Patient-reported dyspnea in COPD reliability and association with stage of disease.

BACKGROUND: Although questionnaires are used frequently with patients to self-report the severity of dyspnea as related to activities of daily living, the reliability of these instruments has not been established. The two purposes of this study were to examine the test-retest reliability of three widely used dyspnea instruments and to compare dyspnea scores at different stages of disease. METHODS: At paired baseline visits, 101 stable patients with COPD were tested; at paired follow-up visits at 3 months, 89 of these patients were tested. At each visit, patients rated dyspnea with three instruments presented in random order and then performed post-bronchodilator therapy lung function tests. RESULTS: Patient-reported dyspnea scores and lung function were similar at baseline (interval, 6 +/- 5 days) and follow-up visits (interval, 4 +/- 2 days). Intraclass correlation coefficients at baseline and at follow-up were 0.82 and 0.82, respectively, for the modified Medical Research Council scale; 0.90 and 0.84, respectively, for the self-administered computerized versions of the baseline dyspnea index and transition dyspnea indexes; and 0.95 and 0.89 for the University of San Diego Shortness of Breath Questionnaire results. Dyspnea ratings were significantly related to the stage of disease severity based on percent predicted FEV(1) (p < 0.001). CONCLUSIONS: Test-retest reliability was acceptable for patient-reported dyspnea scores using three clinical instruments at baseline and at the 3-month follow-up. Our results demonstrate for the first time that patient-reported dyspnea ratings are related to the stage of disease severity.

Validity and responsiveness of the self-administered computerized versions of the baseline and transition dyspnea indexes.

BACKGROUND: Numerous instruments have been developed to examine the impact of activities on breathlessness. The primary purpose of this study was to examine the validity and responsiveness of the self-administered computerized (SAC) versions of the multidimensional baseline dyspnea index (BDI) and the transition dyspnea index (TDI). METHODS: Sixty-five patients with COPD who complained of exertional breathlessness were evaluated at an initial visit and after receiving standard therapy at two academic medical centers. Dyspnea scores from the SAC versions were compared with those obtained with the Medical Research Council (MRC) scale and with the original interview versions of the BDI and TDI. RESULTS: At the initial visit, all three dyspnea instruments showed similar correlations among themselves and with lung function. At the follow-up visit (mean [+/- SD] time after initial visit, 48 +/- 16 days), breathlessness scores were improved on all three instruments. Correlations were consistently higher for both versions of the TDI, and changes in lung function compared with corresponding values for DeltaMRC scale. Although 55% of patients reported no change in breathlessness on the MRC scale following treatment, the mean SAC and interview TDI scores were increased by 1.0 +/- 2.4 and 1.4 +/- 2.5, respectively, in these same patients. CONCLUSIONS: Both versions of the BDI and the MRC scale showed concurrent validity at the initial visit. The SAC TDI demonstrated responsiveness to standard therapy that was comparable with the findings of the interview TDI, but was better than that recorded with the MRC scale. The advantages of the SAC TDI include a patient-reported score on a continuous scale using computer technology.

The effect of pulmonary rehabilitation on healthcare utilization in chronic obstructive pulmonary disease: The Northeast Pulmonary Rehabilitation Consortium.

Although pulmonary rehabilitation results in improvement in multiple outcome areas, relatively few studies in the United States have evaluated its effect on healthcare utilization. This study compared aspects of healthcare utilization during the year before to the year after outpatient pulmonary rehabilitation in patients with chronic obstructive pulmonary disease referred to 11 hospital-based centers in Connecticut and New York. Utilization data from 128 of 132 patients who originally gave informed consent were evaluated; their mean age was 69 years and their forced expiratory volume in 1 second was 44% of predicted. Forty-five percent had 1 or more hospitalizations in the year before beginning pulmonary rehabilitation. In the year after pulmonary rehabilitation, there were 0.25 fewer total hospitalizations (P = .017) and 2.18 fewer hospital days (P = .015) per patient and 271 fewer hospital days for the group. Hospitalizations for respiratory reasons also decreased significantly. Most of the reduction in hospital utilization was due to a decrease in intensive care unit days. The number of physician visits decreased by 2.4 in the year after pulmonary rehabilitation (P < .0001); most of this reduction was due to decreased visits to primary care providers. The estimated costs/charges for the aspects of healthcare utilization that we studied decreased by a mean of 4,694 dollars and a median of 390 dollars (P = .0002). This study suggests that pulmonary rehabilitation leads to a reduction in healthcare utilization.

