Utility of brief questionnaires of health-related quality of life (Airways Questionnaire 20 and Clinical COPD Questionnaire) to predict exacerbations in patients with asthma and COPD

Evaluation of Exacerbation and Symptom-Free Time in Patients with COPD

In clinical practice, clinicians mainly focus on Chronic Obstructive Pulmonary Disease (COPD) exacerbations and symptoms, while patients may prefer to evaluate periods free of COPD exacerbations and deteriorated symptoms. The latter would suit the positive health approach that centralizes people and their beliefs. We aimed to identify patient characteristics and health outcomes relating to: 1) COPD exacerbation-free days; 2) days with no more symptoms than usual; and 3) combined COPD exacerbation and comorbid flare-up-free days (i.e. chronic heart failure, anxiety, depression flare-ups) using negative binomial regression analyzes. Data were obtained from two self-management intervention trials including COPD patients with and without comorbidities. 313 patients (mean age 66.0 years, 63.6% male, 68.7% comorbidity) were included. Better baseline chronic respiratory questionnaire (CRQ) fatigue (incidence rate ratio (IRR) = 1.03 (95% CI 1.01-1.05), p = 0.02) and mastery scores (IRR = 1.03 (95% CI 1.00-1.06), p = 0.04) and fewer courses of antibiotics (IRR = 0.95 (95% CI 0.94-0.96), p < 0.01) were related to more COPD exacerbation-free days. Additionally, better baseline CRQ fatigue (IRR = 1.05 (95% CI 1.00-1.10), p = 0.04) and mastery scores (IRR = 1.06 (95% CI 1.00-1.12), p = 0.04), fewer courses of antibiotics (IRR = 0.94 (95% CI 0.91-0.96), p < 0.01), and improved CRQ dyspnea scores over 12 months of follow-up (IRR = 1.07 (95% CI 1.01-1.12), p < 0.01) were correlated to more days free of deteriorated symptoms. Less baseline dyspnea (modified Medical Research Council score) (IRR = 0.95 (95% CI 0.92-0.98), p < 0.01) and fewer courses of antibiotics (IRR = 0.94 (95% CI 0.93-0.95), p < 0.01) were associated with more combined COPD exacerbation and comorbid flare-up-free days. Healthcare professionals should be aware that less fatigue and better mastering of COPD relate to more exacerbation and symptom-free time in COPD patients.

Independent risk factors of asthma exacerbations: 3-year follow-up in a single-center prospective cohort study

Background

Because minimizing future risk is the goal of asthma chronic asthma management, it is particularly important to identify risk factors. We conducted this 3-year single-center prospective cohort study to determine the independent risk factors of asthma exacerbations (AEs).

Methods

We performed this prospective, longitudinal, observational study with a 3-year follow-up on 257 patients aged 18-81 years with at least a 1-year history of asthma. Follow-up visits are conducted through regular annual phone calls, and the primary endpoints were AE.

Results

The uncontrolled group was more likely to develop AE than the well-controlled group [odds ratio (OR): 6.34, 95% confidence interval (CI): 1.14-35.21, P<0.05]. Patients with low Asthma Quality of Life Questionnaire (AQLQ) scores were more likely to develop AE than these with high AQLQ scores (OR: 0.59, 95% CI: 0.35-0.99, P<0.05). AQLQ and Asthma Control Questionnaires (ACQ) were both strong independent risk factors within 3 years of enrollment; the cut-off values (COV) of the AQLQ and the ACQ (uncontrolled) that better evaluated the risk with the AE were ≤5.4 and >1, respectively. The AQLQ scores had a sensitivity of 79.07% and a specificity of 59.09% [area under curve (AUC): 0.70, P<0.0001], and the ACQ (uncontrolled) had a sensitivity of 81.4% and a specificity of 52.29% (AUC 0.68, P<0.0001).

Conclusions

The findings of this study suggest that patients with uncontrolled asthma and a diminished health-related quality of life had an increased risk of exacerbations in the future. Defining these risk factors associated with AE is important as it will identify these at the highest risk to patients and may guide future interventions.

Temperature-controlled Laminar Airflow (TLA) in symptomatic severe asthma – a post hoc analysis of severe exacerbations, quality of life and health economics

Purpose

Uncontrolled severe asthma constitutes a major economic burden to society. Add-ons to standard inhaled treatments include inexpensive oral corticosteroids and expensive biologics. Nocturnal treatment with Temperature-controlled Laminar Airflow (TLA; Airsonett®) could be an effective, safe and cheaper alternative. The potential of TLA in reducing severe asthma exacerbations was addressed in a recent randomised placebo-controlled trial (RCT) in patients with severe asthma (Global Initiative for Asthma (GINA) step 4/5), but the results were inconclusive. We re-analysed the RCT with severe exacerbations stratified by the level of baseline asthma symptoms and Quality of Life.

