Psychometric evaluation of the COPD assessment test: Data from the BREATHE study in the Middle East and North Africa region

COPD EXACERBATION RATE BY BASELINE COPD ASSESSMENT TEST SCORE IN THE DYNAGITO STUDY

The Chronic Obstructive Pulmonary Disease (COPD) Assessment Test (CAT) measures COPD's impact on well-being and daily activities and is a recommended assessment by the Global Initiative for Obstructive Lung Disease (GOLD). Our research objective was to describe a real-world CAT implementation, including the association of CAT scores with subsequent treatment and clinical outcomes. A retrospective, observational, comparative cohort study was conducted among adults with COPD who received care from M Health Fairview, a US healthcare delivery system. Eligible patients had an initial electronic health record (EHR) enabled CAT administration (index) between 8/2017 and 12/2021. Patients were grouped by score (<10 [low impact]; 11-20 [moderate]; and 21-40 [high]). Demographics, comorbidities, provider specialty, and exacerbation history were derived from EHR data in the 12 months preceding index. Of 11,194 eligible individuals, 821 (7.3%) were administered CAT (cases). Compared to individuals with no documented CAT scores (comparators), cases were older (66.7 vs 63.9 years; p < 0.05) and had higher rates of comorbidities (93.9% vs 79.2%, p < 0.05) and exacerbations (0.31 vs 0.14 PPPY). A total of 61.5% of pulmonologists and 11.5% of primary care providers (PCPs) administered the CAT at least once. Repeated use was more common among pulmonologists (55.7%) than PCPs (7.0%). Medication intensification was most common (28.1%) among individuals with high CAT scores, followed by moderate (21.6%), and low (10.0%). Post-index exacerbations were experienced by 24.2%, 17.4%, and 7.7% of patients with high, moderate, and low CAT scores. In a real-world practice setting, few patients with COPD received a CAT, although pulmonologists demonstrated repeated use. Higher CAT scores were associated with COPD medication regimen intensification and exacerbations. Further investigation on how to incorporate the CAT into routine care and optimize its impact on medical decision making and evaluation is warranted.

Introduction: The COPD Assessment Test (CAT) is a simple method for assessing the impact of COPD on the patient`s health which is not validated with North African COPD patients. Objective: To determine the relationship between the CAT score and the SGRQ, anthropometric, dyspnea, severity of airflow obstruction and Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages in stable COPD patients. Material and Methods: It is a cross-sectional observational study. It consists of a convenience sample of COPD and Smokers subjects aged more than 30 years. Dyspnea was evaluated according to the modified British medical research council (mMRC) 4). Arabic versions of the SGRQ and CAT questionnaires were used. Spirometry was performed in accordance with international standards. Obstructive ventilator defect (OVD) grades and GOLD grades were identified. Results: A total sample of 150 (121 COPD) was collected. A negative correlation was found between CAT score and anthropometric and all functional parameters in the total sample. Correlations between CAT score and mMRC score, pulmonary age and SGRQ score were found in COPD group (p&lt;0.01). CAT score correlated with OVD and GOLD grades, severe COPD (GOLD 3 and 4) had higher CAT scores. Conclusion: There is a strong relationship between CAT score and clinical and functional COPD components. Impact of this research on clinical medicine and basic science: COPD is a complex disease with multiple consequences which can impede the quality of life of patients. The latter can be evaluated by specific questionnaires. The most used questionnaire is St. George’s Respiratory Questionnaire (SGRQ). However, this health status measure is long and not practical for clinical routine use. Therefore, recently a new simple system evaluating health status was developed. It is the COPD Assessment Test (CAT), which was approved, in its French, English and Arabic version. It is a simple method for assessing the impact of COPD on the patient`s health. CAT is composed of only eight questions and a key is not needed to calculate a score. To our own knowledge, there are no studies about CAT scoring in and its relation with clinical and respiratory function characteristics in North Africa. Keywords: COPD- CAT score- SGRQ-FEV1- Spirometry

Objective:In this study, we aimed to investigate the compatibility of modified Medical Research Council (mMRC) and COPD assessment test (CAT) scores of chronic obstructive pulmonary disease (COPD) patients in terms of evaluation of their symptom status.Methods:The study was planned as a single-center, cross-sectional study. Statistically four separate receiver operating characteristic (ROC) curves of CAT scoring were generated for mMRC scores of 1 to 4.Results:Two hundred twenty eight patients with stable COPD, mean age 64.2±8.2 and 88.6% male were included. A strong positive correlation was detected between CAT and mMRC (r=0.60, p<0.001). However, it was observed that 32 patients had mMRC<2 but CAT≥10, while 21 patients had CAT<10 but mMRC≥2. Thus, in 53 patients CAT and mMRC scores were not identical in terms of assessed symptom status. According to the ROC analysis, the mMRC scores of 1 to 4 were most compatible with the CAT scores of 10, 10, 15, and 20, respectively.Conclusions:Expanding current data represents that CAT score of 10 could be more compatible with mMRC score of 1. Moreover we think although a high mMRC or CAT score may be sufficient to assign patients to high symptom groups, it is needed to evaluate mMRC and CAT together to assign a patient to a low symptom group. In this way misclassification of the patients with high symptoms due to insufficient symptom evaluation as if they have low symptoms can be prevented.

