society (6).

Most studies assessing patient-physician discordance in disease evaluation have been conducted on patients with rheumatoid arthritis (RA), exploring disagreements between the patient and physician’s global assessment of disease. In PsA, there is evidence of high discordance levels between the patient and physician’s assessments in various European and American countries, reaching up to 56% of the cases (6–8). One Asian study reported a 38% discordance in PsA activity evaluation (9); however, this study was conducted in a single center in Singapore, where the majority of patients were Chinese (66%).

Achieving concordance can be challenging due to the complex nature of PsA, which can manifest differently in patients and can impact various aspects of a patient’s life (1). Patients and physicians may have different perceptions of disease severity and the impact of the disease on the patient’s quality of life. Furthermore, the evaluation of disease activity and its impact can vary across different regions and cultures (9). To the best of our knowledge, no previous study has explored the discordance between patient and physician assessments of PsA activity in Arab countries.

Therefore, our study aims to investigate the level of discordance between patients and physicians in the evaluation of PsA activity in the Arab countries and to identify the factors associated with discordance. This study aims to provide insights into the factors associated with discordance to improve patient care and outcomes in this world region.
## 2. Patients and methods

### 2.1. Study design and inclusion criteria

The TACTIC study was a multicenter, multinational, cross-sectional study conducted in thirteen Arab countries in 2022. The primary aim was to assess patient-reported outcomes measures in this population and in particular the Psoriatic Arthritis Impact of Disease (PsAID-12) questionnaire (10).

Eligible participants were consecutive adult patients diagnosed with PsA by their rheumatologist, and fulfilling the CASPAR criteria (11). Inclusion criteria required participants to be literate and willing to participate. Patients under 18 years of age, those unable to provide informed consent, and individuals with inflammatory joint diseases unrelated to PsA, neurological disorders, or severe medical conditions that might interfere with study participation were excluded.

### 2.2. Data collection

Data were collected from both patients and rheumatologists. Patients independently completed the Patient Global Assessment (PGA) (12) for PsA disease activity, psoriasis activity, and pain, as well as several PROMs, including the PsAID (13), Health Assessment Questionnaire (HAQ) (14), Patient Health Questionnaire (PHQ-4) (15,16) for anxiety and depression, and the Fibromyalgia Screening Tool (FiRST) (17,18). These questionnaires were available in both English and validated Arabic versions, with each question presented in both languages. Rheumatologists collected demographic and disease characteristics, completed the Physician Global Assessment (PhGA) for PsA and psoriasis activity, conducted a subjective assessment for the presence of fibromyalgia, and performed the 66-68 joint counts for tender and swollen joints (TJC/SJC), which were used to calculate the Disease Activity in Psoriatic Arthritis (DAPSA) score. (19).

The patient's PsA activity was assessed by asking: "How active was your rheumatic disease on average during the last week?", on a visual analogue scale from 0 (not active) to 10 (very active), which was the same formulation used in the DAPSA (20) which is validated in both English and Arabic. The rheumatologists used a similar scale to assess PsA activity; the question was presented as: "How active was the patient's rheumatic disease on average during the last week?", with the same anchors. The patient and physician's assessments of psoriasis activity were expressed similarly, with "psoriasis" used instead of "rheumatic disease".

Factors associated with patient-physician discordance were examined using a multivariable multinomial logistic regression. Discordance in PsA activity assessment, the dependent variable, was categorized as negative discordance, positive discordance, or concordance (|PGA-PhGA| ≤2).

### 2.3. Statistical analysis

The TACTIC study included 554 patients, with an initial goal of including a minimum of 20 patients from each country. The sample size calculation is detailed in the original TACTIC manuscript (10). A power calculation showed that a sample size of 480 patients would allow to detect a correlation of 0.60 (expected with PGA) with a power of 95% for each of the 12 PsAID items.

The correlation between PGA and PhGA, as well as the factors associated with these measures, was first evaluated using the Spearman correlation coefficient for both PsA and psoriasis. Discordance was defined as the absolute difference between PGA and PhGA, with a threshold of 2, based on prior studies and the minimal clinically important improvement for rheumatic conditions. (6,8). Thus, three categories were defined: negative discordance (PGA-PhGA <-2), concordance (-2≤ PGA-PhGA ≤2), and
positive discordance (PGA-PhGA >2). A sensitivity analysis was also conducted, considering a difference
between PGA and PhGA of >1 as a relevant discordance, similar to the approach used by Desthieux et al.
(6).

Finally, the discordance was further illustrated using a Bland-Altman plot, where the average of PGA and PhGA for PsA activity (x-axis) was plotted against the difference between these two measures (y-axis).

Predictors of discordance were initially explored through bivariate analysis, which included demographic, clinical, and PROM variables, using chi-square for categorical variables and ANOVA for continuous variables. Variables significantly associated with positive discordance (p<0.01) and showing correlations less than 0.7 among continuous scores were selected for inclusion in a multivariable multinomial logistic regression. At this stage, TJC and SJC were excluded from the multivariable analysis due to collinearity with DAPSA, and PGA for PsA activity and pain were excluded due to collinearity with PsAID and PhGA PsA for activity.

There was no imputation of missing data. Statistical analyses were performed using SPSS version 27.0, with a p-value of less than 0.05 considered significant.

**2.4. Ethical considerations**

This is an ancillary study of TACTIC, which was approved by the Ethics Committees of *Hotel-Dieu de France* Hospital in Beirut, Lebanon (Code Tfem/2022'/1) and the Institutional Review Boards of participating countries, following their respective local requirements. Participants were required to provide informed consent, and strict measures were implemented to ensure confidentiality.

**3. Results**

**3.1. Patient characteristics**

Of the 589 initial entries in the TACTIC study between September and December 2022, 554 patients were included and analyzed (10). For the discordance analysis, 538 patients (97.1%) had available PGA and PhGA pairs for PsA activity, while 536 patients (96.8%) had available PGA and PhGA pairs for psoriasis activity.

The population consisted of 317 female subjects (58.9%) and 221 male subjects (41.1%), with a mean age of 45.5 years (SD 13.2) (Table 1). The highest contributions came from Iraq (27.8%), Egypt (9.7%), and Jordan (8.5%), with each participating country contributing at least 20 patients. The mean disease duration was 8.8 years (SD 7.3), with moderate disease activity reflected by a mean DAPSA of 19.3 (SD 16.1) and an acceptable impact of disease with a mean total PsAID score of 3.86 (SD 2.33) (Table 2).

**3.2. Patient and physician's global assessments**

The mean PGA and PhGA for PsA activity were 4.67 (SD 2.51) and 3.96 (SD 2.41), respectively (p<0.001), with a mean absolute difference of 1.30 (SD 1.41) and a median absolute difference of 1.00 (IQR 0.00-2.00). For psoriasis activity, the mean PGA and PhGA were 3.92 (SD 2.79) and 3.08 (SD 2.60), respectively (p<0.001), with a mean absolute difference of 0.90 (SD 2.38) and a median absolute difference of 1.00 (IQR 0.00-2.00). The distribution of PGA and PhGA values for PsA activity and the distribution of the difference PGA-PhGA are illustrated in Figure 1.

