Kansas City questionnaire is more accurate for outcome prediction than NYHA class, JAMA study.
The New York Heart Association (NYHA) functional classification system has been a cornerstone nomenclature for quantifying the health status of patients with heart failure (HF) for almost a century, and remains foundational to eligibility criteria for contemporary HF trials and application of clinical guidelines. This clinician-reported classification system has some major limitations. In the March issue of JAMA Cardiology, Greene and colleagues have shown that the patient- vs clinician-reported outcome discrepancy extends to heart failure care and patient-reported Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OS) is more accurate for outcome prediction in heart failure patients.
To characterize longitudinal changes and concordance between NYHA class and the KCCQ-OS, and their associations with clinical outcomes Greene et al included 2872 US outpatients with chronic HF with reduced ejection fraction across 145 practices enrolled in the CHAMP-HF registry. All patients had complete NYHA class and KCCQ-OS data at baseline and 12 months. Longitudinal changes and correlations between the 2 measure were examined.
Multivariable models landmarked at 12 months evaluated associations between improvement in NYHA and KCCQ-OS from baseline to 12 months with clinical outcomes occurring from months 12 through 24.
It was noted that improvement in the KCCQ summary score was significantly associated with decreased mortality, whereas improvement in NYHA class was not. 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.
During outpatient follow-up of 12 months in this cohort study, 75% of 2872 patients had a clinically meaningful change in KCCQ-OS of 5 or more points, whereas 35% had a change of 1 class or more in NYHA class. Improvement in KCCQ-OS of 5 or more points was independently associated with decreased mortality, whereas improvement in NYHA class was not.
The discordance between patient- and clinician-reported outcomes was greater for women, patients with lower income, and individuals with chronic obstructive pulmonary disease (COPD).
This study builds on other findings that suggest that patient-reported outcomes (PROs) are superior to clinician-reported outcomes. In a study of patients with HIV infection, data collected via PROs regarding substance use and depression were found to better estimate antiretroviral therapy adherence compared with data obtained by the clinician.
"Compared with the clinician-assigned NYHA class, the patient-reported KCCQ-OS is more likely to detect meaningful change in health status over time, and changes in KCCQ-OS may have more prognostic value than changes in NYHA class", concluded the authors.
Source: JAMA cardiology: JAMA Cardiol. Published online March 24, 2021. doi:10.1001/jamacardio.2021.0372
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