Differences between patients in whom physicians agree versus disagree about the preoperative diagnosis of heart failure

Abstract

Study objective: To quantify preoperative heart failure (HF) diagnostic agreement and identify characteristics of patients in whom physicians agreed versus disagreed about the diagnosis.

Design: Observational cohort study.

Setting: Patients undergoing major non-cardiac surgery at an academic center between 2015 and 2019.

Patients: 40,659 patients undergoing major non-cardiac surgery, among which a stratified subsample of 1018 patients with and without documented HF was reviewed.

Interventions: Via a panel of physicians frequently managing patients with HF (cardiologists, cardiac anesthesiologists, intensivists), detailed chart reviews were performed (two per patient; median review time 32 min per reviewer per patient) to render adjudicated HF diagnoses.

Measurements: Adjudicated diagnostic agreement measures (percent agreement, Krippendorf's alpha) and univariate comparisons (standardized differences) between patients in whom physicians agreed versus disagreed about the preoperative HF diagnosis.

Main results: Among patients with documented HF, physicians agreed about the diagnosis in 80.0% of cases (consensus positive), disagreed in 13.8% (disagreement), and refuted the diagnosis in 6.3% (consensus negative). Conversely, among patients without documented HF, physicians agreed about the diagnosis in 88.0% (consensus negative), disagreed in 8.4% (disagreement), and refuted the diagnosis in 3.6% (consensus positive). The estimated agreement for the 40,659 cases was 91.1% (95% CI 88.3%-93.9%); Krippendorff's alpha was 0.77 (0.75-0.80). Compared to patients in whom physicians agreed about a HF diagnosis, patients in whom physicians disagreed exhibited fewer guideline-defined HF diagnostic criteria.

Conclusions: Physicians usually agree about HF diagnoses adjudicated via chart review, although disagreement is not uncommon and may be partly explained by heterogeneous clinical presentations. Our findings inform preoperative screening processes by identifying patients whose characteristics contribute to physician disagreement via chart review. Clinical Trial Number / Registry URL: Not applicable.

Keywords: Cardiac risk assessment; Diagnostic agreement; Electronic health record; Heart failure; Non-cardiac surgery; Preoperative evaluation.

Fig. 1 -

Study Exclusion Criteria and Subsample Selection for Physician Reviews The top portion of the figure depicts exclusion criteria to arrive at the full cohort of eligible cases for physician review. The bottom portion of the figure depicts the subsampling technique for physician review, which included (i) “EHR-Documented HF” patients with existing EHR documentation of HF; (ii) “No EHR-Documented HF / High Probability” patients without EHR documentation of HF preoperatively, but developing EHR documentation within 365 days postoperatively; and (iii) “No EHR-Documented HF / Low Probability” patients without EHR documentation of HF preoperatively or within 365 days postoperatively. To maximize the diagnostic value of physician reviews, (i) and (ii) were over-sampled, and (iii) was under-sampled. Gray arrows = patients not reviewed. EHR = electronic health record; HF = heart failure

Fig. 2 -

Physician Review of Electronic Health Records: Preoperative Heart Failure Adjudicated Diagnostic Agreement versus Disagreement - Sankey Diagram Physician reviews stratified by “EHR-Documented HF” patients with existing EHR documentation of HF; (ii) “No EHR-Documented HF / High Probability” patients without EHR documentation of HF preoperatively, but developing EHR documentation within 365 days postoperatively; and (iii) “No EHR-Documented HF / Low Probability” patients without EHR documentation of HF preoperatively or within 365 days postoperatively. EHR = electronic health record; HF = heart failure

Fig. 3 -

Proportions of Patients in Whom Physicians Agreed versus Disagreed on the Diagnosis of Heart Failure versus Preoperative Left Ventricular Ejection Fraction Proportions estimated for full cohort (N = 40,659) of cases meeting inclusion criteria based upon physician-reviewed subsample weights. HF = heart failure

Fig. 4 -

Proportions of Patients in Whom Physicians Agreed versus Disagreed about the Diagnosis of Heart Failure versus Total Number of Guideline-Defined Heart Failure Diagnostic Factors Proportions estimated for full cohort (N = 40,659) of cases meeting inclusion criteria based upon physician-reviewed subsample weights. HF = heart failure