Chronic obstructive pulmonary disease (COPD) is associated with multiple comorbidities, including depression, which carries a higher risk of exacerbation and hospitalization in patients with stable COPD. A newly developed questionnaire, the COPD Assessment Test (CAT), was developed as an alternative to other complex, time-consuming tools for quantifying the symptom burden of COPD in routine practice. It is possible that the correlation between the CAT and depression scales could be useful for early evaluation and management of depression in COPD patients. Thus, we investigated the relationship between the CAT and depression as measured by the Patient Health Questionnaires-9 (PHQ-9). We performed a retrospective observational COPD cohort study. A total of 97 patients were enrolled. The Korean versions of the CAT and PHQ-9 were completed for stable patients. A correlation analysis was performed between the PHQ-9 and CAT scores. Significant depression among the groups based on the 2011 GOLD guidelines occurred only in class Gold B and D patients (40% and 60%, respectively). The frequency of depression was significantly higher in the group with higher CAT scores (20~29 versus ≥30; odds ratio: 5.67 versus 22.66). Significant association was observed between the PHQ-9 and CAT scores (r=0.545 and P<0.001). As a result, the PHQ-9 score was significantly higher in COPD patients with a higher CAT score. The CAT is a simple and valuable predictor of depression in COPD patients, and it should be frequently used to detect COPD patients with depression in clinical practice.

ABSTRACTIntroduction:Chronic obstruction pulmonary disease (COPD) is a chronic airflow disorder along with decreasing health status. COPD assessment test (CAT) is commonly used to assess the health status of patients and their medical results. The aim of this study was to assess the therapeutic outcomes in patients with COPD using CAT in private hospitals in Yogyakarta.Materials and Methods:This was a cross-sectional study involving 156 patients, aged >40 years who had completed the CAT questionnaire. CAT scores were categorized into four groups and consisted of eight items: cough, phlegm, chest tightness, breathlessness going up hills/stairs, activity limitations at home, confidence leaving home, sleep, and energy. The four categories were successful therapy (CAT scores <10), moderately successful CAT 10–19), less successful (CAT scores 20–30), and unsuccessful (CAT score >30). The study was conducted from April to August 2018 at two Private Hospitals in Yogyakarta followed by descriptive-analytical data processing and chi-square analysis.Results:The therapeutic outcomes of COPD were 30.13% successful (CAT score: <10), 60.26% moderately successful (CAT score: 10–19), 9.62% less successful (CAT score: 20–30), and there were no patients with unsuccessful therapy. The majority of patients had moderate airflow severity. Exacerbation condition, severity level, and type of therapy showed a significant result (P < 0.05) toward therapy results with COPD measurement, and from eight CAT items, it was identified that 37.8% of respondents had breathlessness going up hills/stairs.Conclusion:CAT can assess the therapeutic outcomes and COPD patient’s health status with moderately successful therapy (CAT score 10–19) in more than sixty percent of respondents.

The COPD Assessment Test: Can It Discriminate Across COPD Subpopulations?

BackgroundThe 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...

Purpose Our study aimed to compare the predictive value of the COPD Assessment Test (CAT) score at baseline and short-term change in CAT for future exacerbations in chronic obstructive pulmonary disease (COPD) patients. Methods This was a multicentre prospective study. Patients with COPD were recruited into the study and followed up for one year. CAT score and exacerbation in the previous year were collected at baseline. Change in CAT was defined as CAT score changing between baseline and the 6-month follow-up. Exacerbation was recorded during the one-year follow-up from 0th to 12th month. Result A total of 536 patients were enrolled for final analysis. The mean baseline CAT score was 14.5 ± 6.6 and the median (IQR) change in CAT was −2 (8). On Cox regression analysis, baseline CAT score, change in CAT and history of exacerbation were independent risk factors for exacerbation in the one-year follow-up. Compared with the r value of correlation between baseline CAT score and frequency of exacerbations during the one-year follow-up (r = 0.286, p < .001), that correlation between the change in CAT and frequency of exacerbations during follow-up was higher (r = 0.421, p < .001). The receiver operating characteristic (ROC) curves showed that change in CAT had a better predictive capacity for future exacerbation than baseline CAT (0.789 versus 0.609, p = .001). The ROC showed that change in CAT also had a better predictive capacity for future exacerbation than exacerbation in the previous year (0.789 versus 0.689, p = .011). Conclusion The correlation between baseline CAT score and future exacerbation was weak, however, the correlation between change in CAT and future exacerbation was moderate. Change in CAT in the short term had a better predictive value for future exacerbations of COPD than baseline CAT and exacerbation in the previous year.

