Prevalence of symptom exaggeration among North American independent medical evaluation examinees: A systematic review of observational studies, 2025,

[Mij]

Abstract​

Background​

Independent medical evaluations (IMEs) are commonly acquired to provide an assessment of impairment; however, these assessments show poor inter-rater reliability. One potential contributor is symptom exaggeration by patients, who may feel pressure to emphasize their level of impairment to qualify for incentives. This study explored the prevalence of symptom exaggeration among IME examinees in North America, which if common may represent an important consideration for improving the reliability of IMEs.

Methods​

We searched CINAHL, EMBASE, MEDLINE and PsycINFO from inception to July 08, 2024. We included observational studies that used a known-group design or multi-modal determination method. Paired reviewers independently assessed risk of bias and extracted data. We performed a random-effects model meta-analysis to estimate the overall prevalence of symptom exaggeration and explored potential subgroup effects for sex, age, education, clinical condition, and confidence in the reference standard. We used the GRADE approach to assess the certainty of evidence.

Results​

We included 44 studies with 46 cohorts and 9,794 patients. The median of the mean age was 40 (interquartile range [IQR] 38–42). Most cohorts included patients with traumatic brain injuries (n = 31, 67%) or chronic pain (n = 11, 24%). Prevalence of symptom exaggeration across studies ranged from 17% to 67%. We found low certainty evidence suggesting that studies with a greater proportion of women (≥40%) may be associated with higher rates of exaggeration (47%, 95%CI 36–58) vs. studies with a lower proportion of women (<40%) (31%, 95%CI 28–35; test of interaction p = 0.02). Possible explanations include biological differences, greater bodily awareness, or higher rates of negative affectivity. We found no significant subgroup effects for type of clinical condition, confidence in the reference standard, age, or education.

Conclusion​

Symptom exaggeration may occur in almost 50% of women and in approximately a third of men undergoing IMEs. The high prevalence of symptom exaggeration among IME attendees provides a compelling rationale for clinical evaluators to formally explore this issue. Future research should establish the reliability and validity of evaluation criteria for symptom exaggeration and develop a structured IME assessment approach.
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[Mij]

One of the authors,- Jason Bussse

 

[Utsikt]

Of the 32% of studies that described their sampling method (14 of 44), 13 used consecutive sampling and one used random sampling methods to identify IME referrals.

Huge red flag right from the start.

None of the known group designs used to evaluate symptom exaggeration provided evidence of reliability and validity testing; however, there has been formal evaluation of psychometric properties of forced-choice tests that were administered in eligible studies (See S4 Tablein supplementary material for details). (S2 Table).

And another one.

They also used GRADE and the studies had multiple serious risks of bias (all were at low quality, and should be scrapped).

The conclusion in this study should have been:

We found no studies with sufficient methodological quality to assess the research question.

 

[Utsikt]

Symptom exaggeration may occur in almost 50% of women and in approximately a third of men undergoing IMEs. Assessors should evaluate symptom exaggeration when conducting IMEs using a multi-modal approach that includes both clinical findings and validated tests of performance effort, and avoid conflation with malingering which presumes intent. Priority areas for future research include establishing the reliability and validity of current evaluation criteria for symptom exaggeration, and development of a structured IME assessment approach that includes consideration of symptom exaggeration.

Their conclusion is laughable. They found that there are no good tools for measuring symptoms exaggeration, yet they conclude that it was very present, especially among women.