Clinical application of risk assessment in PAH: Expert center APRN recommendations

Abstract

Performing longitudinal and consistent risk assessments for patients with pulmonary arterial hypertension (PAH) is important to help guide treatment decisions to achieve early on and maintain a low‐risk status and improve patient morbidity and mortality. Clinical gestalt or expert perception alone may over or underestimate a patient's risk status. Indeed, regular and continued use of validated risk assessment tools more accurately predict patients' survival. Effective PAH risk assessments are often underutilized even though many seasoned clinicians will attest to using these tools routinely. We present recommendations based on real‐world experience in varied clinical practice settings around the United States for overcoming barriers to facilitate regular, serial formal risk assessment. Expert advanced practice provider clinicians from mid to large‐size medical centers collaborated to formulate recommendations based on multiple discourses and discussions. Enlisting the help of support staff, such as medical assistants and nurses, to fill in available risk parameters in risk assessment tools can save time for providers and increase efficiency, as can technology‐based solutions such as integrating risk assessments into electronic medical records. Modified, abbreviated risk assessment tools can be applied to a patient's clinical scenario when all of a patient's data are not available to complete a more comprehensive assessment. Initial discussions regarding the overall meaning and prognostic importance of risk scores may assist patients to take on a more active role in terms of informed decision‐making regarding their care. A collaborative approach can help clinics establish consistent use of risk assessment.

Evaluation of the European Society of Cardiology/European Respiratory Society derived three- and four-strata risk stratification models in pulmonary arterial hypertension: introducing an internet-based risk stratification calculator

“… 26 In another study based on real-world experience addressing barriers for incorporation of risk assessment into clinical practice, it was found that lack of time among clinicians prevented regular use of risk assessment tools, and technology-based solutions as time-saving tools were recommended to overcome the barrier of suboptimal use of risk assessment. 27 The utilization of risk assessment in the clinics has been influenced by the presence of several contemporary risk stratification models advocating the use of different numbers and combinations of prognostic parameters, 21 , 26 as well as the lack of a time-saving and comprehensive risk calculator. We therefore aimed to establish and introduce an independent html-based webpage to facilitate risk score calculation in PAH and thereby evaluate and provide insight into various ESC/ERS risk assessment models with respect the number of included parameters, during baseline and follow-ups.…”

“…During assessment of patients with PAH, expert perception or clinical gestalt alone may overestimate or underestimate the risk status. 26 , 27 In a study based on real-world experience addressing barriers for incorporation of risk assessment into clinical practice, it was found that risk assessment in PAH is often underutilized although many clinicians attest to the use of validated risk stratification tools. Also, lack of time among clinicians was found to prevent regular use of risk assessment tools.…”

“…Thus, establishing ‘technology-based solutions as time-saving tools’ was recommended to overcome this barrier. 27 To facilitate risk assessment in PAH, we aimed to (i) establish a comprehensive internet-based risk score calculator; (ii) evaluate the prognostic accuracy of the new simplified three-parameter COMPERA 2.0 four-strata model in relation to the original SPAHR/COMPERA three-strata model and the updated SPAHR three-strata model with divided intermediate risk, as a tool for incorporation of additional parameters when clinically needed; and (iii) investigate whether the prognostic accuracy of the original SPAHR/COMPERA and the updated SPAHR three-strata model with divided intermediate risk differ depending on the number of included prognostic parameters.…”

Risk stratification in adult and pediatric pulmonary arterial hypertension: A systematic review

“…Furthermore, the use of risk stratification is not restricted to estimate risk at diagnosis or initiation of therapy. Also serial risk stratification every 3-6 months is proposed in order to use follow-up risk estimates to evaluate treatment response and to identify the need to escalate therapy (47). Recent reports show that risk stratifications may have a better discrimination of outcome at first follow-up RHC compared to baseline (48), and that changes in risk status are predictive of survival (49) Nearly all studies included in this systematic review were judged to have a high ROB based on their analysis.…”

Risk assessment in pulmonary arterial hypertension: A step towards clinical implementation based on the 2022 ESC/ERS pulmonary hypertension guidelines

“…We read with great interest the studies by Wilson et al 1 "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," and "Clinical application of risk assessment in PAH: Expert center APRN recommendations," 2 as well as the recent publication by Sahay et al 3 "Utilization of risk assessment tools in management of PAH: A PAH provider survey"; all published in previous issues of Pulmonary Circulation. We acknowledge the authors for their contributions on assessing the clinical utilization of risk assessment in pulmonary arterial hypertension (PAH), 1,3 identifying potential major barriers impacting clinical underutilization and presenting recommendations to overcome these barriers.…”