Patient-reported health status appeared to be more important than clinician-assigned symptoms in heart failure (HF), a study showed.
In the large CHAMP-HF registry, outpatients with HF with reduced ejection fraction (HFrEF) were often reported as having contradictory baseline health statuses between the clinician-assigned New York Heart Association (NYHA) and patient-reported Kansas City Cardiomyopathy Questionnaire (KCCQ) scales, according to Gregg Fonarow, MD, of the University of California Los Angeles, and colleagues.
Symptom ratings were mildly discordant between the two scales in 52.0% of cases and moderately-to-severely discordant in 10.2% — with people’s NYHA class typically worse than their KCCQ scores, they reported online in JAMA Cardiology.
Change in KCCQ health status was of better prognostic value, given that a 12-month improvement of ≥5 points in KCCQ overall summary score was a predictor of reduced mortality (adjusted HR, 0.59, 95% CI 0.44-0.80); improvement in NYHA class appeared to have no bearing on survival.
“While this finding should not be interpreted to mean that NYHA class has no prognostic value, the result indicates that the KCCQ was more sensitive to changes associated with prognosis,” commented Paul Heidenreich, MD, of the VA Palo Alto Health Care System, California, in an accompanying editorial.
Ultimately, the study implies that NYHA class should be reconsidered if it does not match the patient-reported data, according to Heidenreich.
Fonarow’s group reported that improved KCCQ scores over 12 months were also linked with fewer mortalities or HF hospitalizations (adjusted HR 0.73, 95% CI, 0.59-0.89), but not HF hospitalizations alone.
“Although numerous reliable clinical risk markers for HF already exist, the sheer magnitude of the 41% lower risk of mortality independently associated with improvement in [KCCQ] in the present study is notable,” the group said.
Heidenreich noted that patient-reported outcomes (PROs), like health status measured on the KCCQ, have been shown to conflict with clinician-reported outcomes in various settings (e.g., pain following irradiation, angina in coronary artery disease).
“Although it is tempting to say that the clinician did not take a proper medical history, the patient-clinician relationship is nuanced. Patients may be more interested in providing details on a form than when speaking with a clinician. Patients may pick up on a clinician’s view that their symptoms are stable. Patients may choose to agree with a clinician’s suggestion that they are doing about the same rather than contradict their clinician,” he said.
CHAMP-HF was an observational study of 5,009 HF outpatients with EFs 40% or lower.
The present analysis included the 2,872 patients (median age 68, 30.4% women, 75.1% white) with complete NYHA and KCCQ data at baseline and 12 months. These participants had been enrolled at 145 practices in 2015-2017.
At baseline, patients were separated by NYHA class: class I (10.9%), class II (59.5%), class III (28.0%), class IV (1.6%).
The breakdown according to roughly analogous KCCQ categories was different: scores 75-100 (best health status; 39.4%), scores 50-74 (33.7%), scores 25-49 (21.3%), and scores 0-24 (worst health status; 5.6%).
Older age, female sex, Hispanic ethnicity, and lower household income were among the factors associated with NYHA-KCCQ discordance.
This raises the possibility of clinician bias in assigning NYHA classes and may reflect challenges in patient-clinician communication in some groups, Fonarow and colleagues suggested.
Limiting their study was the lack of accepted corresponding scores between the NYHA and KCCQ. The data also may not be generalizable to patients at all HF clinics, investigators warned.
To date, uptake of PRO measures in HF has been slow across health systems despite recommendations to use them as quality measures and trial outcomes.
Barriers may include the logistics of data collection, results interpretation, and perceived utility and value of PROs by clinicians. “This may stand in contrast with NYHA class, which can conceivably be assigned in seconds by a clinician familiar with the patient,” Fonarow and colleagues said.
“Nonetheless, routine collection of PROs within the HF clinic has proven feasible at some centers, with mean PRO assessment times of less than 7 minutes and computerized scoring within the electronic health record,” they noted.
The study and registry were funded by Novartis.
Fonarow disclosed relevant relationships with, and/or support from, the NIH, Novartis, Abbott, Amgen, AstraZeneca, Bayer, CHF Solutions, Edwards, Janssen, Medtronic, and Merck, as well as serving as a JAMA Cardiology editor.
Heidenreich disclosed no relevant relationships with industry.