Current clinical utilization of risk assessment tools in pulmonary arterial hypertension: a descriptive survey of facilitation strategies, patterns, and barriers to use in the United States

Abstract

Practice guidelines suggest that treatment decisions in pulmonary arterial hypertension be informed by periodic assessment of patients' clinical risk. Several tools, well validated for risk discrimination, such as the Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management calculator, were developed to assess pulmonary arterial hypertension patients' risk of death based on multiple parameters, including functional class, hemodynamics, biomarkers, comorbidities, and exercise capacity. Using an online survey, we investigated the use of risk assessment tools by pulmonary hypertension healthcare providers in the United States. Of 121 survey respondents who make treatment decisions, 59% reported using risk assessment tools. The use of these tools was lower for non-physicians (48% vs. 65% physicians) and for practitioners at centers with 1 to 100 pulmonary arterial hypertension patients compared with centers with >100 patients (47% vs. 64%). Risk was most frequently assessed by decision makers at the time of diagnosis (cited by 54%) and at the time of worsening symptoms (cited by 42%), suggesting that use of pulmonary arterial hypertension risk assessment tools remains low. In our survey, non-physicians compared with physicians cited two major barriers to increased tool use: lack of education and training (20% vs. 4%) and lack of clarity on the best tool to use (30% vs. 18%). Information technology tools, such as electronic medical record integration and web or phone-based risk calculating applications, were cited most frequently as ways to increase the use of risk assessment tools.

Keywords: REVEAL; mortality risk assessment; multiparameter risk assessment; pulmonary arterial hypertension; risk assessment tools.

Fig. 1.

Objective risk assessment tools in PAH. 6MWD: 6-min walk distance; BNP: brain natriuretic peptide; COMPERA: Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension; FC: functional classification; FPHR: French Pulmonary Hypertension Registry; NT-proBNP: N-terminal fragment of pro-brain natriuretic peptide; NYHA: New York Health Association; PAH: pulmonary arterial hypertension; RA Area: right atrial area on cardiac magnetic resonance imaging; RAP: right atrial pressure; REVEAL: Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management; SPAHR: Swedish PAH Register; WHO: World Health Organization.