The correlation between patient and physician's assessments was strong for PsA, with a Spearman's correlation coefficient (Rho) of 0.74, and moderate for psoriasis, with a Rho coefficient of 0.61 (p-value<0.001 for both) (Supplementary Table S1). The PGA and PhGA for PsA activity were highly
correlated with PsAID (Rho=0.78 and 0.69, respectively), DAPSA (Rho=0.75 and 0.74, respectively), and HAQ scores (Rho=0.57 and 0.53, respectively). Pain was the main variable correlated to both global assessments of PsA and showed a stronger correlation with PGA (Rho=0.88) compared to PhGA (Rho=0.73). Conversely, the PhGA for PsA activity was more correlated with tender joint counts (Rho=0.57) and swollen joint counts (Rho=0.48) compared to the PGA for PsA activity (Rho=0.46 and 0.39, respectively). The global assessments for psoriasis activity were strongly correlated with skin problems (Rho=0.81 for PGA and 0.64 for PhGA).

When discordance was defined as an absolute difference greater than 2 between patient and physician global assessments, the concordance rate was 84.4% for PsA (454 out of 538). The negative discordance rate was 2.6%, with PGA-PhGA differences ranging from -6 to -3, and the positive discordance rate was 13.0%, with differences ranging from 3 to 8 (Table 1, Figure 1). Most discordant patients (83.3%) rated their disease higher than the physician (PGA > PhGA). The concordance rate for psoriasis was 76.1% (408 out of 536). The negative discordance rate was 5.0%, with differences ranging from -8 to -3, and the positive discordance rate was 18.8%, with differences ranging from 3 to 10.

The Bland-Altman plot showed a high degree of agreement between patient and physician assessments of PsA, in particular for patients in remission or with a high disease activity (at the two extremes of the x-axis) (Figure 2). Discordance was more common in patients with moderate disease activity. This was also true when considering the discordance status per the DAPSA category: all patients in remission were in concordance with the rheumatologists, whereas a higher level of discordance was observed in patients with moderate disease activity (Table 2).

In the sensitivity analysis, when considering a more stringent definition of discordance as a difference between patient and physician's assessment of >1, the concordance level for PsA decreased to 66.5%, with positive and negative discordance accounting for 27.1% and 6.3% of all patients, respectively.

### 3.3. Determinants of patient-physician discordance

In the bivariate analysis, discordance status was correlated with marital status, psoriasis, uveitis, ESR, treatment with csDMARDs, TJC, SJC, PGA PsA activity, PhGA PsA activity, PhGA psoriasis activity, PGA PsA Pain, DAPSA, FiRST, and PsAID scores (Table 1, Table 2).

The correlations among continuous scores are shown in Supplementary Table S2, as variables with intercorrelation > 0.7 were not included in the final model.

In the multivariable multinomial logistic regression, using concordance as the reference, one-point increase of positive discordance was associated with low level of PhGA of PsA activity (Odds ratio (OR) 3.03 [95%CI 2.18-4.22]), high FiRST (OR 1.28 [95%CI 1.03-1.58]), high DAPSA (OR 1.06 [95%CI 1.03-1.09]), and high PsAID scores (OR 2.63 [95%CI 1.96-3.54]), after adjustment for marital status, skin psoriasis, uveitis, treatment with csDMARDs, ESR, and PhGA for psoriasis activity. In contrast, negative concordance was associated with marital status, uveitis, the level of PhGA for PsA activity, FiRST, and PsAID scores after adjusting for skin psoriasis, treatment with csDMARDs, ESR, DAPSA, and PhGA for psoriasis activity (Table 3). The final model had an acceptable fit with a Nagelkerke R square of 0.53.
## 4. Discussion

This study offers valuable insights into the discordance between patient and rheumatologist assessments of PsA activity in a large cohort of patients from thirteen Arab countries. Notably, this is the first study to assess the determinants of patient-physician discordance in this region.

Our study found a discordance rate of 15.6% between PGA and PhGA, significantly lower than the 30-50% reported in other studies using similar thresholds (>2 or ≥3). (6–9). For instance, Desthieux et al. (6) reported 29.1% discordance in a European cohort, and Eder et al. (7) found 32.8% in Canadian patients. Higher rates, like 38% in a Singaporean study (9) and 56.5% in Denmark (8), may reflect cultural or methodological differences, like a less strict definition of discordance. Therefore, discordance varies with the country/region and is affected by cultural beliefs or patient-physician relationships. The perceptions and reporting of pain change between different ethnic groups (9). Differences in question formulations for PGA and PhGA across studies may also account for some variations. Studies focusing on overall well-being reported higher discordance than those focusing specifically on PsA activity (6). Our study used standardized formulations consistent with the DAPSA score (20), which contributed to our findings.

Reducing the discordance threshold from >2 (or ≥3) to >1 (or ≥2) increased discordance from 15.6% to 33.5% (one-third of patients), which is still lower than the values reported in the sensitivity analysis by Desthieux et al. (6), which increased from 29.1% to 48.3% (almost half the patients). Possible explanations for the lower discordance in our study include cultural acceptance of the disease, more empathetic rheumatologists, or stronger patient-physician relationships. The higher scores of both PGA (4.7±2.5) and PhGA (4.0±2.8) in our study compared to other studies (values between 2 and 4 and between 1 and 3, respectively) (6–9) suggest that physician empathy might play a dominant role.

Several studies have assessed patients' satisfaction and perspectives on shared decision-making, highlighting the importance of effective patient-physician communication. Coates et al. (21) evaluated 1,286 PsA patients through a global online survey across eight countries (Australia, Brazil, Canada, France, Spain, Taiwan, the United Kingdom, and the United States) and found that over 40% were at risk of suboptimal patient-physician communication. An Australian study using face-to-face semi-structured interviews revealed that many patients experienced poor communication, with complaints about an automated approach to treatment and a lack of choice (22). To the best of our knowledge, no study has evaluated PsA patients' perspectives on communication and treatment in the Arab world. We hypothesize that a more compassionate and understanding approach in this region explains the lower discordance levels.

Among the 84 discordant patients, 70 (83.3%) rated their disease higher than the rheumatologist's assessment. This is similar to Desthieux et al. (6) (85.8%), but higher than Wang et al. (9) (53.7%) and lower than Eder et al. (7) (95.1%). The mean absolute difference |PGA-PhGA| for PsA activity in our study (1.3±1.4) was lower than Desthieux et al. (6) (1.9±1.8), but the median absolute difference was 1.0 in both studies.

Our study also assessed psoriasis, making it the first to evaluate patient-physician discordance in psoriasis activity in Arab countries. The correlations between PGA and PhGA were weaker for psoriasis (Rho=0.61) compared to PsA (Rho=0.74), suggesting rheumatologists may assess joints more reliably than skin (6,7). Additionally, the percentage of concordance for psoriasis (76.1%) was lower than for PsA (84.4%), similar to the Canadian cohort of PsA patients (77.8%) (7), but higher than the London cohort of psoriatic patients (61.0%) (23).
The correlation between PGA and PhGA for PsA activity in our study (Rho=0.74) was stronger than those reported by Eder et al. (7) (Rho=0.54), Desthieux et al. (6) (Rho=0.58), and Yanzi et al. (24) (Rho=0.64). Similarly, the correlation between PGA and PhGA for psoriasis activity (Rho=0.61) was higher than Eder et al. (7) (Rho=0.42). Factors correlated with PGA and PhGA were consistent with the literature. Specifically, Wang et al. (9) and Yanzi et al. (24) showed a higher correlation of pain and fatigue with PGA, and a higher correlation of tender and swollen joint counts with PhGA for PsA activity. This suggests that patient perspectives are influenced by subjective factors (pain and other PsAID domains), while physician assessments are influenced by objective factors (joint counts). Eder et al. (7) demonstrated that global assessments for PsA activity were highly correlated with pain and physical function (HAQ and SF-36 PCS), while global assessments for psoriasis activity were highly correlated with skin measures (DLQI).

