Control of COPD Symptoms: Addressing an Unmet Need

Introduction

Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable disease characterized by persistent and often progressive airflow limitation, and it is the fourth leading cause of death worldwide.¹ COPD prevalence data show wide variations due to differences in assessment methodology, diagnostic criteria, and analytic approaches, with evidence suggesting widespread underdiagnosis of COPD.^2,3 Symptoms of COPD, including dyspnea, cough, sputum production, and exacerbations, although important to the assessment and management of the disease, are similarly underreported.⁴ This is particularly concerning because of the link between insufficient COPD symptom control and decreased physical activity, which is associated with increased morbidity and mortality and serious psychological effects, such as anxiety and depression.^1,5,6

Underreporting and underdiagnosis may suggest that discordance between patients’ and physicians’ perceptions of COPD control exists, possibly stemming from patients’ inadequate description of their symptoms and the physicians’ challenges in discovering subacute respiratory symptoms during patient visits, both of which hinder the accurate assessment of COPD symptoms.⁷ Improved patient-physician communication, which hinges to some extent on the physician asking the right questions, can help ensure a thorough assessment of the patient’s COPD control and/or symptoms. Improved communication is also associated with more positive patient perceptions of quality of care, increased patient confidence in dealing with breathing problems, and adherence to treatment,^8-10 without necessarily adding time to the respiratory-related primary care office visit.^11,12 The aim of this newsletter, therefore, is to discuss the contributors to discordance between physicians and patients regarding COPD and areas for improvement in patient-physician communication around COPD symptoms and/or control. In addition, this newsletter provides a guide to more focused COPD assessment tools that could complement lung function assessments and improve COPD management in primary care practice.

Patient and Physician Perceptions of COPD Control

In addition to objective measurements of lung function, a chief component of COPD assessment is the patient’s self-reporting of his/her symptoms during an office visit. Unfortunately, studies in patients with stable COPD have shown that changes in health status assessed by several questionnaires (eg, St. George’s Respiratory Questionnaire [SGRQ] and Chronic Respiratory Disease Questionnaire) worsened over time, but correlated poorly with changes in physiological indices (eg, forced expiratory volume in 1 second [FEV₁]), highlighting the importance of evaluating patient-reported outcomes in COPD.⁷ This presents potential challenges for the family physician.

First, patients often have difficulty describing their disease burden, and they tend to understate their disease severity and underreport COPD exacerbations, and do not convey the impact of the disease on their quality of life.^4,13 Moreover, they may only report if the symptoms of their condition have significantly increased or may not adequately recognize when their symptoms deteriorate.^4,7 Patients may also self-limit their physical activity to avoid the discomfort associated with dyspnea during exertion,¹⁴ which can presumably skew the perceived severity of their symptoms. Indeed, effective management of COPD requires recognition of multiple effects (dyspnea, onset of exacerbations, and decrements in health status), and patients may have undiscussed fears or concerns.^4,15 In addition, patients’ illness beliefs (eg, before receiving pulmonary rehabilitation) may influence outcomes, suggesting the importance of identifying and addressing negative views and misconceptions as early as possible.¹⁶

Second, different patient groups tend to perceive and report elements of their disease differently. Older adults with chronic lung disease are less likely to report significant impairment than their younger counterparts, suggesting that they may perceive less limitation.¹⁷ Gender differences have also been observed in patients with COPD and dyspnea, suggesting that women are more likely to express their symptoms, whereas men may minimize them.¹⁸

Discordance between physician and patient perceptions of COPD control may be an additional barrier to providing effective long-term care for patients. In general, patients and physicians agree that factors such as breathlessness, cough, and fatigue are the major criteria that predict the level of COPD control in patients.¹⁹ However, only 53% of pulmonologists could identify the specific symptom that affected their patient the most.¹⁹ When subjective symptoms (eg, anxiety, fatigue, and nervousness) are the patient’s primary area of concern, they are more difficult for a physician to identify, compared with cases in which more critical symptoms (eg, wheezing, cough, and breathlessness) are a patient’s major complaint.¹⁹ These findings underscore the need for acquiring patient-physician communication skills, including enhanced listening and nonverbal attentiveness, which have been positively associated with improved quality of care.⁸

