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Feasibility and applicability of the paper and electronic COPD assessment test (CAT) and the clinical COPD questionnaire (CCQ) in primary care: a clinimetric study

Feasibility and applicability of the paper and electronic COPD assessment test (CAT) and the... www.nature.com/npjpcrm ARTICLE OPEN Feasibility and applicability of the paper and electronic COPD assessment test (CAT) and the clinical COPD questionnaire (CCQ) in primary care: a clinimetric study 1,2 3 4,5 1,2 1 1,2 4 J. W. H. Kocks , C. M. G. Blom , M. J. Kasteleyn , W. Oosterom , B. J. Kollen , T. Van der Molen and N. H. Chavannes Three questionnaires are recommended in the management of chronic obstructive pulmonary disease by the global initiative for obstructive lung disease, of which two are the more comprehensive assessments: the chronic obstructive pulmonary disease assessment test and the clinical chronic obstructive pulmonary disease questionnaire. Both are carefully designed high-quality questionnaires, but information on the feasibility for routine use is scarce. The aim of this study was to compare the time to complete the chronic obstructive pulmonary disease assessment test and the clinical chronic obstructive pulmonary disease questionnaire and the acceptability of the questionnaires. Furthermore, the agreement between electronic and paper versions of the questionnaires was explored. The time to complete the electronic versions of the questionnaires was 99.6 [IQR 74; 157] vs. 97.5 [IQR 68; 136] seconds for clinical clinical chronic obstructive pulmonary disease questionnaire and chronic obstructive pulmonary disease assessment test, respectively. The difference in time to complete the questionnaire was not significant. The two questionnaires did not differ in “easiness to complete” or “importance of issues raised in questionnaires”. Electronic vs. paper versions revealed high agreement (ICC CCQ = 0.815 [0.712; 0.883] and ICC CAT = 0.751 [0.608; 0.847]) between the administration methods. Based on this study it can be concluded that both questionnaires are equally suitable for use in routine clinical practice, because they are both quick to complete and have a good acceptability by the patient. Agreement between electronic and paper versions of the questionnaires was high, so use of electronic versions is justified. npj Primary Care Respiratory Medicine (2017) 27:20 ; doi:10.1038/s41533-017-0023-0 INTRODUCTION have to be made on the content, quality, responsiveness, and comparability of these questionnaires, the feasibility for actual use Questionnaires are recommended in the management of chronic 1, 2 in clinical practice is essential for successful implementation. obstructive pulmonary disease (COPD). Over the last years To date, only scarce information is available that compares the several compact questionnaires addressing health status have feasibility of the CAT and the CCQ. We studied both ques- been specifically designed to be used in routine clinical practice. tionnaires regarding the average time to complete and accept- The use of these questionnaires is thought to improve commu- 3 2, 4 ability. Furthermore, agreement between electronic and paper nication and can guide treatment. versions of both questionnaires was explored. Since 2011, the global initiative for obstructive lung disease (GOLD) guidelines/strategy has included three questionnaires in the assessment of COPD patients: the modified Medical Research 6 3 Council (mMRC) dyspnea scale, the COPD assessment test (CAT), RESULTS and the clinical COPD questionnaire (CCQ). As the mMRC solely COPD patients were invited to the study (Fig. 1). In total, 95 COPD addresses dyspnea, the CAT and CCQ are the more comprehen- patients participated in the study and completed the question- sive assessments of the three questionnaires providing the clinician with more valuable information regarding burden of naires online. Baseline characteristics are presented in Table 1. The total scores could not be calculated in 10% of CAT, and in 1% of disease. For that reason we focus in this study on the head-to- the CCQ and mMRC due to missing values. head comparison between CAT and CCQ. The CAT consists of eight items scored on a 5-point scale and a total score can be calculated. The CCQ consists of 10 items scored on a 6-point scale, Differences between electronic version of the CAT and CCQ and a total score as well as symptom, functional, and mental status domain scores can be calculated. The differences between the electronic version of the CAT and Guideline developers and clinicians need to make choices on CCQ were tested in 95 patients and reported in Table 2. The which of these two health status questionnaires they should median CAT completion time was 97.5 [IQR 68–136] vs. a median recommend and use in daily practice. Next to the choices that CCQ completion time of 99.6 [IQR 74–157] seconds (p = 0.151). 