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Wide Variation in Clinicians’ Assessments of NYHA/WHO Functional Class

Darren Taichman

Michael McGoon

M. O. Harhay

J. S. Sager

R. Gallop

Harold Palevsky


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Conference: 2008 International PHA Conference and Scientific Sessions

Release Date: 06.20.2008

Presentation Type: Abstracts

Taichman D.B., McGoon M.D., Harhay M.O., Sager J., Gallop R., Palevsky H.I.

University of Pennsylvania School of Medicine, Philadelphia, PA, Mayo Clinic, Rochester, MN, and Sansum Clinic, Santa Barbara, CA, USA

BACKGROUNDThe New York Heart Association/World Health Organization functional classification (FC) is widely used for evaluating patients, as an enrollment criterion and outcome for clinical trials, and in FDA-labeling of therapies for pulmonary arterial hypertension (PAH).  Reliability, however, has never been assessed in PAH.

METHODS: Inter-rater reliability of the FC was assessed using a survey describing the symptoms, therapies, and hemodynamic/exercise variables of 10 patients.  Surveys were completed by physicians and nurses attending a PAH conference, and the results validated separately with physicians and nurses contacted through the Pulmonary Hypertension Association.  Respondents were asked to rank each patient’s FC as they would normally.

RESULTS: 113 physicians and nurses involved in PAH clinical care/research completed the FC evaluations; 44 clinicians participated in the initial survey and 69 the validation.  Approximately one third of the participants had cared for PAH patients for each < 5 years, 5-10 years, and > 10 years.  77% had participated in clinical PAH trials.  A wide variation in the clinicians’ assessments of FC was found.  Overall, the intra-class correlation coefficient was 0.57 on the initial survey, and 0.64 on the second/validation, indicating consistently poor to modest inter-rater agreement.  At best, a patient was ranked as either class II (by 53% of respondents) or III (by 47%).  In all others, even wider variation occurred (e.g., a patient judged as class I, II, III and IV by 10, 38, 26 and 26% of clinicians, respectively).   Equally divergent rankings were observed among nurses and physicians. Cluster analysis indicated that clinicians tended to be either “higher” or “lower” rankers with regard to the FC they assign.  89% of the physicians and nurses believed the patients described in the study resembled those they might see in their own practices.  94% of the participants reported using the FC when deciding therapy for their patients with PAH.   

COMMENTS AND CONCLUSIONS: Despite its wide use, there is poor inter-rater agreement regarding the NYHA/WHO functional classification. Efforts to promote a uniform approach of evaluating FC or identification of more reliable functional parameters might help standardize PAH clinical care and research.