Health status in COPD cannot be measured by the St George's Respiratory Questionnaire alone: an evaluation of the underlying concepts of this questionnaire

Capturing patient-reported and quality of life outcomes with use of shorter regimens for drug-resistant tuberculosis: mixed-methods substudy protocol, TB PRACTECAL-PRO

INTRODUCTION

People living with multidrug-resistant tuberculosis currently have few options for effective treatment and cure. Regimens that are available are toxic, may involve injections and take up to 2 years to complete treatment, with success rates as low as 50%. The TB-PRACTECAL trial is evaluating shorter, more tolerable regimens of oral drugs; we detail the substudy within this trial, PRACTECAL-PRO, which aims to evaluate patient experiences and perspectives on treatment, to understand outcomes more fully.

METHODS AND ANALYSIS

We are conducting a mixed-methods evaluation within both investigational and standard of care arms within the TB-PRACTECAL trial, using sequential quality of life (QoL) surveys and in-depth interviews. Data collection involves the Short Form 12 (SF-12) and St George's Respiratory Questionnaire (SGRQ), collected at up to four fixed timepoints, from baseline, to up to 12 months later. Healthy volunteers will be surveyed to establish locally relevant controls. We will also purposively sample participants for qualitative data collection and analysis, to provide rich explanation of QoL scores. The study will be implemented in all six TB-PRACTECAL study sites in Uzbekistan, South Africa and Belarus. QoL surveys will be scored and analysed according to SF-12 and SGRQ developers' manuals. Differences between scores at baseline and later timepoints will be evaluated as well as graphical exploration of group score trajectories of investigational and standard of care arms.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Médecins Sans Frontières Ethics Review Board. Local ethics approval has been obtained in Uzbekistan, Belarus and South Africa. Results of the substudy will be shared with local health authorities, the WHO and submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03942354; Pre-results.

Validation of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) for individuals with COPD

PURPOSE

COPD fits the profile of disabling health conditions. This study aims to validate the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) in individuals with COPD.

MATERIAL AND METHODS

100 participants with COPD responded to the Brazilian 36-item version of the WHODAS 2.0, as well as the Saint George's Respiratory Questionnaire (SGRQ), and the COPD Assessment Test (CAT). Spirometric data was extracted from medical records.

RESULTS

The internal consistency analysis showed coefficients for all WHODAS 2.0 domains with a strong correlation (0.70-0.85) except for Life activities, which had a moderate correlation (coefficient = 0.60). In the construct analysis, the coefficients for the WHODAS and SGRQ domains presented a consistent correlation among them, varying from 0.40 to 0.69. No correlation was evidenced among the WHODAS domains and the spirometric data, highlighting that linear measures fail when associated with the functioning of an individual with COPD. Discriminative analysis revealed a capacity for the WHODAS 2.0 to distinguish among COPD different levels of clinical impact obtained from CAT excluding the Getting along domain.

CONCLUSION

The WHODAS 2.0 shows as a valid instrument that can sensibly assess functioning differences related to the clinical impact classification level in subjects with COPD.IMPLICATIONS FOR REHABILITATIONWHODAS 2.0 is a valid tool to assess functioning in subjects with COPD.WHODAS 2.0 is sensitive to functioning differences related to classification level and to clinical impact in individuals with COPD.As a Patient-Reported Outcome Measure (PROM), WHODAS 2.0 offers the opportunity to develop clinical patient-centered interventions, improving the health care.As a low-cost, easy-to-use tool, WHODAS can be a useful resource in the process of clinical assessment of patient functioning.

Age-Dependent Associations Between 25-Hydroxy Vitamin D Levels and COPD Symptoms: Analysis of SPIROMICS

INTRODUCTION

Age and vitamin D levels may affect symptom burden in chronic obstructive pulmonary disease (COPD). We used the Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS) to determine independent associations between vitamin D levels and COPD symptoms in different age strata.

METHODS

Serum 25-hydroxy (OH)-vitamin D levels were modeled continuously and categorically (<20 ng/ml versus ≥20 ng/ml). Stratifying by age group (middle-age: 40-64 years old and older: >65 years old), multivariable modeling was performed to identify relationships between 25-OH-vitamin D levels and the COPD Assessment Test (CAT), the modified Medical Research Council score (mMRC), the St George's Respiratory Questionnaire (SGRQ) total and subdomain scores, the Veterans' Specific Activity Questionnaire, and the 6-minute walk test distance.

RESULTS

InIn the middle-aged group, each 5 ng/ml higher 25-OH-vitamin D level was independently associated with more favorable CAT score (-0.35 [-0.67 to -0.03], P=0.03), total SGRQ (-0.91 [-1.65 to -0.17]; P=0.02), and the SGRQ subdomains (Symptoms:-1.07 [-1.96 to -0.18], P=0.02; Impact: -0.77 [-1.53 to -0.003], P=0.049; Activity: -1.07 [-1.96 to -0.18], P=0.02). These associations persisted after the addition of comorbidity score, reported vitamin D supplementation, outdoor time, or season of blood draw to models. No associations were observed between 25-OH-vitamin D levels and symptom scores in the older age group.

DISCUSSION

When controlled for clinically relevant covariates, higher 25-OH-vitamin D levels are associated with more favorable respiratory-specific symptoms and quality-of-life assessments in middle-age but not older COPD individuals. Study of the role of vitamin D supplementation in the symptom burden of younger COPD patients is needed.

The development of a novel Wellness Assessment Instrument and its use in the assessment of wellness status in patients with chronic obstructive pulmonary disease

Aims:

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disorder that affects health outcomes on multiple levels including overall wellbeing. More specifically, factors such as spiritual wellbeing, and psychological, mental and motivational status which may be at least as important as others, have been rarely studied. This article reports the method of validating a new wellness assessment questionnaire and the status of several wellness domains in patients with COPD.

Methods:

The study consisted of two phases: first, the development of a new Wellness Questionnaire with the help of focus groups; second, the validation and use of the questionnaire in a cohort of patients with COPD. For focus groups, healthy people ⩾45 years of age with no known comorbidity as well as people with a clinical diagnosis of COPD were invited to participate in the study.

Results:

Thematic analysis of findings from focus groups and original cohort respondents highlighted some factors that appear to influence wellness status. Five domains were explored as potential markers of wellness in patients with COPD. Quantitative analysis with Spearman correlation demonstrated a significant correlation between Physical/Personal Wellness and other markers of COPD progression such as Global Initiative Obstructive Lung Disease (GOLD; 0.006), force expiratory volume in 1 s (FEV1%; 0.01), health-related quality of life (0.009), multidimensional BOD score and quartile (0.003 and 0.02).

Conclusion:

The findings suggest that a combination of personal, physical, emotional, mental and other psychological factors is responsible for negative COPD outcomes. While there is a need to validate this new wellness questionnaire in further research, it incorporates new markers of wellness that could benefit management of COPD.

A Comparative Effectiveness Review: RESPONSIVENESS OF PATIENT OUTCOME MEASURES IN CARDIAC AND PULMONARY REHABILITATION

BACKGROUND

Cardiac and pulmonary rehabilitation have been shown to reduce the symptoms of disease, as well as reducing health care utilization. To ensure the continuation of these programs, patient outcome measures (POMs) are essential to map treatment effectiveness. This review is a comparative effectiveness literature review of studies with a pre- to post-POM assessment of responsiveness (ie, change in health status over time).

METHODS

A quality review of the literature included not only randomized controlled trials but also parallel studies, as well as all observational and retrospective trials. This review included a list of articles and their characteristics; a quality assessment of the literature and a list of POMs utilized in this setting were assessed for responsiveness.

RESULTS

There was inconsistency in the literature with the measurement of responsiveness or effect size. The most commonly used POM was the SF-36; however, it was found to be less responsive to change in health status pre- to post-rehabilitation, particularly in the mental domain of this instrument. The most responsive POM in this setting was the Global Mood Scale.

CONCLUSION

The surveyed literature found no "gold standard" POM for either cardiac rehabilitation or pulmonary rehabilitation but there was some preference for the disease-specific POMs; however, some of these instruments lose their discriminatory power at the end of the rehabilitation period. This literature review found that a Likert scale is more responsive than a dichotomous scale and that a simple questionnaire is more responsive in a pre- to post-setting than a complex questionnaire.

Health-related quality of life of patients diagnosed with COPD in Extremadura, Spain: results from an observational study

BACKGROUND

COPD is a high prevalence chronic disease that involves large reductions of health-related quality of life (HRQL) of patients. This study aims to describe the HRQL of patients with COPD in Extremadura (Spain).

METHODS

This is a cross-sectional observational study carried out using a representative sample of patients diagnosed with COPD in Extremadura. The inclusion criteria were patients of legal age, diagnosed with COPD at least 12 months prior to the visit, residing in Extremadura, with electronic medical records available for the 12 months prior to the visit and providing informed consent. The intervention aimed to elicit HRQL indicators obtained from two validated questionnaires: EuroQol - 5 Dimensions - 5 Levels (EQ-5D-5L), and St. George's Respiratory Questionnaire-COPD (SGRQ-C). The main outcome measures were general HRQL (utility and visual analogue scale) and specific quality of life of COPD patients (total score and three component scores: Symptoms, Activity, and Impacts). Stepwise multiple regression analysis was applied to evaluate the association of EQ-5D-5L and SGRQ-C with respect to clinical and sociodemographic characteristics of the patients.

RESULTS

We recruited 386 patients (mean age 71.8 ± 10.3 years, 76.2% males). In the EQ-5D-5L, participants reported greater problems with respect to mobility (56.5%) and pain/discomfort (48.2%). The mean utility was 0.72 ± 0.31, and the SGRQ-C total score was 40.9 ± 25.0. The results of both questionnaires were associated with number of exacerbations in the last 12 months, level of COPD severity, gender, and education level of the patient (p < 0.05).

CONCLUSIONS

The results for both utility and total SGRQ-C score indicate that having suffered exacerbations in the last year, presenting a higher level of severity, being a woman, and having a low education level are related to worse HRQL in patients with COPD.

Prediction of Treatment Response in Patients with Chronic Obstructive Pulmonary Disease by Determination of Airway Dimensions with Baseline Computed Tomography

Objective

To determine the predictive factors for treatment responsiveness in patients with chronic obstructive pulmonary disease (COPD) at 1-year follow-up by performing quantitative analyses of baseline CT scans.

