Influence of physical activity on the prognosis of COPD patients: the HADO.2 score - health, activity, dyspnoea and obstruction.

Objective: The aim of this study was to create a prognostic instrument for COPD with a multidimensional perspective that includes physical activity (PA). The score also included health status, dyspnoea and forced expiratory volume in 1 s (HADO.2 score). Methods: A prospective, observational, non-intervention study was carried out. Patients were recruited from the six outpatient clinics of the respiratory service of a single university hospital. The component variables of the HADO.2 score and BODE index were studied, and PA was measured using an accelerometer. The outcomes for the HADO.2 score were mortality and hospitalisations during follow-up and an exploration of the correlation with health-related quality of life at the moment of inclusion in the study. Results: 401 patients were included in the study and followed up for three years. The HADO.2 score showed good predictive capacity for mortality: C-index 0.79 (0.72-0.85). The C-index for hospitalisations was 0.72 (0.66-0.77) and the predictive ability for quality of life, as measured by R2, was 0.63 and 0.53 respectively for the Saint George's Respiratory Questionnaire and COPD Assessment Test. Conclusions: There was no statistically significant difference between the mortality predictive capacity of the HADO.2 score and the BODE index. Adding PA to the original BODE index significantly improved the predictive capacity of the index. The HADO.2 score, which includes PA as a key variable, showed good predictive capacity for mortality and hospitalisations. There were no differences in the predictive capacity of the HADO.2 score and the BODE index.

Changes in health-related quality of life as a marker in the prognosis in COPD patients.

Chronic obstructive pulmonary disease (COPD) is understood as a complex, heterogeneous and multisystem airway obstructive disease. The association of deterioration in health-related quality of life (HRQoL) with mortality and hospitalisation for COPD exacerbation has been explored in general terms. The specific objectives of this study were to determine whether a change in HRQoL is related, over time, to mortality and hospitalisation. Overall, 543 patients were recruited through Galdakao Hospital's five outpatient respiratory clinics. Patients were assessed at baseline, and the end of the first and second year, and were followed up for 3 years. At each assessment, measurements were made of several variables, including HRQoL using the St George's Respiratory Questionnaire (SGRQ). The cohort had moderate obstruction (forced expiratory volume in 1 s 55% of the predicted value). SGRQ total, symptoms, activity and impact scores at baseline were 39.2, 44.5, 48.7 and 32.0, respectively. Every 4-point increase in the SGRQ was associated with an increase in the likelihood of death: "symptoms" domain odds ratio 1.04 (95% CI 1.00-1.08); "activity" domain OR 1.12 (95% CI 1.08-1.17) and "impacts" domain OR 1.11 (95% CI 1.06-1.15). The rate of hospitalisations per year was 5% (95% CI 3-8%) to 7% (95% CI 5-10%) higher for each 4-point increase in the separate domains of the SGRQ. Deterioration in HRQoL by 4 points in SGRQ domain scores over 1 year was associated with an increased likelihood of death and hospitalisation.

Cost-effectiveness of a telemonitoring program (telEPOC program) in frequently admitted chronic obstructive pulmonary disease patients.

Chronic obstructive pulmonary disease is a typical disease among chronic and respiratory diseases. The costs associated with chronic disease care are rising dramatically, and this makes it necessary to redesign care processes, including new tools which allow the health system to be more sustainable without compromising on the quality of the care, compared to that currently provided. One approach may be to use information and communication technologies. In this context, we explored the cost-effectiveness of applying a telemonitoring system to a cohort of chronic obstructive pulmonary disease patients with frequent readmissions (the telEPOC programme).We conducted an intervention study with a control group. The inclusion criteria used were having chronic obstructive pulmonary disease (forced expiratory volume in the first second/forced vital capacity < 70%) and having been hospitalised for exacerbation at least twice in the last year or three times in the last 2 years. We estimated the costs incurred by patients in each group and calculated the quality-adjusted life years and incremental cost-effectiveness ratio.Overall, 77 patients were included in the control group and 86 in the intervention group. The raw cost-effectiveness analysis showed that the cost of the telEPOC intervention was significantly lower than that of usual care, while there were no significant differences between the groups in effectiveness.The incremental cost-effectiveness ratio for the intervention was €175,719.71 per quality-adjusted life-year gained.There were no differences between the intervention group (telemonitoring) and the control group (standard care) from the cost-effectiveness point of view. On the other hand, the intervention programme (telEPOC) was less expensive than routine clinical practice.