Improved communication is an obvious first step toward effective patient education and improved treatment adherence. Patients should have a clear understanding of the need for their treatment, with personalized information that takes into account their specific concerns, and easy access to treatment.²⁰ Physicians list poor inhaler technique, patient difficulties managing multiple dosing regimens, lack of perceived treatment benefits, and cost of treatment as the main contributors to treatment noncompliance and, therefore, poor disease control.¹⁵ Standardized questions can help the physician to effectively and efficiently assess the patient’s range of symptoms. Shared decision-making approaches that encourage physicians to facilitate a more open dialogue regarding respiratory disease management can lead to improved outcomes as well.¹⁰

The results of a survey conducted at the Veterans Administration in Washington state offered insight on how a good physician-patient partnership represents a starting point for a successful management in respiratory disease populations.⁸ High-quality communication between patients and clinicians, as assessed with the Quality of Communication instrument, was associated with better quality of care and increased patient confidence in dealing with breathing problems.⁸ Specific communication attributes having the highest correlation with improved breathing outcome included listening, caring, and attentiveness. The association between general communication and clinician quality care increased the longer the duration of the patient-clinician relationship.⁸ Further to this point, patients who visit their primary care physician for regular COPD control have better perception of the health care system in general and are more likely to think that their health care is well organized.²¹

Questionnaires using precise, but uncomplicated, language that aid patients in communicating with physicians can also help physicians pinpoint severity of disease.⁴ For example, the typical patient is likely to use terms such as “good” and “bad” days to describe how their health-related quality of life is affected by COPD, so simpler self-reporting tools help the patients express specifically how COPD affects them and the intensity of their symptoms.⁴ Additionally, when practitioners focus on single symptoms (eg, dyspnea), patient-reported scores predicted lung function with more reliability.²² In a study of 101 patients with stable COPD, patients were tested initially and at 3-month follow-up; lung function was evaluated by spirometry and inspiratory capacity for each patient, and patients completed dyspnea questionnaires (mMRC, baseline dyspnea index, transition dyspnea index, and University of California, San Diego Shortness of Breath Questionnaire).²² Test-retest reliability was acceptable for the correlation between lung function (FEV₁) and results of the 3 dyspnea-specific questionnaires. The authors concluded that patient-reported dyspnea assessed by the questionnaires used was a reliable way to predict and manage the course of COPD.²²

COPD Assessment Tools

A wide variety of COPD assessment tools have been proposed and tested. Choosing the ideal COPD assessment tool is fairly subjective and may depend on which tools are readily available to health care providers. The 4 most widely used tools are described in Table 1^1,23-27 and below.

In the mMRC questionnaire, dyspnea is graded on a 0 to 4 scale, ranging from breathlessness only with strenuous exercise (score of 0) to being too breathless to leave the house or breathlessness when dressing (score of 4), where a score of ≥2 is considered an adequate threshold separating “less breathlessness” from “more breathlessness.”^1,24 By itself, however, this measure may be inadequate to assess the entirety of symptomatic effects of COPD.²³

The COPD Assessment Tool (CAT) is an 8-item measure of COPD-related health status impairment with a score ranging from 0 to 40, where higher scores indicate worse symptoms, and a score of 10 indicates the level at which the average patient with COPD would benefit from regular treatment for symptoms, including breathlessness.¹ CAT was developed specifically for use in routine clinical practice and is considered a reliable measure of COPD severity from the patient perspective, with worldwide applicability.^23,28 It also correlates well with SGRQ results, despite the differences in complexity between the 2.¹

The Clinical COPD Questionnaire (CCQ) is a self-administered questionnaire that gauges clinical control in COPD based on the frequency of 10 items, such as feeling short of breath or producing phlegm, each scored on a scale of 0 (never) to 6 (almost all the time); it includes entries on emotional function and disease-related limitations.^1,26,29 The CCQ was developed to address the need for a simple tool to evaluate the clinical status of the airways and patient health status.³⁰

Finally, the SGRQ is a standardized questionnaire composed of 50 items that cover respiratory symptoms, impact of breathlessness, and impact on social functioning and psychological health.^23,31 Scoring ranges from 0 to 100 with a higher score indicating more limitation.²³ It is widely used in clinical trials and correlates well with the CAT (as mentioned above), but is generally considered too complex for routine use.^1,23

Although each questionnaire has its merits, the CAT and CCQ were both developed for use in routine clinical practice and may be particularly well suited to family practice because they are completed within only a few minutes, can be used for baseline evaluations to inform treatment decisions, and guide the general practitioner on when to refer patients for evaluation by a pulmonary specialist.²³ Because these assessments provide comprehensive information for a range of COPD symptoms, they may help a physician to determine whether a primary care setting is appropriate or sufficient to adequately address a patient’s needs vs, for example, a specialized pulmonary care setting.