Materials and Methods

COPD patients (n = 226; 212 men, 14 women) were recruited from the Korean Obstructive Lung Disease cohort. Patients received a combination of inhaled long-acting beta-agonists and corticosteroids twice daily for 3 months and subsequently received medications according to the practicing clinician's decision. The emphysema index, air-trapping indices, and airway parameter (Pi10), calculated using both full-width-half-maximum and integral-based half-band (IBHB) methods, were obtained with baseline CT scans. Clinically meaningful treatment response was defined as an absolute increase of ≥ 0.225 L in the forced expiratory volume in 1 second (FEV₁) at the one-year follow-up. Multivariate logistic regression analysis was performed to investigate the predictors of an increase in FEV₁, and receiver operating characteristic (ROC) analysis was performed to evaluate the performance of the suggested models.

Results

Treatment response was noted in 47 patients (20.8%). The mean FEV₁ increase in responders was 0.36 ± 0.10 L. On univariate analysis, the air-trapping index (ATI) obtained by the subtraction method, ATI of the emphysematous area, and IBHB-measured Pi10 parameter differed significantly between treatment responders and non-responders (p = 0.048, 0.042, and 0.002, respectively). Multivariate analysis revealed that the IBHB-measured Pi10 was the only independent variable predictive of an FEV₁ increase (p = 0.003). The adjusted odds ratio was 1.787 (95% confidence interval: 1.220–2.619). The area under the ROC curve was 0.641.

Conclusion

Measurement of standardized airway dimensions on baseline CT by using a recently validated quantification method can predict treatment responsiveness in COPD patients.

Measurement of patient-reported outcomes. 1: The search for the Holy Grail

Patient-reported outcome measures (PROMs) are used to collect information directly from patients. They may cover several different types of outcomes ranging from symptoms, functioning, utility, satisfaction, through to quality-of-life (QoL). They generally consist of self-completed questionnaires that can be administered by means of hard copies or in a range of electronic formats. PROMs vary considerably in terms of the constructs they assess, the care with which they are developed, and their scientific quality. However, none of the PROMs available approach the quality of measurement achieved by measures/instruments used in physics. PROs are examples of latent variables. These are not directly observable, but can be inferred from, for example, responses to a questionnaire. The only measure of a latent variable that approaches the quality of measurement achieved by the physical sciences is the Lexile Framework for Reading. This framework is based on a construct theory that grew out of an analysis of several available reading measures. A specification equation was generated that was able to link the construct theory to scores obtained with the Lexile measure. A fundamental requirement of this quality of measurement is that the data collected with the model fit Rasch Measurement Theory (RMT). It is argued that PROM developers should aspire to match this level of measurement sophistication if their instruments are to provide valid insights into the impacts of disease and its treatment.

'Exacerbation-free time' to assess the impact of exacerbations in patients with chronic obstructive pulmonary disease (COPD): a prospective observational study

COPD exacerbations are commonly quantified as rate per year. However, the total amount of time a patient suffers from exacerbations may be stronger related to his or her disease burden than just counting exacerbation episodes. In this study, we examined the relationship between exacerbation frequency and exacerbation-free time, and their associations with baseline characteristics and health-related quality of life. A total of 166 COPD patients reported symptom changes during 12 months. Symptom-defined exacerbation episodes were correlated to the number of exacerbation-free weeks per year. Analysis of covariance was used to examine the effects of baseline characteristics on annual exacerbation frequency and exacerbation-free weeks, Spearman’s rank correlations to examine associations between the two methods to express exacerbations and the Chronic Respiratory Questionnaire (CRQ). The correlation between exacerbation frequency and exacerbation-free weeks was −0.71 (p < 0.001). However, among frequent exacerbators (i.e., ≥3 exacerbations/year, n = 113) the correlation was weak (r = −0.25; p < 0.01). Smokers had less exacerbation-free weeks than non-smokers (β = −5.709, p < 0.05). More exacerbation-free weeks were related to better CRQ Total (r = 0.22, p < 0.05), Mastery (r = 0.22, p < 0.05), and Fatigue (r = 0.23, p < 0.05) scores, whereas no significant associations were found between exacerbation frequency and CRQ scores. In COPD patients with frequent exacerbations, there is substantial variation in exacerbation-free time. Exacerbation-free time may better reflect the burden of exacerbations in patients with COPD than exacerbation frequency does.

Time spent exacerbation-free may provide a stronger indication of disease burden than exacerbation frequency for patients with chronic lung disease. Exacerbations in chronic obstructive pulmonary disease (COPD) are marked by a sudden decline in lung function, potential hospitalisation and a need to increase medication. Exacerbation frequency is used as a marker in COPD management, but this does not consider the duration of exacerbations or the impact this has on patients’ lives. Lonneke Boer at Radboud University Medical Center, the Netherlands, and co-workers questioned 166 patients every two weeks for a year about their experiences of exacerbation duration and frequency. There was substantial variation in exacerbation-free time between patients, with smokers most likely to suffer longer periods of poorer health. Exacerbation-free time was better correlated with health-related quality of life than exacerbation frequency.

Development of a Conceptual Model of Disease Progression for Use in Economic Modeling of Chronic Obstructive Pulmonary Disease

BACKGROUND

To develop and validate a new conceptual model (CM) of chronic obstructive pulmonary disease (COPD) for use in disease progression and economic modeling. The CM identifies and describes qualitative associations between disease attributes, progression and outcomes.

