Factors associated with changes in quality of life of COPD patients: a prospective study in primary care

Perspectives from patients with chronic lung disease on a telehealth-facilitated integrated palliative care model: a qualitative content analysis study

BACKGROUND

Chronic lung disease affects nearly 37 million Americans and often results in significant quality of life impairment and healthcare burden. Despite guidelines calling for palliative care (PC) integration into pulmonary care as a vital part of chronic lung disease management, existing PC models have limited access and lack scalability. Use of telehealth to provide PC offers a potential solution to these barriers. This study explored perceptions of patients with chronic lung disease regarding a telehealth integrated palliative care (TIPC) model, with plans to use findings to inform development of an intervention protocol for future testing.

METHODS

For this qualitative study, we conducted semi-structured interviews between June 2021- December 2021 with patients with advanced chronic lung disease. Interviews explored experiences with chronic lung disease, understanding of PC, and perceived acceptability of the proposed model along with anticipated facilitators and barriers of the TIPC model. We analyzed findings with a content analysis approach.

RESULTS

We completed 20 interviews, with two that included both a patient and caregiver together due to patient preference. Perceptions were primarily related to three categories: burden of chronic lung disease, pre-conceived understanding of PC, and perspective on the proposed TIPC model. Analysis revealed a high level of disease burden related to chronic lung disease and its impact on day-to-day functioning. Although PC was not well understood, the TIPC model using a shared care planning approach via telehealth was seen by most as an acceptable addition to their chronic lung disease care.

CONCLUSIONS

These findings emphasize the need for a patient-centered, shared care planning approach in chronic lung disease. The TIPC model may be one option that may be acceptable to individuals with chronic lung disease. Future work includes using findings to refine our TIPC model and conducting pilot testing to assess acceptability and utility of the model.

The short- and long-term effects of lower limb endurance training on outpatients with chronic obstructive pulmonary disease

OBJECTIVE

To explore the short- and long-term effects of lower-limb endurance training on chronic obstructive pulmonary disease outpatients.

DESIGN

Prospective quasi-experimental study.

SETTING

1383-bed teaching hospital in Taiwan.

PARTICIPANTS

Overall, 69 outpatients diagnosed with chronic obstructive pulmonary disease were enrolled. A total of 60 patients completed the study.

INTERVENTION

Training group: Lower-limb endurance training; control group: Education only.

MAIN MEASURES

The modified medical research council score, chronic obstructive pulmonary disease assessment test score, pulmonary function test, and number of acute exacerbation within a year.

RESULTS

The training group showed significant improvement in the chronic obstructive pulmonary disease assessment test total score, modified medical research council score (both P < 0.001) at third month sustaining to 12th month (P < 0.001) and presented less events of acute exacerbation (P = 0.011) at 12th month. The chronic obstructive pulmonary disease assessment test decreased by 8 points sustaining to 12th month. The training group presented significant post-training functional capacity improvements in 6-min walking distance, lowest oxygen saturation during 6-min walking test, peak workload, maximum inspiratory/ expiratory pressures, and calf circumference.

CONCLUSIONS

The lower-limb endurance training improved perceived dyspnea in daily activity and health status after completion of training and sustaining for a year. The lower-limb endurance training alleviated disease impacted on reduced acute exacerbations.

High Prevalence and Burden of Physical and Psychological Symptoms in a Chronic Obstructive Pulmonary Disease Population in Primary Care Settings in South Africa

Background

Many deaths globally are attributable to non-communicable disease, and four-fifths of these deaths are in low- and middle-income countries. Globally, COPD is currently the third leading cause of mortality.

Research Question

1) To determine the prevalence and burden of symptoms and concerns, and 2) determine predicting factors of symptom burden among patients with COPD.

Methods

A cross-sectional survey was conducted at eight primary care sites in Western Cape. We collected socio-demographic data (age, gender, smoking status, number of missed doses of prescribed medication in the last seven days) and clinical data (PEF and KPS). The Memorial Symptom Assessment Scale (MSAS), the Medical Outcomes Study, Social Support Survey (MOS-SSS), the London Chest Activity of Daily Living Scale (LCADLS) and the COPD Assessment Test (CAT) (impairment on person's life) were administered to patients. We conducted ordered logistic regression analysis to assess factors associated with the burden of symptoms. MSAS subscales: 1) Global symptom distress index, 2) physical symptom distress and 3) psychological symptom distress were dependent outcomes. We constructed three ordinal logistic regression models for each of the three subscales. Covariates were MOS-SSS, LCADLS, CAT, demographic and clinical variables.

Results

We recruited n=387 patients, mean age 59.5 years, 53.0% female. In multivariate analysis, each of the three models (ie, global, psychological and physical symptom distress) was positively associated with impairment on person's life p<0.001, difficulty to perform activities of daily living p<0.001, and low social support p<0.001. Old age was associated with lower global symptom distress (p=0.004), psychological and (0.014) physical distress (0.005). Missing 1 or more doses of medication was associated with higher levels of global (0.004) and physical (0.005) symptom distress.

Interpretation

The high prevalence and burden of physical and psychological symptoms provides strong evidence of the need for integrating person-centred assessment and management of symptoms in primary care settings.

Comparison of Rescue Medication Prescriptions in Patients with Chronic Obstructive Pulmonary Disease Receiving Umeclidinium/Vilanterol versus Tiotropium Bromide/Olodaterol in Routine Clinical Practice in England

Purpose

Routinely collected healthcare data on the comparative effectiveness of the long-acting muscarinic antagonist/long-acting β2-agonist combination umeclidinium/vilanterol (UMEC/VI) versus tiotropium bromide/olodaterol (TIO/OLO) for chronic obstructive pulmonary disease (COPD) is limited. This study compared rescue medication prescriptions in patients with COPD in England receiving UMEC/VI versus TIO/OLO.

