Patient Risk Interpretation of Symptoms Model (PRISM): How Patients Assess Cardiac Risk

Abstract

Background: While there is a prevailing perception that coronary artery disease (CAD) is a “man’s disease,” little is known about the factors which influence cardiac risk assessment and whether it varies by gender. Objectives: 1) Qualitatively capture the complexity of cardiac risk assessment from a patient-centered perspective. 2) Explore how risk assessment may vary by gender. 3) Quantitatively validate qualitative findings among a new sample. Design: This study was conducted in two parts: (1) semi-structured in-depth interviews were audio-recorded, transcribed verbatim, and analyzed using modified grounded theory; (2) emergent themes were surveyed in a separate sample to validate findings quantitatively. Differences were estimated using 2-tailed t-tests and kappa. Participants: Participants who were referred for their first elective coronary angiogram for suspected CAD with at least 1 prior abnormal test were recruited from a tertiary care hospital. Main Measures: Patient-centered themes were derived from part one. In part two, patients estimated the probability that their symptoms were heart-related at multiple time points. Results: Part 1 included 14 men and 17 women (mean age=63.3±11.8 years). Part 2 included 237 patients, of which 109 (46%) were women (mean age=66.0±11.3 years). Part 1 revealed that patients’ risk assessment evolves in three distinct phases, which were captured using an Ishikawa framework entitled “Patient Risk Interpretation of Symptoms Model” (PRISM). Part 2 validated PRISM findings; while patients were more likely to attribute their symptoms to CAD over time (phase 1 vs. 3: 21% vs. 73%, p<0.001), women were marginally less likely than men to perceive symptoms as heart-related by phase 3 (67% women vs. 78% men, p=0.054). Conclusions: Patient assessment of CAD risk evolves, and women are more likely to underestimate their risk than men. PRISM may be used as a clinical aid to optimize patient-centered care. Future studies should validate PRISM in different clinical settings.