1 2 Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; GRIAC Research Institute, University of Groningen, 3 4 University Medical Center Groningen, Groningen, The Netherlands; Zorgdraad Foundation, Oosterbeek, The Netherlands; Department of Public Health and Primary Care LUMC Leiden, Leiden, The Netherlands and Department of Pulmonology, LUMC Leiden, Leiden, The Netherlands Correspondence: J. W. H. Kocks (j.w.h.kocks@umcg.nl) Received: 15 September 2015 Revised: 3 February 2017 Accepted: 27 February 2017 Published in partnership with Primary Care Respiratory Society UK Comparison of the CAT and the CCQ in primary care JWH Kocks et al. Fig. 1 Flowchart of the study. GRC global rating of change, CCQ clinical COPD questionnaire, CAT COPD assessment test The easiness to complete, importance of issues raised in found patients needed 107 s to complete CAT, and 134 s to questionnaires, and the importance of information for health-care complete CCQ, but did not report whether this difference was provider were not different between the two questionnaires. significant. They also found that the need for assistance while Of the participants who completed the question on ques- answering the questionnaire was 53.9% for CAT, and 36.0% for tionnaire preference (n = 78), the majority (79.5%) had no CCQ. In our study, no assistance was given, but in the CAT preference for one of the questionnaires, while 16.7% preferred questionnaire more questions remained unanswered than in the the CCQ and 3.8% preferred the CAT. CCQ (10 vs. 1%). In contrast, Sundh et al. found a considerably higher proportion of the patients were able to complete the CAT compared with the CCQ, although they found that a slight Agreement between electronic and paper versions of the CAT and majority of the patients preferred the CCQ. CCQ In a study by Tsiligianni and colleagues, 10% of the patients For comparison of the electronic and paper versions, only stable reported that the CCQ was easier to understand than the CAT. patients (n = 65) were included in the analysis. Of those, 64 had no However, 62% indicated that the CCQ reflected their health status missing data on the electronic or paper version of the CCQ and 55 better than the CAT did because the CCQ addresses their had no missing data on the CAT. The absolute agreement breathing problems better while sleep was less important to between electronic and paper versions was high (ICC [95% CI] them. In our study no differences were found regarding easiness CCQ=0.815 [0.712; 0.883] and ICC [95% CI] CAT=0.751 [0.608; to complete the questionnaires or the importance of the topics 0.847]). Interpretation of Bland–Altman plots essentially supports addressed between the questionnaires. agreement between the two versions (Figs 2, 3). The agreement between electronic and paper versions of both CAT and CCQ was high, which justifies electronic use in daily practice or by patients themselves online. DISCUSSION The decision on which health status questionnaire to use can be Main findings made based on local preferences, or based on the fact that in To the best of our knowledge, this is the first study comparing CCQ addition to the total score the CCQ offers three subdomain scores and CAT head-to-head in a primary care population to assess (symptom, functional, and mental status) that can be used to completion time and ease of use. This study demonstrates that in a guide treatment prioritization in practice. Furthermore, the primary care COPD population neither statistically nor clinically usefulness of the questionnaires from a clinician’s perspective, relevant differences in filling out time or acceptability between the including the ease of deriving a score, should be taken into two health status questionnaires were observed. Agreement between account. Also the impact of missing items on the score or the electronic and paper versions of the questionnaires was high. impact of remotely completing the questionnaires should be considered. However, that was not within the scope of this study. Interpretation of findings in relation to previously published work This study adds to our knowledge the acceptance and feasibility One earlier study by Ringbaek in a group of mainly severe COPD for the patients in addition to the known feasibility for primary patients participating in a pulmonary rehabilitation program care as assessed by the IPCRG. npj Primary Care Respiratory Medicine (2017) 20 Published in partnership with Primary Care Respiratory Society UK Comparison of the CAT and the CCQ in primary care JWH Kocks et al. Strengths and limitations of this study characteristics between participants and non-participants could not be compared. Selection bias might reduce generalizability. A limitation of this study is that we could not rule out selection Although it can be thought that factors like COPD severity, bias. Patients are invited to participate, and non-response or age, or comorbidity might influence time to complete the reasons for not participating are not examined. Moreover, questionnaire, we expect that this will be the same for both questionnaires. Table 1. Baseline characteristics Importance of topics addressed is more likely to depend on severity, since more severe patients might have other or more COPD patients (n = 95) symptoms than less severe patients. Our population is relatively mild based on mMRC, CAT, and CCQ scores. We cannot be sure Age in years, mean (SD) 65.0 (10.0) whether the results of this study on importance of the topics Male gender, n (%) 60 (63.2) addressed in the questionnaires can be generalized to more CAT score, mean (SD) 13.2 (7.4) severe populations. CCQ score, mean (SD) 1.6 (1.0) Another factor that might influence the results, especially mMRC score, median [IQR] 1.0 [1.0–2.0] easiness of the questions, is socio-economic status (SES). Participants are included from different parts of the Netherlands Note: Normal distributed variables are presented as mean (SD), non-normal and from different general practices. Nevertheless, we cannot be variables as median [IQR] sure that we included patients from with different SES levels. COPD chronic obstructive pulmonary disease, CCQ clinical COPD ques- tionnaire, CAT COPD assessment test, mMRC modified Medical Research Finally, the questions regarding acceptability of the CAT and Council CCQ were not pilot tested. Nevertheless, those questions were Table 2. Differences between electronic version of the CAT and the electronic version of the CCQ CCQ CAT p-value Completion time in seconds, median [IQR] 99.6 [74–157] 97.5 [68–136] 0.151 Easiness to complete (0–10), median [IQR] 8.0 [5–10] 7.5 [5–9] 0.109 Importance of issues raised (0–10), median [IQR] 5.0 [5–7] 5.0 [5–7] 0.543 Importance of information for health care provider (0–10), median [IQR] 7.0 [5–8] 8.0 [5–8] 0.836 COPD chronic obstructive pulmonary disease, CCQ clinical COPD questionnaire, CAT COPD assessment test, mMRC modified Medical Research Council Analyzed using paired sample t-test based on logtransformed variables Analyzed using Wilcoxon signed-rank tests Fig. 2 Bland–Altman plot showing the relationship between the electronic and paper version of the CCQ. The dashed lines represent the limits of agreement Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2017) 20 Comparison of the CAT and the CCQ in primary care JWH Kocks et al. Fig. 3 Bland–Altman plot showing the relationship between the electronic and paper version of the CAT. The dashed lines represent the limits of agreement quite straight forward and the majority of the patients completed Outcomes those questions. Because the same questions were used for both The primary outcome was the time (in seconds) required to complete the electronic versions of the CAT and CCQ questionnaire. The time running questionnaires we believe it is legitimate to draw conclusions from showing the questionnaire on the screen until clicking “completed, based on those questions. next page” was recorded. The CCQ is an instrument to measure health status in patients with Implications for future research, policy, and practice COPD. It consists of 10 questions on three domains: symptoms, mental state, and functional state. The symptoms and functional state domains Based on this study, both questionnaires seem equally suitable for contain four items each, and the mental state domain two. Questions are use in routine clinical practice, because they are both quick to scored on a 7-point scale from 0–6, with 0 representing the best possible complete and have a good acceptability by the patient. score and 6 representing the worst possible score. Total scores range from 0–6. A higher CCQ value indicates a lower health status. The CAT also measures health status in patients with COPD. The CAT has Conclusions eight items and includes questions about symptoms, energy, sleep, and No significant differences were found in the completion times and 3 activity. Total scores range from 0 to 40, where 0 represents no acceptability between the CCQ and the CAT in Dutch primary care. impairment. Based on this study it can be concluded that both questionnaires Secondary outcomes were the degree of acceptability, measured with three questions on easiness (How difficult was completing the ques- are equally suitable for use in routine clinical practice, because they tionnaire?), importance of issues raised in questionnaires (To what extent are both quick to complete and have a good acceptability by the did you feel the questionnaire addressed all aspects of your disease?) and patient. Agreement between electronic and paper versions of the importance of information for health-care provider (To what degree do you questionnaires was high, so use of electronic versions is justified. think that the questionnaire gives relevant information about your disease to your doctor?), scored on a visual analog scales ranging from 0 to 10, where 0 indicates a low acceptability and 10 indicates high acceptability. In METHODS addition, patients were asked to indicate which questionnaire they would recommend to their general practitioner. Patients The MRC questionnaire is a one-dimensional tool to measure dyspnea COPD patients with a doctors’ diagnosis of COPD according to current during exercise in five levels (range 0–5). The global rating of change guidelines were recruited from general practices and primary care (GRC) questionnaire was used to assess change in breathlessness between rehabilitation physiotherapy programs in and around the Groningen and completing the electronic and paper questionnaires on a 15-point Likert Rotterdam areas in the Netherlands. Inclusion criteria were (1) a doctor’s scale, ranging from −7 (a very great deal worse) to +7 (a very great deal diagnosed COPD and (2) electronic informed consent. Exclusion criteria better). were (1) inability to understand or read the Dutch language and (2) unable to connect to the internet. Study procedures Primary care practitioners identified patients with COPD and invited them by letter or in person to participate in the study. A study-specific online module was designed within the Zorgdraad Participants logged in on the website to sign an electronic informed integrated care IT system. The CAT and CCQ were designed to appear consent form and start with the study. similar to the paper versions. The order in which the CAT or CCQ was npj Primary Care Respiratory Medicine (2017) 20 Published in partnership with Primary Care Respiratory Society UK Comparison of the CAT and the CCQ in primary care JWH Kocks et al. presented to the patient was randomized to eliminate any completing REFERENCES fatigue effects. The time between loading of the webpage and submitting 1. GOLD Committee. Global strategy for diagnosis, management, and prevention of the form was recorded electronically. The easiness to complete, under- COPD. http://goldcopd.org/archived-reports/. Updated February 2013. stand the questions, questionnaire preference, and importance of issues 2. van der Molen, T., Miravitlles, M. & Kocks, J. W. COPD management: role of addressed were assessed using additional questions. symptom assessment in routine clinical practice. Int. J. Chron. Obstruct. Pulmon. Within 1 week after completing the electronic version, the participant Dis. 8, 461–471, doi:10.2147/COPD.S49392 (2013). completed a paper copy of the CAT and the CCQ at their homes. In 3. Jones, P. W., Harding, G., Berry, P., Wiklund, I., Chen, W. H. & Kline, L. N. Devel- addition, the GRC was completed to assess stability of the disease. For opment and first validation of the COPD assessment test. Eur. Respir. J. 34, comparison of the electronic and paper versions, only stable patients with 648–654 (2009). a GRC score between −1 to +1 were included in the analysis. 