‘Striking’ Differences in How Cardiologists, Patients Report Angina Frequency
Cardiologists and patients often are not on the same page when it comes to assessing the frequency of angina symptoms in an outpatient setting, with a new study reporting only “moderate agreement” between their estimates. Moreover, patient assessments of angina are more strongly aligned with quality of life measures than are physician estimates, highlighting the potential benefit of incorporating patient-reported outcomes into clinical practice.
Some discordance was expected based on hints from prior research, but the degree of disagreement in certain cases was “very striking,” lead author Ali Shafiq, MD (Saint Luke’s Mid America Heart Institute, Kansas City, MO), told TCTMD. In particular, he noted, patients who self-reported daily or weekly angina were deemed by cardiologists to not have had any angina in the past month in 26% of cases.
“This discordance between patient and provider assessment of angina highlights a significant impediment to doctor-patient communication that could potentially lead to untreated symptoms and worse quality of life than might be attained if doctors had a better insight into the frequency of patients’ symptoms,” Shafiq and colleagues write in their paper published online ahead of print in the American Heart Journal.
The reason for the discordance is unclear, but it might be related to the busy nature of outpatient clinics, variation in the quality of medical history taking, or the fact that some patients in the study were seeing their cardiologist for reasons other than angina, Shafiq said. Even so, he noted, the cardiologists included in the study knew that the purpose was to evaluate the quality of angina assessment.
Using patient-reported outcome measures like the Seattle Angina Questionnaire, which was used in the study, has the potential to ameliorate disparities in care, Shafiq said.
“We feel that a big implication of our study is that it will highlight the importance of incorporating these patient-reported outcome measures into clinical practice to improve the patient-physician communication and more accurately assess the patient’s angina symptoms,” he said.
The investigators examined data from the cross-sectional Angina Prevalence and Provider Evaluation of Angina Relief (APPEAR) study, which included 1,257 outpatients with stable CAD from 25 US cardiology practices participating in the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) registry.
Patients completed the Seattle Angina Questionnaire before the first visit; 67% reported no angina in the prior month, 25% reported monthly symptoms, and 8% said they had daily or weekly symptoms.
After the visit, cardiologists estimated the frequency of the patients’ angina symptoms, estimating that 76% of patients had no angina, 7% had monthly symptoms, and 17% had daily or weekly symptoms.
Cardiologist and patient assessments agreed 93% of the time when patients reported no angina, but only 17% and 69% of the time when patients reported monthly or daily/weekly symptoms, respectively.
Cardiologists failed to note any chest pain in the prior month for 46% of patients reporting monthly angina and 26% of those who said they had daily or weekly angina.
The agreement between patient and physician assessments was deemed “moderate,” as indicated by a kappa statistic of 0.48.
Commenting on the study, John Erwin III, MD (Texas A&M College of Medicine/Baylor Scott & White Health, Temple, TX), said in an email that “understanding the impairment in activity and quality of life, as well as the frequency at which a patient is affected by their symptoms, is paramount to providing patient-centered care.”
He added that the amount of disagreement observed between cardiologists and patients regarding the frequency of angina symptoms is not surprising because of barriers to communication. These obstacles include overestimation of angina by the patient, time constraints on the part of the physician, and some degree of cognitive bias for both the patient and physician.
“The fact that the concordance was so low even when the physicians knew that they were being studied probably shows us that in day-to-day practice, we are actually communicating less effectively than even this study would show,” Erwin said.
The study does demonstrate, however, that there are tools available to allow physicians to better serve patients’ needs, he said. “The most important [clinical implication] may be the ability to use a form of the Seattle Angina Questionnaire to allow the patient to prepopulate the information to the electronic health record before the visit with the physician to allow those reported symptoms to be the starting point for the conversation in the office.”
In addition, Erwin noted, “the implications for improving the history-taking and patient-doctor communication for other cardiac conditions and other disease processes besides heart disease (arthritis, COPD, etc) is immense.”
Shafiq A, Arnold SV, Gosch K, et al. Patient and physician discordance in reporting symptoms of angina among stable CAD patients: insights from the Angina Prevalence and Provider Evaluation of Angina Relief (APPEAR) study. Am Heart J. 2016;Epub ahead of print.
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- APPEAR was supported by an investigator-initiated grant from Gilead Sciences. Shafiq was supported by a T32 training grant from the National Heart, Lung, and Blood Institute.
- Shafiq reports no relevant conflicts of interest.
- Erwin reports working with one of the study co-authors on the American Heart Association/American College of Cardiology Performance Improvement Committee and serving on the NCDR Science and Quality Oversight Committee (SQOC) Subcommittee for Data Quality.