Health-related quality of life and mortality in male patients with chronic obstructive pulmonary disease

[Budesonide/formoterol in the treatment of COPD]

Two large, 12-month clinical trials have been performed with budesonide-formoterol in patients with stable COPD and have shown clear data on the efficacy of this combination in improving pulmonary function, symptoms and health-related quality of life and in reducing the number of exacerbations. Before these trials, information was already available on the efficacy of both monocomponents in this disease, although the main clinical data obtained with formoterol and budesonide separately in the treatment of COPD come from the respective branches of these drugs in the two large clinical trials described in the present article. Improvement in pulmonary function variables [forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and peak expiratory flow (PEF)] was always greater with the combination of budesonide-formoterol. The scores obtained in quality of life questionnaires were also more favorable in the combination treatment branches as early as the first week of treatment and persisted at 12 months of follow-up. Improvement in symptoms and in the use of reliever medication was also greater in the combination branch. The frequency of mild and severe exacerbations, as well as the use of oral corticosteroids, was lower in the budesonide-formoterol branch. The time to first exacerbation was also more prolonged in this group. The present review discusses the main findings on the efficacy of the combination of budesonide-formoterol in stable COPD.

Factors affecting the relationship between psychological status and quality of life in COPD patients

BACKGROUND

This study aims to (i) evaluate the association between anxiety and depressive symptoms and health-related quality of life (HRQoL); and (ii) identify the effect modifiers of this relationship in patients with chronic obstructive pulmonary disease (COPD).

METHODS

A total of 337 clinically stable COPD patients answered the St. George's Respiratory Questionnaire (SGRQ) (assessing HRQoL) and the Hospital Anxiety and Depression Scale (HADS). Socio-demographic information, lung function, and other clinical data were collected.

RESULTS

Most patients (93%) were male; they had a mean (SD) age of 68 (9) years and mild to very severe COPD (post-bronchodilator FEV1 52 (16)% predicted). Multivariate analyses showed that anxiety, depression, or both conditions were associated with poor HRQoL (for all SGRQ domains). The association between anxiety and total HRQoL score was 6.7 points higher (indicating a worse HRQoL) in current workers than in retired individuals. Estimates for patients with "both anxiety and depression" were 5.8 points lower in stage I-II than in stage III-IV COPD, and 10.2 points higher in patients with other comorbidities than in those with only COPD.

CONCLUSIONS

This study shows a significant association between anxiety, depression, or both conditions and impaired HRQoL. Clinically relevant factors affecting the magnitude of this association include work status, COPD severity, and the presence of comorbidities.

Associations between mortality, asthma, and health-related quality of life in an elderly cohort of Swedes

BACKGROUND

Asthma is a common chronic health condition among the elderly and an important cause of morbidity and mortality. Some studies show that subjective assessments of health-related quality of life (HRQL) are important predictors of mortality and survival. The primary aim of this study was to investigate whether low HRQL was a predictor of mortality in elderly subjects and whether such an association differed between subjects with and without asthma.

METHODS

In 1990, a cohort in middle Sweden was investigated using a respiratory questionnaire. To assess HRQL, the generic instrument Gothenburg Quality of Life (GQL) was used. The participants were also investigated by spirometry and allergy testing. The present study was limited to the subjects in the oldest age group, aged 60-69 years in 1990, and included 222 subjects with clinically verified asthma, 148 subjects with respiratory symptoms but no asthma or other lung diseases, and 102 subjects with no respiratory symptoms. Mortality in the cohort was followed during 1990-2008.

RESULTS

Altogether, 166 of the 472 subjects in the original cohort had died during the follow-up period of 1990-2008. Mortality was significantly higher in men, in older subjects, in smokers, and subjects with a low forced expiratory volume in one second (FEV(1)). There was, however, no difference in mortality between the asthmatic and the nonasthmatic groups. A higher symptoms score for GQL was significantly related to increased mortality. No association between HRQL and mortality was found when limiting the analysis to the asthmatic group, although the asthmatics had a lower symptom score for GQL compared to the other groups.

CONCLUSION

A higher symptom score in the GQL instrument was significantly related to increased mortality, but this association was not found when analyzing the asthmatic group alone. The negative prognostic implications of a low HRQL in the whole group and the fact that the asthmatic group had a lower HRQL than the other group supports the use of HRQL instruments in clinical health assessments.

BODE-Index vs HADO-score in chronic obstructive pulmonary disease: Which one to use in general practice?

BACKGROUND

Forced expiratory volume in one second (FEV1) is used to diagnose and establish a prognosis in chronic obstructive pulmonary disease (COPD). Using multi-dimensional scores improves this predictive capacity.Two instruments, the BODE-index (Body mass index, Obstruction, Dyspnea, Exercise capacity) and the HADO-score (Health, Activity, Dyspnea, Obstruction), were compared in the prediction of mortality among COPD patients.

METHODS

This is a prospective longitudinal study. During one year (2003 to 2004), 543 consecutively COPD patients were recruited in five outpatient clinics and followed for three years. The endpoints were all-causes and respiratory mortality.

RESULTS

In the multivariate analysis of patients with FEV1 < 50%, no significant differences were observed in all-cause or respiratory mortality across HADO categories, while significant differences were observed between patients with a lower BODE (less severe disease) and those with a higher BODE (greater severity). Among patients with FEV1 > or = 50%, statistically significant differences were observed across HADO categories for all-cause and respiratory mortality, while differences were observed across BODE categories only in all-cause mortality.