Methods

More uncontrolled patients, defined by Asthma Control Questionnaire 7 (ACQ7) > 3, EuroQoL 5-Dimension Questionnaire Visual Analogue Scale (EQ5D-VAS) ≤ 65 and Asthma Quality of Life Questionnaire (AQLQ) ≤ 4 were selected for re-analysis. The rates of severe asthma exacerbations, changes in QoL and health-economics were analysed and compared between TLA and placebo.

Results

The study population included 226 patients (113 TLA / 113 placebo.) The rates of severe asthma exacerbations were reduced by 33, 31 and 25% (p = 0.083, 0.073, 0.180) for TLA compared to placebo, dependent on selected control measures (ACQ7, EQ5D-VAS, AQLQ, respectively). For patients with less control defined by AQLQ≤4, the difference in mean AQLQ0-12M between TLA and placebo was 0.31, 0.33, 0.26 (p = 0.085, 0.034, 0.150), dependent on selected covariate (AQLQ, EQ5D-VAS, ACQ7, respectively). For patients with poor control defined by ACQ7 > 3, the difference in EQ5D-5 L utility scores between TLA and placebo was significant at 9 and 12 months with a cost-effective ICER. The results from the original study did not demonstrate these differences.

Conclusion

This post hoc analysis demonstrated an effect of TLA over placebo on severe exacerbations, asthma control and health economics in a subgroup of patients with more symptomatic severe allergic asthma. The results are consistent with the present recommendations for TLA. However, these differences were not demonstrated in the full study. Several explanations for the different outcomes have been outlined, which should be addressed in future studies.

Funding

NIHR Health Technology Assessment Programme and Portsmouth Hospitals NHS Trust.

Automatically Explaining Machine Learning Predictions on Severe Chronic Obstructive Pulmonary Disease Exacerbations: Retrospective Cohort Study

Background

Chronic obstructive pulmonary disease (COPD) is a major cause of death and places a heavy burden on health care. To optimize the allocation of precious preventive care management resources and improve the outcomes for high-risk patients with COPD, we recently built the most accurate model to date to predict severe COPD exacerbations, which need inpatient stays or emergency department visits, in the following 12 months. Our model is a machine learning model. As is the case with most machine learning models, our model does not explain its predictions, forming a barrier for clinical use. Previously, we designed a method to automatically provide rule-type explanations for machine learning predictions and suggest tailored interventions with no loss of model performance. This method has been tested before for asthma outcome prediction but not for COPD outcome prediction.

Objective

This study aims to assess the generalizability of our automatic explanation method for predicting severe COPD exacerbations.

Methods

The patient cohort included all patients with COPD who visited the University of Washington Medicine facilities between 2011 and 2019. In a secondary analysis of 43,576 data instances, we used our formerly developed automatic explanation method to automatically explain our model’s predictions and suggest tailored interventions.

Results

Our method explained the predictions for 97.1% (100/103) of the patients with COPD whom our model correctly predicted to have severe COPD exacerbations in the following 12 months and the predictions for 73.6% (134/182) of the patients with COPD who had ≥1 severe COPD exacerbation in the following 12 months.

Conclusions

Our automatic explanation method worked well for predicting severe COPD exacerbations. After further improving our method, we hope to use it to facilitate future clinical use of our model.

International Registered Report Identifier (IRRID)

RR2-10.2196/13783

Developing a Machine Learning Model to Predict Severe Chronic Obstructive Pulmonary Disease Exacerbations: Retrospective Cohort Study

Background

Chronic obstructive pulmonary disease (COPD) poses a large burden on health care. Severe COPD exacerbations require emergency department visits or inpatient stays, often cause an irreversible decline in lung function and health status, and account for 90.3% of the total medical cost related to COPD. Many severe COPD exacerbations are deemed preventable with appropriate outpatient care. Current models for predicting severe COPD exacerbations lack accuracy, making it difficult to effectively target patients at high risk for preventive care management to reduce severe COPD exacerbations and improve outcomes.

Objective

The aim of this study is to develop a more accurate model to predict severe COPD exacerbations.

Methods

We examined all patients with COPD who visited the University of Washington Medicine facilities between 2011 and 2019 and identified 278 candidate features. By performing secondary analysis on 43,576 University of Washington Medicine data instances from 2011 to 2019, we created a machine learning model to predict severe COPD exacerbations in the next year for patients with COPD.