Patients and Methods

This retrospective cohort study used primary care data from the Clinical Practice Research Datalink Aurum database linked with secondary care administrative data from Hospital Episode Statistics. Patients with a COPD diagnosis at age ≥35 years were included (indexed) following initiation of single-inhaler UMEC/VI or TIO/OLO between July 1, 2015, and September 30, 2019. Outcomes included the number of rescue medication prescriptions at 12-months (primary), and at 6-, 18- and 24-months (secondary), adherence at 6-, 12-, 18- and 24-months post-index, defined as proportion of days covered ≥80% (secondary), and time-to-initiation of triple therapy (exploratory). Inverse probability of treatment weighting (IPTW) was used to balance potential confounding baseline characteristics. Superiority of UMEC/VI versus TIO/OLO for the primary outcome of rescue medication prescriptions was assessed using an intention-to-treat analysis with a p-value < 0.05.

Results

In total, 8603 patients were eligible (UMEC/VI: n = 6536; TIO/OLO: n = 2067). Following IPTW, covariates were well balanced across groups. Patients initiating UMEC/VI had statistically significantly fewer (mean [standard deviation]; p-value) rescue medication prescriptions versus TIO/OLO in both the unweighted (4.84 [4.78] vs 5.68 [5.00]; p < 0.001) and weighted comparison (4.91 [4.81] vs 5.48 [5.02]; p = 0.0032) at 12 months; consistent results were seen at all timepoints. Adherence was numerically higher for TIO/OLO versus UMEC/VI at all timepoints. Time-to-triple therapy was similar between treatment groups.

Conclusion

UMEC/VI was superior to TIO/OLO in reducing rescue medication prescriptions at 12 months after treatment initiation in a primary care cohort in England, potentially suggesting improvements in symptom control with UMEC/VI compared with TIO/OLO.

Chronic Airways Assessment Test: psychometric properties in patients with asthma and/or COPD

BACKGROUND

No short patient-reported outcome (PRO) instruments assess overall health status across different obstructive lung diseases. Thus, the wording of the introduction to the Chronic Obstructive Pulmonary Disease (COPD) Assessment Test (CAT) was modified to permit use in asthma and/or COPD. This tool is called the Chronic Airways Assessment Test (CAAT).

METHODS

The psychometric properties of the CAAT were evaluated using baseline data from the NOVELTY study (NCT02760329) in patients with physician-assigned asthma, asthma + COPD or COPD. Analyses included exploratory/confirmatory factor analyses, differential item functioning and analysis of construct validity. Responses to the CAAT and CAT were compared in patients with asthma + COPD and those with COPD.

RESULTS

CAAT items were internally consistent (Cronbach's alpha: > 0.7) within each diagnostic group (n = 510). Models for structural and measurement invariance were strong. Tests of differential item functioning showed small differences between asthma and COPD in individual items, but these were not consistent in direction and had minimal overall impact on the total score. The CAAT and CAT were highly consistent when assessed in all NOVELTY patients who completed both (N = 277, Pearson's correlation coefficient: 0.90). Like the CAT itself, CAAT scores correlated moderately (0.4-0.7) to strongly (> 0.7) with other PRO measures and weakly (< 0.4) with spirometry measures.

CONCLUSIONS

CAAT scores appear to reflect the same health impairment across asthma and COPD, making the CAAT an appropriate PRO instrument for patients with asthma and/or COPD. Its brevity makes it suitable for use in clinical studies and routine clinical practice.

TRIAL REGISTRATION

NCT02760329.

A model of health-related quality of life during COVID-19 pandemic: the role of food customer loyalty and affordability

Purpose

This research aims to test the simultaneous effects of the perceived threat of COVID-19, e-health literacy, e-health access barrier, loyalty toward healthy foods in general, loyalty toward functional foods, the affordability of healthy foods in general and the affordability of functional foods on health-related quality of life (HrQoL) during the COVID-19 pandemic.

Design/methodology/approach

A survey with 400 respondents in Banten, Indonesia, was performed. The data were analyzed using multiple regression analysis.

Findings

The results of the research showed that HrQoL during the COVID-19 pandemic was positively affected by e-health literacy and the affordability of healthy foods in general while negatively affected by the e-health access barrier, the perceived threat of COVID-19 and loyalty toward healthy foods in general. Furthermore, HrQoL was not influenced by loyalty toward and affordability of functional foods.

Research limitations/implications

This research was conducted in Banten. Due to the operational limitations during the COVID-19 pandemic, this research used a purposive sampling technique. Therefore, the next research should retest the model in different contexts and locations.

Practical implications

To improve HrQoL during the COVID-19 pandemic, citizens need to be educated on finding and utilizing credible online health information during the COVID-19 pandemic. Governments and health service providers should also strive to offer ease of access to credible online health information. Furthermore, the affordability of healthy foods, in general, should be managed well.

Originality/value

A few studies on HrQoL during COVID-19 pandemic were performed. However, there is a lack of paper that examines the role of food customer loyalty and affordability in a model of HrQoL during the COVID-19 pandemic. To the best of the authors’ knowledge, this paper is the first that involved and tested the role of food customer loyalty and affordability in a model of HrQoL during the COVID-19 pandemic.

Reducing the Risk of Mortality in Chronic Obstructive Pulmonary Disease With Pharmacotherapy: A Narrative Review

In 2020, chronic obstructive pulmonary disease (COPD) was the fifth leading cause of death in the United States excluding COVID-19, and its mortality burden has been rising since the 1980s. Smoking cessation, long-term oxygen therapy, noninvasive ventilation, and lung volume reduction surgery have had a beneficial effect on mortality; however, until recently, the effects of pharmacologic therapies on all-cause mortality have been unclear. Inhaled pharmacologic treatments for patients with COPD include combinations of long-acting muscarinic receptor antagonists (LAMAs), long-acting-β_2-agonists (LABAs), and inhaled corticosteroids (ICS). The recent IMPACT and ETHOS clinical trials reported mortality benefits with ICS/LAMA/LABA triple therapy compared with LAMA/LABA dual therapy. In IMPACT, fluticasone furoate/umeclidinium/vilanterol therapy significantly reduced the risk of on-/off-treatment all-cause mortality vs umeclidinium/vilanterol (hazard ratio, 0.72; 95% CI, 0.53 to 0.99; P=.042). The ETHOS trial found a reduction in the risk of on-/off-treatment all-cause mortality in patients treated with budesonide/glycopyrrolate/formoterol vs glycopyrrolate/formoterol (hazard ratio, 0.51 [0.33 to 0.80]; nominal P=.0035). Both trials included populations of patients with symptomatic COPD at high risk of future exacerbations, and a post hoc analysis of the final retrieved vital status data suggested that the observed mortality benefits are conferred by the ICS component. In conclusion, triple therapy reduces the risk of mortality in patients with symptomatic COPD characterized by moderate or severe airflow obstruction and a recent history of moderate or severe exacerbations. This benefit is likely to be driven by reductions in exacerbations. Future research efforts should focus on improving the long-term prognosis of patients living with COPD.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Development and evaluation of air pollution-linked quality of life (AP-QOL) questionnaire: insight from two different cohorts