4. Kocks, J., de Jong, C., Berger, M. Y., Kerstjens, H. A., van der Molen, T. Putting health status guided COPD management to the test: protocol of the MARCH study. BMC Pulm. Med. doi:10.1186/1471-2466-13-41 (2013). Sample size and statistical analysis 5. GOLD Committee. Global strategy for the diagnosis, management and preven- A sample size calculation using data from Ringbaek and colleagues with a tion of COPD. Global initiative for chronic obstructive lung disease (GOLD). http:// power of 80% and a two-sided significance level of 5% indicated that 88 goldcopd.org/archived-reports/. Update 2011. patients were needed to complete the study to show at least a 30 s difference 6. Bestall, J. C., Paul, E. A., Garrod, R., Garnham, R., Jones, P. W. & Wedzicha, J. A. in filling out time, which difference we considered clinically relevant. Usefulness of the medical research council (MRC) dyspnoea scale as a measure of Difference in time to complete the electronic version of the CAT and the disability in patients with chronic obstructive pulmonary disease. Thorax 54, electronic version of the CCQ was tested using a paired sample t-test. In 581–586 (1999). the event assumptions of the t-test were violated, testing was conducted 7. van der Molen, T., Willemse, B. W., Schokker, S., ten Hacken, N. H., Postma, D. S. & on logtransformed variables or, if unsuccessful, Mann–Withney U tests. Juniper, E. F. Development, validity and responsiveness of the clinical COPD Data were descriptively presented as medians with IQRs. questionnaire. Health Qual. Life Outcomes 1, 13 (2003). The differences between the electronic versions of the CAT and the CCQ 8. Ringbaek, T., Martinez, G. & Lange, P. A comparison of the assessment of quality regarding easiness to complete, importance of issues raised in question- of life with CAT, CCQ, and SGRQ in COPD patients participating in pulmonary naires, and the importance of information for health-care provider were rehabilitation. Chron. Obstruct. Pulmon. Dis. 9,12–15, doi:10.3109/ determined using paired sample t-tests, or, when assumptions were violated, 15412555.2011.630248 (2012). paired sample t-tests on logtransformed variables. If logtransformation was 9. Sundh, J., Stallberg, B., Lisspers, K., Kampe, M., Janson, C. & Montgomery, S. unsuccessful Wilcoxon signed-rank tests were used. The intraclass correlation Comparison of the COPD assessment test (CAT) and the clinical COPD ques- coefficient (ICC) and Bland–Altman plots were used to assess agreement tionnaire (CCQ) in a clinical population. Chron. Obstruct. Pulmon. Dis. 13,57–65, between the electronic version and the paper version of the CAT and CCQ. doi:10.3109/15412555.2015.1043426 (2016). The study was registered at the Dutch Trial Register (NTR3384), and The 10. Tsiligianni, I. G. et al. Assessing health status in COPD. A head-to-head University Medical Center Groningen Ethics Board approved the study. comparison between the COPD assessment test (CAT) and the clinical COPD questionnaire (CCQ). BMC Pulm. Med. 12, 20, doi:10.1186/1471-2466-12-20 (2012). FUNDING 11. Cave, A. J., Atkinson, L., Tsiligianni, I. G. & Kaplan, A. G. Assessment of COPD This study was financially supported by an unrestricted research grant by GSK NL. wellness tools for use in primary care: an IPCRG initiative. Int. J. Chron. Obstruct. Publication was financially supported by the International Primary Care Respiratory Pulmon. Dis. 7, 447–456, doi:10.2147/COPD.S29868 (2012). Group and the Primary Care Respiratory Society UK. 12. Smeele, I. et al. M26. NHG-standaard COPD. Huisarts Wet. 50, 362–379 (2007). 13. Juniper, E. F., Guyatt, G. H., Willan, A. & Griffith, L. E. Determining a minimal important change in a disease-specific quality of life questionnaire. J. Clin. Epi- AUTHOR CONTRIBUTIONS demiol. 47,81–87 (1994). K.J.W.H. was involved in the design, data collection, analysis, interpretation, and wrote the first draft. B.C.M.G. was involved in the design and data collection. K.M.J. was involved in analysis and interpretation. O.W. was involved in the design and data This work is licensed under a Creative Commons Attribution 4.0 collection. K.B.J. was involved in the design, data collection, and analysis. V.d.M.T. was International License. The images or other third party material in this involved in the design, data collection, and interpretation. C.N.H. was involved in the article are included in the article’s Creative Commons license, unless indicated design, data collection, analysis, and interpretation. All authors contributed to the otherwise in the credit line; if the material is not included under the Creative Commons writing of the paper. K.J.W.H. and C.N.H. are the guarantors of the paper. license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by/ 4.0/ COMPETING INTERESTS V.d.M.T. developed the CCQ and holds the CCQ’s copyright. The remaining authors © The Author(s) 2017 declare no competing interests. Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2017) 20 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png npj Primary Care Respiratory Medicine Springer Journals