Direct clinician-to-patient feedback discussion of inhaled steroid use: its effect on adherence.

STUDY OBJECTIVES: To evaluate whether direct feedback discussion on inhaled steroid use might influence subsequent adherence with this therapy. DESIGN AND SETTING: A 10-week, single-blind, randomized trial in asthma patients. Inclusion criteria included forced expiratory volume in 1 second <80%, one or more markers for low socioeconomic status, and the use of inhaled steroids. Inhaled steroid and beta-agonist use were electronically monitored. All patients received standard asthma care. The treatment group received direct clinician-to-patient feedback discussion on their inhaled steroid and beta-agonist use on all subsequent visits, whereas this information was withheld during the study period in the control group. MEASURES: 1) Mean weekly inhaled steroid adherence [(number of actuations/prescribed number of actuations) x 100]; 2) number of days with overuse of inhaled steroids; 3) 24-hour and nighttime albuterol use; 4) included forced expiratory volume in 1 second; and 5) Asthma Quality of Life Questionnaire total score. RESULTS: Ten treatment and nine control patients completed the study. Mean weekly inhaled steroid adherence over the first week was not significantly different in the treatment and control groups: 61 +/- 9% versus 51 +/- 5%, respectively. However, by the second week, adherence increased to 81 +/- 7% in the treatment group, whereas it decreased to 47 +/- 7% in the control group (P = 0.003). Adherence remained above 70% in the treatment group for the entire trial, but continued to decrease in the control group. Overuse of inhaled steroids was low in both groups. There were no group differences in any of the asthma outcomes. CONCLUSIONS: Direct clinician-to-patient feedback discussion on inhaled steroid use using electronic printouts did improve adherence in the short-term in asthma patients at high-risk for poor adherence.

An evaluation of two approaches to exercise conditioning in pulmonary rehabilitation.

STUDY OBJECTIVES: To compare the effectiveness of two forms of exercise training in pulmonary rehabilitation. DESIGN: A prospective, randomized, unblinded, 8-week trial. SETTING: A hospital-based outpatient pulmonary rehabilitation program. PATIENTS: Forty patients (20 patients in each group) with COPD who were referred for pulmonary rehabilitation. INTERVENTIONS: We compared the short-term effectiveness of a high-intensity, lower-extremity endurance program with a low-intensity, multicomponent calisthenics program for the rehabilitation of patients with COPD. The high-intensity group trained predominately on the stationary bicycle and treadmill, with a goal of exercising at > or = 80% of maximal level determined from incremental testing for 30 min per session. The low-intensity group performed predominately classroom exercises for approximately 30 min per session. For both groups, twice-weekly sessions were held for 8 weeks. The primary outcome measure was health status, measured using the Chronic Respiratory Disease Questionnaire. Other outcomes included peak oxygen consumption on incremental treadmill exercise testing, exertional dyspnea, treadmill endurance time, the number of sit-to-stand repetitions and arm lifts in 1 min, overall dyspnea, and questionnaire-rated functional status. MEASUREMENTS AND RESULTS: Both groups showed significant postrehabilitation improvement in exercise variables, exertional and overall dyspnea, functional performance, and health status. Patients in the high-intensity group showed greater increases in treadmill endurance and greater reductions in exertional dyspnea, whereas those in the low-intensity group showed greater increases in arm-endurance testing. Both groups had similar improvements in overall dyspnea, functional performance, and health status. CONCLUSIONS: Despite differences in exercise performance, both high-intensity, lower-extremity endurance training and low-intensity calisthenics led to similar short-term improvements in questionnaire-rated dyspnea, functional performance, and health status.