Predictive factors over time of health-related quality of life in COPD patients.

BACKGROUND: Health-related quality of life (HRQoL) should be seen as a tool that provides an overall view of the general clinical condition of a COPD patient. The aims of this study were to identify variables associated with HRQoL and whether they continue to have an influence in the medium term, during follow-up. METHODS: Overall, 543 patients with COPD were included in this prospective observational longitudinal study. At all four visits during a 5-year follow-up, the patients completed the Saint George's Respiratory Questionnaire (SGRQ), pulmonary function tests, the 6-min walk test (6MWT), and a physical activity (PA) questionnaire, among others measurements. Data on hospitalization for COPD exacerbations and comorbidities were retrieved from the personal electronic clinical record of each patient at every visit. RESULTS: The best fit to the data of the cohort was obtained with a beta-binomial distribution. The following variables were related over time to SGRQ components: age, inhaled medication, smoking habit, forced expiratory volume in one second, handgrip strength, 6MWT distance, body mass index, residual volume, diffusing capacity of the lung for carbon monoxide, PA (depending on level, 13 to 35% better HRQoL, in activity and impacts components), and hospitalizations (5 to 45% poorer HRQoL, depending on the component). CONCLUSIONS: Among COPD patients, HRQoL was associated with the same variables throughout the study period (5-year follow-up), and the variables with the strongest influence were PA and hospitalizations.

COPD classification models and mortality prediction capacity.

OBJECTIVE: Our aim was to assess the impact of comorbidities on existing COPD prognosis scores. PATIENTS AND METHODS: A total of 543 patients with COPD (FEV1 <80% and FEV1/FVC <70%) were included between January 2003 and January 2004. Patients were stable for at least 6 weeks before inclusion and were followed for 5 years without any intervention by the research team. Comorbidities and causes of death were established from medical reports or information from primary care medical records. The GOLD system and the body mass index, obstruction, dyspnea and exercise (BODE) index were used for COPD classification. Patients were also classified into four clusters depending on the respiratory disease and comorbidities. Cluster analysis was performed by combining multiple correspondence analyses and automatic classification. Receiver operating characteristic curves and the area under the curve (AUC) were calculated for each model, and the DeLong test was used to evaluate differences between AUCs. Improvement in prediction ability was analyzed by the DeLong test, category-free net reclassification improvement and the integrated discrimination index. RESULTS: Among the 543 patients enrolled, 521 (96%) were male, with a mean age of 68 years, mean body mass index 28.3 and mean FEV1% 55%. A total of 167 patients died during the study follow-up. Comorbidities were prevalent in our cohort, with a mean Charlson index of 2.4. The most prevalent comorbidities were hypertension, diabetes mellitus and cardiovascular diseases. On comparing the BODE index, GOLDABCD, GOLD2017 and cluster analysis for predicting mortality, cluster system was found to be superior compared with GOLD2017 (0.654 vs 0.722, P=0.006), without significant differences between other classification models. When cardiovascular comorbidities and chronic renal failure were added to the existing scores, their prognostic capacity was statistically superior (P<0.001). CONCLUSION: Comorbidities should be taken into account in COPD management scores due to their prevalence and impact on mortality.

Outcomes of a telemonitoring-based program (telEPOC) in frequently hospitalized COPD patients.

