Defining delayed and missed diagnosis of acute and chronic coronary syndromes: a modified Delphi consensus method

Abstract

OBJECTIVES: A clear definition of delayed and missed coronary artery disease (CAD) diagnosis is lacking, hampering research on the epidemiology and determinants of delayed and missed CAD diagnosis. We engaged healthcare professionals, patients and healthy citizens to develop a consensus-based definition of delayed and missed diagnosis in two CAD domains: acute coronary syndrome (ACS) and chronic coronary syndrome (CCS). DESIGN: Modified Delphi method. SETTING: Primary and secondary care. PARTICIPANTS: The study was conducted among an expert panel consisting of cardiologists (n=19), general practitioners (n=35), patients (n=55) and healthy citizens (n=34). RESULTS: 42 definitions for delayed and missed ACS and 30 definitions for delayed and missed CCS were developed during the first 2 Delphi rounds. The expert panel graded these definitions in rounds 3 and 4 by Likert scale (from 1 (strongly disagree) to 5 (strongly agree)). Useful definitions for research purposes were recommended based on predefined criteria: (1) IQR to assess consensus, (2) median to evaluate the level of support for the definition and (3) convergence of the group to assess stability of opinions across rounds. For delayed ACS, 2 definitions were classified as highly recommended, 13 as recommended and 6 as considerable. For missed ACS, none met the threshold for highly recommended; 5 were recommended and 12 were classified as considerable. For CCS, 2 definitions for delayed diagnosis were highly recommended, 13 recommended and 7 considerable. For missed CCS, 1 definition was highly recommended, 6 were recommended and 7 were considerable. CONCLUSIONS: We were unable to establish a one-size-fits-all definition for delayed and missed ACS/CCS diagnosis, reflecting the complexity and context-dependency of CAD diagnostic pathways. However, the developed consensus-based framework and recommended definitions provide a valuable basis for future research, enabling study comparisons across different diagnostic settings. This will ultimately enhance understanding of delayed and missed ACS/CCS diagnosis.