Results

The final model had an area under the receiver operating characteristic curve of 0.866. When using the top 9.99% (752/7529) of the patients with the largest predicted risk to set the cutoff threshold for binary classification, the model gained an accuracy of 90.33% (6801/7529), a sensitivity of 56.6% (103/182), and a specificity of 91.17% (6698/7347).

Conclusions

Our model provided a more accurate prediction of severe COPD exacerbations in the next year compared with prior published models. After further improvement of its performance measures (eg, by adding features extracted from clinical notes), our model could be used in a decision support tool to guide the identification of patients with COPD and at high risk for care management to improve outcomes.

International Registered Report Identifier (IRRID)

RR2-10.2196/13783

Using Computational Methods to Improve Integrated Disease Management for Asthma and Chronic Obstructive Pulmonary Disease: Protocol for a Secondary Analysis

Background

Asthma and chronic obstructive pulmonary disease (COPD) impose a heavy burden on health care. Approximately one-fourth of patients with asthma and patients with COPD are prone to exacerbations, which can be greatly reduced by preventive care via integrated disease management that has a limited service capacity. To do this well, a predictive model for proneness to exacerbation is required, but no such model exists. It would be suboptimal to build such models using the current model building approach for asthma and COPD, which has 2 gaps due to rarely factoring in temporal features showing early health changes and general directions. First, existing models for other asthma and COPD outcomes rarely use more advanced temporal features, such as the slope of the number of days to albuterol refill, and are inaccurate. Second, existing models seldom show the reason a patient is deemed high risk and the potential interventions to reduce the risk, making already occupied clinicians expend more time on chart review and overlook suitable interventions. Regular automatic explanation methods cannot deal with temporal data and address this issue well.

Objective

To enable more patients with asthma and patients with COPD to obtain suitable and timely care to avoid exacerbations, we aim to implement comprehensible computational methods to accurately predict proneness to exacerbation and recommend customized interventions.

Methods

We will use temporal features to accurately predict proneness to exacerbation, automatically find modifiable temporal risk factors for every high-risk patient, and assess the impact of actionable warnings on clinicians’ decisions to use integrated disease management to prevent proneness to exacerbation.

Results

We have obtained most of the clinical and administrative data of patients with asthma from 3 prominent American health care systems. We are retrieving other clinical and administrative data, mostly of patients with COPD, needed for the study. We intend to complete the study in 6 years.

Conclusions

Our results will help make asthma and COPD care more proactive, effective, and efficient, improving outcomes and saving resources.

International Registered Report Identifier (IRRID)

PRR1-10.2196/27065

Effect of nocturnal Temperature-controlled Laminar Airflow on the reduction of severe exacerbations in patients with severe allergic asthma: a meta-analysis

Background: Allergen avoidance is important in allergic asthma management. Nocturnal treatment with Temperature-controlled Laminar Airflow (TLA) has been shown to provide a significant reduction in the exposure to allergens in the breathing zone, leading to a long-term reduction in airway inflammation and improvement in Quality of life (QoL). Allergic asthma patients symptomatic on Global Initiative for Asthma (GINA) step 4/5 were found to benefit the most as measured by Asthma Quality of Life Questionnaire (AQLQ). However, the effect of TLA on severe asthma exacerbations is uncertain and therefore a meta-analysis was performed.

Methods: Patients with severe allergic asthma (GINA 4/5) were extracted from two 1-year randomised, double-blind, placebo-controlled trials conducted with TLA. A meta-analysis of the effect on severe exacerbations was performed by negative binomial regression in a sequential manner, defined by baseline markers of asthma control (symptoms and QoL scores).

Results: The pooled dataset included 364patients. Patients with more symptoms at baseline (ACT<18 or ACQ7>3; N=179), had a significant mean 41% reduction in severe exacerbations (RR=0.59 (0.38-0.90); p=0.015) in favour of TLA. Higher ACQ7 cut-points of 3.5-4.5 resulted in significant reductions of 48-59%.More uncontrolled patients based on AQLQ total and symptom domains ≤3.0 at baseline also showed a significant reduction in severe exacerbations for TLA vs. placebo ((47% (p=0.037) and 53% (p=0.011), respectively). The meta-analysis also confirmed a significant difference in AQLQ-responders ((Minimal Clinically Important Difference)≥0.5; 74% vs. 43%, p=0.04).

Conclusion: This meta-analysis of individual patient data shows a beneficial effect on severe exacerbations and quality of life for TLA over placebo in more symptomatic patients with severe allergic asthma. These outcomes support the national management recommendations for patients with symptomatic severe allergic asthma. The actual effect of TLA on severe exacerbations should be confirmed in a prospective study with larger numbers of patients.