In this study, the air pollution-related quality of life (AP-QOL) questionnaire was carried out in two geographically and economically different groups including New Delhi (Megacity) and Hamirpur, Himachal Pradesh (town), and APE scores were linked with respiratory and cardiovascular illness. The APE-Score was developed by AP-QOL questionnaire responses using Delphi technique and further analyzed using principal component analysis (PCA). For reliability of APE-Score and AP-QOL questionnaire, α-Cronbach's test and basic statistics were performed. The linear mixed-effect model and odds ratios were used to evaluate air pollution exposure and health outcomes. Overall, 720 academicians and 276 security guards were invited to participate in the questionnaire. Cronbach's α coefficients ranged from 0.70 to 0.84 indicated significant reliability in the AP-QOL questionnaire conducted in this study. Substantial variation in respiratory symptoms and their medical history were found - 76.9% ([95% confidential interval (CI)]: (- 83.8, - 66.9) (p < 0.05)) and - 28.6% (95% CI: (- 37.8, - 18.0) (p < 0.05)), respectively, with interquartile range (IQR) increase of APE score. The odds ratios (ORs) of respiratory medical history (MH Res.) showed a significant increase from 1.01 to 1.35 for low to high air pollution exposure in the academic group of IIT Delhi. Interestingly, for an academic group of NITH, the ORs for medical history of cardiovascular (MH Card.) showed an increase from 1.08 to 1.13 for low to high APE which was not the case for IIT Delhi academicians.

Cost Effectiveness of Case Detection Strategies for the Early Detection of COPD

OBJECTIVES

The value of early detection and treatment of chronic obstructive pulmonary disease (COPD) is currently unknown. We assessed the cost effectiveness of primary care-based case detection strategies for COPD.

METHODS

A previously validated discrete event simulation model of the general population of COPD patients in Canada was used to assess the cost effectiveness of 16 case detection strategies. In these strategies, eligible patients (based on age, smoking history, or symptoms) received the COPD Diagnostic Questionnaire (CDQ) or screening spirometry, at 3- or 5-year intervals, during routine visits to a primary care physician. Newly diagnosed patients received treatment for smoking cessation and guideline-based inhaler pharmacotherapy. Analyses were conducted over a 20-year time horizon from the healthcare payer perspective. Costs are in 2019 Canadian dollars ($). Key treatment parameters were varied in one-way sensitivity analysis.

RESULTS

Compared to no case detection, all 16 case detection scenarios had an incremental cost-effectiveness ratio (ICER) below $50,000/QALY gained. In the most efficient scenario, all patients aged ≥ 40 years received the CDQ at 3-year intervals. This scenario was associated with an incremental cost of $287 and incremental effectiveness of 0.015 QALYs per eligible patient over the 20-year time horizon, resulting in an ICER of $19,632/QALY compared to no case detection. Results were most sensitive to the impact of treatment on the symptoms of newly diagnosed patients.

CONCLUSIONS

Primary care-based case detection programs for COPD are likely to be cost effective if there is adherence to best-practice recommendations for treatment, which can alleviate symptoms in newly diagnosed patients.

Effects of the Health Belief Model-Based Intervention on Anxiety, Depression, and Quality of Life in Chronic Obstructive Pulmonary Disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition. COPD causes a heavy burden on the patients through negative impacts on the quality of life and psychological health. The health belief model (HBM) is proposed and modified by several social psychologists and is confirmed to have benefits in the recovery of various diseases. This research aimed to explore the effects of the HBM-based intervention on anxiety, depression, and quality of life in COPD patients entering pulmonary rehabilitation (PR).

METHODS

This research was conducted at the Tianjin Rehabilitation Recuperate Center of Chinese PLA in 2019. A total of 136 COPD patients were randomized into the intervention group and the control group. In the control group, patients received the PR program. In the intervention group, patients received both PR program and the HBM-based intervention. Quality of life was measured by the COPD assessment test. The outcomes of anxiety and depression were measured by the Hospital Anxiety and Depression Scale.

RESULTS

The HBM-based intervention decreased both anxiety and depression scores among COPD patients. The COPD assessment test score was declined by the HBM-based intervention, which also decreased the serum levels of interleukin-6 and C-reactive protein in COPD patients entering PR.

CONCLUSION

The HBM-based intervention alleviates anxiety and depression, enhances quality of life, and inhibits inflammation in COPD patients entering PR.

Impact of Clinical Factors on Generic and Disease-Specific Quality of Life in COPD and Asthma-COPD Overlap with Exacerbations

Purpose

The health-related quality of life (HRQL) in chronic obstructive pulmonary disease (COPD) is worsened by frequent exacerbations, and it can be affected by the concomitant presence of bronchial asthma (asthma-COPD overlap (ACO)). The impacts of clinical factors associated with HRQL have not been compared in patients with COPD and ACO experiencing exacerbations. Patients and Methods. Patients with COPD (N =705) and ACO (N =148) belonging to C and D groups according to GOLD 2017 were recruited in stable condition. Demographic and clinical data were collected, spirometry was performed, and patients rated the intensity of respiratory symptoms during the previous week. The COPD Assessment Test (CAT) and the EQ-5D 3 level version (dimensions and visual analogue scale (VAS)) were used to assess disease-specific and generic HRQL, respectively. Fisher's exact test, χ² test, ANOVA, and Pearson correlation were used for analysis (mean ± SD). Multiple linear regression was applied to identify variables related to CAT and EQ-5D VAS scores.

