Prediction of COPD-specific health-related quality of life in primary care COPD patients: a prospective cohort study

Respiratory medicine curriculum in Portuguese family medicine training: A Delphi study

BACKGROUND

Respiratory diseases (RD) constitute a significant part of the workload of family physicians. There is no consensus on what family doctors should know in this area but established methods for achieving consensus may help to overcome this.

OBJECTIVES

The purpose of the study was to obtain a national consensus on the required knowledge and skills in respiratory medicine for family medicine trainees after vocational training.

METHODS

A Delphi study was conducted via e-mail with a diverse panel of experts. We developed a Learning Curriculum Framework (LCF) with 399 items adapted from the Royal Australasian College of Physicians ..÷ Respiratory Medicine Advanced Training Curriculum. The LCF was submitted to the experts in two rounds for consensus. Consensus was considered for items that had an agreement of 80% in the classifications above 4 on a scale of importance that ranged from 1 (not important) to 5 (very important).

RESULTS

Consensus was obtained for 159 items (38.8%). These included structure and function of the respiratory tract (0.6%), presenting problems (21.4%), diagnosis (7.5%), interventions and prevention (11.3%), COPD-emphysema (12.6%), tumours (3.1%), infections (10.7%), tuberculosis (5.7%), HIV (1.3%), thromboembolic disease (2.5%), pleural-pulmonary disease (3.1%), pregnancy (0.6%) and sleep disorders (3.8%). Items on iatrogenic diseases and respiratory research did not reach consensus.

CONCLUSIONS

Consensus on the respiratory medicine curriculum may contribute to further development of the vocational training curriculum in Portugal. This approach may help teachers in other countries in Europe to develop curricula for respiratory medicine and other areas of general practice.

Inflammatory Markers and Fatigue in Individuals With Moderate to Severe Chronic Obstructive Pulmonary Disease

BACKGROUND

Fatigue, a prevalent complex symptom among patients with chronic obstructive pulmonary disease (COPD), is considered an important clinical indicator of disease severity. However, the underlying mechanisms of COPD-related fatigue are not fully understood.

OBJECTIVES

This analysis explored the relationships between peripheral inflammatory markers and COPD-related fatigue in people with moderate to severe COPD.

METHODS

This is a secondary analysis of a longitudinal observational study of individuals with COPD examining the biological causes and functional consequences of depression. The data used in this study were collected at baseline. Systemic inflammation markers included C-reactive protein (CRP) and three pro-inflammatory cytokines consisting of interleukin-6 (IL-6), IL-8, and tumor necrosis factor-α. COPD-related fatigue was self-reported using the Chronic Respiratory Questionnaire. Covariates included age; gender; smoking status; disease severity; symptoms of depression, anxiety, and pain; and social support. Multivariable linear regression analyses were conducted.

RESULTS

The sample included 300 adults living with COPD; 80% were male, and the average age was 67.6 years. Modest correlations were found between two systemic inflammatory markers (CRP and IL-8) and COPD-related fatigue. CRP was the only inflammatory marker significantly associated with fatigue symptoms after adjusting for covariates in multivariable analyses. Depression, pain, and education level were also significant predictors of COPD-related fatigue.

DISCUSSION

The findings suggest that altered immune response based on CRP may contribute to COPD-related fatigue. Management of depression and pain may work as an effective treatment strategy for COPD-related fatigue. Further longitudinal studies with a broader range of inflammatory markers and multidimensional measures of fatigue symptoms are warranted.

Impact of Lung Function and Exacerbations on Health-Related Quality of Life in COPD Patients Within One Year: Real-World Analysis Based on Claims Data

PURPOSE

Real-world evidence on the impact of forced expiratory volume in one second (FEV1) and exacerbations on health-related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD) is sparse especially with regard to GOLD ABCD groups. This study investigates how changes in FEV1 and exacerbations affect generic and disease-specific HRQoL in COPD patients over one year.