METHODS

A literature review was performed to identify any published CMs or literature reporting the impact and association of COPD disease attributes with outcomes. After critical analysis of the literature, a Steering Group of experts from the disciplines of health economics, epidemiology and clinical medicine was convened to develop a draft CM, which was refined using a Delphi process. The refined CM was validated by testing for associations between attributes using data from the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE).

RESULTS

Disease progression attributes included in the final CM were history and occurrence of exacerbations, lung function, exercise capacity, signs and symptoms (cough, sputum, dyspnea), cardiovascular disease comorbidities, 'other' comorbidities (including depression), body composition (body mass index), fibrinogen as a biomarker, smoking and demographic characteristics (age, gender). Mortality and health-related quality of life were determined to be the most relevant final outcome measures for this model, intended to be the foundation of an economic model of COPD.

CONCLUSION

The CM is being used as the foundation for developing a new COPD model of disease progression and to provide a framework for the analysis of patient-level data. The CM is available as a reference for the implementation of further disease progression and economic models.

The COPD assessment test and St George's Respiratory Questionnaire: are they equivalent in subjects with COPD?

Background

The chronic obstructive pulmonary disease (COPD) assessment test (CAT) is a short questionnaire that has facilitated health status measurements in subjects with COPD. However, it remains controversial as to whether the CAT can be used as a suitable substitute for the St George’s Respiratory Questionnaire (SGRQ). This study investigated the reliability and score distributions of the CAT and SGRQ and evaluated which factors contributed to health status for each questionnaire.

Methods

A total of 109 consecutive subjects with stable COPD from a single center were enrolled in this study. Each subject completed pulmonary function tests, exercise tests, and the following self-administered questionnaires: the Baseline Dyspnea Index, the Hospital Anxiety and Depression Scale, the CAT, and SGRQ.

Results

Internal consistencies of CAT and SGRQ total scores were both excellent (Cronbach’s α coefficients =0.890 and 0.933). Statistically significant correlations were observed between CAT and SGRQ total scores (R=0.668, P<0.001). Correlations of CAT scores with parameters related to pulmonary function, dyspnea, exercise performance, and psychological factors were inferior to correlations with those parameters with SGRQ total scores. Both multiple regression analyses and principal component analyses revealed that there were slight differences between SGRQ total scores and CAT scores.

Conclusion

The CAT is similar to SGRQ in terms of discriminating health status. However, we demonstrated that what is assessed by the CAT may differ slightly from what is measured by SGRQ.

A review of the most common patient-reported outcomes in COPD--revisiting current knowledge and estimating future challenges

Patient-reported outcome (PRO) measures that quantify disease impact have become important measures of outcome in COPD research and treatment. The objective of this literature review was to comprehensively evaluate psychometric properties of available PRO instruments and the ability of each of them to characterize pharmaceutical treatment effects from published clinical trial evidence. Identified in this study were several PRO measures, both those that have been used extensively in COPD clinical trials (St George’s Respiratory Questionnaire and Chronic Respiratory Questionnaire) and new instruments whose full value is still to be determined. This suggests a great need for more information about the patient experience of treatment benefit, but this also may pose challenges to researchers, clinicians, and other important stakeholders (eg, regulatory agencies, pharmaceutical companies) who develop new treatment entities and payers (including but not limited to health technology assessment agencies such as the National Institute for Health and Care Excellence and the Canadian Agency for Drugs and Technologies in Health). The purpose of this review is to enable researchers and clinicians to gain a broad overview of PRO measures in COPD by summarizing the value and purpose of these measures and by providing sufficient detail for interested audiences to determine which instrument may be the most suitable for evaluating a particular research purpose.

Improving communication between the physician and the COPD patient: an evaluation of the utility of the COPD Assessment Test in primary care

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. It is now considered a systemic inflammatory syndrome and is associated with important comorbidities. In addition to spirometry for evaluating the severity of airflow obstruction, an instrument is required for comprehensive assessment of the disease. The COPD Assessment Test (CAT) is a simple and valid tool for evaluating patient symptoms. The CAT can improve patient–physician communication during routine clinical visits and is useful for assessing functional status and response to treatment. The CAT has a strong correlation with other health status questionnaires, such as the St George’s Respiratory Questionnaire. The main advantages of the CAT are its thorough coverage of the important clinical aspects of disease burden and the shorter time involved in completing it. The aim of this paper is to review the role of the CAT, to compare it with other health-related quality of life questionnaires in the assessment and management of COPD patients, and to emphasize the importance of patient–physician communication in the management of patients with the disease.

Identifying key domains of health-related quality of life for patients with chronic obstructive pulmonary disease: the patient perspective

Background

Numerous instruments are available to measure health-related quality of life (HRQoL) in patients with Chronic Obstructive Pulmonary Disease (COPD), covering a wide array of domains ranging from symptoms such as dyspnea, cough and wheezing, to social and emotional functioning. Currently no information or guide is available yet to aid the selection of domains for a particular study or disease population. The aim of this paper is to identify which domains of HRQoL are most important with respect to COPD, from the patient perspective.

Methods

Twenty-one Dutch patients with COPD were asked to describe important domains impacted by COPD freely; second, they were presented with cues (domains from the Patient-Reported Outcomes Measurement Information System (PROMIS) framework) and were asked to select the domains that were most relevant to them. During the interview, the patients were asked to indicate in which way the selected domains impact their lives. Both the answers to the open question, and the patient statements motivating nomination of PROMIS domains were coded into themes.