CONCLUSIONS

HADO-score and BODE-index were good predictors of all-cause and respiratory mortality in the entire cohort. In patients with severe COPD (FEV1 < 50%) the BODE index was a better predictor of mortality whereas in patients with mild or moderate COPD (FEV1 > or = 50%), the HADO-score was as good a predictor of respiratory mortality as the BODE-index. These differences suggest that the HADO-score and BODE-index could be used for different patient populations and at different healthcare levels, but can be used complementarily.

Health-related quality of life and survival in liver transplant candidates

Health-related quality of life (HRQOL) is an important measure of the effects of chronic liver disease in affected patients that helps guide interventions to improve well-being. However, the relationship between HRQOL and survival in liver transplant candidates remains unclear. We examined whether the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the Short Form 36 (SF-36) Health Survey were associated with survival in liver transplant candidates. We administered the SF-36 questionnaire (version 2.0) to patients in the Pulmonary Vascular Complications of Liver Disease study, a multicenter prospective cohort of patients evaluated for liver transplantation in 7 academic centers in the United States between 2003 and 2006. Cox proportional hazards models were used with death as the primary outcome and adjustment for liver transplantation as a time-varying covariate. The mean age of the 252 participants was 54 +/- 10 years, 64% were male, and 94% were white. During the 422 person years of follow-up, 147 patients (58%) were listed, 75 patients (30%) underwent transplantation, 49 patients (19%) died, and 3 patients were lost to follow-up. Lower baseline PCS scores were associated with an increased mortality rate despite adjustments for age, gender, Model for End-Stage Liver Disease score, and liver transplantation (P for the trend = 0.0001). The MCS score was not associated with mortality (P for the trend = 0.53). In conclusion, PCS significantly predicts survival in liver transplant candidates, and interventions directed toward improving the physical status may be helpful in improving outcomes in liver transplant candidates.

Bronchodilatory effects of aclidinium bromide, a long-acting muscarinic antagonist, in COPD patients

BACKGROUND

Aclidinium bromide is a novel, long-acting, inhaled muscarinic antagonist bronchodilator currently in Phase III clinical development for the treatment of chronic obstructive pulmonary disease (COPD). This study evaluated the pharmacodynamics, pharmacokinetics, safety and tolerability of ascending doses of aclidinium bromide in patients with COPD.

METHODS

This double-blind, randomised, placebo-controlled, crossover study was conducted in patients with moderate to severe COPD (forced expiratory volume in 1s [FEV(1)] <65% predicted). Patients were randomly assigned to one of four treatment sequences of aclidinium bromide 100, 300, 900microg and placebo with a washout period between doses. The primary outcome was area under the FEV(1) curve over the 0-24h time interval.

RESULTS

Seventeen patients with COPD were studied. Mean FEV(1) over 24h was 1.583L for placebo, and 1.727L, 1.793L and 1.815L for aclidinium bromide 100, 300 and 900microg, respectively (p<0.001 vs. placebo, all doses). Significant changes from baseline in FEV(1) were detected 15min post-dose for aclidinium bromide 300 and 900microg, with a peak effect 2h post-dose (all doses). Aclidinium bromide was undetected in plasma. The majority of adverse events was unrelated to study medication and did not result in discontinuation.

CONCLUSION

Aclidinium bromide 100-900microg produced sustained bronchodilation over 24h in patients with COPD.

Tiotropium HandiHaler in the treatment of COPD: a safety review

Background

Tiotropium is a long-acting inhaled anticholinergic developed for the treatment of chronic obstructive pulmonary disease (COPD) and has been available since 2002. We sought to update an evaluation of the safety of tiotropium in the HandiHaler^® formulation as significant clinical trial data have become available over time.

Methods

Pooled analysis of adverse event reporting from phase III and IV tiotropium HandiHaler^® clinical trials with the following characteristics was performed: randomized, double-blind, parallel group, placebo-controlled design, tiotropium 18 μg once-daily dosing, COPD indication, duration of at least four weeks. Incidence rates by treatment group, rate differences (tiotropium–placebo), and 95% confidence intervals were determined.

Results

Twenty-six trials were identified involving 17,014 patients. Mean age was 65 years, mean forced expiratory volume in one second was 1.16 L (41% predicted), 76% men. Total exposure to study drug was 11,958 patient-years (tiotropium) and 10,578 patient-years (placebo). Tiotropium was associated with a reduced risk (expressed as rate difference [95% confidence interval] per 100 patients-years at risk) for an adverse event (−17.5 [−22.9, −12.2]), serious adverse event (−1.41 [−2.81, −0.00]) and a fatal event (−0.63 [−1.14, −0.12]). A reduced risk was present for adverse events that were cardiac (−0.79 [−1.48, −0.09]), lower respiratory (−14.2 [−17.0, −11.5]) and for a composite endpoint of major adverse cardiovascular events (−0.45 [−0.85, −0.05]). Typical expected inhaled anticholinergic effects such as dry mouth, constipation, and urinary difficulties were observed in the safety database.

Conclusion

The safety data review does not indicate an increased risk for death or cardiovascular morbidity during tiotropium treatment in patients with COPD.

Comparative study of two quality of life questionnaires in patients with COPD

OBJECTIVE

To compare two quality of life questionnaires-the Saint George's Respiratory Questionnaire (SGRQ) and the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36)-in patients with COPD, focusing on the discriminative properties of the questionnaires and correlating their domains with the following variables: Modified Medical Research Council Dyspnea Scale score; Beck Depression Inventory score; visual analog scale general health perception; Mini-Mental State Examination score; and a COPD clinical score developed specifically for the study.

METHODS

We interviewed 30 COPD patients between May and September of 2006. For the SF-36 and SGRQ, scores (total and domain) were compared and correlated.

RESULTS

With the exception of the pain domain, all of the SF-36 domains correlated significantly with the SGRQ total score (r = -0.5 to -0.69; p < 0.01). Of the SGQR domains, only the symptoms domain correlated significantly with all of the variables studied (p < 0.05).