Additional clinical scales are available for assessing individual aspects of COPD disease (eg, dyspnea), which can complement the above COPD management tools.²⁴ Similarly, composite scores, including the body mass index, obstruction, dyspnea, and exercise (BODE) method,³² are becoming more widely available, but still require validation to determine their applicability for clinical use.¹

Impact of Uncontrolled Symptoms and/or Dyspnea on Psychological and Physical Well-being

Chronic respiratory symptoms, which constitute risk factors for poor health-related quality of life and a decrease in physical activity, are relatively common in patients with COPD.³³ The consequences of reduced activity levels are significant and associated with COPD progression. Decreased physical activity is accompanied by worsening lung function and health status, and sustained physical inactivity is associated with progressive exercise intolerance and muscle wasting.³⁴ The resulting decrease in physical activities is associated with increased morbidity and mortality.³⁴

Uncontrolled COPD also has detrimental psychological effects including depression, anxiety, and negative emotions. In a study conducted in 1589 patients over a 3-year period, approximately one in 4 patients with COPD had persistent depressive symptoms.³⁵ Increasing dyspnea and poor clinical control are also associated with anxiety and depression in COPD.³⁶ Poor sleep in patients with COPD increases levels of depression and anxiety, and decreases exercise capacity results on the 6-minute walk distance test.³⁷ Using Hospital Anxiety and Depression Scale scores, another study found that 20% of patients had anxiety and 26% had probable anxiety.³⁸ Anxiety and dyspnea-related fear were associated with higher baseline dyspnea ratings in patients with COPD, which are correlated with prospective decreases in health-related quality of life.^39,40 Suicidal ideation in patients with COPD is common, particularly in women, and may persist despite treatment.⁴¹ Therefore, it is important to assess for these psychological comorbidities and address the patient’s needs through medication and/or referral to professionals who can provide psychological treatment.

Treatments to Manage Symptoms and Promote Activity

The chief goals of treatments for COPD are to reduce current symptoms and future disease-related risks. Both pharmacologic and nonpharmacologic approaches are recommended for the management of stable COPD (Table 2).¹ The most appropriate pharmacologic treatment depends on the Global Initiative for Chronic Obstructive Lung Disease category that best describes the impact of COPD on an individual patient. This can be assessed by combining information about the patient’s (1) severity of airflow limitation (measured by FEV₁% predicted); (2) COPD-related symptoms (eg, as measured by CAT) or breathlessness (eg, as measured by mMRC); and (3) exacerbation risk (Table 2).¹ Smoking cessation is considered the key intervention for all COPD patients who continue to smoke, regardless of their disease severity. Pharmacotherapies, including nicotine-replacement products and prescription medications, have been shown to increase long-term smoking abstinence and quit rates, respectively.¹ Nonpharmacologic approaches include counseling on smoking cessation, increased physical activity, and influenza and pneumococcus vaccinations for all patients. Pulmonary rehabilitation is also recommended for patients who become dyspneic when walking at their own pace on level ground, as it can improve COPD symptoms, physical and emotional participation in everyday activities, and quality of life.¹

Conclusions

Several factors contribute to the discordance between patients’ and physicians’ perceptions of COPD control, which can result in a lack of accurate assessment of the symptom level and, possibly, noncompliance to treatment. Indeed, insufficient COPD symptom control is associated with decreased physical activity and, therefore, increased morbidity and mortality, as well as serious psychological effects. Therefore, proper communication between patient and physician is critically important as it is associated with more positive perceptions of quality of care, increased patient confidence in dealing with the disease, and improved adherence to treatment. Toward this goal, widely available COPD assessment tools and questionnaires, including CAT, CCQ, mMRC, and SGRQ, can provide an accurate assessment of COPD symptoms and control, which can then assist with determining when specialist care is needed.