Results

The most relevant (sub)domains of HRQoL for patients with COPD were: physical health (fatigue, physical functioning), social health (instrumental support, ability to participate in social roles and activities, companionship, and emotional support), and coping with COPD.

Conclusion

We identified which domains of HRQoL are most important to patients with COPD. One of these (coping with COPD) is not explicitly covered by PROMIS, or by traditional questionnaires that are used to measure HRQoL in COPD.

Effect of a Pulmonary Rehabilitation Program on the levels of anxiety and depression and on the quality of life of patients with chronic obstructive pulmonary disease

OBJECTIVE

To analyze the effect of a Pulmonary Rehabilitation Program (PRP) on the levels of anxiety and depression and the quality of life of patients with chronic obstructive pulmonary disease.

METHOD

Patients with chronic obstructive pulmonary disease (COPD) who completed the PRP of 3 weekly sessions of 60 min duration for 12 weeks, a total of 36 sessions, were assessed using Beck Inventory (BAI and BDI) and Saint George's Respiratory Questionnaire (SGRQ).

RESULTS

A total of 125 individuals, with an average age of 63.7 ± 8.8 years, FEV1: 1.17 ± 0.57L (43.18 ± 18.79% predicted), 61.6% male and 38.4% female, were analyzed. The BAI and BDI before and after PRP were, respectively, 10.15 ± 6.32 vs. 7.67 ± 7.21; p=0.0041 and 12.60 ± 7.99 vs. 8.96 ± 7.29; p=0.00016. The results of the SGRQ domains were, respectively, Before and After symptoms (48.53 ± 20.41 vs. 32.58 ± 18.95), Activity (69.15 ± 20.79 vs. 52.42 ± 23.70), Impact (32.92 ± 18.29 vs. 20.27 ± 16.70), Total (46.69 ± 16.90 vs. 32.07 ± 16.96). When correlating the BDI to the domains of the SGRQ, weak correlations were observed (Symptoms r=0.22; p=0.01; Activity r=0.28; p=0.001; Impact r=0.52; p=2.72; Total r=0.44; p=0.17). In the same way, weak correlations were observed when correlating the BAI to the SGRQ (Symptoms r=0.28; p=0.0009; Activity r=0.32; p=0.0005; Impact r=0.42; p=7.33; Total r=0.43; p=0.74).

CONCLUSION

Although the PRP improves levels of depression and anxiety as well as the quality of life in patients with COPD, no significant correlation of these analyzed variables was observed.

Does the duration of smoking cessation have an impact on hospital admission and health-related quality of life amongst COPD patients?

BACKGROUND

Lack of awareness among ex-smokers on the benefits of sustaining smoking cessation may be the main cause of their smoking relapse. This study explored health-related quality of life (HRQoL) and hospital admission amongst chronic obstructive pulmonary disease (COPD) patients according to the duration of smoking cessation.

MATERIALS AND METHODS

This study recruited COPD patients from a chest clinic who agreed to participate in a medication therapy-adherence program from January to June 2013. They were interviewed during their visits to obtain information regarding their smoking history and HRQoL. They were divided into three groups according to smoking status (sustained quitters, quit ≥5 years; quitters, quit <5 years; and smokers, smoking at least one cigarette/day). The effects of the duration of cessation on HRQoL and hospital admission were analyzed using a multinomial logistic model.

RESULTS

A total of 117 participants with moderate COPD met the inclusion criteria, who were comprised of 41 sustained quitters, 40 quitters, and 36 smokers. Several features were similar across the groups. Most of them were married elderly men (aged >64 years) with low-to-middle level of education, who smoked more than 33 cigarettes per day and had high levels of adherence to the medication regimen. The results showed that sustained quitters were less likely to have respiratory symptoms (cough, phlegm and dyspnea) than smokers (odds ratio 0.02, confidence interval 0-0.12; P<0.001). The hospital admission rate per year was increased in quitters compared to smokers (odds ratio 4.5, confidence interval 1.91-10.59; P<0.005).

CONCLUSION

A longer duration of quitting smoking will increase the benefits to COPD patients, even if they experience increased episodic respiratory symptoms in the early period of the cessation. Thus, the findings of this study show the benefits of early smoking cessation.

An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation

BACKGROUND

Pulmonary rehabilitation is recognized as a core component of the management of individuals with chronic respiratory disease. Since the 2006 American Thoracic Society (ATS)/European Respiratory Society (ERS) Statement on Pulmonary Rehabilitation, there has been considerable growth in our knowledge of its efficacy and scope.

PURPOSE

The purpose of this Statement is to update the 2006 document, including a new definition of pulmonary rehabilitation and highlighting key concepts and major advances in the field.

METHODS

A multidisciplinary committee of experts representing the ATS Pulmonary Rehabilitation Assembly and the ERS Scientific Group 01.02, "Rehabilitation and Chronic Care," determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant clinical and scientific expertise. The final content of this Statement was agreed on by all members.

RESULTS

An updated definition of pulmonary rehabilitation is proposed. New data are presented on the science and application of pulmonary rehabilitation, including its effectiveness in acutely ill individuals with chronic obstructive pulmonary disease, and in individuals with other chronic respiratory diseases. The important role of pulmonary rehabilitation in chronic disease management is highlighted. In addition, the role of health behavior change in optimizing and maintaining benefits is discussed.

CONCLUSIONS

The considerable growth in the science and application of pulmonary rehabilitation since 2006 adds further support for its efficacy in a wide range of individuals with chronic respiratory disease.