METHODS

Using German claims data and survey data, we classified 3016 COPD patients and analyzed their health status by GOLD groups AB and CD. HRQoL was measured with the disease-specific COPD assessment test (CAT) and the visual analog scale (VAS) from the generic Euro-Qol 5D-5L. We applied change score models to assess associations between changes in FEV1 (≥100 mL decrease/no change/≥100 mL increase) or the development of severe exacerbations with change in HRQoL.

RESULTS

FEV1 decrease was associated with a significant but not minimal important difference (MID) deterioration in disease-specific HRQoL (mean change [95% CI]: CAT +0.74 [0.15 to 1.33]), while no significant change was observed in the generic VAS. Experiencing at least one severe exacerbation also had a significant impact on CAT deterioration (+1.58 [0.52 to 2.64]), but again not on VAS. Here, GOLD groups AB showed not only a statistically but also a clinically relevant MID deterioration in CAT (+2.1 [0.88 to 3.32]). These particular patient groups were further characterized by a higher probability of being male, having a higher mMRC and Charlson index, and a lower probability of having higher FEV1 or BMI values.

CONCLUSION

FEV1 decline and the occurrence of ≥1 severe exacerbation are significantly associated with overall deterioration in disease-specific HRQoL. Preventing severe exacerbations particularly in patients without previous severe exacerbations (ABCD groups A and B) may help to stabilize the key patient-reported outcome HRQoL.

Long-term weight gain in obese COPD patients participating in a disease management program: a risk factor for reduced health-related quality of life

BACKGROUND

Little is known about how long-term weight gain affects the health perception of COPD patients.

OBJECTIVES

The aim is to evaluate the long-term association of BMI change and health-related quality of life (HRQoL) in obese COPD patients.

METHODS

Claims and survey data from a COPD disease management program were used to match two groups of COPD patients with BMI ≥ 30 who have differing weight trajectories over a 5-year timespan via propensity score and genetic matching. EQ-5D-5L, including visual analog scale (VAS) and COPD Assessment Test (CAT), were used as outcomes of interest. Sociodemographic and disease-based variables were matched.

RESULTS

Out of 1202 obese COPD patients, 126 with a weight increase of four or more BMI points were matched separately with 252 (propensity score matching) and 197 (genetic matching) control subjects who had relatively stable BMI. For the EQ-5D-5L, patients with BMI increase reported significantly worse health perception for VAS and all descriptive dimensions except pain/discomfort. For the CAT, especially the perception of ability to complete daily activities and overall energy results were significantly worse. VAS differences reach the range of minimal important differences. Stopping smoking and already being in obesity class II were the most influential risk factors for BMI increase.

CONCLUSION

Obese COPD patients who gain four or more BMI points over 5 years report significantly lower results in different dimensions of generic and disease-specific HRQoL than their peers with stable BMI. To improve real-world outcomes, tracking and preventing specific BMI trajectories could constitute a clinically relevant aspect of managing COPD patients.

Analysis of two questionnaires on quality of life of Chronic Obstructive Pulmonary Disease patients

Objective:

to evaluate the efficacy of quality of life questionnaires St. George Respiratory Questionnaire and Chronic Obstructive Pulmonary Disease Assessment Test in patients with chronic obstructive pulmonary disease based on correlation and agreement analyses, and identify the most effective tool to assess their quality of life.

Method:

cross-sectional cohort study with patients hospitalized in a Spanish hospital for exacerbation of chronic obstructive pulmonary disease. Health-related quality of life was assessed with both questionnaires. The correlation and the agreement between the questionnaires were analyzed, as well as the internal consistency. Associations were established between the clinical variables and the results of the questionnaire.

Results:

one hundred and fifty-six patients participated in the study. The scales had a correlation and agreement between them and high internal consistency. A higher sensitivity of the Chronic Obstructive Pulmonary Disease Assessment Test was observed for the presence of cough and expectoration.