Results

The CAT and EQ-5D VAS scores showed similarly low HRQL in COPD and ACO (20.7 ± 6.7 vs. 21.1 ± 6.3 (p = 0.52) and 56.2 ± 17.8 vs. 53.7 ± 18.2 (p = 0.11)). There was a weak correlation between CAT and EQ-5D VAS scores (COPD: r = −0.345, p < 0.001; ACO: r = −0.245, p = 0.003). More patients with COPD had problems related to anxiety/depression in EQ-5D (63.7% vs. 55.4%, p = 0.06). Pack-years exerted a negative effect on HRQL measures both in ACO and COPD. Low HRQL in COPD was associated with female gender, dyspnea, cough, gastroesophageal reflux disease, and arrhythmia, while in ACO, it was related to arrhythmia, hypertension, and cough, but less to dyspnea.

Conclusions

Patients with COPD and ACO experiencing exacerbations have low quality of life, which is influenced by smoking history, symptoms, and comorbidities. These findings have important implications for the development of therapeutic strategies to improve the health status of patients with these conditions.

A structural equation model of health-related quality of life among Thai men with chronic obstructive pulmonary disease

AIM AND OBJECTIVES

To identify physiological, psychological and socioenvironmental factors that affect the health-related quality of life of Thai men living with chronic obstructive pulmonary disease. The vast majority of Thai persons living with chronic obstructive pulmonary disease are men.

BACKGROUND

Little is known about the health-related quality of life of Thai people living with chronic obstructive pulmonary disease or about the physiological and psychosocial factors that most affect it. Applying a prevailing theoretical model of health-related quality of life, we explored how physiological, psychological and socioenvironmental factors simultaneously affect the health-related quality of life of Thai men with chronic obstructive pulmonary disease.

DESIGN

A cross-sectional study design was used, together with the STROBE checklist.

METHODS

In this study, 290 Thai male outpatients at a chronic obstructive pulmonary disease specialist clinic near Bangkok were recruited using purposive sampling. The participants completed the Satisfaction With Life Scale, the St. George Respiratory Questionnaire, the Center for Epidemiologic Studies Depression Scale, the Short Form Health Survey Version 2, the chronic obstructive pulmonary disease Self-Efficacy Scale and the Social Support Questionnaire. A structural equation model was used to examine the relationships between the assessed variables.

RESULTS

Biological function (FEV-1, chronic obstructive pulmonary disease exacerbations), symptoms (chronic obstructive pulmonary disease and depression), functional status, general health perceptions and individual characteristics (age and self-efficacy to control dyspnoea) accounted for 56.9% of the variance in health-related quality of life.

CONCLUSIONS

Symptoms of chronic obstructive pulmonary disease and depression were the main factors with statistically significant direct and indirect effects on the health-related quality of life of the Thai men in this study. The effects of both symptoms included an indirect effect on health-related quality of life through functional status and general health perceptions.

RELEVANCE TO CLINICAL PRACTICE

The study findings may help nurses to better understand factors affecting health-related quality of life among men with chronic obstructive pulmonary disease. Preventing or minimising symptom exacerbations could be important in nursing practice. Cognitive-behavioural interventions addressing chronic obstructive pulmonary disease symptom management, depression screening and smoking cessation may improve health-related quality of life among Thai men with chronic obstructive pulmonary disease.

Goals of COPD treatment: Focus on symptoms and exacerbations

Chronic obstructive pulmonary disease (COPD) is currently a leading cause of death worldwide, and its burden is expected to rise in the coming years. Common COPD symptoms include dyspnea, cough and/or sputum production. Some patients may experience acute worsening of symptoms (known as an exacerbation), and therefore require additional therapy. Exacerbations are mainly triggered by respiratory infections and environmental factors. Healthcare professionals face many challenges in COPD management, including the heterogeneity of the disease and under-reporting of symptoms. The authors review these challenges and provide recommendations for the best methods to assess COPD. The goals of COPD treatment include recognising the impact that both symptoms and exacerbations have on patients' lives when considering optimal patient-focused management. The review discusses the need for COPD management strategies to include both pharmacologic and non-pharmacologic approaches and provides recommendations for monitoring treatment outcomes and adjusting management strategies accordingly. Novel treatment strategies including precision medicine and point-of-care testing are also discussed.

COPD Patients' Experience of Long-Term Domestic Oxygen-Enriched Nasal High Flow Treatment: A Qualitative Study

Little is known about chronic obstructive pulmonary disease (COPD) patients experience with home-based health treatments, which are currently rapidly evolving. A previous randomized controlled trial investigated the use of long-term oxygen enriched high flow nasal cannula (HFNC) treatment at home. The aim of this study was to explore COPD patients' experience using home HFNC treatment. Patients in this qualitative study were included from the previous RCT. All patients used long-term oxygen therapy and HFNC, the latter as a primarily nocturnal add-on. Data were collected using semi-structured interviews focused on four themes: 'Description of daily use', 'Experienced changes', 'Treatment benefits and disadvantages' and 'User-friendliness'. The interviewer played an encouraging, non-normative neutral facilitator role in order to give the participants possibility to explain themselves as fully as possible. Participants were recruited until themes were saturated. A total of 12 patients (5 males, 7 females) and 8 relatives participated. Six themes were identified as important to patient adherence: Perceived lower work of breathing; reduced symptoms; improved quality of sleep; increased activity of daily living; feeling safe; technology use. The results increase our knowledge of patient experience of using HFNC for home treatment, which improved the patients' experience through reducing symptoms and increase the activity of daily living. Furthermore, they substantiate the necessity of perceived usefulness and ease of use as important factors for adherence to treatment.

