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P34 The minimal clinically important difference of the COPD assessment test

Background The COPD (chronic obstructive pulmonary disease) assessment test (CAT) is a simple 8-item, health status instrument (Jones PW et al 2009). It has good psychometric properties and has been shown to be responsive to pulmonary rehabilitation (PR) (Dodd et al 2011) and recovery from exacerbation (Jones PW et al 2011). The CAT has also recently been incorporated into the Global Initiative for Chronic Obstructive Lung Disease (GOLD) combined assessment of COPD, to help assess disease severity. However the minimal clinically important difference (MCID) for the CAT has not been formally established. Aims The aims of this study were to assess the relationship between change in CAT and change in other health related quality of life (HRQoL) questionnaires and to provide estimates for the MCID. Methods The CAT, St. George’s Respiratory Questionnaire (SGRQ), Chronic Respiratory Questionnaire (CRQ) and Clinical COPD Questionnaire (CCQ) were measured in 565 COPD patients before and after outpatient PR. Paired t tests were used to compare outcomes before and after PR. Spearman rank correlation was used to compare changes in CAT with other HRQoL questionnaires. Using an anchor-based approach and receiver operating characteristic (ROC) curves, the CAT change cut-offs that identified patients achieving the known MCID for other health status questionnaires with PR were identified. Results The CAT, SGRQ, CRQ and CCQ all significantly improved with PR. CAT change correlated significantly with change in SGRQ, CRQ and CCQ (r = 0.30, -0.44, 0.52 respectively; all p < 0.001). ROC curves consistently identified -2 points as the best cut-off to identify the MCID for the SGRQ (-4 points), CRQ (10 points) and CCQ (-0.4 points) (AUC: 0.65, 0.77 and 0.74 respectively; all p < 0.001–see Fig.1). Abstract P34 Figure 1. Conclusion The minimal clinically improvement of the CAT is estimated to be a 2 point decrease.

S95 Effect of pulmonary rehabilitation on cardiovascular risk factors in COPD

Background Cardiovascular disease accounts for 27% of excess mortality seen in patients with chronic obstructive pulmonary disease (COPD). This may be attributed to the coexistence of cardiovascular risk factors such as smoking exposure and physical inactivity. Increased arterial stiffness has been demonstrated in patients with COPD, and this is an independent predictor of adverse cardiovascular events. Recent studies have shown that pulmonary rehabilitation (PR) can reduce blood pressure and arterial stiffness in COPD patients (Vivodtzev et al, 2009; Gale et al, 2011). However these studies comprised small numbers of highly selected patients. We investigated the effect of PR on resting blood pressure and heart rate in an unselected COPD population. Methods 179 consecutive COPD patients completing an 8-week outpatient pulmonary rehabilitation programme were recruited. Resting blood pressure, heart rate, incremental shuttle walk (ISW) and Chronic Respiratory Disease Questionnaire (CRDQ) were measured immediately before and after PR. Paired t test (or non-parametric equivalent) was used to test the effect of PR. Results Following PR, there was no significant change in systolic, diastolic, mean arterial pressure and heart rate in all patients with COPD, although ISW and CRDQ improved significantly (see Abstract S95 table 1). Subset analysis in 124 COPD patients with no coexisting cardiovascular disease, diabetes or malignancy, and 31 patients with known hypertension also showed no significant change in blood pressure or heart rate.Abstract S95 Table 1 Effect of PR on haemodynamic variables in patients with COPD Before PR mean After PR mean Mean difference (95% CI) p Value Systolic BP (mm Hg) 138.7 138.6 −0.0(−2.7 to 2.6) ns Diastolic BP (mm Hg) 86.2 86.0 −0.1 (−10.8 to 1.6) ns MAP (mm Hg) 103.7 103.6 −0.1 (−1.8 to 1.6) ns Heart rate (bpm) 81.8 80.8 −1.0 (−2.7 to 0.6) ns ISWT (m) 203.4 262.6 60.5 (48.6 to 72.5) <0.0001 CRDQ 74.5 91.2 16.7 (13.9 to 19.5) <0.0001 Conclusions An 8-week outpatient PR programme has no effect upon resting heart rate or blood pressure in unselected patients with COPD.