Feasibility and applicability of the paper and electronic COPD assessment test (CAT) and the clinical COPD questionnaire (CCQ) in primary care: a clinimetric study

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Medicine & Public Health; Medicine/Public Health, general; Primary Care Medicine; Internal Medicine; Pneumology/Respiratory System; Thoracic Surgery
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www.nature.com/npjpcrm ARTICLE OPEN Feasibility and applicability of the paper and electronic COPD assessment test (CAT) and the clinical COPD questionnaire (CCQ) in primary care: a clinimetric study 1,2 3 4,5 1,2 1 1,2 4 J. W. H. Kocks , C. M. G. Blom , M. J. Kasteleyn , W. Oosterom , B. J. Kollen , T. Van der Molen and N. H. Chavannes Three questionnaires are recommended in the management of chronic obstructive pulmonary disease by the global initiative for obstructive lung disease, of which two are the more comprehensive assessments: the chronic obstructive pulmonary disease assessment test and the clinical chronic obstructive pulmonary disease questionnaire. Both are carefully designed high-quality questionnaires, but information on the feasibility for routine use is scarce. The aim of this study was to compare the time to complete the chronic obstructive pulmonary disease assessment test and the clinical chronic obstructive pulmonary disease questionnaire and the acceptability of the questionnaires. Furthermore, the agreement between electronic and paper versions of the questionnaires was explored. The time to complete the electronic versions of the questionnaires was 99.6 [IQR 74; 157] vs. 97.5 [IQR 68; 136] seconds for clinical clinical chronic obstructive pulmonary disease questionnaire and chronic obstructive pulmonary disease assessment test, respectively. The difference in time to complete the questionnaire was not significant. The two questionnaires did not differ in “easiness to complete” or “importance of issues raised in questionnaires”. Electronic vs. paper versions revealed high agreement (ICC CCQ = 0.815 [0.712; 0.883] and ICC CAT = 0.751 [0.608; 0.847]) between the administration methods. Based on this study it can be concluded that both questionnaires are equally suitable for use in routine clinical practice, because they are both quick to complete and have a good acceptability by the patient. Agreement between electronic and paper versions of the questionnaires was high, so use of electronic versions is justified. npj Primary Care Respiratory Medicine (2017) 27:20 ; doi:10.1038/s41533-017-0023-0 INTRODUCTION have to be made on the content, quality, responsiveness, and comparability of these questionnaires, the feasibility for actual use Questionnaires are recommended in the management of chronic 1, 2 in clinical practice is essential for successful implementation. obstructive pulmonary disease (COPD). Over the last years To date, only scarce information is available that compares the several compact questionnaires addressing health status have feasibility of the CAT and the CCQ. We studied both ques- been specifically designed to be used in routine clinical practice. tionnaires regarding the average time to complete and accept- The use of these questionnaires is thought to improve commu- 3 2, 4 ability. Furthermore, agreement between electronic and paper nication and can guide treatment. versions of both questionnaires was explored. Since 2011, the global initiative for obstructive lung disease (GOLD) guidelines/strategy has included three questionnaires in the assessment of COPD patients: the modified Medical Research 6 3 Council (mMRC) dyspnea scale, the COPD assessment test (CAT), RESULTS and the clinical COPD questionnaire (CCQ). As the mMRC solely COPD patients were invited to the study (Fig. 1). In total, 95 COPD addresses dyspnea, the CAT and CCQ are the more comprehen- patients participated in the study and completed the question- sive assessments of the three questionnaires providing the clinician with more valuable information regarding burden of naires online. Baseline characteristics are presented in Table 1. The total scores could not be calculated in 10% of CAT, and in 1% of disease. For that reason we focus in this study on the head-to- the CCQ and mMRC due to missing values. head comparison between CAT and CCQ. The CAT consists of eight items scored on a 5-point scale and a total score can be calculated. The CCQ consists of 10 items scored on a 6-point scale, Differences between electronic version of the CAT and CCQ and a total score as well as symptom, functional, and mental status domain scores can be calculated. The differences between the electronic version of the CAT and Guideline developers and clinicians need to make choices on CCQ were tested in 95 patients and reported in Table 2. The which of these two health status questionnaires they should median CAT completion time was 97.5 [IQR 68–136] vs. a median recommend and use in daily practice. Next to the choices that CCQ completion time of 99.6 [IQR 74–157] seconds (p = 0.151). 