Determinants of Clinical COPD Questionnaire in Patients with COPD: A Cross-Sectional Observational Study

BACKGROUND

The Clinical COPD Questionnaire (CCQ) has been suggested by the Global Initiative of Chronic Obstructive Lung Disease (GOLD) as a comprehensive symptom measurement tool, which helps to classify patients in order to direct pharmacological treatment. Therefore, it is essential to understand its determinants.

OBJECTIVES

To identify the determinants of the overall CCQ score and scores of its 3 subdomains among chronic obstructive pulmonary disease (COPD) patients from China.

METHODS

A total of 1,241 COPD patients in the outpatient department of the Second Xiangya Hospital in China were recruited. Basic information and clinical data were collected. Differences in the GOLD categories based on Modified Medical Research Council Dyspnea Scale (mMRC), COPD Assessment Test (CAT), and CCQ were compared. Multiple linear regression analyses were performed to evaluate determinant factors of the total CCQ and subdomain scores.

RESULTS

The total CCQ and/or separate domain scores significantly differed with sex, age, BMI, smoking status, biomass fuel exposure, exacerbation frequency, mMRC, CAT, and GOLD grades and groups. Subjects with asthma-COPD overlap (ACO) had worse health status based on CCQ than those with COPD alone. As for the 16 subgroups based on GOLD 2017, statistical differences in the total CCQ and functional domain scores were found among subgroups 1A-4A, 1B-4B, and 1D-4D. The mMRC classified much more patients into more symptom groups than CAT and CCQ. No significant difference was observed in the GOLD categories between the CAT and CCQ (cut point = 1.5). Multiple linear regression analysis showed that smoking status, underweight, ACO, post-bronchodilator FEV1% predicted <50%, exacerbation history, and mMRC were independently associated with the total CCQ score. Only 3 variables were significantly associated with the symptom domain: ACO, exacerbations, and mMRC; for the functional domain, age ≥75 years, ACO, post-bronchodilator FEV1% predicted <50%, exacerbation history, and mMRC were significant; female sex, underweight, frequent exacerbations (≥2), and mMRC were significantly associated with higher scores in the mental domain.

CONCLUSIONS

The classification of COPD produced by mMRC, CAT, and CCQ was not identical. Smoking status, underweight, ACO, post-bronchodilator FEV1% predicted <50%, exacerbation history, and mMRC were associated with lower health-related quality of life assessed by the total CCQ score, while different subdomains of CCQ had different determinant factors.

Estimating loss in quality of life associated with asthma-related crisis events (ESQUARE): a cohort, observational study

BACKGROUND

Evidence of quality of life implications of asthma attacks are limited, particularly when measured on a utility scale, which enables calculating Quality-Adjusted Life-Years (QALYs) and comparisons with other health conditions and services. Therefore, this study sought to estimate the utility loss associated with an asthma-related crisis event (accident and emergency (A&E) attendance or hospital admission).

METHODS

Participants were recruited in a cohort study from A&E and hospital admissions at three UK hospitals. They completed the EuroQol-5 Dimensions 5-Level (EQ-5D-5 L), Asthma Quality of Life Questionnaire (AQLQ), Time trade-off (TTO), and peak flow and symptom diary over 8 weeks, where three different methods (EQ-5D-5 L, AQLQ, and TTO), were used to estimate utilities. The mean difference between two time points were estimated using the Wilcoxon signed rank test.

RESULTS

From baseline to week 8, mean increases (95% CI) were estimated to be 0.086 (0.019-0.153), 0.154 (0.112-0.196) and 0.132 (0.063-0.201) for EQ-5D-5 L, AQL-5D (preference-based measure derived from AQLQ), and TTO respectively over 8 weeks (p < 0.01).

CONCLUSION

Asthma crisis events are estimated to be associated with a mean utility loss of between 0.086 and 0.132. The utility decrement can be used to assign values to asthma-related crisis events, which can enhance economic evaluations.

TRIAL REGISTRATION

NCT02771678 . Registered 13 May 2016.