CONCLUSIONS

The majority of the expected correlations between the SGRQ and the SF-36 were observed, as were those expected between the two questionnaires and the other variables studied. The SGRQ, notably the symptoms domain, presented better discriminative properties than did the generic SF-36 questionnaire. The SF-36 is not an appropriate instrument for determining the affective state of COPD patients.

St. George's Respiratory Questionnaire: MCID

The SGRQ is a disease-specific measure of health status for use in COPD. A number of methods have been used for estimating its minimum clinically important difference (MCID). These include both expert and patient preference-based estimates. Anchor-based methods have also been used. The calculated MCID from those studies was consistently around 4 units, regardless of assessment method. By contrast, the MCID calculated using distribution-based methods varied across studies and permitted no consistent estimate. All measurements of clinical significance contain sample and measurement error. They also require value judgements, if not about the calculation of the MCID itself then about the anchors used to estimate it. Under these circumstances, greater weight should be placed upon the overall body of evidence for an MCID, rather than one single method. For that reason, estimates of MCID should be used as indicative values. Methods of analysing clinical trial results should reflect this, and use appropriate statistical tests for comparison with the MCID. Treatments for COPD that produced an improvement in SGRQ of the order of 4 units in clinical trials have subsequently found wide acceptance once in clinical practice, so it seems reasonable to expect any new treatment proposed for COPD to produce an advantage over placebo that is not significantly inferior to a 4-unit difference.

Integrating health status and survival data: the palliative effect of lung volume reduction surgery

RATIONALE

In studies that address health-related quality of life (QoL) and survival, subjects who die are usually censored from QoL assessments. This practice tends to inflate the apparent benefits of interventions with a high risk of mortality. Assessing a composite QoL-death outcome is a potential solution to this problem.

OBJECTIVES

To determine the effect of lung volume reduction surgery (LVRS) on a composite endpoint consisting of the occurrence of death or a clinically meaningful decline in QoL defined as an increase of at least eight points in the St. George's Respiratory Questionnaire total score from the National Emphysema Treatment Trial.

METHODS

In patients with chronic obstructive pulmonary disease and emphysema randomized to receive medical treatment (n = 610) or LVRS (n = 608), we analyzed the survival to the composite endpoint, the hazard functions and constructed prediction models of the slope of QoL decline.

MEASUREMENTS AND MAIN RESULTS

The time to the composite endpoint was longer in the LVRS group (2 years) than the medical treatment group (1 year) (P < 0.0001). It was even longer in the subsets of patients undergoing LVRS without a high risk for perioperative death and with upper-lobe-predominant emphysema. The hazard for the composite event significantly favored the LVRS group, although it was most significant in patients with predominantly upper-lobe emphysema. The beneficial impact of LVRS on QoL decline was most significant during the 2 years after LVRS.

CONCLUSIONS

LVRS has a significant effect on the composite QoL-survival endpoint tested, indicating its meaningful palliative role, particularly in patients with upper-lobe-predominant emphysema.

Defining disease modification in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a debilitating condition characterized by airflow limitation that is not fully reversible. It is a major cause of morbidity and mortality and represents substantial economic and social burden throughout the world. A range of interventions has been developed that decrease symptoms and address complications associated with COPD. However, to date few interventions have been unequivocally demonstrated to modify disease progression. Assessment of the potential for interventions to modify disease progression is complicated by the lack of a clear definition of disease modification and disagreement over appropriate markers by which modification should be evaluated. To clarify these issues, a working group of physicians and scientists from the USA, Canada and Europe was convened. The proposed working definition of disease modification resulting from the group discussions was "an improvement in, or stabilization of, structural or functional parameters as a result of reduction in the rate of progression of these parameters which occurs whilst an intervention is applied and may persist even if the intervention is withdrawn". According to this definition, pharmacologic interventions may be considered disease-modifying if they provide consistent and sustained improvements in structural and functional parameters. Smoking cessation and lung volume reduction surgery would both qualify as disease-modifying interventions.

Health status and the spiral of decline

COPD is complex and there are multiple determinants of poor health, so most studies of Chronic Obstructive Pulmonary Disease (COPD) now include health status, or health related quality of life measurement, along with FEV(1) as a primary endpoint. It is important to make a distinction between quality of life-which is unique to the individual, and health status measurement-which is standardized quantification of the impact of disease. Health status scores correlate weakly with FEV(1) but they are predictors of mortality independently of age and FEV(1). The determinants of impaired health status may change over time and the clinical consequences associated with a given change in score may change with disease progression. The largest study to date suggests that health status decline is linear over time, but longer-term studies are needed to confirm these findings. Inhaled corticosteroids have been shown to reduce the rate of decline of health status, possibly due to exacerbation prevention.

Health-related quality of life in outpatient women with COPD in daily practice: the MUVICE Spanish study

AIMS

A cross-sectional multicenter study was designed to assess health-related quality of life (HRQL) in women with chronic obstructive pulmonary disease (COPD) who were attended in the outpatient setting in actual conditions of the daily practice.

METHODS

A total of 1786 women with COPD (mean age of 66.5 years) and 1661 pairs of men and women matched by age and COPD severity participated in a cross-sectional study. HRQL was measured with the Short Form 12 Health Survey Questionnaire (SF-12).