Minimal Clinically Important Differences for Patient-Reported Outcome Measures of Cough and Sputum in Patients with COPD

Background

Cough and sputum are highly prevalent in patients with chronic obstructive pulmonary disease (COPD). Pulmonary rehabilitation (PR) has shown to be effective in managing these symptoms. However, the interpretation of the magnitude of PR effects is hindered by the lack of minimal clinically important differences (MCIDs).

Purpose

This study established MCIDs for the Leicester cough questionnaire (LCQ) and the cough and sputum assessment questionnaire (CASA-Q), in patients with COPD after PR.

Patients and Methods

An observational prospective study was conducted in patients with COPD who participated in a 12-weeks community-based PR program. Anchor- (mean change, receiver operating characteristic curves and linear regression analysis) and distribution-based methods [0.5*standard deviation; standard error of measurement (SEM); 1.96*SEM; minimal detectable change and effect size] were used to compute the MCIDs. The anchors used were: i) patients and physiotherapists global rating of change scale, ii) COPD assessment test, iii) St. George’s respiratory questionnaire and iv) occurrence of an exacerbation during PR. Pooled MCIDs were computed using the arithmetic weighted mean (2/3 for anchor- and 1/3 for distribution-based methods).

Results

Forty-nine patients with COPD (81.6% male, 69.8±7.4years, FEV₁50.4±19.4_%predicted) were used in the analysis. The pooled MCIDs were 1.3 for LCQ and for CASA-Q domains were: 10.6 - cough symptoms; 10.1 - cough impact; 9.5 - sputum symptoms and 7.8 - sputum impact.

Conclusion

The MCIDs found in this study are potential estimates to interpret PR effects on cough and sputum, and may contribute to guide interventions.

The Role of Guaifenesin in the Management of Chronic Mucus Hypersecretion Associated with Stable Chronic Bronchitis: A Comprehensive Review

Chronic obstructive pulmonary disease is the third leading cause of death and disease burden worldwide. It includes a spectrum of diseases including chronic bronchitis which is characterized by overproduction, hypersecretion and decreased elimination of mucus. Chronic bronchitis has numerous clinical consequences, including predisposition to lower respiratory tract infections, accelerated decline in lung function, increased exacerbation rate and decreased health-related quality of life.

Although the inflammatory mechanisms responsible for mucus cell metaplasia in chronic obstructive pulmonary disease and stable chronic bronchitis are poorly understood, the main goals of therapy are to decrease mucus hypersecretion by controlling inflammation and to increase mucus clearance. Non-pharmacological measures include smoking cessation and chest physiotherapy. Pharmacological interventions include expectorants and mucolytics together with long-acting beta2-adrenergic receptor agonists, anticholinergics, glucocorticoids, phosphodiesterase-4 inhibitors, antioxidants, and antibiotics.

Guaifenesin is an expectorant that is thought to increase hydration and decrease viscosity of mucus leading to improved clearance of accumulated secretions from the upper and lower airway. Although guaifenesin has a Food and Drug Administration Over-the-Counter (OFC) Monograph indication to "help loosen phlegm (mucus) and thin bronchial secretions in patients with stable chronic bronchitis," there is limited published evidence of either mechanism of action or clinical efficacy in this disease state. Here we review the pathophysiology and consequences of chronic mucus hypersecretion and examine the evidence for the use of guaifenesin in patients with stable chronic bronchitis.

Weighing the evidence for pharmacological treatment interventions in mild COPD; a narrative perspective

There is increasing focus on understanding the nature of chronic obstructive pulmonary disease (COPD) during the earlier stages. Mild COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD] stage 1 or the now-withdrawn GOLD stage 0) represents an early stage of COPD that may progress to more severe disease. This review summarises the disease burden of patients with mild COPD and discusses the evidence for treatment intervention in this subgroup.

Overall, patients with mild COPD suffer a substantial disease burden that includes persistent or potentially debilitating symptoms, increased risk of exacerbations, increased healthcare utilisation, reduced exercise tolerance and physical activity, and a higher rate of lung function decline versus controls. However, the evidence for treatment efficacy in these patients is limited due to their frequent exclusion from clinical trials. Careful assessment of disease burden and the rate of disease progression in individual patients, rather than a reliance on spirometry data, may identify patients who could benefit from earlier treatment intervention.

Impact of cough and mucus on COPD patients: primary insights from an exploratory study with an Online Patient Community

Background: Qualitative research provides real-life information on patients' condition and facilitates informed design of future clinical studies. Objective: We used Online Communities as a qualitative research tool to evaluate the effect of cough and mucus on COPD patients. Methods: Two 2-week Online Communities were run in parallel in the UK and in the USA, including COPD patients with persistent cough and excessive mucus. Patients anonymously posted their responses to pre-assigned tasks, supervised and guided by a trained moderator. Five themes around the impact of cough and mucus were explored with new questions posted every 2-3 days. On the final day, high-level conclusions were shared with patients for feedback. Data were analyzed following the principles of grounded theory. Results: Twenty COPD patients (UK, n=10; USA, n=10) participated in the Online Communities. We found that cough and mucus disrupted COPD patients' lives at functional, emotional, social and economic levels. Patients created daily rituals and adjusted their lifestyle to cope with the impact of these symptoms. Patients identified themselves with our conclusions and saw the Online Community as an effective forum to share their experiences. Conclusion: Findings of our study add to the body of evidence on the negative impact of COPD symptoms and unmet needs of these patients.

Patient-Reported Burden of Illness in a Prevalent COPD Population Treated with Long-Acting Muscarinic Antagonist Monotherapy: A Claims-Linked Patient Survey Study

INTRODUCTION

Symptom burden in inadequately controlled chronic obstructive pulmonary disease (COPD) considerably impacts quality of life, healthcare resource utilization (HCRU) and associated costs. This claims-linked cross-sectional survey study assessed symptom burden and HCRU among a prevalent population of COPD patients prescribed long-acting muscarinic antagonist (LAMA) monotherapy.

