Feasibility of measuring patient-reported health status at time of percutaneous coronary intervention: Results from a single-center quality-improvement initiative

Percutaneous coronary intervention (PCI) in patients with stable coronary artery disease (CAD) alleviates anginal symptoms and improves quality of life. Although substantial heterogeneity between patient and physician assessment of anginal burden has been reported,1,2 clinicians typically use the Canadian Cardiovascular Society (CCS) classification to grade the severity of angina in such patients. The Seattle Angina Questionnaire (SAQ)3,4 was developed to obtain patient-reported health status in patients with CAD, thus serving as a validated patient-reported outcome measure (PROM). Although general acknowledgement on the importance of patient-reported health status exists, significant barriers seem to prohibit the routine incorporation of these assessments into routine clinical practice.5 We report on the feasibility and process of implementing the short form of the SAQ (SAQ-7)4 among patients referred for elective, outpatient PCI as part of a quality-improvement initiative at our institution. Furthermore, we aimed to identify determinants of patient-reported health status and to evaluate the degree of correlation between objective clinical assessment and patient-level perception of the same. The SAQ-7 was programmed as an editable electronic form within our institutional electronic medical record and administered prior to elective cardiac catheterization. All patients referred for outpatient, elective coronary angiography were eligible to receive the SAQ-7. Among this sample, those patients undergoing PCI served as the target population for the present analysis. Patients with acute coronary syndrome as well as inpatients did not receive the SAQ-7 and were excluded. An institutional review board approved this registry. Associations between clinical and procedural parameters with SAQ-7 scores were examined using multivariable linear regression. Variables demonstrating significant univariable associations with the dependent outcome of SAQ-7 were entered as candidate covariates in a multivariable model, which was generated using backward selection with an exit criterion of p < 0.05. All statistical analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC, USA). Seattle Angina Questionnaire score according to clinical assessment of angina severity by means of Canadian Cardiovascular Society classification. Ptrend < 0.0001. SAQ: Seattle Angina Questionnaire; CCS: Canadian Cardiovascular Society. Seattle Angina Questionnaire score according to clinical assessment of angina severity by means of Canadian Cardiovascular Society classification. Ptrend < 0.0001. SAQ: Seattle Angina Questionnaire; CCS: Canadian Cardiovascular Society. Multivariable linear regression model for correlates of Seattle Angina Questionnaire score. BMI: body mass index; HGB: hemoglobin; CABG: coronary artery bypass graft; ISR: in-stent restenosis. Note: physician included as random effect. Multivariable linear regression model for correlates of Seattle Angina Questionnaire score. BMI: body mass index; HGB: hemoglobin; CABG: coronary artery bypass graft; ISR: in-stent restenosis. Note: physician included as random effect. In the present report, we demonstrate that integrating the SAQ-7 within clinical workflows in a high-volume PCI center was efficient and feasible; lower SAQ-7 scores were associated with a higher prevalence of cardiovascular risk factors and comorbidities, while angiographic and procedural parameters appeared less influential on patient-reported health status and SAQ-7 was aligned with physician assessment of the same using the CCS scale. The increasing relevance of PROMs is highlighted by the incorporation of such tools within national quality metrics, clinical workflows and even reimbursement models for regional and federal payors.6,7 Although validated in several investigations, implementation of the SAQ-7 in daily clinical routine remains challenging, and concerns for additional burden on clinical staff serve as barriers for widespread use. Our single-center quality-improvement initiative might serve as a test-use case for collecting the SAQ-7 prior to PCI with a high rate of completion in eligible patients. Moreover, the lack of significant association between treating physician and anginal severity further justifies using a patient-reported measure such as the SAQ to obtain a more consistent estimate of patients’ symptom status. Certainly, our process could be expanded upon or even made more efficient – for example, utilizing an electronic tablet-based system to collect data in the patient’s native language. Our analysis showed a higher prevalence of cardiovascular risk factors and comorbidities in patients with lower versus higher SAQ-7 scores. In contrast, procedural and angiographic indices such as lesion length, SYNTAX score and ejection fraction did not emerge as correlates of health status. Linear regression identified female sex, lower hemoglobin, hypertension, BMI history of CABG and chronic lung disease as independent determinants for lower SAQ-7 scores (Table 1). These factors might contribute to aggravate the imbalance of oxygen supply and thereby impact quality of life. The CCS classification is used to categorize the level of angina from a clinical point of view.8 However, the clinical evaluations performed by the physician may not always be aligned with the patient-level perception of angina symptoms and health status.1,2 Such discordance may result in either over- or under-treatment of patients with anginal symptoms and CAD, respectively. Several studies found a discordance between PROM and clinical assessment of angina,2 especially among patients who reported daily/weekly angina,1,9 and that less frequent angina was independently associated with greater odds of angina under-recognition.10 The findings of our analysis are congruent to those obtained in those studies. In conclusion, we show that collecting the SAQ-7 in the stable outpatients setting is feasible and that lower scores are associated with more cardiovascular risk factors and comorbidities. SAQ-7 can serve as the link between patient’s symptoms and the clinical assessment of angina severity in patients referred for elective PCI.