RESULTS

The mean PCS-12 and MCS-12 scores were 36.5+/-10.3 and 44.1+/-11.8, respectively. General health and physical functioning domains were those with the lowest scores, whereas role emotional and social functioning were those with the highest scores. The percentage of women with low HRQL increased according to age, whereas the percentage of women with high or normal HRQL decreased significantly. In relation to COPD severity, more women rated HRQL as low in the physical component than in the mental component. HRQL correlated significantly with FEV(1) in both PCS-12 and MCS-12 scales. As expected, an inverse significant correlation between HRQL and degree of dyspnea in the PCS-12 and the MCS-12 scales was observed. Women had also a significantly worse HRQL than men in all physical and mental domains.

CONCLUSIONS

In outpatient women with COPD, HRQL was impaired especially the physical component of the SF-12. For the same age and severity of COPD, women showed significantly lower scores in all physical and mental domains of the SF-12 than men.

[Causes of death and risk factors for mortality in patients with severe chronic obstructive pulmonary disease]

OBJECTIVE

The objective of this study was to assess the causes of death and risk factors for mortality in a cohort of patients with severe chronic obstructive pulmonary disease (COPD).

PATIENTS AND METHODS

We studied 203 patients with severe COPD (forced expiratory volume in 1 second [FEV(1)] <50%), who were attended in our respiratory department day hospital (2001-2006). Clinical variables were recorded on inclusion, and clinical course and causes of death were retrospectively reviewed.

RESULTS

The mean (SD) age of patients was 69 (8) years and the mean FEV(1) was 30.8% (8.2%). One-hundred and nine patients died (53.7%); death was attributed to respiratory causes in 72 (80.9%), with COPD exacerbation being the most frequent specific cause within this category (48.3%). During follow-up, 18.7% required admission to the intensive care unit (ICU). Survival at 1, 3, and 5 years was 80%, 53%, and 26%, respectively. The multivariate analysis showed that mortality was associated with age, stage IV classification according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), cor pulmonale, and hospital admission during the year prior to inclusion. Need for admission to the ICU during follow-up was a factor independently associated with higher mortality.

CONCLUSIONS

Mortality in patients with severe COPD was high and exacerbation of the disease was one of the most frequent causes of death. Age, GOLD stage, cor pulmonale, prior admission to hospital, and need for admission to the ICU during follow-up were independent predictors of mortality.

Tiotropium and exercise training in COPD patients: effects on dyspnea and exercise tolerance

BACKGROUND

Exercise training improves exercise tolerance in chronic obstructive pulmonary disease (COPD). Tiotropium 18 microg once daily induces sustained bronchodilation throughout the day and reduces hyperinflation, one of the pathophysiological factors contributing to exertional dyspnea in COPD patients.

AIM

To determine whether tiotropium enhances the effects of exercise training in patients with COPD.

DESIGN

Multicenter, 25 week randomized, double-blind, placebo-controlled, parallel-group study.

SETTING

Twelve Italian Pulmonary Units practicing pulmonary rehabilitation.

PATIENTS AND INTERVENTION

Two hundred thirty four COPD patients (196 males; mean age: 67.4 +/- 7.6; forced expiratory volume at 1 second (FEV1): 41.4 +/- 13.0% predicted) were randomised to tiotropium 18 microg or placebo inhalation capsules taken once daily. Both groups underwent a 8 week pulmonary rehabilitation program (PR) consisting of 3 exercise training session per week.

MEASUREMENTS

Baseline, at the end of PR and after 12 weeks, patients completed pulmonary function testing, six minute walking test (6MWT), the Baseline and Transition Dyspnea Index (BDI and TDI), and the St. George's Respiratory Questionnaire (SGRQ).

RESULTS

Relative to placebo, tiotropium had larger trough and post-study drug FEV1 responses on all test days. At the end of and 12 weeks following PR, patients on tiotropium showed no statistically significant differences in 6MWT compared to patients on placebo. Compared to the period immediately prior to PR, the mean improvement in 6MWT was only 29.7 meters (7.1%) for the combined cohort. Mean TDI focal scores at the end of PR were 3.60 for tiotropium and 2.25 for placebo (p < 0.01). At 12 weeks after PR, TDI focal scores were 2.71 for tiotropium and 2.11 for placebo (p = 0.16). Reduction in all four SGRQ component scores, indicating an improvement in health-related quality of life, was observed for the tiotropium group over the duration of the study compared to placebo but the differences were not statistically significant. During the study period, there were fewer exacerbations and exacerbation days in the tiotropium group.

CONCLUSION

Although significant improvements were observed with perceived dyspnea, compared to placebo, the addition of tiotropium to pulmonary rehabilitation did not improve the 6MWT.

Health-related quality of life in outpatients with COPD in daily practice: the VICE Spanish Study

BACKGROUND

The objective of this study was to measure health-related quality of life (HRQL) in outpatients with chronic obstructive pulmonary disease (COPD) and to assess differences in HRQL according to age, gender, and severity of COPD.

METHODS

A total of 9405 patients (79% men, mean age 68 years) participated in a cross-sectional study. HRQL was measured with the Short Form 12 Health Survey Questionnaire (SF-12). Severity of COPD was graded into three levels according to forced expiratory volume in one second value.

RESULTS

COPD severity was mild in 33.8% of cases, moderate in 49.3% and severe in 16.8%. The mean physical component summary (PCS-12) and mental component summary (MCS-12) scores were 36.8 +/- 10.4 and 47.2 +/- 11.2, respectively. General health and physical functioning domains were those with the lowest scores. The mean MCS-12 scores were significantly higher in men (47.9 +/- 10.9) than in women (44.1 +/- 11.8) (P < 0.001). Patients older than 60 years rated HRQL worse than patients aged 40-59 years. There were statistically significant differences according to severity of disease in the mean scores of all domains of the PCS-12 and MCS-12 scales.

CONCLUSIONS

The present findings show the influence of female gender, older age and moderate-to-severe of airflow limitation on HRQL in outpatients with COPD attended in daily practice.