Psychometric Properties of the German Version of the Pulmonary-Specific Quality-of-Life Scale in Lung Transplant Patients

The Pulmonary-Specific Quality-of-Life Scale (PQLS) is a validated self-report questionnaire assessing health-related quality of life (HRQoL) in patients with end-stage lung disease awaiting lung transplantation. The aim of our study was to evaluate the psychometric properties of the German version of the PQLS. One hundred and forty patients awaiting lung transplantation (55% men) with a median age of 53 years [Interquartile range (IQR) 13] answered the PQLS. A group of the participants (n = 43) was evaluated again 1 year later after transplantation. A confirmatory factor analysis (CFA) of the PQLS was conducted to test the three-factor structure of the PQLS. We examined the internal consistency of the scales using Cronbach's α. Convergent validity was explored through correlations with generic measures of HRQoL [Short-Form 8 Health Survey (SF-8), 10-item quality of life (QoL) scale], measures of depression (nine-item Patient Health Questionnaire-Depression Scale), anxiety (Generalized Anxiety Scale), and measures of lung disease severity (supplemental oxygen use, stairway steps). In the group of 43 patients assessed before and after transplantation, sensitivity to change was explored. The CFA confirmed the three-factor model with an acceptable fit. The PQLS total and the three subscale scores "task interference," "psychological," and "physical" showed acceptable internal consistency. The PQLS and its subscales showed a significant negative correlation with the 10-item QoL measure and the physical component score of the SF-8, whereas the mental component score of the SF-8 showed a significant negative correlation only with the PQLS subscale "psychological." Negative correlation was found due to the opposed alignment of the PQLS compared to the 10-item QoL and the SF-8. Symptoms of depression and anxiety were significantly and positively correlated with the subscale "psychological." Measures of lung disease severity also exhibited a significant positive correlation with the subscales "task interference" and "physical" but not "psychological." In patients 1 year after a successful transplantation, the PQLS scores were significantly reduced by 50%. The three-factor structure of the PQLS could be replicated using CFA. The results indicate good reliability, validity, and sensitivity to change of the German version of the PQLS.

Health related quality of life and emergency department visits in adults of age ≥ 66 years: a prospective cohort study

Background

Age increases the risk of emergency department [ED] visits. Health related quality of life (HRQoL) is often estimated as an outcome of ED visits, but it can be a risk factor of ED visits. This study aims to assess the association of HRQoL with time to first ED visit and/or frequent ED use in older adults during four-year period and if this association differs in 66–80 and 80+ age groups.

Methods

Data from the Swedish National Study on Aging and Care-Blekinge of wave 2007–2009 was used in combination with electronic health records on ED visits. The analytical sample included 673 participants of age 66 years and older with information on HRQoL. Cox proportional hazard model was used to assess the association between HRQoL and time to first ED visit. Logistic regression analysis was performed to estimate the association of HRQoL with frequent ED use.

Results

During the study period, 55.3% of older adults visited the ED and 28.8% had a frequent ED use. Poor physical HRQoL was independently associated with first ED visit both in total sample (p < 0.001) and in 66–80 (p < 0.001) and 80+ (p = 0.038) age groups. Poor mental HRQoL had no significant association with first ED visit and frequent ED use.

Conclusion

Findings suggest that poor physical HRQoL is associated with time to first ED visit in older adults. Therefore, physical HRQoL should be considered while planning interventions on the reduction of ED utilisation in older adults. Explanatory factors of frequent ED use may differ in age groups. Further studies are needed to identify associated factors of frequent ED visits in 80+ group.

Evaluating the Clinical COPD Questionnaire: A systematic review

The Clinical COPD Questionnaire (CCQ) is recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) to evaluate health status in patients with COPD. The objective of this work was to systemically assess the reliability, validity, responsiveness and minimum clinically important difference (MCID) of the CCQ. A structured search was conducted in three databases to identify articles that evaluated the psychometric properties of the CCQ in individuals with COPD. Two investigators screened the title, abstract and full text of the articles to determine study eligibility and performed the data extraction. Quality assessment of included studies was assessed by the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) checklist. Finally, 43 studies were included, over half of which had fair methodological quality. Internal consistency (reliability) of the CCQ total score ranged from 0.84 to 0.94, and test-retest reliability was 0.70-0.99. The overall CCQ had a better correlation with St George's Respiratory Questionnaire (SGRQ; from 0.71 to 0.88) and COPD Assessment Test (CAT; from 0.64 to 0.88) than modified Medical Research Council (mMRC; from 0.392 to 0.668) and forced expiratory volume in 1 s (FEV₁ % predicted; from -0.31 to -0.68). Scores were different within GOLD stages, groups, composite events and co-morbidities. CCQ was sensitive to exacerbations, pulmonary rehabilitation and smoking cessation with the MCID of 0.4. The CCQ is a very useful and practical tool that can be used in clinical populations with good reliability, validity and responsiveness to interventions.

