ORIGINAL ARTICLE
Wide Variation in Clinicians' Assessment of New York Heart Association/World Health Organization Functional Class in Patients With Pulmonary Arterial Hypertension

https://doi.org/10.4065/84.7.586Get rights and content

OBJECTIVE

To assess interrater reliability of the New York Heart Association/World Health Organization functional classification as applied by clinicians (defined as both physicians and nurses in this article) to patients with pulmonary arterial hypertension (PAH).

PATIENTS AND METHODS

Between March 16 and August 31, 2007, a survey that described 10 hypothetical patients was completed by physicians and nurses attending a conference on PAH. Results were subsequently validated with physicians and nurses who were contacted online through the Pulmonary Hypertension Association. Respondents were asked to assign each patient's functional class as they would normally in clinical practice.

RESULTS

The functional class evaluations were completed by 113 clinicians, 87 (77%) of whom had participated in PAH trials; 106 (94%) reported using functional class when determining therapy. Clinicians reported a broad range of factors they considered when evaluating functional class, and their assessments of functional class varied widely. The intraclass correlation coefficient was 0.58 for the initial patient survey and 0.62 for the online survey. At best, one patient was ranked as either class II (by 60 clinicians [53%]) or class III (by 53 [47%]). Clinicians' rankings spanned at least 3 functional classes for each of the other patients. Equally divergent rankings were observed among nurses and physicians. Cluster analysis identified clinicians' tendencies toward “higher” or “lower” functional class rankings. Of the 113 clinicians, 101 (89%) thought that the patients described resembled those seen in their practices.

CONCLUSION

Despite the wide use of the New York Heart Association/World Health Organization functional class in clinical care and as a research tool, interrater agreement may be inadequate. Efforts to promote a uniform approach to evaluating functional class might help to standardize PAH care and research.

Section snippets

Clinicians' Evaluations of NYHA/WHO Functional Class

We evaluated agreement between clinicians in their assessment of NYHA/WHO functional class by presenting information about 10 hypothetical patients with PAH (eAppendix online linked to this article). The patients described were selected to represent a range of PAH severity. Because the goal was to assess whether clinicians approached functional class in the same manner, no “gold standard” or “correct” method of determining functional class was assumed; a “correct” functional class ranking for

Clinician Participants

A total of 113 clinicians participated in the 2 evaluations (Table 1). The initial paper administration involved 28 physicians and 16 nurses; 40 physicians and 29 nurses completed the online version. An additional 6 physicians who completed the online evaluation indicated that they had also participated in the initial paper version and thus were excluded from the second analysis. All participants indicated that they were actively involved in the clinical care of patients with PAH. In the

DISCUSSION

We found a wide variation in the NYHA/WHO functional class assessments made by clinicians who care for and conduct clinical research in patients with PAH. The findings were consistent in 2 independent groups of clinicians assessed with paper and online presentations of patients with PAH. Agreement on a single functional class was not seen for any patient, and in most cases judgments spanned 2 or 3 classes. Consistent with the discrepant conclusions reached was the reported wide variation in

CONCLUSION

We observed a wide variation in the NYHA/WHO functional class assignments made by both physicians and nurses for descriptions of patients with PAH. Despite the wide use of the NYHA/WHO functional class in clinical care and as a research tool, interrater agreement may be inadequate. Our findings further suggest potential systematic differences in clinicians' approach, such that some routinely rank patients in higher (or lower) functional class than do other practitioners. Regardless of whether a

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Dr Taichman has received research support from Actelion for participation in REVEAL (Registry to Evaluate Early and Long-Term PAH Disease Management). Dr McGoon has received grant support from Gilead and serves on a data safety and management/clinical end point committee for Actelion. Dr Sager has served as a consultant for Actelion and Gilead and has received research support from Acetelion. Dr Palevsky has served as a consultant for Actelion and Gilead.

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