1 2 Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; GRIAC Research Institute, University of Groningen, 3 4 University Medical Center Groningen, Groningen, The Netherlands; Zorgdraad Foundation, Oosterbeek, The Netherlands; Department of Public Health and Primary Care LUMC Leiden, Leiden, The Netherlands and Department of Pulmonology, LUMC Leiden, Leiden, The Netherlands Correspondence: J. W. H. Kocks (j.w.h.kocks@umcg.nl) Received: 15 September 2015 Revised: 3 February 2017 Accepted: 27 February 2017 Published in partnership with Primary Care Respiratory Society UK Comparison of the CAT and the CCQ in primary care JWH Kocks et al. Fig. 1 Flowchart of the study. GRC global rating of change, CCQ clinical COPD questionnaire, CAT COPD assessment test The easiness to complete, importance of issues raised in found patients needed 107 s to complete CAT, and 134 s to questionnaires, and the importance of information for health-care complete CCQ, but did not report whether this difference was provider were not different between the two questionnaires. significant. They also found that the need for assistance while Of the participants who completed the question on ques- answering the questionnaire was 53.9% for CAT, and 36.0% for tionnaire preference (n = 78), the majority (79.5%) had no CCQ. In our study, no assistance was given, but in the CAT preference for one of the questionnaires, while 16.7% preferred questionnaire more questions remained unanswered than in the the CCQ and 3.8% preferred the CAT. CCQ (10 vs. 1%). In contrast, Sundh et al. found a considerably higher proportion of the patients were able to complete the CAT compared with the CCQ, although they found that a slight Agreement between electronic and paper versions of the CAT and majority of the patients preferred the CCQ. CCQ In a study by Tsiligianni and colleagues, 10% of the patients For comparison of the electronic and paper versions, only stable reported that the CCQ was easier to understand than the CAT. patients (n = 65) were included in the analysis. Of those, 64 had no However, 62% indicated that the CCQ reflected their health status missing data on the electronic or paper version of the CCQ and 55 better than the CAT did because the CCQ addresses their had no missing data on the CAT. The absolute agreement breathing problems better while sleep was less important to between electronic and paper versions was high (ICC [95% CI] them. In our study no differences were found regarding easiness CCQ=0.815 [0.712; 0.883] and ICC [95% CI] CAT=0.751 [0.608; to complete the questionnaires or the importance of the topics 0.847]). Interpretation of Bland–Altman plots essentially supports addressed between the questionnaires. agreement between the two versions (Figs 2, 3). The agreement between electronic and paper versions of both CAT and CCQ was high, which justifies electronic use in daily practice or by patients themselves online. DISCUSSION The decision on which health status questionnaire to use can be Main findings made based on local preferences, or based on the fact that in To the best of our knowledge, this is the first study comparing CCQ addition to the total score the CCQ offers three subdomain scores and CAT head-to-head in a primary care population to assess (symptom, functional, and mental status) that can be used to completion time and ease of use. This study demonstrates that in a guide treatment prioritization in practice. Furthermore, the primary care COPD population neither statistically nor clinically usefulness of the questionnaires from a clinician’s perspective, relevant differences in filling out time or acceptability between the including the ease of deriving a score, should be taken into two health status questionnaires were observed. Agreement between account. Also the impact of missing items on the score or the electronic and paper versions of the questionnaires was high. impact of remotely completing the questionnaires should be considered. However, that was not within the scope of this study. Interpretation of findings in relation to previously published work This study adds to our knowledge the acceptance and feasibility One earlier study by Ringbaek in a group of mainly severe COPD for the patients in addition to the known feasibility for primary patients participating in a pulmonary rehabilitation program care as assessed by the IPCRG. npj Primary Care Respiratory Medicine (2017) 20 Published in partnership with Primary Care Respiratory Society UK Comparison of the CAT and the CCQ in primary care JWH Kocks et al. Strengths and limitations of this study characteristics between participants and non-participants could not be compared. Selection bias might reduce generalizability. A limitation of this study is that we could not rule out selection Although it can be thought that factors like COPD severity, bias. Patients are invited to participate, and non-response or age, or comorbidity might influence time to complete the reasons for not participating are not examined. Moreover, questionnaire, we expect that this will be the same for both questionnaires. Table 1. Baseline characteristics Importance of topics addressed is more likely to depend on severity, since more severe patients might have other or more COPD patients (n = 95) symptoms than less severe patients. Our population is relatively mild based on mMRC, CAT, and CCQ scores. We cannot be sure Age in years, mean (SD) 65.0 (10.0) whether the results of this study on importance of the topics Male gender, n (%) 60 (63.2) addressed in the questionnaires can be generalized to more CAT score, mean (SD) 13.2 (7.4) severe populations. CCQ score, mean (SD) 1.6 (1.0) Another factor that might influence the results, especially mMRC score, median [IQR] 1.0 [1.0–2.0] easiness of the questions, is socio-economic status (SES). Participants are included from different parts of the Netherlands Note: Normal distributed variables are presented as mean (SD), non-normal and from different general practices. Nevertheless, we cannot be variables as median [IQR] sure that we included patients from with different SES levels. COPD chronic obstructive pulmonary disease, CCQ clinical COPD ques- tionnaire, CAT COPD assessment test, mMRC modified Medical Research Finally, the questions regarding acceptability of the CAT and Council CCQ were not pilot tested. Nevertheless, those questions were Table 2. Differences between electronic version of the