Health Status of Patients with Moderate to Severe COPD after Treatment with Nebulized Arformoterol Tartrate or Placebo for 1 Year

PURPOSE

Chronic obstructive pulmonary disease (COPD) is a progressive disease that impairs both objectively measured lung function and patient-reported health status. In a randomized clinical trial of patients with moderate to severe COPD, we compared changes in health status after adding arformoterol tartrate or placebo to patients' treatment regimens.

METHODS

In this multicenter, double-blind trial, patients were randomized to receive nebulized arformoterol 15 µg BID (n = 420) or matched placebo (n = 421). Treatment with other COPD medications was permitted, except for long-acting β₂-agonists. Inclusion criteria were a forced expiratory volume in 1 second (FEV₁) ≤65% of predicted, FEV₁ >0.50 L, age ≥40 years, smoking history ≥15 pack-years, and a baseline breathlessness severity grade ≥2. The Clinical COPD Questionnaire (CCQ) was used to measure health status at randomization and at months 3, 6, and 12. CCQ scores range from 0 to 6, with higher scores indicating worse health status, and a decrease from baseline in total score by 0.4 point is considered clinically significant. Outcomes were analyzed by using mixed models for repeated measures.

FINDINGS

At baseline, patients' mean age was 63.8 years; 42.9% of patients were female, and 51.4% were current smokers. The mean baseline CCQ total scores were 2.88 and 2.91 for the arformoterol and placebo groups, respectively. A total of 841 patients were randomized to receive either arformoterol (n = 420) or placebo (n = 421); among them, 211 (50.1%) who received placebo and 255 (60.7%) who received arformoterol completed the trial. Arformoterol-treated patients had greater mean improvement from baseline in CCQ total score (-0.18 vs 0.02; P = 0.001), symptoms (-0.21 vs 0.01; P = 0.002), functional state (-0.15 vs 0.02; P = 0.018), and mental state (-0.18 vs 0.02; P = 0.023) than patients receiving placebo. At study end, 38.3% of the arformoterol-treated patients and 30.8% of patients receiving placebo reported clinically significant improvements on the CCQ (P = 0.026). These improvements were only modestly correlated with improvements in FEV₁ (r = -0.15; P < 0.01).

IMPLICATIONS

In this 52-week trial, arformoterol-treated patients had greater improvements in health status than patients receiving placebo. Assessing health status along with lung function seems to provide additional information regarding the effectiveness of COPD maintenance treatments. ClinicalTrials.gov identifier: NCT00909779.

The evaluation of a remote support program on quality of life and evolution of disease in COPD patients with frequent exacerbations

Background

Chronic obstructive pulmonary disease (COPD) patients often present considerable individual medical burden in their symptoms, limitations, and well-being that complicate medical treatment. To improve their overall health status, while reducing the number of exacerbations, a multidisciplinary approach including different elements of care is needed. The aim of this study was to evaluate the effects of a remote support program on COPD patients at high risk of experiencing worsening of their disease and other health-related outcomes.

Methods

An observational, multicenter, prospective study aimed at evaluating the impact of a 7-month remote support program on COPD patients in exacerbations control and changes in health status measured with the COPD assessment test (CAT). Factors associated with a clinically relevant decrease in CAT were assessed using a logistic regression analysis.

Results

A total of 114 subjects started the program. The majority of the study population were males (81.6 %), retired (70.2 %), without academic qualifications or with a low level of education (68.4 %), and ex-smokers (79.8 %). The mean ± SD age was 69.6 ± 9.1 years and the BMI was 27.8 ± 5.5 Kg/m². Overall, 41.9 % (95 % CI 31.9–52.0) patients, significantly improved health status (CAT decrease ≥ 2 points). Univariate analysis showed that significant improvement in CAT was associated with baseline CAT scores [high CAT score 19.2 (±7.5) vs. low CAT score 12.4 (±6.4); OR = 1.15, 95 % CI: 1.07–1.24; p < 0.001] and with being non-compliant [62.5 % (15/24) of non-compliant vs 34.7 % (24/69) of compliant patients significantly improved CAT scores; OR = 3.13, 95 % CI: 1.19–8.19; p = 0.021). After controlling for the effect of all variables in a multivariable logistic regression model, the only factor that remained significant was baseline CAT score. The proportion of smokers in the total population remained constant during the study. There was a significant reduction in the number of exacerbations after entering this remote support program with median -1 (IQR: -2, 0), (p < 0.001). The Morisky-Green questionnaire showed an increase of treatment compliance, namely at baseline, 25.8 % (24/93) of patients were noncompliant while in the end 66.7 % (16/24) of them became compliant) (p = 0.053).