References

1. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of COPD—2016. https://www.goldcopd.org. Accessed February 24, 2016.
2. Halbert RJ, Natoli JL, Gano A, Badamgarav E, Buist AS, Mannino DM. Global burden of COPD: systematic review and meta-analysis. Eur Respir J. 2006;28(3):523-532.
3. van den Boom G, van Schayck CP, van Möllen MP, et al. Active detection of chronic obstructive pulmonary disease and asthma in the general population. Results and economic consequences of the DIMCA program. Am J Respir Crit Care Med. 1998;158(6):1730-1738.
4. Jones PW, Price D, van der Molen T. Role of clinical questionnaires in optimizing everyday care of chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2011;6:289-296.
5. Maurer J, Rebbapragada V, Borson S, et al; Workshop Panel on Anxiety and Depression in COPD. Anxiety and depression in COPD: current understanding, unanswered questions, and research needs. Chest. 2008;134(4 suppl):43S-56S.
6. Waschki B, Kirsten A, Holz O, et al. Physical activity is the strongest predictor of all-cause mortality in patients with COPD: a prospective cohort study. Chest. 2011;140(2):331-342.
7. Oga T, Nishimura K, Tsukino M, Sato S, Hajiro T, Mishima M. Longitudinal deteriorations in patient reported outcomes in patients with COPD. Respir Med. 2007;101(1):146-153.
8. Slatore CG, Cecere LM, Reinke LF, et al. Patient-clinician communication: associations with important health outcomes among veterans with COPD. Chest. 2010;138(3):628-634.
9. Blais L, Bourbeau J, Sheehy O, LeLorier J. Inhaled corticosteroids in COPD: determinants of use and trends in patient persistence with treatment. Can Respir J. 2004;11(1):27-32.
10. Wilson SR, Strub P, Buist AS, et al; Better Outcomes of Asthma Treatment (BOAT) Study Group. Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. Am J Respir Crit Care Med. 2010;181(6):566-577.
11. Clark NM, Gong M, Schork MA, et al. Impact of education for physicians on patient outcomes. Pediatrics. 1998;101(5):831-836.
12. Brown R, Bratton SL, Cabana MD, Kaciroti N, Clark NM. Physician asthma education program improves outcomes for children of low-income families. Chest. 2004;126(2):369-374.
13. Langsetmo L, Platt RW, Ernst P, Bourbeau J. Underreporting exacerbation of chronic obstructive pulmonary disease in a longitudinal cohort. Am J Respir Crit Care Med. 2008;177(4):396-401.
14. ZuWallack R. How are you doing? What are you doing? Differing perspectives in the assessment of individuals with COPD. COPD. 2007;4(3):293-297.
15. Menezes AM, Landis SH, Han MK, et al. Continuing to confront COPD International Surveys: comparison of patient and physician perceptions about COPD risk and management. Int J Chron Obstruct Pulmon Dis. 2015;10:159-172.
16. Zoeckler N, Kenn K, Kuehl K, Stenzel N, Rief W. Illness perceptions predict exercise capacity and psychological well-being after pulmonary rehabilitation in COPD patients. J Psychosom Res. 2014;76(2):146-151.
17. Berry CE, Han MK, Thompson B, et al. Older adults with chronic lung disease report less limitation compared with younger adults with similar lung function impairment. Ann Am Thorac Soc. 2015;12(1):21-26.
18. Watson L, Vestbo J, Postma DS, et al. Gender differences in the management and experience of chronic obstructive pulmonary disease. Respir Med. 2004;98(12):1207-1213.
19. Miravitlles M, Ferrer J, Baró E, Lleonart M, Galera J. Differences between physician and patient in the perception of symptoms and their severity in COPD. Respir Med. 2013;107(12):1977-1985.
20. Horne R, Chapman SC, Parham R, Freemantle N, Forbes A, Cooper V. Understanding patients' adherence-related beliefs about medicines prescribed for long-term conditions: a meta-analytic review of the Necessity-Concerns Framework. PLoS One. 2013;8(12):e80633.
21. Bjørnholt Nielsen P, Witzel S. Regular control at the general practitioner is positively correlated with patient satisfaction with chronic care management. Dan Med J. 2016;63(3):A5200.