CAT and the electronic version of the CCQ CCQ CAT p-value Completion time in seconds, median [IQR] 99.6 [74–157] 97.5 [68–136] 0.151 Easiness to complete (0–10), median [IQR] 8.0 [5–10] 7.5 [5–9] 0.109 Importance of issues raised (0–10), median [IQR] 5.0 [5–7] 5.0 [5–7] 0.543 Importance of information for health care provider (0–10), median [IQR] 7.0 [5–8] 8.0 [5–8] 0.836 COPD chronic obstructive pulmonary disease, CCQ clinical COPD questionnaire, CAT COPD assessment test, mMRC modified Medical Research Council Analyzed using paired sample t-test based on logtransformed variables Analyzed using Wilcoxon signed-rank tests Fig. 2 Bland–Altman plot showing the relationship between the electronic and paper version of the CCQ. The dashed lines represent the limits of agreement Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2017) 20 Comparison of the CAT and the CCQ in primary care JWH Kocks et al. Fig. 3 Bland–Altman plot showing the relationship between the electronic and paper version of the CAT. The dashed lines represent the limits of agreement quite straight forward and the majority of the patients completed Outcomes those questions. Because the same questions were used for both The primary outcome was the time (in seconds) required to complete the electronic versions of the CAT and CCQ questionnaire. The time running questionnaires we believe it is legitimate to draw conclusions from showing the questionnaire on the screen until clicking “completed, based on those questions. next page” was recorded. The CCQ is an instrument to measure health status in patients with Implications for future research, policy, and practice COPD. It consists of 10 questions on three domains: symptoms, mental state, and functional state. The symptoms and functional state domains Based on this study, both questionnaires seem equally suitable for contain four items each, and the mental state domain two. Questions are use in routine clinical practice, because they are both quick to scored on a 7-point scale from 0–6, with 0 representing the best possible complete and have a good acceptability by the patient. score and 6 representing the worst possible score. Total scores range from 0–6. A higher CCQ value indicates a lower health status. The CAT also measures health status in patients with COPD. The CAT has Conclusions eight items and includes questions about symptoms, energy, sleep, and No significant differences were found in the completion times and 3 activity. Total scores range from 0 to 40, where 0 represents no acceptability between the CCQ and the CAT in Dutch primary care. impairment. Based on this study it can be concluded that both questionnaires Secondary outcomes were the degree of acceptability, measured with three questions on easiness (How difficult was completing the ques- are equally suitable for use in routine clinical practice, because they tionnaire?), importance of issues raised in questionnaires (To what extent are both quick to complete and have a good acceptability by the did you feel the questionnaire addressed all aspects of your disease?) and patient. Agreement between electronic and paper versions of the importance of information for health-care provider (To what degree do you questionnaires was high, so use of electronic versions is justified. think that the questionnaire gives relevant information about your disease to your doctor?), scored on a visual analog scales ranging from 0 to 10, where 0 indicates a low acceptability and 10 indicates high acceptability. In METHODS addition, patients were asked to indicate which questionnaire they would recommend to their general practitioner. Patients The MRC questionnaire is a one-dimensional tool to measure dyspnea COPD patients with a doctors’ diagnosis of COPD according to current during exercise in five levels (range 0–5). The global rating of change guidelines were recruited from general practices and primary care (GRC) questionnaire was used to assess change in breathlessness between rehabilitation physiotherapy programs in and around the Groningen and completing the electronic and paper questionnaires on a 15-point Likert Rotterdam areas in the Netherlands. Inclusion criteria were (1) a doctor’s scale, ranging from −7 (a very great deal worse) to +7 (a very great deal diagnosed COPD and (2) electronic informed consent. Exclusion criteria better). were (1) inability to understand or read the Dutch language and (2) unable to connect to the internet. Study procedures Primary care practitioners identified patients with COPD and invited them by letter or in person to participate in the study. A study-specific online module was designed within the Zorgdraad Participants logged in on the website to sign an electronic informed integrated care IT system. The CAT and CCQ were designed to appear consent form and start with the study. similar to the paper versions. The order in which the CAT or CCQ was npj Primary Care Respiratory Medicine (2017) 20 Published in partnership with Primary Care Respiratory Society UK Comparison of the CAT and the CCQ in primary care JWH Kocks et al. presented to the patient was randomized to eliminate any completing REFERENCES fatigue effects. The time between loading of the webpage and submitting 1. GOLD Committee. Global strategy for diagnosis, management, and prevention of the form was recorded electronically. The easiness to complete, under- COPD. http://goldcopd.org/archived-reports/. Updated February 2013. stand the questions, questionnaire preference, and importance of issues 2. van der Molen, T., Miravitlles, M. & Kocks, J. W. COPD management: role of addressed were assessed using additional questions. symptom assessment in routine clinical practice. Int. J. Chron. Obstruct. Pulmon. Within 1 week after completing the electronic version, the participant Dis. 8, 461–471, doi:10.2147/COPD.S49392 (2013). completed a paper copy of the CAT and the CCQ at their homes. In 3. Jones, P. W., Harding, G., Berry, P., Wiklund, I., Chen, W. H. & Kline, L. N. Devel- addition, the GRC was completed to assess stability of the disease. For opment and first validation of the COPD assessment test. Eur. Respir. J. 34, comparison of the electronic and paper versions, only stable patients with 648–654 (2009). a GRC score between −1 to +1 were included in the analysis. 