Positive discordance was associated with PhGA, DAPSA, FiRST, and PsAID scores. High DAPSA, PsAID, and FiRST, along with low PhGA, predicted positive discordance. These findings align with previous studies, which often identify pain as a key predictor of discordance in RA and PsA (7–9,25). DAPSA, PsAID, and FiRST include pain as a major component, and several PsAID domains were associated with positive discordance in Desthieux et al. (6). RA, being more painful than PsA (7,26), is usually associated with higher discordance levels (around 36%) (27). No significant differences related to age or gender were found, contrasting with some studies that suggest higher discordance among female patients (6,8). Negative discordance was associated with a higher PhGA of PsA activity, increased FiRST score, and the presence of uveitis, supporting the idea that physician assessments correlate with objective measures.

One notable finding was the high concordance for patients in remission. In our study, all patients in remission presented concordant results with physician assessments, unlike other studies where remission was associated with higher discordance and more correlation to PGA than PhGA (24,28). Ferreira et al. (28) found that discrepancies between PhGA and MDA criteria hindered treatment escalation in non-MDA patients.

In our study, the highest discordance was observed in patients with moderate disease activity, as shown in the Bland-Altman plot, which indicated good concordance at low and high disease activity levels but higher discordance in the middle (Figure 2, Table 2). This finding is important for clinical practice. Incorporating PROMs in routine practice can reduce clinic visit time, allowing rheumatologists more time to discuss treatment options with patients. For patients reporting low or high PsA activity in Arab countries, physicians can rely on patient assessments to maintain or change treatment. Reevaluation and objective measures are needed for patients with moderate disease activity.

Our study has limitations. We did not assess physician characteristics that could affect PhGA, as it was not a primary concern and studies suggest minimal influence (8). We evaluated global assessments of both skin and joint activity, while focusing on PsA. The strengths include a large and diverse cohort from 13 Arab countries, enhancing the generalizability and reliability of our findings. (24). We collected a robust database, incorporating all PsA core domains (29), with limited missing data, allowing for consideration of several contributing factors.

To conclude, the current study demonstrated a lower patient-physician discordance in assessing PsA activity in Arab countries compared to the values reported elsewhere. Positive discordance was associated with PhGA of PsA activity, disease activity, fibromyalgia, and PsA impact on patients. Discordance was higher in patients with moderate disease activity, suggesting closer rheumatologist evaluation is needed in these cases. Further studies on patient-physician communication and shared decision-making in PsA patients in this region would be useful.
**Acknowledgments:** We acknowledge the significant role of the Arab League of Associations for Rheumatology (ArLAR) Research Group (ARCH) in supporting and facilitating this collaborative work.

This work was presented at the ArLAR23 Kuwait Congress, EULAR 2023 Congress, and ACR Convergence 2023, with the following corresponding abstracts:

Ziade N, Abbas N, Kibbi L, et al. AB1148 Patient and Physician Global Assessment of Psoriatic Arthritis Appear More in Agreement in Arab Countries than Previously Reported Elsewhere – An International Study Under the Aegis of ArLAR. *Ann Rheum Dis.* 2023;82:1804-1805.
https://doi.org/10.1136/annrheumdis-2023-eular.2371.

Ziade N, Abbas N, El Kibbi L, et al. Patient and Physician Global Assessment of Psoriatic Arthritis Disease Activity: High Concordance in an ArLAR Multinational Study. *Arthritis Rheumatol.* 2023; 75 (suppl 9).
https://acrabSTRACTS.org/abstract/patient-and-physician-global-assessment-of-psoriatic-arthritis-disease-activity-high-concordance-in-an-arlar-multinational-study.

**Ethics approval and consent to participate:** Informed consent was obtained from all participants. This is an ancillary study of TACTIC, which was approved by the Ethics Committee of *Hotel-Dieu de France* Hospital (Lebanon) and by the Institutional Review Boards of the participating countries, when necessary, according to local requirements.

**Data availability:** Data supporting the findings of this study are available upon request from the corresponding author.