Recommendations for fitness for work medical evaluations in chronic respiratory patients. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR)

Chronic respiratory diseases often cause impairment in the functions and/or structure of the respiratory system, and impose limitations on different activities in the lives of persons who suffer them. In younger patients with an active working life, these limitations can cause problems in carrying out their normal work. Article 41 of the Spanish Constitution states that «the public authorities shall maintain a public Social Security system for all citizens guaranteeing adequate social assistance and benefits in situations of hardship». Within this framework is the assessment of fitness for work, as a dual-nature process (medico-legal) that aims to determine whether it is appropriate or not to recognise a person's right to receive benefits which replace the income that they no longer receive as they cannot carry out their work, due to loss of health. The role of the pulmonologist is essential in evaluating the diagnosis, treatment, prognosis and functional capacity of respiratory patients. These recommendations seek to bring the complex setting of fitness for work evaluation to pulmonologists and thoracic surgeons, providing action guidelines that allow them to advise their own patients about their incorporation into working life.

A simple method to enable patient-tailored treatment and to motivate the patient to change behaviour

In clinical practice and in self-management studies it appears that it is very difficult to change behaviour in patients with chronic obstructive pulmonary disease (COPD) in order to achieve adequate self-management. In this respect the role of motivational processes is underestimated and rarely is specifically targeted in interventions. In this article, the fundamentals of motivational processes are discussed followed by a detailed description of the Nijmegen Clinical Screening Instrument (NCSI) method. The NCSI method is a simple method that enables patient-tailored treatment and to motivate patients to adhere to treatment goals. The NCSI method consists of three distinct but highly integrated components: (1) a short instrument measuring many details of health status; (2) an intervention that helps to identify individual treatment goals and to motivate the patient to change his behaviour; (3) an automated monitoring system that simply identifies patients with new problems in health status of self-management. All components are embedded in a web-based application which enhances simplicity, efficiency, and effectiveness of the NCSI method. The NCSI method is illustrated by a case study.

Beyond FEV₁ in COPD: a review of patient-reported outcomes and their measurement

Patients with chronic obstructive pulmonary disease (COPD) present with a variety of symptoms and pathological consequences. Although primarily viewed as a respiratory disease, COPD has both pulmonary and extrapulmonary effects, which have an impact on many aspects of physical, emotional, and mental well-being. Traditional assessment of COPD relies heavily on measuring lung function, specifically forced expiratory volume in 1 second (FEV(1)). However, the evidence suggests that FEV(1) is a relatively poor correlate of symptoms such as breathlessness and the impact of COPD on daily life. Furthermore, many consequences of the disease, including anxiety and depression and the ability to perform daily activities, can only be described and reported reliably by the patient. Thus, in order to provide a comprehensive view of the effects of interventions in clinical trials, it is essential that spirometry is accompanied by assessments using patient-reported outcome (PRO) instruments. We provide an overview of patient-reported outcome concepts in COPD, such as breathlessness, physical functioning, and health status, and evaluate the tools used for measuring these concepts. Particular attention is given to the newly developed instruments emerging in response to recent regulatory guidelines for the development and use of PROs in clinical trials. We conclude that although data from the development and validation of these new PRO instruments are emerging, to build the body of evidence that supports the use of a new instrument takes many years. Furthermore, new instruments do not necessarily have better discriminative or evaluative properties than older instruments. The development of new PRO tools, however, is crucial, not only to ensure that key COPD concepts are being reliably measured but also that the relevant treatment effects are being captured in clinical trials. In turn, this will help us to understand better the patient's experience of the disease.

Decline of health status sub-domains by exacerbations of chronic obstructive pulmonary disease: a prospective survey

BACKGROUND

Exacerbations of chronic obstructive pulmonary disease (COPD) are held responsible for a decline in health status (HS). This may not apply equally to all exacerbations, because different definitions are required for quite different illnesses. Selection of definitions and the sensitivity of the HS instrument may affect results regarding the impact of exacerbations. Sensitivity of a new HS instrument, which covers different and more aspects, has not yet been tested, with respect to exacerbations.

OBJECTIVES

Confirmation of the negative HS effect of exacerbations by using a highly differentiated instrument, and to evaluate which aspects of HS are affected most.

METHODS

One hundred and sixty-eight ambulatory patients with COPD were evaluated prospectively with regard to a wide range of HS aspects, at the beginning and end of a 1-year follow-up. Recording of symptom changes and treatment on monthly diary cards resulted in the identification of event-based exacerbations. HS was assessed via a newly validated instrument integrating both physiological and non-physiological sub-domains. Parametric correlations were calculated between exacerbation frequency and HS scores at the end of the study. Partial corre-lations were then explored using HS scores at baseline to correct for prior HS levels.

RESULTS

Correlations between -exacerbation frequency and HS sub-domains were found to be frequent, predominantly in non-physiological sub--domains. After correction for hs scores at baseline, only 2 sub-domains (belonging to the main domain 'complaints') remained significantly but weakly correlated.

CONCLUSION

Exacerbation frequency and HS show weak correlations after a year, but most of these disappear after correction for prior HS levels. In such exacerbations, aggravated HS probably takes much longer to manifest itself.