METHODS

Patients were identified using claims data from the Optum Research Database. Eligible patients were aged ≥ 40 years with 12 months' continuous enrollment in a US health plan, ≥ 2 medical claims containing COPD diagnosis codes ≥ 30 days apart, and ≥ 2 claims for LAMA monotherapy in the latter half of the 12-month sample identification period. Patients were mailed a cross-sectional survey assessing patient-reported outcomes (PROs) [COPD assessment test (CAT) and modified medical research council dyspnea scale (mMRC)], clinical characteristics, smoking history, and demographics. Patients also completed the Exacerbations of Chronic Pulmonary Disease Tool (EXACT-PRO) daily diary for 7 days. HCRU was assessed from claims data.

RESULTS

The study included 433 patients with a self-reported healthcare provider COPD diagnosis, and both claims-based and self-reported LAMA monotherapy treatment (mean age 71.0 years; 59.8% female). Most patients (85.5%) reported a high symptom burden (CAT score ≥ 10), 45.5% had high levels of dyspnea (mMRC grade ≥ 2), and 64.4% reported more severe daily symptoms by the EXACT-PRO. Most patients (71.6%) reported high scores on ≥ 2 PROs. More patients with high symptom burden had COPD-related emergency department visits than those with lower disease burden (27.6% vs 12.7%, P = 0.012).

CONCLUSIONS

In conclusion, a large proportion of patients with COPD receiving LAMA monotherapy experienced a high symptom burden and may benefit from therapy escalation. Healthcare professionals can use validated PROs to help them assess symptom burden.

FUNDING

GlaxoSmithKline (GSK study number: 205862).

Heterogeneity in the respiratory symptoms of patients with mild-to-moderate COPD

Background

The burden of symptoms varies markedly between patients with COPD and is only weakly correlated with lung function impairment. While heterogeneity in lung function decline and exacerbations have been previously studied, the extent of heterogeneity in symptoms and the factors associated with this heterogeneity are not well understood.

Methods

A sample of the general Canadian population ≥40 years with persistent airflow limitation was followed for up to 3 years. Participants reported whether they experienced chronic coughing, phlegm, wheezing, or dyspnea during visits at 18-month intervals. We used mixed-effect logistic regression models (separately for each symptom) to assess overall heterogeneity in the occurrence of symptoms between individuals, and the proportion of variation in symptom burden explained by lung function vs all other clinical characteristics of participants.

Results

Four hundred forty-nine participants (53% male, mean age 67 years) contributed 968 visits in total, and 89% of patients reported at least one symptom during follow-up. There was substantial heterogeneity in the individual-specific probabilities for the occurrence of symptoms. This heterogeneity was highest for wheeze and dyspnea (IQR of probabilities: 0.13–0.78 and 0.19–0.81, respectively). FEV₁ explained 28% of the variation between individuals in the occurrence of dyspnea, 8% for phlegm, 3% for cough, and 2% for wheeze. All clinical characteristics of participants (including FEV₁) explained between 26% of heterogeneity in the occurrence of cough to 49% for dyspnea.

Conclusion

There is marked heterogeneity in the burden of respiratory symptoms between COPD patients. The ability of lung function and other commonly measured clinical characteristics to explain this heterogeneity differs between symptoms.

Anxiety and depression among dairy farmers: the impact of COPD

Background

Chronic obstructive pulmonary disease (COPD) and farming are two conditions that have been associated with an increased risk of anxiety and depression. Dairy farming is an independent risk factor for COPD.

Objective

To test the hypotheses that the prevalence of anxiety and/or depression is higher in dairy farmers with COPD than in farmers without COPD, and higher in dairy farmers with COPD than in non-farmers with COPD.

Methods

Anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale in 100 dairy farmers with COPD (DF-COPD), 98 dairy farmers without COPD (DF-controls), 85 non-farming patients with COPD (NF-COPD) and 89 non-farming subjects without COPD (NF-controls), all identified by screening in the Franche-Comté region of France. Anxiety and depression were considered present when the Hospital Anxiety and Depression Scale score was ≥8. COPD was defined by a post-bronchodilator forced expiratory volume in 1 second/forced vital capacity ratio <0.7.

Results

The crude prevalence of anxiety did not differ between the four groups, ranging from 36% in NF-controls to 47% in NF-COPD (p=0.15 between groups). Similarly, the prevalence of depression did not differ significantly between the four groups (p=0.16 between groups). In dairy farmers (n=198), the only factors associated with anxiety were quality of life and current smoking. Depression in dairy farmers was associated with airflow limitation (lower forced expiratory volume in 1 second and COPD grade 2 or more) as well as with some COPD-related features (dyspnea severity, current smoking, and poorer quality of life). In non-farmers, both anxiety and depression were associated with airflow limitation and COPD-related features.

Conclusion

In our population, the prevalence of anxiety and/or depression was similar in dairy farmers with and without COPD and in non-farmers with COPD. Nevertheless, the degree of airway obstruction and some COPD-related features were associated with depression among dairy farmers, whereas these factors were not associated with anxiety.

Fat-free mass depletion in patients with COPD in Brazil: development of a new cutoff point and its relation with mortality and extrapulmonary manifestations

BACKGROUND/OBJECTIVES

None of the cutoff points for fat-free mass index (FFMI) were tested for the Brazilian population, and it is unknown whether the available ones are able to discriminate extrapulmonary disease manifestations. This cross-sectional study aims to develop and validate a cutoff point for FFM depletion based on Brazilian patients with chronic obstructive pulmonary disease (COPD) and to verify its association and of previously published cutoffs with extrapulmonary manifestations.

SUBJECTS/METHODS

A new cutoff point was obtained from the best FFMI value for discrimination of preserved exercise capacity in a sample of patients (n=57). The discriminative capacity was assessed in another sample (n=96). The new cutoff point and other previously published ones were tested to discriminate low exercise capacity, physical inactivity, sedentary lifestyle and low quality of life. A receiver operation characteristics curve with area under the curve (AUC) value was plotted and each cutoff points' discriminative capacity was calculated. Cox regression and Kaplan-Meier method assessed the association between the cutoff points and mortality.