S109 Five-Repetition Sit-To-Stand Test: Reliability, Validity and Response to Pulmonary Rehabilitation in COPD

Background Validated field exercise tests, such as the six minute walk test and incremental/endurance shuttle walks, require space and may be time-consuming as repeat walks are needed due to learning effect. Hence they are rarely used outside the research or pulmonary rehabilitation (PR) setting. The five-repetition Sit to Stand test (STS) is a simple test that is feasible in most settings. It measures the quickest time taken to stand and sit five times from a chair, with arms folded. We hypothesized that the STS would be reliable, correlate with the incremental shuttle walk (ISW), and be responsive to PR. Methods The STS was measured in 80 COPD patients on two occasions 24–48 hours apart. Test-retest reliability was calculated using ICCs. STS and ISW were measured in a convenience sample of 396 COPD patients (Mean (SD) age 69 (10); FEV1%predicted 47 (20); ISW 202 (141)) recruited from hospital outpatient clinics. Spearman rank correlation was used to evaluate the relationship between STS and ISW. The STS was measured before and after an 8-week outpatient PR programme in 168 COPD patients. Paired t-tests were used to compare pre- and post-PR outcomes. Results The STS demonstrated excellent test-retest reliability with an ICC value of 0.99 with no learning effect. A significant correlation was seen between STS and ISW (rho = –0.68; p<0.001). The STS improved significantly following PR (Pre: 20.91 (16.23) versus Post: 17.87 (14.93) seconds; 95% confidence interval –1.5 to –4.6 seconds; p<0.001). Conclusions The STS is reliable, correlates with the incremental shuttle walk, and is responsive to PR in patients with COPD. The STS is a practical functional outcome measure suitable for use in most healthcare settings.

P43 Patients’ experiences of early post-hospitalisation pulmonary rehabilitation: A quality improvement initiative

Background Early post-hospitalisation pulmonary rehabilitation (PR) following acute exacerbation of COPD (AECOPD) improves health-related quality of life, increases exercise capacity and reduces rate of hospital readmission. However, only a minority of eligible patients are referred to or receive this intervention (Jones et al Thorax 2013). We explored patient acceptability for post-AECOPD PR and the referral process through face-to-face audio- and video-taped interviews. Methods Ten patients were interviewed using experience based co-design (EBCD) methodology: six PR “completers”, one PR starter who subsequently withdrew, and 3 patients who declined PR. The films were analysed and edited to represent the common themes. A patient-staff event was held to co-design a patient information leaflet and video. Results Overall, the patient completers were positive about their experience. They most liked: the atmosphere; the equipment; group social interaction; doing more exercise than they thought they could; learning how to manage their lung condition. They least liked: getting there; being ‘shattered’ afterwards; no tea and coffee break; no introductions. For patients who declined, the reasons given were: “I don’t know what rehab is …… no-one has explained it”; “I was never offered rehab”; “It is too far away- I would go if transport was paid for.” A recurring theme was that patients had poor recall of information provided during hospital admission. Conclusion The findings highlighted the complexity of interactions between patient and healthcare professionals. In response to this, an information leaflet and video are being produced using the filmed interviews and feedback from the patient staff co-design event to facilitate the referral process. The best timing and delivery of patient information is currently being evaluated. Other themes were improving PR accessibility and enhancing social aspects of PR. Two new community sites were opened to provide wider coverage of the borough andrefreshments are now offered routinely during education classes. Furthermore, patients and staff are introduced to each other routinely at the beginning of PR classes. 159 referrals for post-AECOPD PR have been made in the past 18 months and patient satisfaction rates are 98%. The EBCD approach was ideal in engaging patients in the co-design of service improvements.

P100 The Clinical COPD Questionnaire: Response to Pulmonary Rehabilitation

Background The Clinical COPD Questionnaire (CCQ) is a 10-item health status instrument which has been shown to be reliable and valid in COPD. It takes only two minutes to complete and is simple to score, ranging from 0 (best) – 6 (worst health status). A change in the total CCQ score of 0.4 or more is considered clinically significant (Kocks et al Respir Res 2006). There is a relative paucity of data assessing the responsiveness of the CCQ to pulmonary rehabilitation (PR). We hypothesised that the CCQ would be responsive to PR and that changes would correlate with changes in other well established health status instruments (Chronic Respiratory Questionnaire: CRQ, St George’s Respiratory Questionnaire: SGRQ and the COPD Assessment Test: CAT). Methods 75 consecutive COPD patients referred to an 8-week outpatient PR programme were recruited. The CCQ, along with the CRQ, SGRQ, CAT, and incremental shuttle walk (ISW), were measured before and after PR. Paired t-test was used to compare outcomes before and after PR, whilst Spearman’s rank correlation was used to assess association between change in CCQ with change in other health status questionnaires. Results 53 patients completed PR. Baseline characteristics were 33 Male:20 Female, mean (standard deviation) age 68.5(9.9) years, FEV1% predicted 58 (27) and ISW 224 (178) metres. There was a significant reduction (improvement) in CCQ following PR (Pre: 2.9 (1.3) versus Post: 2.1 (1.2); 95% confidence interval –0.4 to –1.0). Significant improvements were also seen in ISW, CRQ domains, SGRQ and CAT with PR. Changes in CCQ correlated significantly with changes in the other health status instruments (see table 1). Abstract P100 Table 1 Relationship between change in CCQ and change in CRQ, SGRQ and CAT with PR Δ = Change in PR ΔCCQ Rho p-value ΔCRQ Dyspnoea -0.44 0.001 ΔCRQ Fatigue -0.44 0.001 ΔCRQ Emotion -0.34 0.01 ΔCRQ Mastery -0.46 <0.001 ΔSGRQ Symptoms 0.42 0.005 ΔSGRQ Activities 0.59 <0.001 ΔSGRQ Impact 0.60 <0.001 ΔSGRQ Total 0.65 <0.001 ΔCAT 0.64 <0.001 Conclusion The CCQ is responsive to PR and a practical alternative to longer-established health status instruments.

