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Heart failure diagnosis in primary health care: clinical characteristics of problematic patients. A clinical judgement analysis study.

Skånér Y, Bring J, Ullman B, Strender LE - BMC Fam Pract (2003)

Bottom Line: Early detection of chronic heart failure has become increasingly important since the introduction of effective treatment.The purpose of this study is to analyse how patient characteristics contribute to difficulties in diagnosing systolic heart failure. A Clinical Judgement Analysis study of 40 case vignettes based on authentic patients, including relevant clinical data except echocardiography.Primary health care and two cardiology outpatient clinics in Stockholm. 70 participants with different types of clinical experience; 27 specialists in general practice, 22 cardiologists, and 21 medical students.

View Article: PubMed Central - HTML - PubMed

Affiliation: Family Medicine Stockholm, Karolinska Institutet, Alfred Nobels allé 12, SE-141 83 Huddinge, Sweden. ylva.skaner@klinvet.ki.se

ABSTRACT

Background: Early detection of chronic heart failure has become increasingly important since the introduction of effective treatment. However, clinical diagnosis of heart failure is known to be difficult, especially in mild cases or early in the course of the disease. The purpose of this study is to analyse how patient characteristics contribute to difficulties in diagnosing systolic heart failure.

Design: A Clinical Judgement Analysis study of 40 case vignettes based on authentic patients, including relevant clinical data except echocardiography.

Setting: Primary health care and two cardiology outpatient clinics in Stockholm.

Subjects: 70 participants with different types of clinical experience; 27 specialists in general practice, 22 cardiologists, and 21 medical students.

Main outcome measures: The assessed probability of heart failure for each case vignette, and the disagreement between the participants. The number of clinical variables (cues) indicative of heart failure in the case vignettes.

Results: The ten case vignettes with the least diverging assessments more often had increased relative cardiac volume and atrial fibrillation. No further specific clinical patterns could be found in subgroups of the case vignettes. The ten case vignettes with the most diverging assessments were those with an intermediate number of clinical variables. The case vignettes with the least diverging assessments more often represented patients with cardiac enlargement and atrial fibrillation.

Conclusion: Diagnosing mild heart failure is difficult, as these patients are not easy to characterise. In our study, a larger number of positive cues resulted in more diagnostic conformity among the participants, and the most important information was cardiac enlargement. The importance of more objective diagnostic methods in diagnosing suspected cases of heart failure should be emphasised.

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Related in: MedlinePlus

The case vignettes with the least and the most divergent assessments. The box size (= the interquartile range) reflects the participants' divergence in rating the probability of heart failure for each individual patient. The bottom of the box is at the first quartile (Q1), the top is at the third quartile (Q3), and the line across the box is at the median value. The "whiskers" (= the lines that extend from the top and bottom of the box) extend to the smallest and the largest observation (= participant) that is not considered an outlier. Outliers (*) are observations outside these limits.
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Figure 1: The case vignettes with the least and the most divergent assessments. The box size (= the interquartile range) reflects the participants' divergence in rating the probability of heart failure for each individual patient. The bottom of the box is at the first quartile (Q1), the top is at the third quartile (Q3), and the line across the box is at the median value. The "whiskers" (= the lines that extend from the top and bottom of the box) extend to the smallest and the largest observation (= participant) that is not considered an outlier. Outliers (*) are observations outside these limits.

Mentions: For all of the vignettes the variation between the probability assessments was large. The differences between maximum and minimum assessments (the range) for the individual vignettes varied between 48 and 100 percentage units. The assessments of the case vignettes with the least and the most divergent assessments are presented in Figure 1. The interquartile ranges (box sizes) for the vignettes with the least divergent assessments were between 10 and 19 percentage units, and for those with the most divergent assessments they were between 30 and 42 percentage units. The fact that the participants had converging opinions about a vignette did not mean, however, that their assessment was correct (for example, patients 20 and 26 in Figure 1, who were assessed as probable heart failure patients but who did not have that diagnosis).


