fibromyalgia may be driving discordance in MHDA states. Wolfe [37] coined the term fibromyalgianess, noting that the distribution of polysymptomatic distress does not suggest a discrete entity but rather a continuous spectrum of illness. Perhaps the findings of the present study indicate interactions between higher inflammatory activity and abnormal pain processing in the development of complex, disease-related centralized pain and polysymptomatic distress [38, 39]. As suggested by Wolfe et al. [39], consideration should be given to disaggregation of domains within the patient global assessment to develop management pathways targeting optimal patient-centered outcomes. For example, high PHQ-9 scores in the present study identified several patients with undiagnosed depression. The findings suggest that routine measurement of patient-reported outcomes could help identify the central drivers of adverse health status apart from inflammatory disease activity and thereby could suggest potential interventions. Further research is necessary to develop a feasible, time-efficient set of patient-reported outcomes and determine how to integrate them into typical practice settings. In the meantime, rheumatologists may consider implementation of the tools reported in this study. The patient-reported outcome measures used in this study may be obtained at the following websites: for PROMIS,.net/ PHQ-9,.com/select-screener; and for the fibromyalgia WPI and SS score,.org/Practice-Quality/Clinical-Support/Criteria/ACR-Endorsed-Criteria. Ultrasonography is a more sensitive measure of disease activity than clinical examination [40]. In the present study, although patients in the discordant group commonly had active synovitis, ultrasonography-defined synovitis did not discriminate the groups. Unrecognized disease activity does not appear to be a major factor in discordance. Nonetheless, this tool could be useful in evaluating disease activity and guiding disease-modifying therapy in patients with patient-provider discordance, considering that composite disease activity scores are less reliable in this clinical setting [41]. Previous studies have emphasized differences between the patient global assessment of disease activity and the patient general health assessment [4, 42]. The question for the patient global assessment in the present study did not specifically ask about joint tenderness, swelling, or inflammation, but the wording was similar to previous studies [3, 43]. The cross-sectional design prevented assessment of the persistence of discordance over time, as well as causal associations. Future studies are necessary to understand the clinical factors leading to the development of discordance. Morning stiffness is an important symptom of RA but was not assessed in this study. The results show some evidence of selection bias in the prospective substudy, in which patients who chose to participate were somewhat less likely to have positivity for RF and anti-CCP antibodies and erosive disease than nonparticipants. However, participants and nonparticipants were otherwise similar for pain, disability, and clinical disease activity, so it is unlikely that this minor selection bias had a major impact on the patient-reported outcome and ultrasonography results. Speculatively, patients with seronegative RA may perceive greater uncertainty on the part of their providers, leading them to be more interested in participating in a study on patient-provider discordance. Discordance