BACKGROUND: The increasing prevalence of chronic diseases requires changes in health care delivery. In COPD, telemedicine appears to be a useful tool. Our objective was to evaluate the efficacy (in improving health care-resource use and clinical outcomes) of a telemonitoring-based program (telEPOC) in COPD patients with frequent hospitalizations. MATERIALS AND METHODS: We conducted a nonrandomized observational study in an intervention cohort of 119 patients (Galdakao-Usansolo Hospital) and a control cohort of 78 patients (Cruces Hospital), followed up for 2 years (ClinicalTrials.gov identifier: NCT02528370). The inclusion criteria were two or more hospital admissions in the previous year or three or more admissions in the previous 2 years. The intervention group received telemonitoring plus education and controls usual care. RESULTS: Most participants were men (13% women), and the sample had a mean age of 70 years, forced expiratory volume in 1 second of 45%, Charlson comorbidity index score of 3.5, and BODE (body mass index, airflow obstruction, dyspnea, and exercise capacity) index score of 4.1. In multivariate analysis, the intervention was independently related to lower rates of hospital admission (odds ratio [OR] 0.38, 95% confidence interval [CI] 0.27-0.54; P<0.0001), emergency department attendance (OR 0.56, 95% CI 0.35-0.92; P<0.02), and 30-day readmission (OR 0.46, 95% CI 0.29-0.74; P<0.001), as well as cumulative length of stay (OR 0.58, 95% CI 0.46-0.73; P<0.0001). The intervention was independently related to changes in several clinical variables during the 2-year follow-up. CONCLUSION: An intervention including telemonitoring and education was able to reduce the health care-resource use and stabilize the clinical condition of frequently admitted COPD patients.

Chronic Obstructive Pulmonary Disease Subtypes. Transitions over Time.

BACKGROUND: Although subtypes of chronic obstructive pulmonary disease are recognized, it is unknown what happens to these subtypes over time. Our objectives were to assess the stability of cluster-based subtypes in patients with stable disease and explore changes in clusters over 1 year. METHODS: Multiple correspondence and cluster analysis were used to evaluate data collected from 543 stable patients included consecutively from 5 respiratory outpatient clinics. RESULTS: Four subtypes were identified. Three of them, A, B, and C, had marked respiratory profiles with a continuum in severity of several variables, while the fourth, subtype D, had a more systemic profile with intermediate respiratory disease severity. Subtype A was associated with less dyspnea, better health-related quality of life and lower Charlson comorbidity scores, and subtype C with the most severe dyspnea, and poorer pulmonary function and quality of life, while subtype B was between subtypes A and C. Subtype D had higher rates of hospitalization the previous year, and comorbidities. After 1 year, all clusters remained stable. Generally, patients continued in the same subtype but 28% migrated to another cluster. Together with movement across clusters, patients showed changes in certain characteristics (especially exercise capacity, some variables of pulmonary function and physical activity) and changes in outcomes (quality of life, hospitalization and mortality) depending on the new cluster they belonged to. CONCLUSIONS: Chronic obstructive pulmonary disease clusters remained stable over 1 year. Most patients stayed in their initial subtype cluster, but some moved to another subtype and accordingly had different outcomes.

Influence of changes in physical activity on frequency of hospitalization in chronic obstructive pulmonary disease.

BACKGROUND AND OBJECTIVE: To evaluate whether changes in regular physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) affect the rate of hospitalizations for COPD exacerbation (eCOPD). METHODS: Five hundred forty-three ambulatory clinic patients being treated for COPD were prospectively identified. PA was self-reported by patients, and the level was established by the distance they walked (km/day) at least 3 days per week. Hospitalizations were recorded from hospital databases. All patients with at least a 2-year follow-up after enrollment were included in the analysis. The response variable was the number of hospitalizations for eCOPD within the 3-year period from 2 to 5 years after study enrollment. RESULTS: Three hundred ninety-one survivors were studied. Mean forced expiratory volume in 1 s was 52% (±14%) of the predicted value. Patients who maintained a lower level of PA had an increased rate of hospitalization (odds ratio 1.901; 95% confidence interval 1.090-3.317). After having had the highest level of PA, those patients who decreased their PA in the follow-up showed an increasing rate of hospitalizations (odds ratio 2.134; 95% confidence interval 1.146-3.977). CONCLUSIONS: Patients with COPD with a low level of PA or who reduced their PA over time were more likely to experience a significant increase in the rate of hospitalization for eCOPD. Changes to a higher level of PA or maintaining a moderate or high level of PA over time, with a low intensity activity such as walking for at least 3-6 km/day, could reduce the rate of hospitalizations for eCOPD.

The health, activity, dyspnea, obstruction, age, and hospitalization: prognostic score for stable COPD patients.