Validation of the clinical COPD Questionnaire (CCQ) in primary care

BACKGROUND

Patient centred outcomes, such as health status, are important in Chronic Obstructive Pulmonary Disease (COPD). Extensive questionnaires on health status have good measurement properties, but are not suitable for use in primary care. The newly developed, short Clinical COPD Questionnaire, CCQ, was therefore validated against the St George's Respiratory Questionnaire (SGRQ).

METHODS

111 patients diagnosed by general practitioners as having COPD completed the questionnaires twice, 2-3 months apart, without systematic changes in treatment. Within this sample of patients with "clinical COPD" a subgroup of patients with spirometry verified COPD was identified. All analyses was performed on both groups.

RESULTS

The mean FEV1 (% predicted) was 58.1% for all patients with clinical COPD and 52.4% in the group with verified COPD (n = 83). Overall correlations between SGRQ and CCQ were strong for all patients with clinical COPD (0.84) and the verified COPD subgroup (0.82). The concordance intra-class correlation between SGRQ and CCQ was 0.91 (p < 0.05). Correlations between CCQ and SGRQ were moderate to good, regardless of COPD severity.

CONCLUSION

The CCQ is a valid and reliable instrument for assessments of health status on the group level in patients treated for COPD in primary care but its reliability may not be sufficient for the monitoring of individual patients.

[Phenotypic heterogeneity of chronic obstructive pulmonary disease]

A functional definition of chronic obstructive pulmonary disease (COPD) based on airflow limitation has largely dominated the field. However, a view has emerged that COPD involves a complex array of cellular, organic, functional, and clinical events, with a growing interest in disentangling the phenotypic heterogeneity of COPD. The present review is based on the opinion of the authors, who have extensive research experience in several aspects of COPD. The starting assumption of the review is that current knowledge on the pathophysiology and clinical features of COPD allows us to classify phenotypic information in terms of the following dimensions: respiratory symptoms and health status, acute exacerbations, lung function, structural changes, local and systemic inflammation, and systemic effects. Twenty-six phenotypic traits were identified and assigned to one of the 6 dimensions. For each dimension, a summary is provided of the best evidence on the relationships among phenotypic traits, in particular among those corresponding to different dimensions, and on the relationship between these traits and relevant events in the natural history of COPD. The information has been organized graphically into a phenotypic matrix where each cell representing a pair of phenotypic traits is linked to relevant references. The information provided has the potential to increase our understanding of the heterogeneity of COPD phenotypes and help us plan future studies on aspects that are as yet unexplored.

Assessment of a primary and tertiary care integrated management model for chronic obstructive pulmonary disease

BACKGROUND

The diagnosis and treatment of patients with chronic obstructive pulmonary disease (COPD) in Spain continues to present challenges, and problems are exacerbated when there is a lack of coordinated follow-up between levels of care. This paper sets out the protocol for assessing the impact of an integrated management model for the care of patients with COPD. The new model will be evaluated in terms of 1) improvement in the rational utilization of health-care services and 2) benefits reflected in improved health status and quality of life for patients.

METHODS/DESIGN

A quasi-experimental study of the effectiveness of a COPD management model called COPD PROCESS. The patients in the study cohorts will be residents of neighborhoods served by two referral hospitals in Barcelona, Spain. One area comprises the intervention group (n = 32,248 patients) and the other the control group (n = 32,114 patients). The study will include pre- and post-intervention assessment 18 months after the program goes into effect. Analyses will be on two datasets: clinical and administrative data available for all patients, and clinical assessment information for a cohort of 440 patients sampled randomly from the intervention and control areas. The main endpoints will be the hospitalization rates in the two health-care areas and quality-of-life measures in the two cohorts.

DISCUSSION

The COPD PROCESS model foresees the integrated multidisciplinary management of interventions at different levels of the health-care system through coordinated routine clinical practice. It will put into practice diagnostic and treatment procedures that are based on current evidence, multidisciplinary consensus, and efficient use of available resources. Care pathways in this model are defined in terms of patient characteristics, level of disease severity and the presence or absence of exacerbation. The protocol covers the full range of care from primary prevention to treatment of complex cases.

Factors determining the quality of life of patients with COPD in primary care

OBJECTIVES

To describe the health-related quality of life (HRQL) in a cohort of COPD patients recruited in primary care and identify the variables of the patients and the treatment associated with impaired HRQL.

METHOD

Multicenter, observational study of patients with COPD recruited in Primary Care centers. Data regarding HRQL measured by the St. George's respiratory questionnaire (SGRQ) are presented. The total population was divided into two subgroups, high and Low SGRQ, using the median of the total SGRQ score. Univariate analysis and logistic regression analysis with calculation of adjusted odds ratios were used to investigate the factors significantly associated with a higher SGRQ score (poor HRQL).

RESULTS

A total of 27 investigators included 222 valid patients with a mean age of 68.2 years (SD = 9.9) and a mean FEV1(%) of 49.2% (SD = 15.4%). The median total SGRQ score was 39.5 and patients with a high score had a longer evolution of COPD (p < 0.0001), more severe dyspnea (p < 0.0001) and a worse FEV1(%) (46.3% vs. 51.9%; p = 0.008). Factors independently associated with the total SGRQ score were cough and dyspnea, duration of COPD and treatment with inhaled steroids.

CONCLUSION

: Patients with COPD controlled in primary care demonstrate an important impairment in HRQL, with chronic cough and dyspnea being associated with more impaired HRQL. Strategies aimed at modifying these factors should significantly improve the well-being of COPD patients.

