"While the clinician-interpreted and reported NYHA class has been utilized for decades to quantitate heart failure patient functional status and outcomes in clinical trials and clinical practice, data directly collected from patients has been increasingly utilized in clinical trials," Dr. Gregg Fonarow of the University of California, Los Angeles, told Reuters Health by email.
"We found that compared with the clinician-assigned NYHA class, the patient-reported KCCQ was more likely to detect meaningful change in...health status longitudinally," he said. "Further, the changes detected with KCCQ were more reliable indicators of subsequent risk of heart failure hospitalization or mortality."
Overall, he said, "Patient-centered heart failure care is best served when relying on data directly reported from patients. Patient-reported outcomes measures should be collected, reported, and acted on in routine clinical practice in heart failure. Further studies are needed on how to best achieve this aim in all clinical care settings."
As reported in JAMA Cardiology, Dr. Fonarow and colleagues analyzed data on 2,872 US outpatients with chronic heart failure with reduced ejection fraction (mean age, 68; 30%, women; 75%, White) across 145 practices enrolled in the CHAMP-HF registry between 2015 - 2017. All had NYHA class and KCCQ-OS data at baseline and 12 months.
At baseline, 10.9% were NYHA class I; 59.5%, class II; 28%, class III; and 1.6%, class IV. KCCQ-OS scores were 75 to 100 (best health status) for 39.4%; 50 to 74 for 33.7%; 25 to 49 for 21.3%; and 0 to 24 (worst health status) for 5.6%.
At 12 months, 34.9% had a change in NYHA class - 20.9% improved, whereas 14% worsened. Seventy-five percent had a change of 5 or more points in KCCQ-OS - 48.3% improved, while 26.8% worsened.
For NYHA class, the most common trajectory was no change (65.1%), whereas for KCCQ-OS, it was an improvement of at least 10 points (36.5%).
After adjustment, improvement in NYHA class was not associated with subsequent clinical outcomes, whereas an improvement of five or more points in KCCQ-OS was independently associated with decreased all-cause mortality (hazard ratio, 0.59), and with the composite of all-cause death or heart failure hospitalization (HR, 0.73). No significant association was seen between improvement in KCCQ-OS and HF hospitalization.
Dr. Paul Heidenreich of Stanford University School of Medicine and the VA Palo Alto Health Care System, author of a related editorial, commented in an email to Reuters Health, "Several studies have shown that heart failure-specific patient-reported outcomes (PROs) provide information not captured by the NYHA class. Clinicians should consider using PROs to supplement their clinical history. Some patients may downplay symptoms when asked by their physician and the PRO will be more accurate for them."
"PROs can be collected in advance of a visit as part of the online check-in and be made available to providers at the time of the encounter," he noted. "Not all patients will want to or be able to provide PROs. But for those that do, a clearer picture of their health status can be obtained when combined with a medical history than from a history alone."
Like Dr. Fonarow, he said, "Health systems should collect PROs just as they collect data on mortality, surgical complications and readmission, as this is an important health outcome for their population."
The analysis and the CHAMP-HF registry were funded by Novartis. Dr. Fonarow and many of the coauthors have received fees from the company.
SOURCE: https://bit.ly/31wPc2s and https://bit.ly/2OaeX5S JAMA Cardiology, online March 24, 2021.
By Marilynn Larkin
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