**Contribution statement:** This study was started by NA and NZ with expertise from LG (initial developer of the PsAID and advisor on the present study); the protocol was written by NA, NZ, IH, and LG. All authors included patients except for LG (France). Statistical analysis was performed by NA and NZ. Then all authors participated in the analyses and the writing up. All authors made substantial contributions to this study, are accountable for its intellectual content, and approved the submitted version to *Arthritis Care & Research*.
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<table><caption>**Table 1.** Demographic and risk factors of 538 patients with PsA according to the patient-physician discordance status.</caption><thead><tr><th>Variable</th><th>All</th><th>Negative discordance</th><th>Concordance</th><th>Positive discordance</th><th>p-value</th></tr></thead><tbody><tr><td>N</td><td>538</td><td>14 (2.6)</td><td>454 (84.4)</td><td>70 (13.0)</td><td>-</td></tr><tr><td>Age (mean, SD)</td><td>45.5 (13.2)</td><td>41.0 (12.5)</td><td>45.5 (13.2)</td><td>46.2 (13.3)</td><td>0.530</td></tr><tr><td>Sex (N, %)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Male subjects</td><td>221 (41.1)</td><td>8 (57.1)</td><td>186 (41.0)</td><td>27 (38.6)</td><td>0.443</td></tr><tr><td>- Female subjects</td><td>317 (58.9)</td><td>6 (42.9)</td><td>268 (59.0)</td><td>43 (61.4)</td><td></td></tr><tr><td>Marital status: Married (N, %)</td><td>431 (80.1)</td><td>7 (50.0)</td><td>368 (81.1)</td><td>56 (80.0)</td><td>0.016</td></tr><tr><td>Profession: Active (N, %)</td><td>289 (53.7)</td><td>5 (35.7)</td><td>242 (53.3)</td><td>42 (60.0)</td><td>0.226</td></tr><tr><td>University Education (N, %)</td><td>263 (48.9)</td><td>3 (21.4)</td><td>226 (49.8)</td><td>34 (48.6)</td><td>0.317</td></tr><tr><td>Country (N, %)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Iraq</td><td>154 (27.8)</td><td>2 (14.3)</td><td>116 (25.6)</td><td>31 (44.3)</td><td></td></tr><tr><td>- Egypt</td><td>54 (9.7)</td><td>0 (0.0)</td><td>47 (10.4)</td><td>7 (10.0)</td><td></td></tr><tr><td>- Jordan</td><td>47 (8.5)</td><td>1 (7.1)</td><td>40 (8.8)</td><td>6 (8.6)</td><td></td></tr><tr><td>- United Arab Emirates</td><td>44 (7.9)</td><td>2 (14.3)</td><td>37 (8.1)</td><td>5 (7.1)</td><td></td></tr><tr><td>- Libya</td><td>41 (7.4)</td><td>0 (0.0)</td><td>34 (7.5)</td><td>6 (8.6)</td><td></td></tr><tr><td>- Syria</td><td>40 (7.2)</td><td>0 (0.0)</td><td>40 (8.8)</td><td>0 (0.0)</td><td></td></tr><tr><td>- Algeria</td><td>37 (6.7)</td><td>2 (14.3)</td><td>33 (7.3)</td><td>2 (2.9)</td><td>&lt;0.001</td></tr><tr><td>- Morocco</td><td>28 (5.1)</td><td>2 (14.3)</td><td>20 (4.4)</td><td>0 (0.0)</td><td></td></tr><tr><td>- Saudi Arabia</td><td>25 (4.5)</td><td>0 (0.0)</td><td>21 (4.6)</td><td>4 (5.7)</td><td></td></tr><tr><td>- Lebanon</td><td>22 (4.0)</td><td>0 (0.0)</td><td>16 (3.5)</td><td>6 (8.6)</td><td></td></tr><tr><td>- Palestine</td><td>22 (4.0)</td><td>2 (14.3)</td><td>19 (4.2)</td><td>1 (1.4)</td><td></td></tr><tr><td>- Bahrain</td><td>20 (3.6)</td><td>0 (0.0)</td><td>19 (4.2)</td><td>1 (1.4)</td><td></td></tr><tr><td>- Tunisia</td><td>20 (3.6)</td><td>3 (21.4)</td><td>12 (2.6)</td><td>1 (1.4)</td><td></td></tr><tr><td>BMI (N, %)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Underweight</td><td>9 (1.7)</td><td>0 (0.0)</td><td>6 (1.3)</td><td>3 (4.3)</td><td></td></tr><tr><td>- Healthy</td><td>135 (25.1)</td><td>7 (50.0)</td><td>108 (23.8)</td><td>20 (28.6)</td><td>0.187</td></tr><tr><td>- Overweight</td><td>205 (38.2)</td><td>4 (28.6)</td><td>177 (39.1)</td><td>24 (34.3)</td><td></td></tr><tr><td>- Obese</td><td>188 (35.0)</td><td>3 (21.4)</td><td>162 (35.8)</td><td>23 (32.9)</td><td></td></tr><tr><td>Current smoking (N, %)</td><td>99 (18.4)</td><td>4 (28.6)</td><td>87 (19.2)</td><td>8 (11.4)</td><td>0.164</td></tr><tr><td>Past smoking (N, %)</td><td>44 (8.2)</td><td>0 (0.0)</td><td>36 (7.9)</td><td>8 (11.4)</td><td>0.370</td></tr><tr><td>Comorbidities (N, %)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Hypertension</td><td>157 (29.2)</td><td>5 (35.7)</td><td>137 (30.2)</td><td>15 (21.4)</td><td>0.280</td></tr><tr><td>- Diabetes</td><td>84 (15.6)</td><td>4 (28.6)</td><td>73 (16.1)</td><td>7 (10.0)</td><td>0.145</td></tr><tr><td>- Dyslipidemia</td><td>86 (16.0)</td><td>5 (35.7)</td><td>69 (15.2)</td><td>12 (17.1)</td><td>0.114</td></tr><tr><td>- Cardiovascular events</td><td>33 (6.1)</td><td>0 (0.0)</td><td>31 (6.8)</td><td>2 (2.9)</td><td>0.395</td></tr><tr><td>- Chronic infections</td><td>11 (2.0)</td><td>0 (0.0)</td><td>7 (1.5)</td><td>4 (5.7)</td><td>0.096</td></tr><tr><td>- Cancer</td><td>7 (1.3)</td><td>0 (0.0)</td><td>5 (1.1)</td><td>2 (2.9)</td><td>0.367</td></tr><tr><td>- Known depression</td><td>34 (6.3)</td><td>0 (0.0)</td><td>31 (6.8)</td><td>3 (4.3)</td><td>0.622</td></tr><tr><td>- Osteoporosis</td><td>23 (4.3)</td><td>0 (0.0)</td><td>22 (4.8)</td><td>1 (1.4)</td><td>0.480</td></tr><tr><td>- Gastric ulcers</td><td>16 (3.0)</td><td>0 (0.0)</td><td>16 (3.5)</td><td>0 (0.0)</td><td>0.282</td></tr><tr><td>Family history (N, %)</td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>
<table><tr><td>- Family PsA</td><td>90 (16.7)</td><td>3 (21.4)</td><td>69 (15.2)</td><td>18 (25.7)</td><td>0.123</td></tr><tr><td>- Family psoriasis</td><td>231 (42.9)</td><td>6 (42.9)</td><td>191 (42.1)</td><td>34 (48.6)</td><td>0.837</td></tr><tr><td>- Family axial spondylarthritis</td><td>28 (5.2)</td><td>1 (7.1)</td><td>21 (4.6)</td><td>6 (8.6)</td><td>0.244</td></tr></table>