P106 Validity of the Clinical COPD Questionaire (CCQ) in Non-COPD Patients

Background The Clinical COPD Questionnaire (CCQ) is a 10-item health status instrument that takes only two minutes to complete, and has been shown to be reliable and valid in patients with COPD (van der Molen T et al 2003, Damato S et al 2005). In COPD patients, the CCQ correlates with established health status instruments such as the Chronic Respiratory Disease Questionnaire (CRQ), COPD Assessment Test (CAT) and St George’s Respiratory Questionnaire (SGRQ) (Tsiligianni IG et al 2012). Although the CRQ and SGRQ were originally developed in patients with chronic airway obstruction, they are commonly used in clinical practise in chronic respiratory diseases other than COPD. We hypothesised that the CCQ would correlate with existing health status measures and exercise capacity in a survey of non-COPD patients Methods 60 patients were recruited from respiratory outpatient clinics. Disease classifications included interstitial lung disease (n=23), asthma (n=10), bronchiectasis (n=17), extrathoracic restriction (n=8) and thoracic surgery for lung cancer (n=2). CCQ, CAT, CRQ, SGRQ and incremental shuttle walk (ISW) were recorded. Spearman’s rank correlation was used to assess the relationship between CCQ and other outcome measures. Results Baseline characteristics are presented as mean (standard deviation) or median (25th, 75th percentiles); Age 65 (58, 77), FEV1% predicted 69.8 (24.4), BMI 28.0 (25.4, 32.3), MRC 3(1), CCQ 2.1 (1.5, 3.8) and ISW 210 (90, 320). There was a significant correlation between the total CCQ and CAT, SGRQ, CRDQ, MRC and ISW (all p<0.01 see Table. 1). In addition individual domains of the CCQ correlated significantly with MRC, CAT and individual domains of the CRQ (p<0.01). Abstract P106 Table 1 Relationship between CCQ and other outcome measures, r = Spearman’s Correlation Coefficient ISW (m) MRC CAT CRQ-D CRQ- F CRQ-E CRQ-M SGRQ Symptom SGRQ Activities SGRQ Impact SGRQ Total CCQ Symptoms –0.41 0.54 0.63 –0.46 –0.42 –0.50 –0.58 0.47 0.61 0.55 0.63 CCQ Functional –0.44 0.52 0.65 –0.42 –0.67 –0.78 –0.72 0.21 0.58 0.75 0.66 CCQ Mental –0.59 0.64 0.67 –0.64 –0.63 –0.62 –0.76 0.27 0.81 0.71 0.77 CCQ Total –0.54 0.65 0.74 –0.59 –0.66 –0.71 –0.79 0.37 0.78 0.76 0.79 Conclusions The CCQ correlates well with existing health status and functional outcome measures in non-COPD patients. CCQ may be a useful assessment tool to test the efficacy of interventions such as pulmonary rehabilitation in this population, but longitudinal studies are required to confirm.

