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.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Mayo Clinic ProceedingsAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
REFERENCES
- Pulmonary arterial hypertension.Circulation. 2006; 114: 1417-1431
- End points and clinical trial designs in pulmonary arterial hypertension: clinical and regulatory perspectives.J Am Coll Cardiol. 2004; 43: 48S-55S
- Medical therapy for pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines.Chest. 2004; 126: 35S-62S
- Medical therapy for pulmonary arterial hypertension: updated ACCP evidence-based clinical practice guidelines.Chest. 2007; 131: 1917-1928
- Diagnosis and differential assessment of pulmonary arterial hypertension.J Am Coll Cardiol. 2004; 43: 40S-47S
- Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Little, Brown, Boston, MA1994
- Validity and reliability of the NYHA classes for measuring research outcomes in patients with cardiac disease.Heart Lung. 2002; 31: 262-270
- Assessment of functional status in patients with cardiac disease.Heart Lung. 1998; 27: 263-273
- REVEAL registry: treatment history and treatment at baseline.Chest. 2007; 132: 631S
- A meta-analysis of trials of pulmonary hypertension: a clinical condition looking for drugs and research methodology.Am Heart J. 2007; 153: 1037-1047
- The value of approved therapies for pulmonary arterial hypertension [editorial].Am Heart J. 2007; 153: 889-890
- The measurement of observer agreement for categorical data.Biometrics. 1977; 33: 159-174
- Kappa coefficients in epidemiology: an appraisal of a reappraisal.J Clin Epidemiol. 1988; 41: 959-968
- Sample size and optimal designs for reliability studies.Stat Med. 1998; 17: 101-110
- SAS/STAT User's Guide. 4th ed. SAS Institute, Cary, NC1990
- Applied Multivariate Statistical Analyses. 3rd ed. Prentice Hall, Englewood Cliffs, NJ1992
- Natural classes of treatment response.J Consult Clin Psychol. 1997; 65: 673-685
- Prognosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines.Chest. 2004; 126: 78S-92S
- The New York Heart Association Classes and functional status: what are we really measuring?.Heart Lung. 2006; 35: 217-224
- Classification and prognosis of pulmonary arterial hypertension.in: Mandel J Taichman DB Pulmonary Vascular Disease. Elsevier Science, Philadelphia, PA2006: 66-82
- 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
Article Info
Footnotes
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.
Identification
Copyright
© 2009 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