22. Mahler DA, Ward J, Waterman LA, McCusker C, Zuwallack R, Baird JC. Patient-reported dyspnea in COPD reliability and association with stage of disease. Chest. 2009;136(6):1473-1479.
23. Jones PW, Watz H, Wouters EF, Cazzola M. COPD: the patient perspective. Int J Chron Obstruct Pulmon Dis. 2016;11(Spec Iss):13-20.
24. Crisafulli E, Clini EM. Measures of dyspnea in pulmonary rehabilitation. Multidiscip Respir Med. 2010;5(3):202-210.
25. American Thoracic Society. COPD assessment test (CAT). https://www.thoracic.org/members/assemblies/assemblies/srn/questionaires/copd.php. Last Reviewed June 2016. Accessed August 16, 2016.
26. Kon SS, Dilaver D, Mittal M, et al. The Clinical COPD Questionnaire: response to pulmonary rehabilitation and minimal clinically important difference. Thorax. 2014;69(9):793-798.
27. Jones PW. St. George’s Respiratory Questionnaire: MCID. COPD. 2005;2(1):75-79.
28. Jones PW, Harding G, Berry P, Wiklund I, Chen WH, Kline Leidy N. Development and first validation of the COPD Assessment Test. Eur Respir J. 2009;34(3):648-654.
29. Reda AA, Kotz D, Kocks JW, Wesseling G, van Schayck CP. Reliability and validity of the clinical COPD questionnaire and chronic respiratory questionnaire. Respir Med. 2010;104(11):1675-1682.
30. van der Molen T, Willemse BW, Schokker S, ten Hacken NH, Postma DS, Juniper EF. Development, validity and responsiveness of the Clinical COPD Questionnaire. Health Qual Life Outcomes. 2003;1:13.
31. Jones PW, Quirk FH, Baveystock CM, Littlejohns P. A self-complete measure of health status for chronic airflow limitation. The St. George's respiratory questionnaire. Am Rev Respir Dis. 1992;145(6):1321-1327.
32. Sarkar SK, Basuthakur S, Das SK, et al. Evaluation of correlation of BODE index with health-related quality of life among patients with stable COPD attending a tertiary care hospital. Lung India. 2015;32(1):24-28.
33. Wheaton AG, Ford ES, Thompson WW, Greenlund KJ, Presley-Cantrell LR, Croft JB. Pulmonary function, chronic respiratory symptoms, and health-related quality of life among adults in the United States--National Health and Nutrition Examination Survey 2007-2010. BMC Public Health. 2013;13:854.
34. Waschki B, Kirsten AM, Holz O, et al. Disease progression and changes in physical activity in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2015;192(3):295-306.
35. Yohannes AM, Müllerová H, Hanania N, et al. Long-term course of depression trajectories in patients with COPD: a 3-year follow-up analysis of the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints cohort. Chest. 2016;149(4):916-926.
36. Borges-Santos E, Wada JT, da Silva CM, et al. Anxiety and depression are related to dyspnea and clinical control but not with thoracoabdominal mechanics in patients with COPD. Respir Physiol Neurobiol. 2015;210:1-6.
37. Chen R, Tian JW, Zhou LQ, et al. The relationship between sleep quality and functional exercise capacity in COPD. Clin Respir J. 2016;10(4):477-485.
38. Parreira VF, Kirkwood RN, Towns M, et al. Is there an association between symptoms of anxiety and depression and quality of life in patients with chronic obstructive pulmonary disease? Can Respir J. 2015;22(1):37-41.
39. Janssens T, De Peuter S, Stans L, et al. Dyspnea perception in COPD: association between anxiety, dyspnea-related fear, and dyspnea in a pulmonary rehabilitation program. Chest. 2011;140(3):618-625.
40. Blakemore A, Dickens C, Guthrie E, et al. Depression and anxiety predict health-related quality of life in chronic obstructive pulmonary disease: systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis. 2014;9(1):501-512.
41. Fleehart S, Fan VS, Nguyen HQ, et al. Prevalence and correlates of suicide ideation in patients with COPD: a mixed methods study. Int J Chron Obstruct Pulmon Dis. 2014;9(1):1321-1329.