P104 Response of the COPD Assessment Test (CAT) to Pulmonary Rehabilitation in Non-COPD Patients

Background The COPD (chronic obstructive pulmonary disease) assessment test (CAT) is a recently introduced, simple to use health status instrument, which takes less time to complete than better-established health status instruments (Jones PW et al 2009, Ringbaek T et al 2012). In COPD patients, the CAT improves with pulmonary rehabilitation (PR) and correlates with improvements in longer established health status instruments such as the Chronic Respiratory Disease Questionnaire (CRDQ) (Dodd et al 2011). As increasing numbers of non-COPD patients are referred for PR we investigated whether the CAT is responsive to PR in these populations. Methods 365 consecutive patients (255 COPD, 110 non-COPD) completing an eight week outpatient pulmonary rehabilitation programme were recruited. For the non-COPD group, disease classifications included interstitial lung disease (n=27), asthma (n=37), bronchiectasis (n=29), extrathoracic restriction (n=12) and thoracic surgery for lung cancer (n=5). CAT, CRDQ and incremental shuttle walk (ISW) were collected prospectively. Paired t-tests were used to assess the CAT in COPD and non-COPD patients, and a Pearson’s correlation coefficient used to assess the relationship between change in CAT and change in CRQ with PR for non-COPD and COPD patients. Results Following PR there was a significant improvement in the CAT, CRDQ and ISW in both non-COPD and COPD (p<0.001). There was a similar improvement in the mean (95% confidence interval) CAT score in both non-COPD and COPD patients (non-COPD: –2.1 (–1.0, –3.2) versus COPD: –3.0 (–2.2, –3.8); p=0.19). Change in CAT was significantly correlated with all domains of the CRQ in non-COPD patients (all p<0.01 see Table 1). Abstract P104 Table 1 Relationship between change in CAT and change in CRQ with PR for non-COPD and COPD patients Non-COPD r p-value Δ CRQ Dyspnoea –0.29 0.003 Δ CRQ Fatigue –0.33 0.004 Δ CRQ Emotion –0.38 <0.001 Δ CRQ Mastery –0.25 0.009 COPD r p-value Δ CRQ Dyspnoea –0.32 <0.001 Δ CRQ Fatigue –0.38 <0.001 Δ CRQ Emotion –0.43 <0.001 Δ CRQ Mastery –0.39 <0.001 Δ = Change with PR; CRQ = self-report Chronic Respiratory Questionnaire; r=Pearson Correlation Coefficient. Conclusions As in COPD patients, the CAT is immediately responsive to PR in non-COPD patients. Even in unselected patients undergoing PR, the CAT is a practical but robust health status instrument.

P102 Post-Hospitalisation Outpatient Pulmonary Rehabilitation: A Translational Gap?

Background Recent trials and meta-analyses of early post-hospitalisation pulmonary rehabilitation (PR) in COPD have demonstrated improvements in exercise capacity, health-related quality of life and a reduction in hospital readmissions (Man et al., 2004; Seymour et al. 2010; Puhan et al. 2011). However anecdotal observation and evidence from recent trials suggest poor uptake of outpatient PR. The aim of the study was to map patient journeys to identify gaps or deficiencies in the referral pathway. Methods All 224 patients discharged from Hillingdon Hospital following an acute exacerbation of COPD between November 2011 and May 2012 were included in the analysis. Referrals for post-exacerbation PR from Hillingdon Hospital were monitored during the same time period. A collaborative of 18 stakeholders from seven organisations across primary, secondary and community care services was convened and performed local process mapping. Structured telephone interviews were held with a convenience sample of 36 COPD patients who declined post-hospitalisation PR. Results Despite excellent compliance with a COPD discharge bundle (95%), only 63 (28%) of the 224 discharges from Hillingdon Hospital were referred to the local PR provider. All referrals were offered initial assessment for PR within 2 weeks of discharge but 18 failed to attend on at least 2 occasions. A further 9 patients failed to start PR despite attending initial assessment. In total, only 36 (16%) patients out of all hospital discharges over a 6-month period started outpatient PR. The main reasons for patients declining outpatient PR were accessibility issues (40%), commitment to PR “too time-consuming” (20%) or “too unwell” (13%). Conclusion Despite a strong evidence base, there is poor uptake of post-hospitalisation early PR. The majority of missed opportunities occur at the initial referral stage, although there is a significant drop-out even in those referred. Ongoing experience based design work will explore staff and patient attitudes that may influence referral and uptake rates.