BMI, body mass index; PsA, psoriatic arthritis; SD, standard deviation.
<table><caption>**Table 2.** Clinical characteristics of 538 patients with PsA according to the patient-physician discordance status.</caption><thead><tr><th>Variable</th><th>All</th><th>Negative discordance</th><th>Concordance</th><th>Positive discordance</th><th>p-value</th></tr></thead><tbody><tr><td><strong>N</strong></td><td><strong>538</strong></td><td><strong>14 (2.6)</strong></td><td><strong>454 (84.4)</strong></td><td><strong>70 (13.0)</strong></td><td><strong>-</strong></td></tr><tr><td>PsA duration (mean, SD)</td><td>8.8 (7.3)</td><td>11.0 (10.9)</td><td>8.7 (7.3)</td><td>6.7 (0.8)</td><td>0.490</td></tr><tr><td>PsA diagnostic delay (mean, SD)</td><td>2.6 (4.5)</td><td>4.1 (9.7)</td><td>2.5 (4.2)</td><td>3.0 (4.9)</td><td>0.333</td></tr><tr><td>PsA manifestations (N, %)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Polyarthritis</td><td>297 (55.2)</td><td>8 (57.1)</td><td>254 (55.9)</td><td>35 (50.0)</td><td>0.641</td></tr><tr><td>- Oligoarthritis</td><td>177 (32.9)</td><td>4 (28.6)</td><td>152 (33.5)</td><td>21 (30.0)</td><td>0.801</td></tr><tr><td>- Monoarthritis</td><td>24 (4.5)</td><td>0 (0.0)</td><td>19 (4.2)</td><td>5 (7.1)</td><td>0.346</td></tr><tr><td>- Enthesitis</td><td>183 (34.0)</td><td>6 (42.9)</td><td>150 (33.0)</td><td>27 (38.6)</td><td>0.515</td></tr><tr><td>- Dactylitis</td><td>128 (23.8)</td><td>0 (0.0)</td><td>111 (24.4)</td><td>17 (24.3))</td><td>0.093</td></tr><tr><td>- Axial involvement</td><td>179 (33.3)</td><td>5 (35.7)</td><td>158 (34.8)</td><td>16 (22.9)</td><td>0.140</td></tr><tr><td>Extra-musculoskeletal manifestations (N, %)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Psoriasis</td><td>493 (91.3)</td><td>9 (64.3)</td><td>420 (92.5)</td><td>64 (91.4)</td><td><strong>&lt;0.001</strong></td></tr><tr><td>- Nail psoriasis</td><td>240 (44.6)</td><td>6 (42.9)</td><td>206 (45.4)</td><td>28 (40.0)</td><td>0.695</td></tr><tr><td>- Uveitis</td><td>29 (5.4)</td><td>4 (28.6)</td><td>22 (4.8)</td><td>3 (4.3)</td><td><strong>0.009</strong></td></tr><tr><td>- Crohn's disease</td><td>11 (2.0)</td><td>0 (0.0)</td><td>8 (1.8)</td><td>3 (4.3)</td><td>0.382</td></tr><tr><td>- Ulcerative colitis</td><td>11 (2.0)</td><td>0 (0.0)</td><td>9 (2.0)</td><td>2 (2.9)</td><td>0.737</td></tr><tr><td>Positive HLA-B27 (N, %)</td><td>35 (6.5)</td><td>0 (0.0)</td><td>25 (5.5)</td><td>10 (14.3)</td><td>0.385</td></tr><tr><td>ESR (mean, SD)</td><td>30.2 (22.8)</td><td>39.9 (13.4)</td><td>31.1 (23.5)</td><td>23.0 (18.0)</td><td><strong>0.007</strong></td></tr><tr><td>CRP mg/l (mean, SD)</td><td>11.2 (23.1)</td><td>20.8 (20.2)</td><td>11.7 (24.6)</td><td>6.2 (8.1)</td><td>0.082</td></tr><tr><td>High CRP (N, %)</td><td>234 (49.4)</td><td>7 (58.3)</td><td>205 (51.2)</td><td>22 (35.5)</td><td><strong>0.057</strong></td></tr><tr><td>Erosions on X-rays (N, %)</td><td>172 (32.0)</td><td>3 (21.4)</td><td>148 (32.6)</td><td>21 (30.0)</td><td>0.608</td></tr><tr><td>Treatment (ever) (N, %)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- csDMARDs</td><td>467 (87.1)</td><td>8 (57.1)</td><td>399 (88.3)</td><td>60 (85.7)</td><td><strong>0.003</strong></td></tr><tr><td>- bDMARDs</td><td>250 (49.3)</td><td>2 (15.4)</td><td>214 (50.2)</td><td>34 (50.0)</td><td><strong>0.049</strong></td></tr><tr><td>- tsDMARDs</td><td>14 (2.8)</td><td>0 (0.0)</td><td>11 (2.7)</td><td>3 (4.4)</td><td>0.597</td></tr><tr><td>Treatment (current) (N, %)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- csDMARDs</td><td>317 (93.0)</td><td>9 (90.0)</td><td>275 (92.6)</td><td>33 (97.1)</td><td>0.472</td></tr><tr><td>- bDMARDs</td><td>326 (93.1)</td><td>5 (83.3)</td><td>272 (92.5)</td><td>49 (98.0)</td><td>0.163</td></tr><tr><td>- tsDMARDs</td><td>11 (31.4)</td><td>0 (0.0)</td><td>8 (26.7)</td><td>3 (75.0)</td><td>0.082</td></tr><tr><td>Tender joint count (0-68) (mean, SD)</td><td>6.6 (9.5)</td><td>14.6 (14.7)</td><td>6.4 (8.7)</td><td>6.6 (12.5)</td><td><strong>0.005</strong></td></tr><tr><td>Swollen joint count (0-66) (mean, SD)</td><td>1.9 (4.0)</td><td>5.2 (8.7)</td><td>1.7 (3.5)</td><td>1.9 (5.2)</td><td><strong>0.006</strong></td></tr><tr><td>DAPSA score (mean, SD)</td><td>19.3 (16.1)</td><td>28.7 (23.0)</td><td>18.4 (15.1)</td><td>22.9 (20.1)</td><td><strong>0.015</strong></td></tr><tr><td>DAPSA categories (N, %)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Remission (0-4)</td><td>52 (12.0)</td><td>0 (0.0)</td><td>52 (14.2)</td><td>0 (0.0)</td><td></td></tr><tr><td>- Low (5-14)</td><td>155 (35.9)</td><td>2 (18.2)</td><td>132 (36.1)</td><td>21 (38.2)</td><td><strong>0.004</strong></td></tr><tr><td>- Moderate (15-28)</td><td>135 (31.3)</td><td>4 (36.4)</td><td>110 (30.1)</td><td>21 (38.2)</td><td></td></tr><tr><td>- High (&gt;28)</td><td>90 (20.8)</td><td>5 (45.45)</td><td>72 (19.7)</td><td>13 (23.6)</td><td></td></tr><tr><td>Fibromyalgia, according to the rheumatologist (N, %)</td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>
<table><tbody><tr><td>- Yes</td><td>134 (24.9)</td><td>1 (7.1)</td><td>111 (24.4)</td><td>22 (31.4)</td><td>0.333</td></tr><tr><td>- No</td><td>354 (65.8)</td><td>7 (50.0)</td><td>305 (67.2)</td><td>42 (60.0)</td><td></td></tr><tr><td>- Uncertain</td><td>50 (9.3)</td><td>6 (42.9)</td><td>38 (8.4)</td><td>6 (8.6)</td><td></td></tr><tr><td><strong>PGA for PsA activity (0-10) (mean, SD)</strong></td><td>4.7 (2.5)</td><td>3.1 (1.5)</td><td>4.5 (2.4)</td><td>6.7 (1.9)</td><td><strong>&lt;0.001</strong></td></tr><tr><td><strong>PGA for psoriasis activity (0-10) (mean, SD)</strong></td><td>4.0 (2.8)</td><td>3.5 (3.4)</td><td>3.9 (2.8)</td><td>4.6 (2.7)</td><td><strong>0.109</strong></td></tr><tr><td><strong>PGA for PsA pain (0-10) (mean, SD)</strong></td><td>4.8 (2.6)</td><td>3.8 (2.2)</td><td>4.6 (2.6)</td><td>6.1 (2.4)</td><td><strong>&lt;0.001</strong></td></tr><tr><td><strong>PhGA for PsA activity (0-10) (mean, SD)</strong></td><td>4.0 (2.4)</td><td>7.0 (1.4)</td><td>4.1 (2.4)</td><td>2.7 (1.8)</td><td><strong>&lt;0.001</strong></td></tr><tr><td><strong>PhGA for psoriasis activity (0-10) (mean, SD)</strong></td><td>3.1 (2.6)</td><td>4.1 (3.0)</td><td>3.2 (2.7)</td><td>2.3 (2.0)</td><td><strong>0.010</strong></td></tr><tr><td><strong>HAQ score (0-3) (mean, SD)</strong></td><td>1.1 (0.8)</td><td>1.2 (0.8)</td><td>1.0 (0.8)</td><td>1.2 (0.8)</td><td>0.358</td></tr><tr><td><strong>PHQ-4 total score (0-12) (mean, SD)</strong></td><td>3.3 (2.9)</td><td>2.5 (2.4)</td><td>3.3 (2.9)</td><td>3.6 (2.9)</td><td>0.411</td></tr><tr><td><strong>FiRST score (0-6) (mean, SD)</strong></td><td>2.2 (2.1)</td><td>2.8 (2.2)</td><td>2.1 (2.1)</td><td>2.7 (2.3)</td><td><strong>0.044</strong></td></tr><tr><td><strong>FiRST positive screening (≥5/6) (N, %)</strong></td><td>102 (19.0)</td><td>4 (28.6)</td><td>79 (17.4)</td><td>19 (27.1)</td><td>0.085</td></tr><tr><td><strong>High PsAID score (&gt;4) (N, %)</strong></td><td>243 (45.2)</td><td>4 (28.6)</td><td>201 (44.3)</td><td>38 (54.3)</td><td>0.129</td></tr><tr><td><strong>PsAID total score (0-10) (mean, SD)</strong></td><td>3.86 (2.33)</td><td>3.53 (1.99)</td><td>3.83 (2.33)</td><td>4.56 (2.18)</td><td><strong>0.038</strong></td></tr><tr><td><strong>PsAID subscales (0-10) (mean, SD)</strong></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- <strong>Pain</strong></td><td>4.66 (2.63)</td><td>3.79 (2.39)</td><td>4.57 (2.59)</td><td>5.93 (2.50)</td><td><strong>&lt;0.001</strong></td></tr><tr><td>- <strong>Fatigue</strong></td><td>4.50 (2.76)</td><td>3.93 (2.67)</td><td>4.45 (2.72)</td><td>5.44 (2.79)</td><td><strong>0.013</strong></td></tr><tr><td>- <strong>Skin problems</strong></td><td>3.60 (2.81)</td><td>2.71 (2.34)</td><td>3.56 (2.79)</td><td>4.47 (2.81)</td><td><strong>0.017</strong></td></tr><tr><td>- Work and/or leisure activities</td><td>3.86 (2.87)</td><td>3.64 (2.31)</td><td>3.84 (2.84)</td><td>4.47 (3.08)</td><td>0.214</td></tr><tr><td>- Functional capacity</td><td>3.85 (2.90)</td><td>4.00 (3.26)</td><td>3.79 (2.84)</td><td>4.53 (3.10)</td><td>0.137</td></tr><tr><td>- <strong>Discomfort</strong></td><td>4.31 (3.01)</td><td>4.00 (2.29)</td><td>4.21 (2.96)</td><td>5.51 (3.11)</td><td><strong>0.003</strong></td></tr><tr><td>- Sleep disturbance</td><td>3.69 (3.05)</td><td>3.71 (2.95)</td><td>3.67 (2.99)</td><td>4.37 (3.42)</td><td>0.196</td></tr><tr><td>- Coping</td><td>3.29 (2.75)</td><td>3.21 (2.58)</td><td>3.34 (2.75)</td><td>3.39 (2.86)</td><td>0.976</td></tr><tr><td>- Anxiety, fear and uncertainty</td><td>3.58 (3.06)</td><td>3.50 (2.59)</td><td>3.67 (3.10)</td><td>3.57 (2.95)</td><td>0.956</td></tr><tr><td>- Embarrassment and/or shame</td><td>2.73 (2.93)</td><td>2.43 (2.82)</td><td>2.71 (2.90)</td><td>3.29 (3.16)</td><td>0.283</td></tr><tr><td>- Social participation</td><td>2.98 (2.97)</td><td>2.86 (2.18)</td><td>3.06 (2.99)</td><td>2.89 (3.09)</td><td>0.875</td></tr><tr><td>- Depression</td><td>2.98 (2.98)</td><td>3.14 (2.25)</td><td>3.08 (2.98)</td><td>2.76 (3.18)</td><td>0.691</td></tr></tbody></table>