Conclusions

A remote support program for high-risk COPD patients results in an improvement of the patients’ health status, particularly in those with initially poor health status, and it helps to reduce COPD exacerbations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0304-3) contains supplementary material, which is available to authorized users.

Looking beyond patients: Can parents' quality of life predict asthma control in children?

BACKGROUND

Social and family factors may influence the probability of achieving asthma control in children. Parents' quality of life has been insufficiently explored as a predictive factor linked to the probability of achieving disease control in asthmatic children.

OBJECTIVE

Determine whether the parents' quality of life predicts medium-term asthma control in children.

METHODS

Longitudinal study of children between 4 and 14 years of age, with active asthma. The parents' quality of life was evaluated using the specific IFABI-R instrument, in which scores were higher for poorer quality of life. Its association with asthma control measures in the child 16 weeks later was analyzed using multivariate methods, adjusting the effect for disease, child and family factors.

RESULTS

The data from 452 children were analyzed (median age 9.6 years, 63.3% males). The parents' quality of life was predictive for asthma control; each point increase on the initial IFABI-R score was associated with an adjusted odds ratio (95% confidence interval) of 0.56 (0.37-0.86) for good control of asthma on the second visit, 2.58 (1.62-4.12) for asthma exacerbation, 2.12 (1.33-3.38) for an unscheduled visit to the doctor, and 2.46 (1.18-5.13) for going to the emergency room. The highest quartile for the IFABI-R score had a sensitivity of 34.5% and a specificity of 82.2% to predict poorly controlled asthma.

CONCLUSIONS

Parents' poorer quality of life is related to poor, medium-term asthma control in children. Assessing the parents' quality of life could aid disease management decisions. Pediatr Pulmonol. 2016;51:670-677. © 2015 Wiley Periodicals, Inc.

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.

The chronic obstructive pulmonary disease assessment test improves the predictive value of previous exacerbations for poor outcomes in COPD

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) exacerbations have a negative impact on the quality of life of patients and the evolution of the disease. We have investigated the prognostic value of several health-related quality of life questionnaires to predict the appearance of a composite event (new ambulatory or emergency exacerbation, hospitalization, or death) over a 1-year follow-up.

METHODS

This was a multicenter, prospective, observational study. Patients completed four questionnaires after recovering from an exacerbation (COPD Assessment Test [CAT], a Clinical COPD Questionnaire [CCQ], COPD Severity Score [COPDSS], and Airways Questionnaire [AQ20]). Patients were followed-up until the appearance of the composite event or for 1 year, whichever came first.

RESULTS

A total of 497 patients were included in the study. The majority of them were men (89.7%), with a mean age of 68.7 (SD 9.2) years, and a forced expiratory volume in 1 second of 47.1% (SD 17.5%). A total of 303 (61%) patients experienced a composite event. Patients with an event had worse mean scores of all questionnaires at baseline compared to patients without event: CAT=12.5 vs 11.3 (P=0.028); CCQ=2.2 vs 1.9 (P=0.013); COPDSS=12.3 vs 10.9 (P=0.001); AQ20=8.3 vs 7.5 (P=0.048). In the multivariate analysis, only previous history of exacerbations and CAT score ≥13.5 were significant risk factors for the composite event. A CAT score ≥13.5 increased the predictive value of previous exacerbations with an area under the receiver operating characteristic curve of 0.864 (95% CI: 0.829-0.899; P=0.001).

CONCLUSION

The predictive value of previous exacerbations significantly increased only in one of the four trialled questionnaires, namely in the CAT questionnaire. However, previous history of exacerbations was the strongest predictor of the composite event.

Validation of the Japanese version of HFS-14, a disease-specific quality of life scale for patients suffering from hand-foot syndrome

PURPOSE

The purpose of this study was to develop a Japanese version of hand-foot syndrome (HFS)-specific quality of life (QOL) questionnaire (HFS-14) to evaluate and monitor the QOL of patients with a possibility of HFS.

METHODS

The original English version of HFS-14 was translated and slightly modified into Japanese, and the Japanese HFS-14 was administered to 187 patients receiving chemotherapy with high risk of developing HFS as outpatients in four institutions in Japan. Factor validity, internal consistency, correlation with the Skindex-16 and Dermatology Life Quality Index (DLQI) scores, known group validity, and test-retest reliability were analyzed for 105 patients who developed HFS. Next, we compared HFS-14 with DLQI and Skindex-16.