4. Kocks, J., de Jong, C., Berger, M. Y., Kerstjens, H. A., van der Molen, T. Putting health status guided COPD management to the test: protocol of the MARCH study. BMC Pulm. Med. doi:10.1186/1471-2466-13-41 (2013). Sample size and statistical analysis 5. GOLD Committee. Global strategy for the diagnosis, management and preven- A sample size calculation using data from Ringbaek and colleagues with a tion of COPD. Global initiative for chronic obstructive lung disease (GOLD). http:// power of 80% and a two-sided significance level of 5% indicated that 88 goldcopd.org/archived-reports/. Update 2011. patients were needed to complete the study to show at least a 30 s difference 6. Bestall, J. C., Paul, E. A., Garrod, R., Garnham, R., Jones, P. W. & Wedzicha, J. A. in filling out time, which difference we considered clinically relevant. Usefulness of the medical research council (MRC) dyspnoea scale as a measure of Difference in time to complete the electronic version of the CAT and the disability in patients with chronic obstructive pulmonary disease. Thorax 54, electronic version of the CCQ was tested using a paired sample t-test. In 581–586 (1999). the event assumptions of the t-test were violated, testing was conducted 7. van der Molen, T., Willemse, B. W., Schokker, S., ten Hacken, N. H., Postma, D. S. & on logtransformed variables or, if unsuccessful, Mann–Withney U tests. Juniper, E. F. Development, validity and responsiveness of the clinical COPD Data were descriptively presented as medians with IQRs. questionnaire. Health Qual. Life Outcomes 1, 13 (2003). The differences between the electronic versions of the CAT and the CCQ 8. Ringbaek, T., Martinez, G. & Lange, P. A comparison of the assessment of quality regarding easiness to complete, importance of issues raised in question- of life with CAT, CCQ, and SGRQ in COPD patients participating in pulmonary naires, and the importance of information for health-care provider were rehabilitation. Chron. Obstruct. Pulmon. Dis. 9,12–15, doi:10.3109/ determined using paired sample t-tests, or, when assumptions were violated, 15412555.2011.630248 (2012). paired sample t-tests on logtransformed variables. If logtransformation was 9. Sundh, J., Stallberg, B., Lisspers, K., Kampe, M., Janson, C. & Montgomery, S. unsuccessful Wilcoxon signed-rank tests were used. The intraclass correlation Comparison of the COPD assessment test (CAT) and the clinical COPD ques- coefficient (ICC) and Bland–Altman plots were used to assess agreement tionnaire (CCQ) in a clinical population. Chron. Obstruct. Pulmon. Dis. 13,57–65, between the electronic version and the paper version of the CAT and CCQ. doi:10.3109/15412555.2015.1043426 (2016). The study was registered at the Dutch Trial Register (NTR3384), and The 10. Tsiligianni, I. G. et al. Assessing health status in COPD. A head-to-head University Medical Center Groningen Ethics Board approved the study. comparison between the COPD assessment test (CAT) and the clinical COPD questionnaire (CCQ). BMC Pulm. Med. 12, 20, doi:10.1186/1471-2466-12-20 (2012). FUNDING 11. Cave, A. J., Atkinson, L., Tsiligianni, I. G. & Kaplan, A. G. Assessment of COPD This study was financially supported by an unrestricted research grant by GSK NL. wellness tools for use in primary care: an IPCRG initiative. Int. J. Chron. Obstruct. Publication was financially supported by the International Primary Care Respiratory Pulmon. Dis. 7, 447–456, doi:10.2147/COPD.S29868 (2012). Group and the Primary Care Respiratory Society UK. 12. Smeele, I. et al. M26. NHG-standaard COPD. Huisarts Wet. 50, 362–379 (2007). 13. Juniper, E. F., Guyatt, G. H., Willan, A. & Griffith, L. E. Determining a minimal important change in a disease-specific quality of life questionnaire. J. Clin. Epi- AUTHOR CONTRIBUTIONS demiol. 47,81–87 (1994). K.J.W.H. was involved in the design, data collection, analysis, interpretation, and wrote the first draft. B.C.M.G. was involved in the design and data collection. K.M.J. was involved in analysis and interpretation. O.W. was involved in the design and data This work is licensed under a Creative Commons Attribution 4.0 collection. K.B.J. was involved in the design, data collection, and analysis. V.d.M.T. was International License. The images or other third party material in this involved in the design, data collection, and interpretation. C.N.H. was involved in the article are included in the article’s Creative Commons license, unless indicated design, data collection, analysis, and interpretation. All authors contributed to the otherwise in the credit line; if the material is not included under the Creative Commons writing of the paper. K.J.W.H. and C.N.H. are the guarantors of the paper. license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by/ 4.0/ COMPETING INTERESTS V.d.M.T. developed the CCQ and holds the CCQ’s copyright. The remaining authors © The Author(s) 2017 declare no competing interests. Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2017) 20

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Published: Mar 28, 2017

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