Assessing health status in COPD. A head-to-head comparison between the COPD assessment test (CAT) and the clinical COPD questionnaire (CCQ)

BACKGROUND

Health status provides valuable information, complementary to spirometry and improvement of health status has become an important treatment goal in COPD management. We compared the usefulness and validity of the COPD Assessment Test (CAT) and the Clinical COPD Questionnaire (CCQ), two simple questionnaires, in comparison with the St. George Respiratory Questionnaire (SGRQ).

METHODS

We administered the CAT, CCQ and SGRQ in patients with COPD stage I-IV during three visits. Spirometry, 6 MWT, MRC scale, BODE index, and patients perspectives on questionnaires were recorded in all visits. Standard Error of Measurement (SEM) was used to calculate the Minimal Clinical Important Difference (MCID) of all questionnaires.

RESULTS

We enrolled 90 COPD patients. Cronbach's alpha for both CAT and CCQ was high (0.86 and 0.89, respectively). Patients with severe COPD reported worse health status compared to milder subgroups. CAT and CCQ correlated significantly (rho =0.64, p < 0.01) and both with the SGRQ (rho = 0.65; CAT and rho = 0.77; CCQ, p < 0.01). Both questionnaires exhibited a weak correlation with lung function (rho = -0.35;CAT and rho = -0.41; CCQ, p < 0.01). Their reproducibility was high; CAT: ICC = 0.94 (CI 0.92-0.96), total CCQ ICC = 0.95 (0.92-0.96) and SGRQ = 0.97 (CI 0.95-0.98). The MCID calculated using the SEM method showed results similar to previous studies of 3.76 for the CAT, 0.41 for the CCQ and 4.84 for SGRQ. Patients suggested both CAT and CCQ as easier tools than SGRQ in terms of complexity and time considerations. More than half of patients preferred CCQ instead of CAT.

CONCLUSIONS

The CAT and CCQ have similar psychometric properties with a slight advantage for CCQ based mainly on patients' preference and are both valid and reliable questionnaires to assess health status in COPD patients.

The validity and precision of the Leicester Cough Questionnaire in COPD patients with chronic cough

Background

A validated instrument to assess the effects of chronic cough on health status in patients with chronic obstructive pulmonary disease (COPD) is currently not available. The Leicester Cough Questionnaire (LCQ) is a cough-specific health status questionnaire which is originally validated for a population of general patients presenting with chronic cough. We examined the psychometric performance of the LCQ in patients with COPD and chronic productive cough.

Methods

Concurrent validity, internal consistency, reproducibility and responsiveness were determined. The St. George's Respiratory Questionnaire (SGRQ) and the Short Form-36 (SF-36) were used as external criteria. Questionnaires were completed at the start of the study. After 2 and 12 weeks the LCQ was repeated, together with a global rating of change.

Results

In total 54 patients were included. Concurrent validity analysis showed significant correlations between corresponding domains of the LCQ and the SGRQ (r_s -0.31 to -0.60). Corresponding domains of the LCQ and the SF-36 showed weaker correlations (r_s 0.04 to 0.41). Internal consistency was adequate for two of the three domains (Cronbach's α 0.74 - 0.86). Test-retest reliability in stable patients was high (intraclass correlation coefficients 0.79 - 0.93). The mean difference after two weeks was 0.73 (± 1.75). Responsiveness analysis indicated that the LCQ was able to detect changes after 12 weeks.

Conclusion

The LCQ is a valid, reliable, responsive instrument to measure health status in COPD patients with chronic productive cough.

Trial Registration

ClinicalTrials.gov: NCT01071161

Epidemic Q fever in humans in the Netherlands

In 2005, Q fever was diagnosed on two dairy goat farms and 2 years later it emerged in the human population in the south of the Netherlands. From 2007 to 2010, more than 4,000 human cases were notified with an annual seasonal peak. The outbreaks in humans were mainly restricted to the south of the country in an area with intensive dairy goat farming. In the most affected areas, up to 15% of the population may have been infected. The epidemic resulted in a serious burden of disease, with a hospitalisation rate of 20% of notified cases and is expected to result in more cases of chronic Q fever among risk groups in the coming years. The most important risk factor for human Q fever is living close (<5 km) to an infected dairy goat farm. Occupational exposure plays a much smaller role. In 2009 several veterinary control measures were implemented including mandatory vaccination of dairy goats and dairy sheep, improved hygiene measures, and culling of pregnant animals on infected farms. The introduction of these drastic veterinary measures has probably ended the Q fever outbreak, for which the Netherlands was ill-prepared.

The future of chronic obstructive pulmonary disease treatment--difficulties of and barriers to drug development

Although chronic obstructive pulmonary disease (COPD) is a major global health problem with a rising incidence and morbidity, few pharmacotherapeutic advances have been made over the past several decades. The challenges of development of such agents are multifactorial and include rudimentary understanding of the biological genesis of human disease, inadequate in-vitro and in-vivo models, unvalidated biomarkers, inefficient physiological and clinical endpoints, and variable regulatory review worldwide. Blockade of various inflammatory pathways and mediators is a reasonable therapeutic strategy to alter the natural history of COPD. Substantial heterogeneity is evident with respect to clinical presentation, physiology, imaging, response to therapy, decline in lung function, and survival. Numerous endpoints have been proposed for clinical studies in COPD, with new approaches under study. The novel strategy that seems most promising is the use of biomarkers. We hope that with these approaches novel pharmacotherapies will be developed in the near future.