Conclusion:

the questionnaires have similar reliability and validity to measure the quality of life in patients with acute chronic obstructive pulmonary disease, and the Chronic Obstructive Pulmonary Disease Assessment Test is more sensitive to detect cough and expectoration and requires a shorter time to be completed.

Patient education during hospital admission due to exacerbation of chronic obstructive pulmonary disease: Effects on quality of life-Controlled and randomized experimental study

The objective of this study was to assess the effectiveness of an education program and telephone call follow-up at improving the health related quality of life (HRQL) of patients with chronic obstructive pulmonary disease (COPD).

METHOD

Experimental, controlled, randomized, single blind study, masked data analysis. Duration of 2 years and 3 months. Patients hospitalised for exacerbation. The effectiveness was evaluated by calculating the absolute and relative change (%) of the St. George questionnaire scores (total and by dimensions) before and after the intervention program. Calculation of the effect of the group variable on the absolute and relative changes of the variables, Multiple Analysis of Variance (MANOVA).

RESULTS

Completed study of 116 patients. Greater effects on their HRQL reported at admission (48.3 ± SD 20.0 years). Patients in the intervention group improved significantly in their total SGRQ scores (-6.83) in absolute and relative terms and more significantly in their activity dimension (-16.05).

CONCLUSIONS

The education program was effective at improving global HRQL, especially the activity dimension, in exacerbated COPD patients.

PRACTICE IMPLICATIONS

This research contributes to clarifying the benefits and contents of education programs for patients with COPD; hospital admission is the suitable moment to contact these patients.

Self management of patients with mild COPD in primary care: randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of telephone health coaching delivered by a nurse to support self management in a primary care population with mild symptoms of chronic obstructive pulmonary disease (COPD).

DESIGN

Multicentre randomised controlled trial.

SETTING

71 general practices in four areas of England.

PARTICIPANTS

577 patients with Medical Research Council dyspnoea scale scores of 1 or 2, recruited from primary care COPD registers with spirometry confirmed diagnosis. Patients were randomised to telephone health coaching (n=289) or usual care (n=288).

INTERVENTIONS

Telephone health coaching intervention delivered by nurses, underpinned by Social Cognitive Theory. The coaching promoted accessing smoking cessation services, increasing physical activity, medication management, and action planning (4 sessions over 11 weeks; postal information at weeks 16 and 24). The nurses received two days of training. The usual care group received a leaflet about COPD.

MAIN OUTCOME MEASURES

The primary outcome was health related quality of life at 12 months using the short version of the St George's Respiratory Questionnaire (SGRQ-C).

RESULTS

The intervention was delivered with good fidelity: 86% of scheduled calls were delivered; 75% of patients received all four calls. 92% of patients were followed-up at six months and 89% at 12 months. There was no difference in SGRQ-C total score at 12 months (mean difference -1.3, 95% confidence interval -3.6 to 0.9, P=0.23). Compared with patients in the usual care group, at six months follow-up, the intervention group reported greater physical activity, more had received a care plan (44% v 30%), rescue packs of antibiotics (37% v 29%), and inhaler use technique check (68% v 55%).

CONCLUSIONS

A new telephone health coaching intervention to promote behaviour change in primary care patients with mild symptoms of dyspnoea did lead to changes in self management activities, but did not improve health related quality of life.

TRIAL REGISTRATION

Current controlled trials ISRCTN 06710391.