P37 Muscle mass in COPD patients receiving angiotensin II receptor blockers and ACE-inhibitors

Background Skeletal muscle dysfunction is well recognised in chronic obstructive pulmonary disease (COPD) and is associated with increased morbidity and mortality. Considerable circumstantial evidence supports a role for renin-angiotensin systems in skeletal muscle turnover. Angiotensin II (ATII) administration causes cachexia through several biological mechanisms. Angiotensin converting enzyme inhibitors (ACE-I) block the conversion of angiotensin I to ATII. Previous pilot studies have shown that the administration of ATII receptor blockers (ARB) or ACE-I to COPD patients may increase quadriceps strength and peak work rate (Andreas et al, 2006; Di Marco et al, 2010). We hypothesised that in an unselected COPD population referred for pulmonary rehabilitation (PR), those receiving ARB or ACE-I drugs would have preserved muscle mass. Methods Data from 373 consecutive COPD patients (213M: 160F; mean age 68.3; median FEV1 41% predicted) referred to an outpatient pulmonary rehabilitation programme were analysed. Patients were divided into those receiving either an ARB or ACE-I and controls (those receiving neither drug). Fat free mass (FFM; measured by bioelectric impedance analysis), incremental shuttle walk (ISW), Chronic Respiratory Disease Questionnaire (CRDQ), MRC Dyspnoea score (MRC) and COPD assessment test (CAT) were measured. Between group differences were compared using Mann–Whitney U or unpaired t-test. Results Data are presented as median (25th, 75th centiles), and summarised in Abstract P37 table 1. 130 COPD patients from this cohort were taking either an ACE-I (n=82), ARB (n=45) or both (n=3). The groups were matched for gender distribution and long-term oral corticosteroid use. Compared with the control COPD patients, those on ACE-I or ARB were older, had better FEV1 % predicted but similar ISW, CRDQ, MRC and CAT. However, the patients receiving ACE-I or ARB had significantly higher fat free mass (FFM) and fat free mass index (FFMI).Abstract P37 Table 1 Mean (SD) or median (27th, 75th centile). p Values represent between group differences (Mann–Whitney or unpaired t-test) ARB/ACE-I No ARB/ACE-I p Value Age (years) 71 (64, 78) 67.6 (9.8) 0.004 FEV1 (% predicted) 44.5 (32.3, 60.8) 39.0 (26.0, 58.5) 0.007 FFM (kg) 51.1 (11.2) 45.5 (40.1, 52.0) <0.001 FFMI (kg/m2) 17.8 (16.0, 19.8) 16.5 (14.9, 18.4) <0.001 ISWT (m) 140 (60, 250) 160 (80, 280) 0.10 CRDQ 71.5 (55.8, 91.0) 68.0 (56.0, 87.0) 0.45 MRC 4 (3, 5) 4 (3, 5) 0.79 CAT 23.0 (8.0) 22.0 (7.0) 0.76 Conclusions In an unselected COPD cohort referred for pulmonary rehabilitation, patients on ACE-I or ARB appear to have increased muscle mass compared with those receiving neither drug. Future longitudinal studies and randomised controlled trials are required to further define the effect of ACE-I and ARB in COPD.

P140 Uptake and completion of pulmonary rehabilitation: the influence of referral source

Background Pulmonary rehabilitation (PR) leads to significant improvements in exercise capacity, health status and dyspnoea in patients with chronic respiratory disease, supported by a strong evidence base. Despite the known benefits of PR, a proportion of referred patients never attend while others fail to complete the programme. The doctor-patient relationship is complex and may influence uptake and adherence to therapy. We hypothesised that uptake and completion of PR would be greater in patients referred from a senior doctor (hospital consultant or GP) compared with those referred by junior doctors or allied health professionals. Methods 466 consecutive referrals to the Pulmonary Rehabilitation (PR) programme were divided according to referral source: Senior Doctor (Hospital consultant or GP), Junior Doctor (Any trainee doctor from hospital or primary care) and Allied Health Professional (AHP: typically community/practice nurses or hospital physiotherapists). Uptake (proportion of referrals that start PR), and completion (proportion of patients that attended more than 8 PR sessions and the post-course assessment) were calculated for each referral source and compared using χ2 test. Results Overall uptake and completion rates were 78% and 75% respectively (raw data Abstract P140 table 1). Uptake was significantly greater in referrals from Senior Doctor compared with Junior Doctor or AHP (82% vs 67% and 74% respectively; χ2 p=0.02), although no significant difference was seen in completion (77% vs 70% and 68%; χ2 p=0.25). Abstract P140 table 1 shows the raw data. There was no significant difference in baseline patient characteristics between the referral sources (age, FEV1%, MRC dyspnoea score, Hospital Anxiety and Depression score, incremental shuttle walk distance, Chronic Respiratory Disease Questionnaire, Lung Information Needs Questionnaire or COPD Assessment Test).Abstract P140 Table 1 Referrer Referrals Uptake Completers Senior doctor 318 260 200 Junior doctor 64 43 30 Allied health professional 84 62 42 Total 466 365 272 Conclusion There is increased uptake of PR in patients referred by a hospital consultant or GP than if referred by a junior doctor or AHP. Further work is required to explore the reasons for this observation.