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

      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.
      ICC (intraclass correlation coefficient), NYHA (New York Heart Association), PAH (pulmonary arterial hypertension), REVEAL (Registry to Evaluate Early and Long-Term PAH Disease Management), WHO (World Health Organization)
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      REFERENCES

        • McLaughlin VV
        • McGoon MD
        Pulmonary arterial hypertension.
        Circulation. 2006; 114: 1417-1431
        • Hoeper MM
        • Oudiz RJ
        • Peacock A
        • et al.
        End points and clinical trial designs in pulmonary arterial hypertension: clinical and regulatory perspectives.
        J Am Coll Cardiol. 2004; 43: 48S-55S
        • Badesch DB
        • Abman SH
        • Ahearn GS
        • et al.
        Medical therapy for pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines.
        Chest. 2004; 126: 35S-62S
        • Badesch DB
        • Abman SH
        • Simonneau G
        • Rubin LJ
        • McLaughlin VV
        Medical therapy for pulmonary arterial hypertension: updated ACCP evidence-based clinical practice guidelines.
        Chest. 2007; 131: 1917-1928
        • Barst RJ
        • McGoon M
        • Torbicki A
        • et al.
        Diagnosis and differential assessment of pulmonary arterial hypertension.
        J Am Coll Cardiol. 2004; 43: 40S-47S
        • Criteria Committee of the New York Heart Association
        Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Little, Brown, Boston, MA1994
        • Bennett JA
        • Riegel B
        • Bittner V
        • Nichols J
        Validity and reliability of the NYHA classes for measuring research outcomes in patients with cardiac disease.
        Heart Lung. 2002; 31: 262-270
        • Coyne KS
        • Allen JK
        Assessment of functional status in patients with cardiac disease.
        Heart Lung. 1998; 27: 263-273
        • McGoon MD
        • Barst RJ
        • Doyle RL
        • Liou TG
        • Miller D
        • Feldkircher K
        REVEAL registry: treatment history and treatment at baseline.
        Chest. 2007; 132: 631S
        • Macchia A
        • Marchioli R
        • Marfisi R
        • et al.
        A meta-analysis of trials of pulmonary hypertension: a clinical condition looking for drugs and research methodology.
        Am Heart J. 2007; 153: 1037-1047
        • Rich S
        The value of approved therapies for pulmonary arterial hypertension [editorial].
        Am Heart J. 2007; 153: 889-890
        • Landis JR
        • Koch GG
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Kraemer HC
        • Bloch DA
        Kappa coefficients in epidemiology: an appraisal of a reappraisal.
        J Clin Epidemiol. 1988; 41: 959-968
        • Walter SD
        • Eliasziw M
        • Donner A
        Sample size and optimal designs for reliability studies.
        Stat Med. 1998; 17: 101-110
        • Statistical Analysis Systems Institute
        SAS/STAT User's Guide. 4th ed. SAS Institute, Cary, NC1990
        • Johnson RA
        • Wichern DW
        Applied Multivariate Statistical Analyses. 3rd ed. Prentice Hall, Englewood Cliffs, NJ1992
        • Morral AR
        • Iguchi MY
        • Belding MA
        • Lamb RJ
        Natural classes of treatment response.
        J Consult Clin Psychol. 1997; 65: 673-685
        • McLaughlin VV
        • Presberg KW
        • Doyle RL
        • et al.
        Prognosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines.
        Chest. 2004; 126: 78S-92S
        • Miller-Davis C
        • Marden S
        • Leidy NK
        The New York Heart Association Classes and functional status: what are we really measuring?.
        Heart Lung. 2006; 35: 217-224
        • Friedman EB
        • Palevsky HI
        • Taichman DB
        Classification and prognosis of pulmonary arterial hypertension.
        in: Mandel J Taichman DB Pulmonary Vascular Disease. Elsevier Science, Philadelphia, PA2006: 66-82
        • Murugappan M
        • Sundy R
        • Byers D
        • et al.
        Application of a standardized questionnaire to assign World Health Organization functional classification in pulmonary arterial hypertension patients [abstract C46].
        Am J Respir Crit Care Med. 2008; 177: A919