bDMARDs, biological disease-modifying anti-rheumatic drugs; CRP, C-reactive protein; cDMARDs, conventional synthetic DMARDs; DAPSA, Disease Activity index for Psoriatic Arthritis; ESR, erythrocyte sedimentation rate; HAQ, Health Assessment Questionnaire; HLA-B27, human leucocyte antigen-B27; FiRST, Fibromyalgia Rapid Screening Tool; PGA, patient global assessment; PhGA, physician global assessment; PHQ-4, Patient Health Questionnaire-4; PsA, psoriatic arthritis; PsAID, Psoriatic Arthritis Impact of Disease; SD, standard deviation; tsDMARDs, targeted synthetic DMARDs.
<table><caption>**Table 3.** Factors associated with patient-physician discordance in the assessment of PsA activity using a multivariable multinomial logistic regression model (N=538 patients).</caption><thead><tr><th>DISCORDANCE STATUS<br>(Reference = Concordance)</th><th>Number of<br>respondents</th><th>OR</th><th>95%<br>Interval</th><th>Confidence<br>p-value</th></tr></thead><tbody><tr><td><strong>Negative</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Married</td><td>538</td><td>0.05</td><td>0.004</td><td>0.64</td><td><strong>0.022</strong></td></tr><tr><td>Skin psoriasis</td><td>538</td><td>0.10</td><td>0.003</td><td>3.76</td><td>0.214</td></tr><tr><td>Uveitis</td><td>538</td><td>54.55</td><td>1.92</td><td>1546.37</td><td><strong>0.019</strong></td></tr><tr><td>Treatment with csDMARDs</td><td>536</td><td>0.13</td><td>0.01</td><td>1.28</td><td>0.081</td></tr><tr><td>ESR</td><td>526</td><td>0.97</td><td>0.93</td><td>1.02</td><td>0.277</td></tr><tr><td>DAPSA</td><td>432</td><td>0.93</td><td>0.86</td><td>1.01</td><td>0.079</td></tr><tr><td>FiRST score</td><td>538</td><td>2.08</td><td>1.02</td><td>4.24</td><td><strong>0.044</strong></td></tr><tr><td>Low PsAID score</td><td>538</td><td>6.06</td><td>2.06</td><td>17.86</td><td><strong>0.001</strong></td></tr><tr><td>PhGA PsA Activity</td><td>538</td><td>6.93</td><td>2.26</td><td>21.22</td><td><strong>0.001</strong></td></tr><tr><td>PhGA PsO Activity</td><td>537</td><td>1.71</td><td>0.91</td><td>3.24</td><td>0.098</td></tr><tr><td><strong>Positive</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Married</td><td>538</td><td>0.85</td><td>0.37</td><td>1.94</td><td>0.697</td></tr><tr><td>Skin psoriasis</td><td>538</td><td>1.61</td><td>0.35</td><td>7.50</td><td>0.541</td></tr><tr><td>Uveitis</td><td>538</td><td>0.82</td><td>0.16</td><td>4.28</td><td>0.818</td></tr><tr><td>Treatment with csDMARDs</td><td>536</td><td>2.03</td><td>0.64</td><td>6.41</td><td>0.228</td></tr><tr><td>ESR</td><td>526</td><td>0.99</td><td>0.97</td><td>1.01</td><td>0.457</td></tr><tr><td>DAPSA</td><td>432</td><td>1.06</td><td>1.03</td><td>1.09</td><td><strong>&lt;0.001</strong></td></tr><tr><td>FiRST score</td><td>538</td><td>1.28</td><td>1.03</td><td>1.58</td><td><strong>0.025</strong></td></tr><tr><td>PsAID score</td><td>538</td><td>2.63</td><td>1.96</td><td>3.54</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Low PhGA PsA Activity</td><td>538</td><td>3.03</td><td>2.18</td><td>4.22</td><td><strong>&lt;0.001</strong></td></tr><tr><td>PhGA PsO Activity</td><td>537</td><td>0.86</td><td>0.72</td><td>1.03</td><td>0.105</td></tr></tbody></table>

csDMARDs, conventional synthetic disease-modifying anti-rheumatic drugs; DAPSA, Disease Activity index for Psoriatic Arthritis; ESR, erythrocyte sedimentation rate; FiRST, Fibromyalgia Rapid Screening Tool; OR, odds ratio; PhGA, Physician Global Assessment, PsA, psoriatic arthritis; PsAID, Psoriatic Arthritis Impact of Disease.
**Figure Legends**

**Figure 1.** Patient and physician global assessments of Psoriatic Arthritis (PsA) activity in 538 patients. (A) Distribution of Patient Global Assessment (PGA) and Physician Global Assessment (PhGA) of disease activity using box-and-whisker plot. (B) Discordance status according to the difference PGA-PhGA.
PGA, patient global assessment; PhGA, physician global assessment.
A

<figure><img src="image_7.png" /></figure>

B

<figure><img src="image_8.png" /></figure>
**Figure 2.** Agreement between patient and physician global assessments of PsA activity using the Bland-Altman plot (N=538 patients).