RESULTS

The new cutoff points for FFMI were 14.65 kg/m² for women (AUC=0.744; sensitivity (Se)=0.88; specificity (Sp)=0.60) and 20.35 kg/m² for men (AUC=0.565; Se=0.36; Sp=0.81). The new cutoffs were the best to discriminate poor exercise capacity assessed by walked distance in % predicted and quality of life. Only the new cutoff point was associated with mortality (HR=2.123; 95% CI: 1.03-4.33, P=0.039, log rank P=0.035).

CONCLUSIONS

Only the new cutoff point was associated with all-cause mortality, and it had the highest discriminating capacity for exercise capacity and quality of life in Brazilian patients with COPD.

Understanding the impact of symptoms on the burden of COPD

Chronic obstructive pulmonary disease (COPD) imposes a substantial burden on individuals with the disease, which can include a range of symptoms (breathlessness, cough, sputum production, wheeze, chest tightness) of varying severities. We present an overview of the biomedical literature describing reported relationships between COPD symptoms and disease burden in terms of quality of life, health status, daily activities, physical activity, sleep, comorbid anxiety, and depression, as well as risk of exacerbations and disease prognosis. In addition, the substantial variability of COPD symptoms encountered (morning, daytime, and nighttime) is addressed and their implications for disease burden considered. The findings from this narrative review, which mainly focuses on real-world and observational studies, demonstrate the impact of COPD symptoms on the burden of disease and that improved recognition and understanding of their impact is central to alleviating this burden.

Change in health status in COPD: a seven-year follow-up cohort study

Health status is a prognostic factor included in the assessment of chronic obstructive pulmonary disease (COPD). The aim of our study was to examine the associations of clinical factors with change in health status over a 7-year follow-up period. In 2005, 970 randomly selected primary and secondary care patients with a COPD diagnosis completed questionnaires including the Clinical COPD Questionnaire (CCQ); and in 2012, 413 completed the CCQ questionnaire again. Linear regression used difference in mean total CCQ score between 2005 and 2012 as the dependent variable. Independent variables were CCQ score at baseline 2005, sex, age, educational level, body mass index (BMI), smoking status, heart disease, diabetes, depression, number of exacerbations in the previous 6 months, dyspnoea (modified Medical Research Council (mMRC)). Health status worsened from mean total CCQ (s.d.) 2.03 (1.26) in 2005 to 2.16 (1.37) in 2012 (P=0.011). In linear regression with adjustment for baseline CCQ; older age, lower education, higher mMRC and BMI below 25 kg/m2 at baseline were associated with worsened health status in 2012. When sex, age and all statistically significant measures were included simultaneously in the analysis of the main study group, higher mMRC and BMI below 25 kg/m2 were were associated with deteriorated health status (P<0.0001). A higher level of dyspnoea and lower weight were associated with worse health status in COPD. Strategies for decreasing dyspnoea and awareness of the possible increased risk of worsening disease in under- and normal-weight COPD patients are clinically important.

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a common disease with high global morbidity and mortality. COPD is characterized by poorly reversible airway obstruction, which is confirmed by spirometry, and includes obstruction of the small airways (chronic obstructive bronchiolitis) and emphysema, which lead to air trapping and shortness of breath in response to physical exertion. The most common risk factor for the development of COPD is cigarette smoking, but other environmental factors, such as exposure to indoor air pollutants - especially in developing countries - might influence COPD risk. Not all smokers develop COPD and the reasons for disease susceptibility in these individuals have not been fully elucidated. Although the mechanisms underlying COPD remain poorly understood, the disease is associated with chronic inflammation that is usually corticosteroid resistant. In addition, COPD involves accelerated ageing of the lungs and an abnormal repair mechanism that might be driven by oxidative stress. Acute exacerbations, which are mainly triggered by viral or bacterial infections, are important as they are linked to a poor prognosis. The mainstay of the management of stable disease is the use of inhaled long-acting bronchodilators, whereas corticosteroids are beneficial primarily in patients who have coexisting features of asthma, such as eosinophilic inflammation and more reversibility of airway obstruction. Apart from smoking cessation, no treatments reduce disease progression. More research is needed to better understand disease mechanisms and to develop new treatments that reduce disease activity and progression.

Sleep and Quality of Life in People With COPD

Sleep disorders are very common in patients with chronic obstructive pulmonary disease (COPD). However, it is not clear how sleep disorders and quality of life (QoL) affect each other in the different stages of disease progression. This descriptive-correlational study investigated the relationship between QoL, quality of sleep, and degree of disease progression in 102 outpatients with COPD. The results showed that the QoL in patients with COPD is compromised and worsens with disease progression, and the quality of sleep is significantly associated with QoL and worsened as the disease progressed. The early identification of a risk of alteration of the quality of sleep, especially in nursing care, could facilitate a preventive approach for COPD patients that could positively affect their QoL.

Differential changes in quality of life components over 5 years in chronic obstructive pulmonary disease patients

BACKGROUND

The aim of the study was to examine the longitudinal change in quality of life components of patients with chronic obstructive pulmonary disease (COPD).

METHODS

In the Hokkaido COPD Cohort Study, 261 subjects were appropriately treated and followed over 5 years with a 74% follow-up rate at the end. The longitudinal changes in St George's Respiratory Questionnaire (SGRQ) scores were annually evaluated with forced expiratory volume in 1 second (FEV1). The subjects were classified into the rapid decliners, slow decliners, and sustainers based on ΔFEV1/year.

RESULTS

The activity component of SGRQ generally deteriorated over time, and its annual decline was the greatest in the rapid decliners (<25th percentile). In contrast, the symptom component improved significantly year by year in the sustainers (>75 percentile), and it did not deteriorate even in the rapid decliners. Of the baseline data, predictors for worsening of the activity component were older age and lower body mass index. Larger reversibility was related to symptom component improvement. Of the follow-up data, ΔFEV1/year was the best predictor for worsening of the components of SGRQ. Continuous smoking was another factor for worsening of the activity component. For the symptom component, a history of exacerbation by admission definition was the determinant of its deterioration, whereas use of beta agonists was related to improvement.