Heart failure diagnosis in primary health care: clinical characteristics of problematic patients. A clinical judgement analysis study.

Skånér Y, Bring J, Ullman B, Strender LE - BMC Fam Pract (2003)

The case vignettes with the least and the most divergent assessments. The box size (= the interquartile range) reflects the participants' divergence in rating the probability of heart failure for each individual patient. The bottom of the box is at the first quartile (Q1), the top is at the third quartile (Q3), and the line across the box is at the median value. The "whiskers" (= the lines that extend from the top and bottom of the box) extend to the smallest and the largest observation (= participant) that is not considered an outlier. Outliers (*) are observations outside these limits.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC222938&req=5

Figure 1: The case vignettes with the least and the most divergent assessments. The box size (= the interquartile range) reflects the participants' divergence in rating the probability of heart failure for each individual patient. The bottom of the box is at the first quartile (Q1), the top is at the third quartile (Q3), and the line across the box is at the median value. The "whiskers" (= the lines that extend from the top and bottom of the box) extend to the smallest and the largest observation (= participant) that is not considered an outlier. Outliers (*) are observations outside these limits.
Mentions: For all of the vignettes the variation between the probability assessments was large. The differences between maximum and minimum assessments (the range) for the individual vignettes varied between 48 and 100 percentage units. The assessments of the case vignettes with the least and the most divergent assessments are presented in Figure 1. The interquartile ranges (box sizes) for the vignettes with the least divergent assessments were between 10 and 19 percentage units, and for those with the most divergent assessments they were between 30 and 42 percentage units. The fact that the participants had converging opinions about a vignette did not mean, however, that their assessment was correct (for example, patients 20 and 26 in Figure 1, who were assessed as probable heart failure patients but who did not have that diagnosis).

Bottom Line: Early detection of chronic heart failure has become increasingly important since the introduction of effective treatment.The purpose of this study is to analyse how patient characteristics contribute to difficulties in diagnosing systolic heart failure. A Clinical Judgement Analysis study of 40 case vignettes based on authentic patients, including relevant clinical data except echocardiography.Primary health care and two cardiology outpatient clinics in Stockholm. 70 participants with different types of clinical experience; 27 specialists in general practice, 22 cardiologists, and 21 medical students.

View Article: PubMed Central - HTML - PubMed

Affiliation: Family Medicine Stockholm, Karolinska Institutet, Alfred Nobels allé 12, SE-141 83 Huddinge, Sweden. ylva.skaner@klinvet.ki.se

ABSTRACT

Background: Early detection of chronic heart failure has become increasingly important since the introduction of effective treatment. However, clinical diagnosis of heart failure is known to be difficult, especially in mild cases or early in the course of the disease. The purpose of this study is to analyse how patient characteristics contribute to difficulties in diagnosing systolic heart failure.

Design: A Clinical Judgement Analysis study of 40 case vignettes based on authentic patients, including relevant clinical data except echocardiography.

Setting: Primary health care and two cardiology outpatient clinics in Stockholm.

Subjects: 70 participants with different types of clinical experience; 27 specialists in general practice, 22 cardiologists, and 21 medical students.

Main outcome measures: The assessed probability of heart failure for each case vignette, and the disagreement between the participants. The number of clinical variables (cues) indicative of heart failure in the case vignettes.

Results: The ten case vignettes with the least diverging assessments more often had increased relative cardiac volume and atrial fibrillation. No further specific clinical patterns could be found in subgroups of the case vignettes. The ten case vignettes with the most diverging assessments were those with an intermediate number of clinical variables. The case vignettes with the least diverging assessments more often represented patients with cardiac enlargement and atrial fibrillation.

Conclusion: Diagnosing mild heart failure is difficult, as these patients are not easy to characterise. In our study, a larger number of positive cues resulted in more diagnostic conformity among the participants, and the most important information was cardiac enlargement. The importance of more objective diagnostic methods in diagnosing suspected cases of heart failure should be emphasised.

Show MeSH
Related in: MedlinePlus