PGA, patient global assessment; PhGA, physician global assessment; PsA, psoriatic arthritis; SD, standard deviation.

<figure><img src="image_9.png" /></figure>
<table><caption>**Supplementary Table S1.** Correlation between patient characteristics and global assessment measures using Spearman's correlation coefficient (N=538 patients).</caption><thead><tr><th rowspan="2">Variables</th><th colspan="3">Joint activity (psoriatic arthritis)</th><th colspan="3">Skin activity (psoriasis)</th></tr><tr><th>PGA</th><th>PhGA</th><th>Difference<br>PGA-<br>PhGA</th><th>PGA</th><th>PhGA</th><th>Difference<br>PGA-<br>PhGA</th></tr></thead><tbody><tr><td>Correlation of PGA<br>with PhGA</td><td colspan="3">0.74**</td><td colspan="3">0.61**</td></tr><tr><td>Age</td><td>0.04</td><td>-0.003</td><td>0.06</td><td>-0.04</td><td>-0.09*</td><td>0.05</td></tr><tr><td>Sex</td><td>-0.09*</td><td>-0.07</td><td>-0.04</td><td>-0.02</td><td>0.07</td><td>-0.06</td></tr><tr><td>Active profession</td><td>-0.08</td><td>-0.10*</td><td>0.01</td><td>-0.02</td><td>0.02</td><td>-0.01</td></tr><tr><td>University education</td><td>-0.10*</td><td>-0.11**</td><td>&lt;0.001</td><td>-0.06</td><td>-0.06</td><td>0.03</td></tr><tr><td>Diagnostic delay</td><td>0.14**</td><td>0.13**</td><td>0.03</td><td>0.01</td><td>0.002</td><td>-0.002</td></tr><tr><td>Skin psoriasis</td><td>0.02</td><td>-0.01</td><td>0.04</td><td>0.16**</td><td>0.33**</td><td>-0.07</td></tr><tr><td>Nail psoriasis</td><td>0.05</td><td>0.09*</td><td>-0.06</td><td>0.11*</td><td>0.17**</td><td>-0.07</td></tr><tr><td>Polyarthritis</td><td>0.07</td><td>0.12**</td><td>-0.11*</td><td>0.09*</td><td>0.04</td><td>-0.02</td></tr><tr><td>Monoarthritis</td><td>-0.07</td><td>-0.12**</td><td>0.04</td><td>-0.04</td><td>-0.001</td><td>-0.05</td></tr><tr><td>Axial involvement</td><td>0.09*</td><td>0.14**</td><td>-0.10*</td><td>0.12**</td><td>0.15**</td><td>-0.05</td></tr><tr><td>Enthesitis</td><td>0.02</td><td>-0.01</td><td>0.001</td><td>0.02</td><td>-0.08</td><td>0.09*</td></tr><tr><td>Crohn disease</td><td>-0.01</td><td>-0.06</td><td>0.03</td><td>0.02</td><td>-0.08</td><td>0.09*</td></tr><tr><td>HLA-B27</td><td>0.07</td><td>0.17**</td><td>-0.15**</td><td>0.04</td><td>0.12**</td><td>-0.15**</td></tr><tr><td>ESR</td><td>0.25**</td><td>0.38**</td><td>-0.11*</td><td>0.18**</td><td>0.26**</td><td>-0.10*</td></tr><tr><td>CRP positive</td><td>0.28**</td><td>0.39**</td><td>-0.12*</td><td>0.20**</td><td>0.28**</td><td>-0.08</td></tr><tr><td>Erosions on X-rays</td><td>0.02</td><td>0.09*</td><td>-0.06</td><td>0.05</td><td>-0.002</td><td>-0.003</td></tr><tr><td>Family history of</td><td>0.05</td><td>0.09*</td><td>-0.01</td><td>0.04</td><td>0.02</td><td>0.03</td></tr></tbody></table>
<table><tbody><tr><td>PsA</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Family history of psoriasis</td><td>0.07</td><td>0.11*</td><td>-0.02</td><td>0.03</td><td>0.06</td><td>-0.02</td></tr><tr><td>Family history of axial SpA</td><td>0.08</td><td>0.09*</td><td>-0.003</td><td>0.04</td><td>-0.002</td><td>0.03</td></tr><tr><td>Current smoking</td><td>0.02</td><td>0.04</td><td>-0.01</td><td>0.02</td><td>0.09*</td><td>-0.10*</td></tr><tr><td>Past smoking</td><td>-0.09*</td><td>-0.13**</td><td>&lt;0.001</td><td>-0.01</td><td>-0.06</td><td>0.03</td></tr><tr><td>Dyslipidemia</td><td>-0.01</td><td>0.01</td><td>-0.03</td><td>0.08*</td><td>-0.02</td><td>0.09*</td></tr><tr><td>BMI category</td><td>0.02</td><td>0.02</td><td>0.01</td><td>0.06</td><td>-0.03</td><td>0.09*</td></tr><tr><td>CV events</td><td>0.06</td><td>0.05</td><td>0.04</td><td>-0.06</td><td>0.05</td><td>-0.12**</td></tr><tr><td>Depression</td><td>0.12**</td><td>0.13**</td><td>0.02</td><td>0.13**</td><td>0.03</td><td>0.09*</td></tr><tr><td>Tender joint count</td><td>0.46**</td><td><strong>0.57**</strong></td><td>-0.11*</td><td>0.29**</td><td>0.28**</td><td>0.02</td></tr><tr><td>Swollen joint count</td><td>0.39**</td><td>0.48**</td><td>-0.07</td><td>0.24**</td><td>0.22**</td><td>0.01</td></tr><tr><td>DAPSA category</td><td><strong>0.75**</strong></td><td><strong>0.74**</strong></td><td>0.08</td><td><strong>0.52**</strong></td><td>0.41**</td><td>0.12*</td></tr><tr><td>FiRST</td><td>0.45**</td><td>0.39**</td><td>0.09*</td><td>0.37**</td><td>0.21**</td><td>0.18*</td></tr><tr><td>HAQ</td><td><strong>0.57**</strong></td><td><strong>0.53**</strong></td><td>0.06</td><td>0.38**</td><td>0.30**</td><td>0.06</td></tr><tr><td>PHQ-4</td><td>0.47**</td><td>0.41**</td><td>0.07</td><td>0.36**</td><td>0.24**</td><td>0.11*</td></tr><tr><td>PsAID subscales</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Pain</td><td><strong>0.88**</strong></td><td><strong>0.73**</strong></td><td>0.22**</td><td><strong>0.53**</strong></td><td>0.37**</td><td>0.18**</td></tr><tr><td>- Fatigue</td><td><strong>0.73**</strong></td><td><strong>0.63**</strong></td><td>0.16**</td><td><strong>0.52**</strong></td><td>0.36**</td><td>0.16**</td></tr><tr><td>- Skin problems</td><td>0.46**</td><td>0.37**</td><td>0.11*</td><td><strong>0.81**</strong></td><td><strong>0.64**</strong></td><td>0.27**</td></tr><tr><td>- Work and/or leisure activities</td><td><strong>0.64**</strong></td><td><strong>0.58**</strong></td><td>0.09*</td><td>0.49**</td><td>0.41**</td><td>0.11**</td></tr><tr><td>- Functional capacity</td><td><strong>0.64**</strong></td><td><strong>0.59**</strong></td><td>0.08</td><td><strong>0.51**</strong></td><td>0.41**</td><td>0.13**</td></tr><tr><td>- Discomfort</td><td><strong>0.68**</strong></td><td><strong>0.58**</strong></td><td>0.13**</td><td><strong>0.55**</strong></td><td>0.38**</td><td>0.18**</td></tr><tr><td>- Sleep disturbance</td><td><strong>0.56**</strong></td><td>0.50**</td><td>0.09*</td><td>0.42**</td><td>0.29**</td><td>0.13**</td></tr></tbody></table>
<table><tr><td>- Coping</td><td><strong>0.60**</strong></td><td><strong>0.55**</strong></td><td>0.09*</td><td>0.42**</td><td>0.31**</td><td>0.11*</td></tr><tr><td>- Anxiety, fear and uncertainty</td><td>0.49**</td><td>0.49**</td><td>0.01</td><td>0.43**</td><td>0.30**</td><td>0.11*</td></tr><tr><td>- Embarrassment and/or shame</td><td>0.43**</td><td>0.39**</td><td>0.05</td><td>0.49**</td><td>0.40**</td><td>0.10*</td></tr><tr><td>- Social participation</td><td><strong>0.51**</strong></td><td><strong>0.53**</strong></td><td>-0.01</td><td>0.40**</td><td>0.34**</td><td>0.04</td></tr><tr><td>- Depression</td><td>0.47**</td><td>0.50**</td><td>-0.04</td><td>0.38**</td><td>0.30**</td><td>0.04</td></tr><tr><td>PsAID score</td><td><strong>0.78**</strong></td><td><strong>0.69**</strong></td><td>0.13**</td><td><strong>0.63**</strong></td><td>0.47**</td><td>0.18**</td></tr><tr><td>High PsAID</td><td><strong>0.63**</strong></td><td><strong>0.55**</strong></td><td>0.11*</td><td>0.50**</td><td>0.37**</td><td>0.14**</td></tr></table>