CONCLUSION

The longitudinal changes of quality of life and their determinants are markedly different and independent between its components. The activity component of SGRQ generally deteriorated over years, while the symptom component rather improved in some patients with COPD under appropriate treatment.

One-year change in health status and subsequent outcomes in COPD

BACKGROUND

Poor health status has been associated with morbidity and mortality in patients with COPD. To date, the impact of changes in health status on these outcomes remains unknown.

AIMS

To explore the relationship of clinically relevant changes in health status with exacerbation, hospitalisation or death in patients with COPD.

METHODS

Characteristics and health status (St George's Respiratory Questionnaire, SGRQ) were assessed over a period of 3 years in 2138 patients with COPD enrolled in the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study: a longitudinal, prospective, observational study. Associations between change in health status (=4 units in SGRQ score) during year 1 and time to first exacerbation, hospitalisation and death during 2-year follow-up were assessed using Kaplan-Meier plots and log-rank test.

RESULTS

1832 (85.7%) patients (age 63.4±7.0 years, 65.4% male, FEV1 48.7±15.6% predicted) underwent assessment at baseline and 1 year. Compared with those who deteriorated, patients with improved or stable health status in year 1 have a lower likelihood of exacerbation (HR 0.78 (95% CI 0.67 to 0.89), p<0.001 and 0.84 (0.73 to 0.97), p=0.016, respectively), hospitalisation (0.72 (0.58 to 0.90), p=0.004 and 0.77 (0.62 to 0.96), p=0.023, respectively) or dying (0.61 (0.39 to 0.95), p=0.027 and 0.58 (0.37 to 0.92), p=0.019, respectively) during 2-year follow-up. This effect persisted after stratification for age and the number of exacerbations and hospitalisations during the first year of the study.

CONCLUSIONS

Patients with stable or improved health status during year 1 of ECLIPSE had a lower likelihood of exacerbation, hospitalisation or dying during 2-year follow-up. Interventions that stabilise and improve health status may also improve outcomes in patients with COPD.

TRIAL REGISTRATION NUMBER

NCT00292552, registered at ClinicalTrials.gov.

Observational study to characterise 24-hour COPD symptoms and their relationship with patient-reported outcomes: results from the ASSESS study

BACKGROUND

Few studies have investigated the 24-hour symptom profile in patients with COPD or how symptoms during the 24-hour day are inter-related. This observational study assessed the prevalence, severity and relationship between night-time, early morning and daytime COPD symptoms and explored the relationship between 24-hour symptoms and other patient-reported outcomes.

METHODS

The study enrolled patients with stable COPD in clinical practice. Baseline night-time, early morning and daytime symptoms (symptom questionnaire), severity of airflow obstruction (FEV1), dyspnoea (modified Medical Research Council Dyspnoea Scale), health status (COPD Assessment Test), anxiety and depression levels (Hospital Anxiety and Depression Scale), sleep quality (COPD and Asthma Sleep Impact Scale) and physical activity level (sedentary, moderately active or active) were recorded.

RESULTS

The full analysis set included 727 patients: 65.8% male, mean ± standard deviation age 67.2 ± 8.8 years, % predicted FEV1 52.8 ± 20.5%. In each part of the 24-hour day, >60% of patients reported experiencing ≥1 symptom in the week before baseline. Symptoms were more common in the early morning and daytime versus night-time (81.4%, 82.7% and 63.0%, respectively). Symptom severity was comparable for each period assessed. Overall, in the week before baseline, 56.7% of patients had symptoms throughout the whole 24-hour day (3 parts of the day); 79.9% had symptoms in ≥2 parts of the 24-hour day. Symptoms during each part of the day were inter-related, irrespective of disease severity (all p < 0.001). Early morning and daytime symptoms were associated with the severity of airflow obstruction (p < 0.05 for both). Night-time, early morning and daytime symptoms were all associated with worse dyspnoea, health status and sleep quality, and higher anxiety and depression levels (all p < 0.001 versus patients without symptoms in each corresponding period). In each part of the 24-hour day, there was also an association between symptoms and a patient's physical activity level (p < 0.05 for each period).

CONCLUSIONS

More than half of patients experienced COPD symptoms throughout the whole 24-hour day. There was a significant relationship between night-time, early morning and daytime symptoms. In each period, symptoms were associated with worse patient-reported outcomes, suggesting that improving 24-hour symptoms should be an important consideration in the management of COPD.

Depression and anxiety predict health-related quality of life in chronic obstructive pulmonary disease: systematic review and meta-analysis

BACKGROUND

The causal association between depression, anxiety, and health-related quality of life (HRQoL) in chronic obstructive pulmonary disease (COPD) is unclear. We therefore conducted a systematic review of prospective cohort studies that measured depression, anxiety, and HRQoL in COPD.

METHODS

Electronic databases (Medline, Embase, Cumulative Index to Nursing and Allied Health Literature [CINAHL], British Nursing Index and Archive, PsycINFO and Cochrane database) were searched from inception to June 18, 2013. Studies were eligible for inclusion if they: used a nonexperimental prospective cohort design; included patients with a diagnosis of COPD confirmed by spirometry; and used validated measures of depression, anxiety, and HRQoL. Data were extracted and pooled using random effects models.

RESULTS

Six studies were included in the systematic review; of these, three were included in the meta-analysis for depression and two were included for the meta-analysis for anxiety. Depression was significantly correlated with HRQoL at 1-year follow-up (pooled r=0.48, 95% confidence interval 0.37-0.57, P<0.001). Anxiety was also significantly correlated with HRQoL at 1-year follow-up (pooled r=0.36, 95% confidence interval 0.23-0.48, P<0.001).

CONCLUSION

Anxiety and depression predict HRQoL in COPD. However, this longitudinal analysis does not show cause and effect relationships between depression and anxiety and future HRQoL. Future studies should identify psychological predictors of poor HRQoL in well designed prospective cohorts with a view to isolating the mediating role played by anxiety disorder and depression.