Comparative analysis of the psychometric parameters of two quality-of-life questionnaires, the SGRQ and CAT, in the assessment of patients with COPD exacerbations during hospitalization: A multicenter study

The aim of this study was to assess health-related quality of life (HRQL) in patients with chronic obstructive pulmonary disease (COPD) and to discuss the different tools available for its assessment. The most widely used assessments are the St. George respiratory questionnaire (SGRQ) and the COPD assessment test (CAT) questionnaire. Both have a different difficulty in exam completion, calculation, and scoring. No studies exist that analyze the validity and internal consistency of using both questionnaires on patients admitted to the hospital for a COPD exacerbation. A multicenter, cross-sectional analytic observational study of patients admitted to the hospital due to a COPD exacerbation (CIE 491.2). During their hospital stay, they were administered the SGRQ and the CAT questionnaire within the framework of a therapeutic education program (APRENDEPOC). Descriptive and comparative analysis, correlations between the scales (Pearson’s correlation index), consistency and reliability calculations (Cronbach’s α), and a forward stepwise multiple linear regression were performed, with significant correlations in both questionnaires considered p < 0.01 with the total scores. A statistical significance of p < 0.05 was assumed. Altogether, 231 patients were admitted for a COPD exacerbation (n = 77) at Hospital Clínic of Barcelona (HCB) and (n = 154) at Hospital Universitario General of Castellón (HUGC). The sample profile was not homogeneous between both centers, with significant differences in HRQL between hospitals. Correlation were noted between both scales (p < 0.01), along with high levels of internal consistency and reliability (CAT 0.836 vs. SGRQ 0.827). The HRQL is related to dyspnea, wheezing, daytime drowsiness, and edema, as well as to the need to sleep in a sitting position, anxiety, depression, and dependence on others in the execution of daily activities. Our regression analysis showed that the SGRQ questionnaire could predict more changes in HRQL with a higher number of variables.

Large-scale external validation and comparison of prognostic models: an application to chronic obstructive pulmonary disease

BACKGROUND

External validations and comparisons of prognostic models or scores are a prerequisite for their use in routine clinical care but are lacking in most medical fields including chronic obstructive pulmonary disease (COPD). Our aim was to externally validate and concurrently compare prognostic scores for 3-year all-cause mortality in mostly multimorbid patients with COPD.

METHODS

We relied on 24 cohort studies of the COPD Cohorts Collaborative International Assessment consortium, corresponding to primary, secondary, and tertiary care in Europe, the Americas, and Japan. These studies include globally 15,762 patients with COPD (1871 deaths and 42,203 person years of follow-up). We used network meta-analysis adapted to multiple score comparison (MSC), following a frequentist two-stage approach; thus, we were able to compare all scores in a single analytical framework accounting for correlations among scores within cohorts. We assessed transitivity, heterogeneity, and inconsistency and provided a performance ranking of the prognostic scores.

RESULTS

Depending on data availability, between two and nine prognostic scores could be calculated for each cohort. The BODE score (body mass index, airflow obstruction, dyspnea, and exercise capacity) had a median area under the curve (AUC) of 0.679 [1st quartile-3rd quartile = 0.655-0.733] across cohorts. The ADO score (age, dyspnea, and airflow obstruction) showed the best performance for predicting mortality (difference AUCADO - AUCBODE = 0.015 [95% confidence interval (CI) = -0.002 to 0.032]; p = 0.08) followed by the updated BODE (AUCBODE updated - AUCBODE = 0.008 [95% CI = -0.005 to +0.022]; p = 0.23). The assumption of transitivity was not violated. Heterogeneity across direct comparisons was small, and we did not identify any local or global inconsistency.

CONCLUSIONS

Our analyses showed best discriminatory performance for the ADO and updated BODE scores in patients with COPD. A limitation to be addressed in future studies is the extension of MSC network meta-analysis to measures of calibration. MSC network meta-analysis can be applied to prognostic scores in any medical field to identify the best scores, possibly paving the way for stratified medicine, public health, and research.

Multiple Score Comparison: a network meta-analysis approach to comparison and external validation of prognostic scores

BACKGROUND

Prediction models and prognostic scores have been increasingly popular in both clinical practice and clinical research settings, for example to aid in risk-based decision making or control for confounding. In many medical fields, a large number of prognostic scores are available, but practitioners may find it difficult to choose between them due to lack of external validation as well as lack of comparisons between them.