Chronic obstructive pulmonary disease (COPD) is multifaceted, with some patients experiencing anxiety and depression. Depression in COPD has been associated with worse total scores for the COPD assessment test (CAT). Also, CAT score worsening has been observed during the COVID-19 pandemic. The relationship between the Center for Epidemiologic Studies Depression Scale (CES-D) score and CAT sub-component scores has not been evaluated. We investigated the relationship between CES-D score and CAT component scores during the COVD-19 pandemic. Sixty-five patients were recruited. Pre-pandemic (baseline) was defined as 23rd March 2019-23rd March 2020, CAT scores and information related to exacerbations were collected via telephone at 8-week intervals between 23rd March 2020-23rd March 2021. There were no differences in CAT scores pre- compared to during the pandemic (ANOVA p = 0.97). Total CAT scores were higher in patients with symptoms of depression compared to those without both pre- (p < 0.001) and during-pandemic (eg, at 12 months 21.2 versus 12.9, mean difference = 8.3 (95% CI = 2.3-14.2), p = 0.02). Individual CAT component scores showed significantly higher chest tightness, breathlessness, activity limitation, confidence, sleep and energy scores in patients with symptoms of depression at most time points (p < 0.05). Significantly fewer exacerbations were observed during- compared to pre-pandemic (p = 0.04). We observed that COPD patients with symptoms of depression had higher CAT scores both pre- and during the COVID-19 pandemic. Presence of depressive symptoms was selectively associated with individual component scores. Symptoms of depression may potentially influence total CAT scores.

It is widely recognised that health-related quality of life (HRQOL) is impaired in chronic obstructive pulmonary disease (COPD) patients. Most previous studies were conducted among the younger adult population and there is limited information on the elderly population. This study aimed to determine the COPD assessment test (CAT) score in the elderly with COPD. Methods: This was a crosssectional study involving 140 elderly patients who had been diagnosed with COPD at two selected government institutions. Data on socio-demographic and health status were collected by interviewing patients and reviewing their medical records. The HRQOL was measured using CAT. The independence sample t-test and one-way ANOVA were conducted to compare the CAT scores with socio-demographic and health status. Results: The socio-demographic and health characteristics of the patients were as follows: majority (54%) were aged 60-70 years, male (97%), Malay (59%), married (75%), ex-smokers (72%), had attained primary education (48%), had co-morbidities (54%), no history of hospitalisation or visits to the emergency department due to COPD (57%), and were in moderate stage of airflow obstruction (53%). The mean of CAT score was 21.876.85 and the majority of the patients were classified as having worst symptoms of COPD (93%) as they had high CAT score which was 10. Conclusion: Majority of the patients in this study had high scores of CAT, which indicated poor HRQOL. Ex-smokers had higher scores compared to non-smokers. More attention need to be given to these subgroups in order to increase their quality of life.

Dear editor In a recent issue of the International Journal of COPD, Rhee et al1 have demonstrated considerable discrepancies between modified Medical Research Council (mMRC) dyspnea scoring and COPD assessment test (CAT) scoring in patients with COPD. The current data are also supported by the findings described in another article, which indicates that more than 50% of COPD patients show discrepancies between the severity of CAT scores and that of mMRC scores in the real world.2 In principle, CAT and mMRC scores are not correlated. The CAT scoring is for continuous variables, while mMRC scoring is for categorical variables. Furthermore, the severity of CAT scores is not correlated with that of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) staging. Because CAT scoring is based on eight different items, the sleep disturbance score 5 is not correlated with the cough/sputum symptom score 5 or with the exertional dyspnea score 5. This justifies the discrepancy found between the scores in the two scoring systems. The study by Rhee et al1 strongly indicates that comprehensive assessment using both the CAT and the mMRC dyspnea scoring systems is necessary for personalized therapy for COPD patients. The evaluation of health status and the assessment of dyspnea severity suggest the different aspects of pathophysiology of COPD patients. However, there is a problem in COPD practice and research at the current juncture. By searching PubMed literature of the past 5 years using keywords “CAT” and “COPD”, 280 papers were extracted. However, a search using the keywords “mMRC” and “COPD” extracted less than half this number (135 papers). Unfortunately, a search using all keywords “CAT”, “mMRC”, and “COPD” extracted very few papers (46 papers, 16.4% of the number of papers extracted using the search terms “CAT” and “COPD”). Therefore, it is reasonable to speculate that mMRC and CAT assessment may not be performed simultaneously for the assessment of COPD patients in clinical practice. The CAT and mMRC scores are affected differently by bronchodilator therapy in COPD patients.3 Ohno et al3 demonstrated that a novel, once-daily inhaled long-acting beta 2-agonist, indacaterol, improved pulmonary function variables, mMRC dyspnea scale score, and CAT scores. However, a switch in replacement therapy from salmeterol to indacaterol significantly improved the mMRC and forced vital capacity values, but did not significantly improve the CAT scores or other pulmonary function variables.3 Importantly, mMRC and CAT assessments can be used to predict the prognosis of COPD patients. The COPD History Assessment in Spain (CHAIN) study revealed that the CAT could be used for predicting all-cause mortality in patients with COPD, but was inferior to mMRC dyspnea scores in this respect.4 COPD patients who died had higher CAT and MRC dyspnea scores than survivors. Unfortunately, the CHAIN study used original MRC scores instead of mMRC scores. When personalized therapy for different phenotypes of COPD is implemented, bidirectional assessment using CAT and mMRC scoring will be necessary in clinical settings, in addition to assessment of pulmonary function and presence of inflammatory indicators in exhaled breath, sputum, and blood.