UNLABELLED: Multidimensional instruments for determining the severity and prognosis of chronic obstructive pulmonary disease (COPD) must be used in daily clinical practice. OBJECTIVE: To develop and validate a new COPD severity score using variables readily obtained in clinical practice and to compare its predictive capacity with that of other multidimensional indexes. Data collected from a prospective cohort of 611 stable COPD patients were used to derive a clinical prediction rule that was later validated in a separate prospective cohort of 348 patients. In the multivariate analyses, six independent predictive factors were correlated with overall and respiratory mortality: health status, physical activity, dyspnea, airway obstruction (FEV(1)), age, and hospitalizations for COPD exacerbations in the previous two years. These create the HADO-AH score. Based on the ß parameter obtained in the multivariate model, a score was assigned to each predictive variable. The area under the curve for 5-year mortality was 0.79 (95% CI, 0.74-0.83) in the derivation cohort and 0.76 (95% CI, 0.71-0.81) in the validation cohort. The HADO-AH score was a significantly better predictor of mortality than the HADO-score and the Body-mass index, Obstruction, Dyspnea, Exercise-index were statistically significant (p < 0.0004 and p = 0.021, respectively), but was similar to the Age, Dyspnea, and Obstruction-index (p = 0.345). The HADO-AH score provides estimates of all-cause and respiratory mortality that are equal to, or better than, those of other multidimensional instruments. Because it uses only easily accessible measures, it could be useful at all levels of care.

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.

Impact of hospitalisations for exacerbations of COPD on health-related quality of life.

Exacerbations of chronic obstructive pulmonary disease (COPD) impair health-related quality of life (HRQoL). It is unknown whether exacerbations requiring hospitalisation have an impact on HRQoL. 611 ambulatory COPD patients were prospectively identified. The average age (SD) was 65.5 (8.6), FEV(1) (SD) was 52% (14%) of the predicted value. All patients completed the Saint George's Respiratory Questionnaire (SGRQ) and the Medical Outcomes Study Short Form (SF-36) questionnaire at the beginning of the study. After five years of follow-up, the 391 survivors again completed these HRQoL instruments. No changes in HRQoL were observed among patients not hospitalised for COPD exacerbations. Those hospitalised during follow-up experienced significant declines in HRQoL. The largest changes were observed among patients with >or=3 hospitalisations, with a 13.6 unit increase in the total SGRQ and a 10.5 unit decrease in the physical component summary scale of the SF-36. Similar changes were observed among patients with FEV(1)>or=50% at baseline. In the multivariate analysis, after adjustment by FEV(1%), age, comorbidities, and HRQoL in the respective HRQoL domain at baseline, hospitalisations were an independent predictor of the change in HRQoL. Hospitalisations for exacerbations of COPD have an independent and negative impact on the evolution of HRQoL, regardless of COPD severity.

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.

Use of medication and quality of life among patients with COPD.

STUDY OBJECTIVES: To determine the medications prescribed to patients with chronic obstructive pulmonary disease (COPD) and their relationship to health-related quality of life (HRQL). METHODS: Cross-sectional study of 611 consecutive patients with stable, mild-to-severe COPD who attended at the respiratory service of a single hospital during a 1-year period. HRQL was evaluated using the St. George Respiratory Questionnaire (SGRQ) and the Short Form 36-item (SF-36) questionnaires. Linear regression analysis was used to determine the influence of the number or type of medication on the total SGRQ score, adjusting by disease severity and other relevant variables. RESULTS: Significant differences were observed among the number of drugs prescribed according to dyspnea levels, percentage of predicted FEV1 (FEV1%), SGRQ scores and some areas of SF-36. Fifty-nine percent of patients with an FEV1%>50% were prescribed inhaled corticosteroids (ICS). Those who took an ICS had a worse HRQL than patients with an FEV1%>50% who did not receive ICS. CONCLUSIONS: A relationship exists between the number of medicines prescribed to patients with COPD and their HRQL, measured by the total SGRQ score, after adjustment by severity of the disease. Within the group of patients who should not have been prescribed ICS, there are subgroups that might benefit from this medication.