METHODS

Borrowing methodology from network meta-analysis, we describe an approach to Multiple Score Comparison meta-analysis (MSC) which permits concurrent external validation and comparisons of prognostic scores using individual patient data (IPD) arising from a large-scale international collaboration. We describe the challenges in adapting network meta-analysis to the MSC setting, for instance the need to explicitly include correlations between the scores on a cohort level, and how to deal with many multi-score studies. We propose first using IPD to make cohort-level aggregate discrimination or calibration scores, comparing all to a common comparator. Then, standard network meta-analysis techniques can be applied, taking care to consider correlation structures in cohorts with multiple scores. Transitivity, consistency and heterogeneity are also examined.

RESULTS

We provide a clinical application, comparing prognostic scores for 3-year mortality in patients with chronic obstructive pulmonary disease using data from a large-scale collaborative initiative. We focus on the discriminative properties of the prognostic scores. Our results show clear differences in performance, with ADO and eBODE showing higher discrimination with respect to mortality than other considered scores. The assumptions of transitivity and local and global consistency were not violated. Heterogeneity was small.

CONCLUSIONS

We applied a network meta-analytic methodology to externally validate and concurrently compare the prognostic properties of clinical scores. Our large-scale external validation indicates that the scores with the best discriminative properties to predict 3 year mortality in patients with COPD are ADO and eBODE.

Salford Lung Study in chronic obstructive pulmonary disease (SLS COPD): follow-up interviews on patient-centred outcomes

This study investigated patient perceptions, experiences and management of COPD throughout the SLS COPD study. Follow-up interviews were conducted with 400 patients who completed SLS COPD; a mixed-methods approach was used to collect quantitative and qualitative information. Structured interviews using closed-ended questions were conducted with 360 patients, detailing aspects of background/lifestyle information and COPD. Extended interviews containing open-ended questions on perceptions of COPD and quality of life (QoL) in addition to the closed-ended questions were completed by 40 further patients. Participants also completed the Adherence Starts with Knowledge-12 (ASK-12) and the COPD and Asthma Sleep Impact Scale (CASIS) questionnaire. Quantitative data were analysed descriptively; qualitative data were analysed using qualitative description. The participants (n = 400) were reasonably representative of the SLS COPD population; mean age was 66.2 years. Breathlessness was the most commonly recalled symptom of/associated with COPD (88.5% of patients) and was the symptom that changed the most (improved, 26.8%/worsened, 20.9%) throughout the study. Participants' daily functioning and activities were most affected by symptoms of/associated with COPD, followed by relationships and psychological issues. 66.5% of participants experienced exacerbations, 60.5% of whom reported self-management as their first treatment strategy (taking antibiotics, resting and/or corticosteroids). Qualitative analysis revealed COPD symptoms, breathlessness in particular, to have a significant impact on mobility and in turn QoL. In conclusion, breathlessness was cited in these interviews as the COPD symptom with the greatest impact on participants' daily functioning, activities and self-care. The findings provided significant additional knowledge to the SLS COPD study findings.

Health-related quality of life in a nationwide cohort of patients with COPD related to other characteristics

Background

In chronic obstructive pulmonary disease (COPD), various factors, such as dyspnoea, obstruction, exacerbations, smoking, exercise capacity, and body mass index, have been found to influence mortality and health-related quality of life (HRQOL). In order to identify subgroups of patients needing special attention, the aim of the present study was to explore the relationships between disease progression factors and HRQOL across COPD stages.

Methods

Baseline registrations from the Swedish COPD register of demographic, clinical, and patient-reported variables of 7,810 patients are presented. Dyspnoea was measured by the modified Medical Research Council (mMRC) dyspnoea scale and HRQOL by the Clinical COPD Questionnaire (CCQ).