Effects of pulmonary rehabilitation on quality of life in chronic obstructive pulmonary disease patients

PURPOSE OF REVIEW

Pulmonary rehabilitation plays a key role in the management of chronic obstructive pulmonary disease (COPD). Although the American Thoracic Society recently provided a grade of 1A for evidence of health-related quality of life (HRQoL) benefits related to pulmonary rehabilitation, knowledge about the psychological and behavioral processes explaining the impact of pulmonary rehabilitation on HRQoL in COPD patients remains limited. This review describes the state of knowledge over the past year concerning HRQoL benefits after pulmonary rehabilitation and suggests avenues for future research.

RECENT FINDINGS

HRQoL outcomes related to pulmonary rehabilitation explores five themes: optimizing pulmonary rehabilitation components to improve HRQoL; characterization of a responder phenotype; suitability of pulmonary rehabilitation following acute exacerbations; exploration of psychological and behavioral mechanisms explaining pulmonary rehabilitation benefits; and long-term maintenance of HRQoL benefits after pulmonary rehabilitation.

SUMMARY

Evidence supports the use of pulmonary rehabilitation to improve HRQoL in patients with moderate-to-severe COPD. However, it is unclear how pulmonary rehabilitation improves HRQoL and which characteristics confer the greatest HRQoL benefits. Moreover, most studies failed to provide a compelling theoretical rationale for the intervention employed. Future research should focus on improving the understanding of the psychological mechanisms implicated in the adoption and maintenance of healthy behavior.

The health status of Q-fever patients after long-term follow-up

BACKGROUND

In the Netherlands, from 2007 to 2009, 3,522 Q-fever cases were notified from three outbreaks. These are the largest documented outbreaks in the world. Previous studies suggest that symptoms can persist for a long period of time, resulting in a reduced quality of life (QoL). The aim of this study was to qualify and quantify the health status of Q-fever patients after long-term follow-up.

METHODS

870 Q-fever patients of the 2007 and 2008 outbreaks were mailed a questionnaire 12 to 26 months after the onset of illness. We assessed demographic data and measured health status with the Nijmegen Clinical Screening Instrument (NCSI). The NCSI consists of three main domains of functional impairment, symptoms and QoL that are divided into eight sub-domains. The NCSI scores of Q-fever patients older than 50 years (N=277) were compared with patients younger than 50 years (N=238) and with norm data from healthy individuals (N=65) and patients with chronic obstructive pulmonary disease (N=128).

RESULTS

The response rate was 65.7%. After applying exclusion criteria 515 Q-fever patients were included in this study. The long-term health status of two thirds of Q-fever patients (both younger and older than 50 years) was severely affected for at least one sub-domain. Patients scores were most severely affected on the sub-domains general QoL (44.9%) and fatigue (43.5%). Hospitalisation in the acute phase was significantly related to long-term behavioural impairment (OR 2.8, CI 1.5-5.1), poor health related QoL (OR 2.3,CI 1.5-4.0) and subjective symptoms (OR 1.9, CI 1.1-3.6). Lung or heart disease, depression and arthritis significantly affected the long-term health status of Q-fever patients.

CONCLUSIONS

Q-fever patients presented 12 to 26 months after the onset of illness severe -clinically relevant- subjective symptoms, functional impairment and impaired QoL. All measured sub-domains of the health status were impaired. Hospitalisation and co-morbidity were predictors for worse scores. Our data emphasise that more attention is needed not only to prevent exposure to Q-fever but also for the prevention and treatment of the long-term consequences of this zoönosis.

Different profiles of IL-10+IFN-gamma-IL-4-CD4+ T cells in the peripheral blood in atopic and non-atopic asthmatics

BACKGROUND

The impaired production of interleukin (IL) 10 from regulatory T cells has been proposed as a causal mechanism of asthma. Although IL-10-producing (IL-10+) T cells are detectable in the peripheral blood, their significance in the pathophysiology of asthma remains uncertain.

OBJECTIVES

This study aimed to investigate the profile of circulating IL-10+CD4+ T cells in atopic and non-atopic asthma.

METHODS

Atopic and non-atopic asthmatics were divided into a mild and severe group. Their peripheral blood mononuclear cells (PBMCs) were stimulated with anti-CD3 and anti-CD28 antibodies and then processed for triple cytokine flow cytometry directed to IL-10, interferon (IFN) gamma and IL-4.

RESULTS

IL-10+CD4+ cells were exclusively detected in the IFN-gamma-IL-4- population. In atopic asthma, the frequency of IL-10+IFN-gamma-IL-4-CD4+ cells in the severe group was significantly lower than that in the mild group. The frequency of IL-10+IFN-gamma-IL-4-CD4+ cells in the severe group was not significantly different from that in the mild group of those with non-atopic asthma. The frequency of IL-4+IFN-gamma-IL-10-CD4+ cells (Th2) was significantly higher in the group with mild atopic asthma than in that with mild non-atopic asthma. IFN-gamma+IL-4-IL-10-CD4+ cells (Th1) did not differ between groups, irrespective whether the subjects suffered from atopic or non-atopic asthma.

CONCLUSIONS

IL-10+CD4+ cells in PBMCs may be distinct from Th1 or Th2 and likely have the profile of regulatory T cells. The differential association of IL-10+IFN-gamma-IL-4-CD4+ cells with clinical severity between atopic and non-atopic asthma implies that its pathophysiological significance may differ among asthma phenotypes.