RESULTS

Factor analysis confirmed the factor structure (one putative scale) of the Japanese HFS-14. Cronbach's alpha was over 0.90. The Japanese HFS-14 score was correlated with the Skindex-16 and DLQI score. Intra-class correlation coefficients were over 0.80. Patients with severe HFS reported significantly poorer HFS-14 score than those with mild HFS. The Skindex-16 and DLQI scores were also significantly different in patients with different Common Terminology Criteria for Adverse Events (CTCAE) grades, but with smaller effect sizes than those for the HFS-14 score.

CONCLUSIONS

The Japanese HFS-14 provides a valid and reliable score for monitoring and evaluating HFS.

Patient-reported outcome measures in inflammatory bowel disease

Patient-reported outcome measures (PROMs) are increasingly used in both research and clinical health settings. With the recent development of United States Food and Drug Administration guidance on PROMs, more attention is being devoted to their role and importance in health care. Several methodological challenges in the development, validation and implementation of PROMs must be resolved to ensure their appropriate utilization and interpretation. The present review discusses recent developments and updates in PROMs, with specific focus on the area of inflammatory bowel disease.

Co-morbidities are the key nominators of the health related quality of life in mild and moderate COPD

Background

Co-morbidities are common in chronic obstructive pulmonary disease (COPD). We assessed the contribution of common co-morbidities on health related quality of life (HRQoL) among COPD patients.

Methods

Using both generic (15D) and respiratory-specific (AQ20) instruments, HRQoL was assessed in a hospital based COPD population (N = 739, 64% males, mean age 64 years, SD 7 years) in this observational study with inferential analysis. The prevalence of their co-morbidities was compared with those of 5000 population controls. The patients represented all severity stages of COPD and the patterns of common concomitant disorders differed between patients.

Results

Co-morbidities such as psychiatric conditions, alcohol abuse, cardiovascular diseases, and diabetes were more common among COPD patients than in age and gender matched controls. Psychiatric conditions and alcohol abuse were the strongest determinants of HRQoL in COPD and could be detected by both 15D (Odds Ratio 4.7 and 2.3 respectively) and AQ20 (OR 2.0 and 3.0) instruments. Compared to respiratory specific AQ20, generic 15D was more sensitive to the effects of comorbidities while AQ20 was slightly more sensitive for the low FEV₁. FEV₁ was a strong determinant of HRQoL only at more severe stages of disease (FEV₁ < 40% of predicted). Poor HRQoL also predicted death during the next five years.

Conclusions

The results suggest that co-morbidities may impair HRQoL at an early stage of the disease, while bronchial obstruction becomes a significant determinant of HRQoL only in severe COPD.

The influence of hospitalizations due to exacerbations or spontaneous pneumothoraxes on the quality of life, mental function and symptoms of depression and anxiety in patients with COPD or asthma

BACKGROUND

Patients with bronchial asthma or chronic obstructive pulmonary disease (COPD) frequently have a low quality of life (QoL) in addition to depression symptoms. The aim of this study was to compare the QoL, depression symptoms, mental function and anxiety in patients with asthma or COPD exacerbations or spontaneous pneumothoraxes (SP) to patients with stable disease.

MATERIALS AND METHODS

Patients with a confirmed diagnosis of severe (III degree) bronchial asthma or COPD were included in this study. Prospective observations of asthma or COPD exacerbations or SP were performed over a three-year period. QoL was assessed using St. George's Respiratory Questionnaire (SGRQ). In addition, the AQ20 questionnaire (AQ20), the Hospital Anxiety and Depression Scale (HADS) and the Mini-Mental State Examination (MMSE) were administered.

RESULTS

A total of 233 patients (112 with asthma and 121 with COPD; mean age 57.9 ± 11.9 years) were included in the study. Patients with COPD or asthma had a low QoL as estimated by the SGRQ (mean ± SD: 27.5 ± 12.9 and 25.1 ± 10.2 for asthma and COPD, respectively). Asthma exacerbations, COPD exacerbations or SP requiring hospitalization were associated with lower SGRQ scores over the three-year observation period (41.5 ± 11.7, 57.9 ± 14.3 and 65.3 ± 11.4, respectively). The mean MMSE score significantly decreased after an asthma exacerbation compared to the baseline (29.9 ± 2.1 versus 27.2 ± 3.1; p < 0.05). The mean MMSE score decreased after COPD exacerbations (28.5 ± 0.9 versus 26.9 ± 1.2; p < 0.05) and after COPD with an SP event (28.8 ± 1.2 versus 24.1 ± 2.2; p < 0.05).

CONCLUSION

Low QoL and mental impairment were observed in patients with asthma and COPD. In addition, the QoL significantly decreased following hospitalizations due to exacerbations or SP.