BMI, body mass index; CRP, C-reactive protein; DAPSA, Disease Activity index for Psoriatic Arthritis; ESR, erythrocyte sedimentation rate; HAQ, Health Assessment Questionnaire; HLA-B27, human leucocyte antigen-B27; FiRST, Fibromyalgia Rapid Screening Tool; PGA, patient global assessment; PhGA, physician global assessment; PHQ-4, Patient Health Questionnaire-4; PsA, psoriatic arthritis; PsAID, Psoriatic Arthritis Impact of Disease.

The first line of results represents the correlation between PGA and PhGA for PsA and psoriasis activity, while the other lines represent the correlation of each of these global assessment measures with patient and disease characteristics.

<footnote>*p-value <0.05</footnote>

<footnote>**p-value <0.01</footnote>

<footnote>** (with bold) p-value <0.01 with high correlation (Rho >0.5)</footnote>
<table><caption>**Supplementary Table S2.** Correlation table for continuous patient-reported scores.</caption><thead><tr><th></th><th></th><th>PGA for<br>PsA<br>Activity</th><th>PGA for<br>PsA<br>Activity</th><th>PGA for<br>PsA<br>Activity</th><th>DAPSA</th><th>FiRST</th><th>PsAID</th><th>HAQ</th><th>PHQ-4</th></tr></thead><tbody><tr><td rowspan="2">PGA for<br>PsA<br>Activity</td><td>Pearson<br>Correlation</td><td>--</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>N</td><td>538</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td rowspan="3">PGA for<br>PsA<br>Activity</td><td>Pearson<br>Correlation</td><td>0.539</td><td>--</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>p-value</td><td>&lt;0.001</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>N</td><td>537</td><td>537</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td rowspan="3">PGA for<br>PsA<br>Activity</td><td>Pearson<br>Correlation</td><td><strong>0.888</strong></td><td>0.551</td><td>--</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>p-value</td><td>&lt;0.001</td><td>&lt;0.001</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>N</td><td>538</td><td>537</td><td>538</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td rowspan="3">DAPSA</td><td>Pearson<br>Correlation</td><td>0.602</td><td>0.387</td><td>0.632</td><td>--</td><td></td><td></td><td></td><td></td></tr><tr><td>p-value</td><td>&lt;0.001</td><td>&lt;0.001</td><td>&lt;0.001</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>N</td><td>457</td><td>456</td><td>457</td><td>457</td><td></td><td></td><td></td><td></td></tr><tr><td rowspan="3">FiRST</td><td>Pearson<br>Correlation</td><td>0.448</td><td>0.376</td><td>0.479</td><td>0.499</td><td>--</td><td></td><td></td><td></td></tr><tr><td>p-value</td><td>&lt;0.001</td><td>&lt;0.001</td><td>&lt;0.001</td><td>&lt;0.001</td><td></td><td></td><td></td><td></td></tr><tr><td>N</td><td>538</td><td>537</td><td>538</td><td>457</td><td>538</td><td></td><td></td><td></td></tr><tr><td rowspan="3">PsAID</td><td>Pearson<br>Correlation</td><td><strong>0.768</strong></td><td><strong>0.639</strong></td><td><strong>0.771</strong></td><td>0.559</td><td>0.637</td><td>--</td><td></td><td></td></tr><tr><td>p-value</td><td>&lt;0.001</td><td>&lt;0.001</td><td>&lt;0.001</td><td>&lt;0.001</td><td>&lt;0.001</td><td></td><td></td><td></td></tr><tr><td>N</td><td>538</td><td>537</td><td>538</td><td>457</td><td>538</td><td>538</td><td></td><td></td></tr></tbody></table>
<table><tbody><tr><td rowspan="3">HAQ</td><td>Pearson Correlation</td><td>0.563</td><td>0.378</td><td>0.575</td><td>0.494</td><td>0.513</td><td><strong>0.693</strong></td><td>--</td></tr><tr><td>p-value</td><td>&lt;0.001</td><td>&lt;0.001</td><td>&lt;0.001</td><td>&lt;0.001</td><td>&lt;0.001</td><td>&lt;0.001</td><td></td></tr><tr><td>N</td><td>538</td><td>537</td><td>538</td><td>457</td><td>538</td><td>538</td><td>538</td></tr><tr><td rowspan="3">PHQ-4</td><td>Pearson Correlation</td><td>0.462</td><td>0.388</td><td>0.458</td><td>0.307</td><td>0.571</td><td><strong>0.708</strong></td><td>0.523</td></tr><tr><td>p-value</td><td>&lt;0.001</td><td>&lt;0.001</td><td>&lt;0.001</td><td>&lt;0.001</td><td>&lt;0.001</td><td>&lt;0.001</td><td></td></tr><tr><td>N</td><td>538</td><td>537</td><td>538</td><td>457</td><td>538</td><td>538</td><td>538</td></tr></tbody></table>

DAPSA, Disease Activity index for Psoriatic Arthritis; HAQ, Health Assessment Questionnaire; FiRST, Fibromyalgia Rapid Screening Tool; PGA, patient global assessment; PhGA, physician global assessment; PHQ-4, Patient Health Questionnaire-4; PsA, psoriatic arthritis; PsAID, Psoriatic Arthritis Impact of Disease.