Results

This study shows as expected that patients with spirometrically more severe COPD had a significantly higher number of exacerbations and hospitalisations, significantly increasing dyspnoea, significantly decreasing body mass index and exercise capacity, and significantly worsening HRQOL. When adjusting for spirometric stage of COPD, deteriorated HRQOL was predicted by increasing dyspnoea, depression/anxiety, increasing number of exacerbations, and decreased exercise capacity. Further, these data show that an mMRC value of 2 corresponds to a CCQ value of 1.9.

Conclusion

The COPD patients suffered from a significant symptom burden, influencing HRQOL. A surprisingly great proportion of patients in spirometric stages II–IV showed marked changes of CCQ, indicating a need for an improved collaboration between clinical pulmonary medicine and palliative care.

Validation of the Clinical COPD Questionnaire in Taiwan

Health status improvement is a critical treatment goal for physicians managing chronic obstructive pulmonary disease (COPD). Numerous instruments to measure the disease-specific health-related quality of life (HRQOL) for patients with COPD have been used in daily clinical practice. The Clinical COPD Questionnaire (CCQ) is one of these recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). This study examined the psychometric properties of the CCQ in patients with COPD in Taiwan. A descriptive, cross-sectional design was conducted. Data were collected in a secondary care unit. We administered the CCQ, the modified Medical Research Council (mMRC) dyspnea scale, and the 12-item Short Form Health Survey (SF-12) for patients with COPD. Reliability was assessed using Cronbach's alpha and item-total correlation coefficients. Construct validity was assessed using confirmatory factor analysis (CFA) and testing the hypothesis that severity of dyspnea measured using the mMRC dyspnea scale is associated with the CCQ scores. Convergent validity was assessed by testing the correlation between the CCQ and the SF-12. Discriminant validity was assessed to differentiate among the classifications of COPD Groups A to D. A total of 114 subjects were recruited in the study. Cronbach's alpha was high (0.90) for the total score of the CCQ. Significant correlations were found between the CCQ scores and those of the mMRC dyspnea scale (ρ = 0.67) and domains of the SF-12 (ρ = -0.44 to -0.75). Furthermore, the CCQ scores showed a significant difference among the classifications of COPD Groups A to D. CFA confirmed the construct validity, with a good model fit. Good to excellent psychometric properties of the Chinese Version CCQ were demonstrated in the study. Wide usage of the Chinese Version CCQ for Taiwanese COPD patients can be recommended in daily clinical practice or clinical trials.

Psychological predictors for health-related quality of life and disability in persons with chronic obstructive pulmonary disease (COPD)

OBJECTIVE

Individuals with chronic obstructive pulmonary disease (COPD) exhibit low physical and mental health-related quality of life (HRQL) and high susceptibility to disability. We investigated the influence of psychological factors on HRQL and disability in COPD individuals recruited from the general population. In line with Leventhal's common sense model, we expected psychological factors to be associated with HRQL and disability even after controlling for medical status.

METHODS

Individuals with COPD (n = 502; 59.7 years old; GOLD grades were I: 3%, II: 17%, III: 34%, IV: 46%) were assessed through an online survey administered via COPD patient organisations in Germany. Individuals filled in the Short Form Health Survey (SF-12), COPD Assessment Test, Patient Health Questionnaire (modules: GAD-2, PHQ-15, PHQ-9), Brief Illness Perception Questionnaire, a questionnaire that assesses causal illness attributions, and the internal illness-related locus of control scale of the 'KKG questionnaire for the assessment of control beliefs about illness and health'. Multiple linear regressions were calculated.

RESULTS

The investigated factors explained high variances (disability = 56%, physical HRQL = 28%, mental HRQL = 63%, p ≤ .001). Better mental health, more optimistic illness perceptions, attribution to psychological causes, and stronger internal locus of control were associated with lower disability and better HRQL. Comorbid somatic symptoms contributed to high disability and low quality of life.

CONCLUSION

Psychological factors, such as illness perception, attribution and internal locus of control, were associated with disability and HRQL. These factors should be considered when designing treatments for individuals with COPD, and adequate interventions should be provided to enhance illness understanding and self-management skills.