Depressive symptoms as predictors of mortality in patients with COPD

OBJECTIVE

Prognostic studies of mortality in patients with COPD have mostly focused on physiologic variables, with little attention to depressive symptoms. This stands in sharp contrast to the attention that depressive symptoms have been given in the outcomes of patients with other chronic health conditions. The present study investigated the independent association of depressive symptoms in stable patients with COPD with all-cause mortality.

METHODS

The baseline characteristics of 121 COPD patients (78 men and 43 women; mean [+/- SD] age, 61.5 +/- 9.1 years; and mean FEV(1), 36.9 +/- 15.5% predicted) were collected on hospital admission to a pulmonary rehabilitation center. The data included demographic variables, body mass index (BMI), post-bronchodilator therapy FEV(1), and Wpeak (peak workload [Wpeak]). Depressive symptoms were assessed using the Beck depression inventory. The vital status was ascertained using municipal registrations. In 8.5 years of follow-up, 76 deaths occurred (mortality rate, 63%). Survival time ranged from 88 days to 8.5 years (median survival time, 5.3 years). The Cox proportional hazard model was used to quantify the association of the baseline characteristics (ie, age, sex, marital status, smoking behavior, FEV(1), BMI, Wpeak, and depressive symptoms) with mortality.

RESULTS

Depressive symptoms (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.12 to 3.33) were associated with mortality in patients with COPD, independent of other factors including male sex (OR, 1.73; 95% CI, 1.03 to 2.92), older age (OR, 1.05; 95% CI, 1.02 to 1.08), and lower Wpeak (OR, 0.98; 95% CI, 0.97 to 0.99).

CONCLUSIONS

This study provides evidence that depressive symptoms assessed in stable patients with COPD are associated with their subsequent all-cause mortality.

Targeting the COPD exacerbation

Exacerbations of COPD have a profound detrimental effect on the patient and impose a significant burden on healthcare resource utilization. Prevention and treatment of exacerbations are major objectives of the clinical management of COPD. For this approach to be successful, clinicians must combine both pharmacologic approaches and non-pharmacologic strategies aimed at improving the patient's disease management. Non-pharmacologic approaches include those that can be incorporated into the office setting as well as intervention strategies that are integrated into the lifelong management of COPD. These strategies include developing a partnership with the patient and their social supports, encouraging and facilitating smoking cessation, immunizations, proper use of supplemental oxygen, and most importantly, giving the patient the tools to manage their illness appropriately. Moreover there is clear evidence of an irrevocable decline in pulmonary function after each exacerbation, usually resulting in reduced physical activity and impaired skeletal muscle function. Not surprisingly, pulmonary rehabilitation after such events has been shown to prevent relapse, improve survival and enhance patients' overall function after acute exacerbations.

Predictors of mortality in patients with stable COPD

OBJECTIVES

To determine which easily available clinical factors are associated with mortality in patients with stable COPD and if health-related quality of life (HRQoL) provides additional information.

DESIGN

Five-year prospective cohort study.

SETTING

Five outpatient clinics of a teaching hospital.

PARTICIPANTS

Six hundred stable COPD patients recruited consecutively.

MEASUREMENTS

The variables were age, FEV(1%), dyspnea, previous hospital admissions and emergency department visits for COPD, pack-years of smoking, comorbidities, body mass index, and HRQoL measured by Saint George's Respiratory Questionnaire (SGRQ), Chronic Respiratory Questionnaire (CRQ), and Short-Form 36 (SF-36). Logistic and Cox regression models were used to assess the influence of these variables on mortality and survival.

RESULTS

FEV(1%)(OR: 0.62, 95% CI 0.5 to 0.75), dyspnea (OR 1.92, 95% CI 1.2 to 3), age (OR 2.41, 95% CI 1.6 to 3.6), previous hospitalization due to COPD exacerbations (OR 1.53, 1.2 to 2) and lifetime pack-years (OR 1.15, 95% CI 1.1 to 1.2) were independently related to respiratory mortality. Similarly, these factors were independently related to all-cause mortality with dyspnea having the strongest association (OR 1.54, 95% CI 1.1 to 2.2). HRQoL was an independent predictor of respiratory and all-cause mortality only when dyspnea was excluded from the models, except scores on the SGRQ were associated with all-cause mortality with dyspnea in the model.

CONCLUSIONS

Among patients with stable COPD, FEV(1%) was the main predictor of respiratory mortality and dyspnea of all-cause mortality. In general, HRQoL was not related to mortality when dyspnea was taken into account, and CRQ and SGRQ behaved in similar ways regarding mortality.

Discriminative and predictive properties of disease-specific and generic health status indexes in elderly COPD patients

Background

The association between bronchial obstruction severity and mortality in Chronic Obstructive Pulmonary Disease (COPD) is well established, but it is unknown whether disease-specific health status measures and multidimensional assessment (MDA) have comparable prognostic value.

Methods

We analyzed data coming from the Salute Respiratoria nell'Anziano (Respiratory Health in the Elderly – SaRA) study, enrolling elderly people attending outpatient clinics for respiratory and non-respiratory problems. From this population we selected 449 patients with bronchial obstruction (77.3% men, mean age 73.1). We classified patients' health status using tertiles of the Saint George Respiratory Questionnaire (SGRQ) and a MDA including functional (the 6' walking test, WT), cognitive (Mini-Mental State Examination, MMSE) and affective status (Geriatric Depression Scale, GDS). The agreement of the classification methods was calculated using the kappa statistic, and survival associated with group membership was evaluated using survival analysis.

