Patient-Reported Outcomes in Cardiology: Comparison of Two Programs to Assess Angina Burden in Coronary Artery Disease

Angina predicts outcomes from coronary artery disease, including mortality, morbidity, reduced quality of life, and increased healthcare spending.¹ However, patient symptoms are underreported and incompletely documented, limiting understanding of the efficacy of therapies.² Angina can be reliably assessed using patient-reported outcomes measures (PROMs): short, well-validated questionnaires assessing symptoms and quality of life.^3,4 However, implementation barriers continue to hinder routine use of PROMs. We describe two strategies designed to evaluate the feasibility of PROMs assessment. In strategy 1, we implemented a system for collecting the Seattle Angina Questionnaire-7 (SAQ-7), 7 questions evaluating angina; the Rose Dyspnea Scale, 4 questions evaluating dyspnea; and the Patient Health Questionnaire-2, 2 questions evaluating depression, via electronic self-administered surveys before elective coronary angiography at the Beth Israel Deaconess Medical Center, and at 3 follow-up times. In strategy 2, we created a system for phone-based administration of the SAQ-7 in CAD patients receiving care at most of Massachusetts General Hospital’s (MGH) primary care clinics and affiliated health centers.

Phone-based administration of PROMs may be particularly useful for evaluating symptoms longitudinally among several patient populations. Health systems participating in risk-based contracts including a mandate to assess patient-reported health status may also find it useful to develop web- or phone-based PROMs programs. Further comparison of web- versus phone-based strategies is warranted to elicit which strategies work best locally.

We describe the motivation, design, implementation, and early outcomes of 2 complementary programs to evaluate the feasibility of collecting PROMs in the inpatient and outpatient setting among patients with CAD (Figure).

In strategy 1, PROMs were administered by tablet to patients undergoing coronary angiography. Response rates were reasonable (42.3%), and the innovation demonstrated that PROMs can be administered in a semi-automated fashion in a busy catheterization laboratory. Challenges included competing responsibilities among staff, hospital technological requirements that did not integrate well into workflow, and lack of incentives for participation. While feedback was given on low response rates to staff, the perception of increased workload was a sufficient barrier to implementation. Whether staff incentives for participation could improve response rates is unknown.

In strategy 2, the SAQ-7 was administered by phone to a population of primary care patients with stable CAD, with 2 findings: (1) the program’s 34% response rate compares favorably with the 15% to 20% response rates achieved when the SAQ-7 is administered via tablet device to patients during outpatient clinic appointments with MGH providers (unpublished data), and (2) the infrastructure for PROMs administration can be embedded within existing population health management programs. Challenges included contacting patients, responding promptly to concerning surveys, and off-hours administration. The human capital needed to administer PROMs by phone could substantially limit efforts to scale this approach.

Challenges common to both programs include integration into busy clinical workflows and engaging patients in follow-up. Both innovations confirmed higher success rates with phone contact compared with email, including in elderly, comorbid populations. These two innovations demonstrate the need to standardize workflow for PROMs administration and underscore the importance of providing training and support to administering personnel. Integrating PROMs into daily workflow may not be possible without increasing staff capacity to offset additional workload. Both innovations achieved low absolute response rates suggesting that full participation may not be realistic. Strategies for improving response rates include tailoring surveys to participants’ language and literacy levels, conducting interviews face-to-face, setting deadlines for participation, and using non-monetary incentives. Additionally, it is possible that iterative improvement through Plan-Do-Study-Act cycles may improve response rates in the future, similar to observational registries. Using a structured approach, such as the Reach-Effectiveness-Adoption-Implementation-Maintenance schematic (www.RE-AIM.org) could result in improved responses. While clinicians were encouraged to share PROMs with patients and use them for counseling, it is unclear how many clinicians chose to do so, and whether this was associated with increased follow-up response rates. Moreover, while the current projects were designed to evaluate the feasibility of PROMs collection, with appropriate training, routine integration of PROMs into clinical workflow as a vital sign may help to improve response rates and clinical utilization. Both MGH and the Beth Israel Deaconess Medical Center have plans to continue and modify existing programs through adding staffing and electronic work-arounds, but these interventions may not apply to all institutions. Until evidence-based strategies exist to improve response rates and overcome common barriers to PROMs administration, institutions are encouraged to develop pilot programs to start collecting PROMs to identify the most effective local strategies for administration. Through pooled knowledge and expertise, we can start to build the evidence base for extracting meaningful and reproducible information from our most important and underutilized resource, the patient.

The authors would like to acknowledge Kim Fong for his contribution to this work and the Centers for Healthcare Delivery Science at Beth Israel Deaconess Medical Center.