title: Predictors of Physician Under-Recognition of Angina in Outpatients With Stable Coronary Artery Disease.
abstract: Under-recognition of angina by physicians may result in undertreatment with revascularization or medications that could improve patients' quality of life. We sought to describe characteristics associated with under-recognition of patients' angina.
  
  
  
  Patients with coronary disease from 25 US cardiology outpatient practices completed the Seattle Angina Questionnaire before their clinic visit, quantifying their frequency of angina during the previous month. Immediately after the clinic visit, physicians independently quantified their patients' angina. Angina frequency was categorized as none, monthly, and daily/weekly. Among 1257 patients, 411 reported angina in the previous month, of whom 173 (42%) were under-recognized by their physician, defined as the physician reporting a lower frequency category of angina than the patient. In a hierarchical logistic model, heart failure (odds ratio, 3.06, 95% confidence interval, 1.89-4.95) and less-frequent angina (odds ratio for monthly angina [versus daily/weekly], 1.69; 95% confidence interval, 1.12-2.56) were associated with greater odds of under-recognition. No other patient or physician factors were associated with under-recognition. Significant variability across physicians (median odds ratio, 2.06) was observed.
  
  
  
  Under-recognition of angina is common in routine clinical practice. Although patients with less-frequent angina and those with heart failure more often had their angina under-recognized, most variation was unrelated to patient and physician characteristics. The large variation across physicians suggests that some physicians are more accurate in assessing angina frequency than others. Standardized prospective use of a validated clinical tool, such as the Seattle Angina Questionnaire, should be tested as a means to improve recognition of angina and, potentially, improve appropriate treatment of angina.
authors.affiliation: From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., A.G., K.L.G., M.K., P.G.J., T.B., J.A.S.); University of Missouri-Kansas City (S.V.A., A.G., M.K., A.T., J.A.S.); University of Adelaide, Australia (J.B.); and Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (K.P.A.). suz.v.arnold@gmail.com.
authors.forename: Suzanne V
authors.initials: SV
authors.lastname: Arnold
authors.affiliation: From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., A.G., K.L.G., M.K., P.G.J., T.B., J.A.S.); University of Missouri-Kansas City (S.V.A., A.G., M.K., A.T., J.A.S.); University of Adelaide, Australia (J.B.); and Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (K.P.A.).
authors.forename: Anna
authors.initials: A
authors.lastname: Grodzinsky
authors.affiliation: From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., A.G., K.L.G., M.K., P.G.J., T.B., J.A.S.); University of Missouri-Kansas City (S.V.A., A.G., M.K., A.T., J.A.S.); University of Adelaide, Australia (J.B.); and Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (K.P.A.).
authors.forename: Kensey L
authors.initials: KL
authors.lastname: Gosch
authors.affiliation: From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., A.G., K.L.G., M.K., P.G.J., T.B., J.A.S.); University of Missouri-Kansas City (S.V.A., A.G., M.K., A.T., J.A.S.); University of Adelaide, Australia (J.B.); and Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (K.P.A.).
authors.forename: Mikhail
authors.initials: M
authors.lastname: Kosiborod
authors.affiliation: From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., A.G., K.L.G., M.K., P.G.J., T.B., J.A.S.); University of Missouri-Kansas City (S.V.A., A.G., M.K., A.T., J.A.S.); University of Adelaide, Australia (J.B.); and Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (K.P.A.).
authors.forename: Philip G
authors.initials: PG
authors.lastname: Jones
authors.affiliation: From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., A.G., K.L.G., M.K., P.G.J., T.B., J.A.S.); University of Missouri-Kansas City (S.V.A., A.G., M.K., A.T., J.A.S.); University of Adelaide, Australia (J.B.); and Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (K.P.A.).
authors.forename: Tracie
authors.initials: T
authors.lastname: Breeding
authors.affiliation: From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., A.G., K.L.G., M.K., P.G.J., T.B., J.A.S.); University of Missouri-Kansas City (S.V.A., A.G., M.K., A.T., J.A.S.); University of Adelaide, Australia (J.B.); and Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (K.P.A.).
authors.forename: Arooge
authors.initials: A
authors.lastname: Towheed
authors.affiliation: From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., A.G., K.L.G., M.K., P.G.J., T.B., J.A.S.); University of Missouri-Kansas City (S.V.A., A.G., M.K., A.T., J.A.S.); University of Adelaide, Australia (J.B.); and Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (K.P.A.).
authors.forename: John
authors.initials: J
authors.lastname: Beltrame
authors.affiliation: From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., A.G., K.L.G., M.K., P.G.J., T.B., J.A.S.); University of Missouri-Kansas City (S.V.A., A.G., M.K., A.T., J.A.S.); University of Adelaide, Australia (J.B.); and Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (K.P.A.).
authors.forename: Karen P
authors.initials: KP
authors.lastname: Alexander
authors.affiliation: From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., A.G., K.L.G., M.K., P.G.J., T.B., J.A.S.); University of Missouri-Kansas City (S.V.A., A.G., M.K., A.T., J.A.S.); University of Adelaide, Australia (J.B.); and Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (K.P.A.).
authors.forename: John A
authors.initials: JA
authors.lastname: Spertus
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000787:Angina Pectoris / Q000175:diagnosis*; D016009:Chi-Square Distribution; D002983:Clinical Competence / Q000592:standards; D003324:Coronary Artery Disease / Q000175:diagnosis*; D003430:Cross-Sectional Studies; D003951:Diagnostic Errors; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D017711:Nonlinear Dynamics; D016017:Odds Ratio; D010820:Physicians / Q000592:standards; D010818:Practice Patterns, Physicians' / Q000592:standards; D011237:Predictive Value of Tests; D019984:Quality Indicators, Health Care; D012307:Risk Factors; D011795:Surveys and Questionnaires; D014481:United States
keywords: angina pectoris; coronary artery disease; quality of healthcare