Results

Pulmonary function, expressed by the FEV1, worsened with increasing SGRQ or MDA scores. Cognitive function was not associated with the SGRQ, while physical performance and mood status were impaired only in the highest tertile of SGRQ. A poor agreement was found between the two classification systems tested (k = 0.194). Compared to people in the first tertile of SGRQ score, those in the second tertile had a sex-adjusted HR of 1.22 (0.75 – 1.98) and those in the third tertile of 2.90 (1.92 – 4.40). The corresponding figures of the MDA were 1.49 (95% CI 1.02 – 2.18) and 2.01 (95% CI: 1.31 – 3.08). After adjustment for severity of obstruction, only a SGRQ in the upper tertile was associated with mortality (HR: 1.86; 95% CI: 1.14 – 3.02).

Conclusion

In elderly outpatients with mild-moderate COPD, a disease-specific health status index seems to be a better predictor of death compared to a MDA.

Comparison of Short Form-36 Health Survey and Nottingham Health Profile in moderate to severe patients with COPD

OBJECTIVE

To compare the health-related quality of life (HRQoL) assessed by Short Form-36 Health Survey (SF-36) and Nottingham Health Profile (NHP) on the basis of lung function and exercise capacity parameters in patients with moderate to severe chronic obstructive pulmonary disease (COPD).

METHODS AND MATERIALS

The investigation was a prospective, quality-of-life survey and cross-sectional study of 130 consecutive COPD patients. The NHP and SF-36 as generic HRQoL instruments, the Chronic Respiratory Disease questionnaire (CRQ) as a disease-specific HRQoL instrument and 6-minute walking test, severity of dyspnea, leg fatigue and lung function, were the measurements and instruments used in the study.

RESULTS

It was determined that the subscales of both questionnaires were generally related with the FEV(1), walking distance, CRQ, severity of dyspnea and leg fatigue values (P<0.05). The much higher correlation coefficient was determined between these parameters and NHP compared with the SF-36. Only NHP was found to be correlated with the age, body mass index and smoking consumption (P<0.05).

CONCLUSIONS

The stronger relation of NHP with the clinical and physical parameters of the patients compared with that of SF-36 may be associated with the increased sensitivity of NHP to the clinical state owing to the increasing respiratory symptoms of our old patients with moderate to severe obstruction and/or the more intelligible and easy-to-respond nature of NHP compared with SF-36.

Repeated waon therapy improves pulmonary hypertension during exercise in patients with severe chronic obstructive pulmonary disease

OBJECTIVES

Repeated Waon therapy, which uses a far infrared-ray dry sauna system, improved the vascular endothelial function and the cardiac function in patients with chronic heart failure. In patients with chronic obstructive pulmonary disease (COPD), pulmonary hypertension (PH) is associated with a poor prognosis. We investigated whether repeated Waon therapy improves PH, cardiac function, exercise tolerance, and the quality of life (QOL) in patients with COPD.

METHODS

Consecutive 13 patients with COPD, who met the Global Initiative for Chronic Obstructive Lung Disease criteria and had breathlessness despite receiving conventional treatments, were recruited for this study. They underwent Waon therapy at 60 degrees C in sauna for 15 min following 30 min warmth with blankets outside of the sauna room. This therapy was performed once a day, for 4 weeks. Cardiac function, exercise tolerance, and St. George's Respiratory Questionnaire (SGRQ) were assessed before and 4 weeks after Waon therapy.

RESULTS

Right ventricular positive dP/dt at rest elevated significantly from 397 +/- 266 to 512 +/- 320 mmHg/s (p = 0.024) after the therapy. While the PH at rest did not significantly decrease, the PH during exercise decreased significantly from 64 +/- 18 to 51 +/- 13 mmHg (p = 0.028) after Waon therapy. Furthermore, the therapy prolonged the mean exercise time of the constant load of cycle ergometer exercise test from 360 +/- 107 to 392 +/- 97 s (p = 0.032). The total scores of SGRQ improved from 59.7 +/- 16.9 to 55.3 +/- 17.2 (p = 0.002). In addition, no adverse effects were observed related to Waon therapy.

CONCLUSIONS

Repeated Waon therapy improved right ventricular positive dP/dt, PH during exercise, exercise tolerance and the QOL in patients with severe COPD.

Mortality in COPD: inevitable or preventable? Insights from the cardiovascular arena

Mortality due to chronic obstructive pulmonary disease continues to rise, whereas mortality rates related to cardiovascular disease appear to be slowing, or even declining. This is due at least in part to more widespread use of preventative therapies that have been shown to reduce cardiovascular mortality, raising the question of whether appropriate use of therapies for chronic obstructive pulmonary disease which potentially reduce mortality could have a similar impact. This article discusses approaches used successfully in managing heart disease and considers whether these can be applied to chronic obstructive pulmonary disease and whether a better understanding of the strongest predictors of mortality in chronic obstructive pulmonary disease is needed. It reviews the role of inhaled corticosteroids, both alone and in combination with long-acting beta(2)-agonists, in individuals with chronic obstructive pulmonary disease, including the role of combination therapy with inhaled corticosteroids/long-acting beta(2)-agonists (budesonide/formoterol or salmeterol/fluticasone propionate) in decreasing exacerbations and improving health status, potentially providing survival benefits in chronic obstructive pulmonary disease. This review also discusses the potential impact of treatments indicated for cardiovascular disease on chronic obstructive pulmonary disease and possible links between the two diseases.

Exacerbations worsen the quality of life of chronic obstructive pulmonary disease patients in primary healthcare

AIMS

To investigate the evolution of the quality of life of patients with chronic obstructive pulmonary disease (COPD) and quantify the impact of exacerbations on the deterioration of quality of life over 2 years.

METHODS

Multicentre, observational, prospective 2-year study carried out in primary care. Patients with COPD were seen every 6 months. All the exacerbations developing during the study period were recorded and the quality of life of these patients was measured with the St. George's Respiratory Questionnaire (SGRQ).