Tests of the Responsiveness of the COPD Assessment Test Following Acute Exacerbation and Pulmonary Rehabilitation

ABSTRACTPrevious research has shown that personality traits are associated with self-reported health status in the general population. COPD Assessment Test (CAT) is increasingly used to assess health status such as the impact of chronic obstructive pulmonary disease (COPD) on patients' daily life, but knowledge about the influence of personality traits on CAT score is lacking. The aim of this study was to examine the influence of Big Five personality traits on CAT score and the relation between personality traits and mental symptoms with respect to their influence on CAT score. A sample of 168 patients diagnosed with COPD was consecutively recruited in a secondary care outpatient clinic. All participants completed CAT, NEO Five-Factor Inventory, and Hospital Depression and Anxiety Scale. Multiple linear regression analysis was used to explore the association between personality traits and CAT scores and how this association was influenced by mental symptoms. The personality traits neuroticism, agreeableness and conscientiousness; and the mental symptoms depression and anxiety showed significant influence on CAT score when analysed in separate regression models. Identical R-square (R = 0.24) was found for personality traits and mental symptoms, but combining personality traits and mental symptoms in one regression model showed substantially reduced effect estimates of neuroticism, conscientiousness and anxiety, reflecting the strong correlations between personality traits and mental symptoms. We found that the impact of COPD on daily life measured by CAT was related to personality and mental symptoms, which illustrates the necessity of taking individual differences in personality and mental status into account in the management of COPD.

BackgroundChronic obstructive pulmonary disease (COPD) can greatly impact the quality of life by limiting patients’ activities. However, data on impact of symptomatic burden on the health care resource utilization (HCRU) and employment in COPD are lacking. We examined the association between COPD Assessment Test (CAT) score and direct/indirect costs associated with HCRU and work productivity.MethodsData from >2,100 patients with COPD consulting for routine care were derived from respiratory disease-specific programs in Europe, the USA and China. Questionnaires, including CAT and Work Productivity and Activity Impairment (WPAI), were used to collect the past and current disease status data and HCRU characteristics from physicians (general practitioners/specialists) and patients. A regression approach was used to quantify the association of CAT with HCRU and WPAI variables. CAT score was modeled as a continuous independent variable (range: 0–40).ResultsNinety percent of patients with COPD had a CAT score ≥10. Short-acting therapy and maintenance bronchodilator monotherapy, respectively, were currently prescribed to patients with CAT scores of 10–19 (5.8% and 27.6%), 20–29 (5.1% and 13.1%) and 30–40 (2.8% and 6.6%). Prescribing of maintenance bronchodilator dual therapy was low across the CAT score groups (0–9, 7.8%; 10–19, 6.4%; 20–29, 5.9%; 30–40, 4.4%), whereas maintenance triple combination therapy was prescribed more commonly in patients with higher CAT scores (0–9, 16.1%; 10–19, 23.2%; 20–29, 25.9%; 30–40, 35.5%). Increasing CAT scores were significantly associated with a higher frequency of primary care physician visits (P<0.001), pulmonologist visits (P=0.007), exacerbations requiring hospitalization (P<0.001) and WPAI scores (P<0.001).ConclusionMost patients with COPD presented with high symptom levels, despite being treated for COPD. Increasing symptom burden was associated with increasing HCRU and had a detrimental impact on work productivity.