RESULTS

Twenty-seven physicians participated and collected information on 136 patients with a mean age of 70 years (SD: 9.7) and a mean forced expiratory volume in 1 s (FEV(1)) of 48.7% predicted (SD: 14.5%). The mean global score of the SGRQ was 39.6 at the beginning of the study and 37.9 at the end. Patients without exacerbations improved an average of -5.32 units compared with a worsening of +0.2 among patients with exacerbations (p = 0.023). Among the latter, patients with only one exacerbation improved -3.8 units (p = 0.012) compared with a worsening of +2.4 in those with two or more exacerbations (p = 0.134). The impact of exacerbations was greater in patients with more preserved pulmonary function, with a change in the SGRQ among patients with or without exacerbations of +0.23 and -6.17 (p = 0.017), respectively in patients with a FEV(1) > 50%, vs. +0.18 and -4.39 (p = 0.32) in patients with a FEV(1) </= 50%.

CONCLUSIONS

Exacerbations are associated with a significant worsening in the quality of life of patients with COPD measured with the SGRQ. The degree of impairment depends on the number of exacerbations, being greater in patients with more preserved pulmonary function.

Nocturnal oxygen therapy in patients with chronic obstructive pulmonary disease: a survey of Canadian respirologists

BACKGROUND

Current evidence does not clearly support the provision of nocturnal oxygen therapy in patients with chronic obstructive pulmonary disease (COPD) who desaturate during sleep but who would not otherwise qualify for long-term oxygen therapy (LTOT).

OBJECTIVES

To characterize the perception and clinical practice of Canadian respirologists regarding the indications and prescription of nocturnal oxygen therapy in COPD, and to determine what Canadian respirologists consider an important treatment effect of nocturnal oxygen therapy in a randomized, placebo-controlled trial.

METHODS

A mail survey of all the respirologists registered in the 2006 Canadian Medical Directory was conducted.

RESULTS

A total of 543 physicians were surveyed. The response rate was 60%, and 99% of the respondents indicated that the problem of nocturnal oxygen desaturation is clinically relevant. Eighty-two per cent interpret oximetry tracings themselves, and 87% have access to a sleep laboratory. Forty-two per cent believe that all COPD patients with significant nocturnal desaturation should have a polysomnography to rule out sleep apnea, and 41% would prescribe nocturnal oxygen therapy to active smokers. Assuming a risk of death or progression to LTOT of 40% over a three-year period, the respirologists indicated that to declare nocturnal oxygen therapy effective in reducing the rate of major clinical events in a clinical trial, the minimal absolute risk difference of death or progression to LTOT between oxygen and room air breathing should be 14%.

CONCLUSIONS

Canadian respirologists are interested in the issue of nocturnal oxygen desaturation in COPD. There is variation in clinical practices among Canadian respirologists in several aspects of the management of this problem.

End of life care in chronic obstructive pulmonary disease: in search of a good death

Chronic obstructive pulmonary disease (COPD) is an incurable, progressive illness that is the fourth commonest cause of death worldwide. Death tends to occur after a prolonged functional decline associated with uncontrolled symptoms, emotional distress and social isolation. There is increasing evidence that the end of life needs of those with advanced COPD are not being met by existing services. Many barriers hinder the provision of good end of life care in COPD, including the inherent difficulties in determining prognosis. This review provides an evidence-based approach to overcoming these barriers, summarising current evidence and highlighting areas for future research. Topics include end of life needs, symptom control, advance care planning, and service development to improve the quality of end of life care.

Health-related quality of life and long-term prognosis in chronic hypercapnic respiratory failure: a prospective survival analysis

Background

Health-related quality of life (HRQL) is considered as an important outcome parameter in patients with chronic diseases. This study aimed to assess the role of disease-specific HRQL for long-term survival in patients of different diagnoses with chronic hypercapnic respiratory failure (CHRF).

Methods

In a cohort of 231 stable patients (chronic obstructive pulmonary disease (COPD), n = 98; non-COPD (obesity-hypoventilation syndrome, restrictive disorders, neuromuscular disorders), n = 133) with CHRF and current home mechanical ventilation (HMV), HRQL was assessed by the disease-specific Severe Respiratory Insufficiency (SRI) questionnaire and its prognostic value was prospectively evaluated during a follow-up of 2–4 years, using univariate and multivariate regression analysis.

Results

HRQL was more impaired in COPD (mean ± SD SRI-summary score (SRI-SS) 52.5 ± 15.6) than non-COPD patients (67.6 ± 16.4; p < 0.001). Overall mortality during 28.9 ± 8.8 months of follow-up was 19.1% (31.6% in COPD, 9.8% in non-COPD). To identify the overall role of SRI, we first evaluated the total study population. SRI-SS and its subdomains (except attendance symptoms and sleep), as well as body mass index (BMI), leukocyte number and spirometric indices were associated with long-term survival (p < 0.01 each). Of these, SRI-SS, leukocytes and forced expiratory volume in 1 s (FEV₁) turned out to be independent predictors (p < 0.05 each). More specifically, in non-COPD patients SRI-SS and most of its subdomains, as well as leukocyte number, were related to survival (p < 0.05), whereas in patients with COPD only BMI and lung function but not SRI were predictive.

Conclusion

In patients with CHRF and HMV, the disease-specific SRI was an overall predictor of long-term survival in addition to established risk factors. However, the SRI predominantly beared information regarding long-term survival in non-COPD patients, while in COPD patients objective measures of the disease state were superior. This on one hand highlights the significance of HRQL in the long-term course of patients with CHRF, on the other hand it suggests that the predictive value of HRQL depends on the underlying disease.