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      A comprehensive assessment using COPD assessment test scoring and modified Medical Research Council dyspnea scoring is necessary for personalized therapy for COPD patients

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          Abstract

          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.

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          Real-world characterization and differentiation of the Global Initiative for Chronic Obstructive Lung Disease strategy classification

          Background This study aimed to characterize and differentiate the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy 2011 cut points through the modified Medical Research Council dyspnea scale (mMRC) and chronic obstructive pulmonary disease (COPD) assessment test (CAT). Methods Analysis of COPD patient data from the 2012 Adelphi Respiratory Disease Specific Program was conducted in Europe and US. Matched data from physicians and patients included CAT and mMRC scores. Receiver operating characteristic curves and kappa analysis determined a cut point for CAT and mMRC alignment and thus defined patient movement (“movers”) within GOLD groups A–D, depending on the tool used. Logistic regression analysis, with a number of physician- and patient-reported covariates, characterized those movers. Results Comparing GOLD-defined high-symptom patients using mMRC and CAT cut points (≥2 and ≥10, respectively), there were 890 (53.65%) movers; 887 of them (99.66%) moved from less symptomatic GOLD groups A and C (using mMRC) to more symptomatic groups B and D (using CAT). For receiver operating characteristic (area under the curve: 0.82, P<0.001) and kappa (maximized: 0.45) recommended CAT cut points of ≥24 and ≥26, movers reduced to 429 and 403 patients, respectively. Logistic regression analysis showed variables significantly associated with movers were related to impact on normal life, age, cough, and sleep (all P<0.05). Within movers, direction of movement was significantly associated with the same variables (all P<0.05). Conclusion Use of current mMRC or CAT cut points leads to inconsistencies for COPD assessment classification. It is recommended that cut points are aligned and both tools administered simultaneously for optimal patient care and to allow for closer management of movers. Our research may suggest an opportunity to investigate a combined score approach to patient management based on the worst result of mMRC and CAT. The reduced number of remaining movers may then identify patients who have greater impact of disease and may require a more personalized treatment plan.
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            Real-world characterization and differentiation of the Global Initiative for Chronic Obstructive Lung Disease strategy classification

             DB Price,  CL Baker,  KH Zou (2014)
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              Discrepancies between modified Medical Research Council dyspnea score and COPD assessment test score in patients with COPD

              Background and objective According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, either a modified Medical Research Council (mMRC) dyspnea score of ≥2 or a chronic obstructive pulmonary disease (COPD) assessment test (CAT) score of ≥10 is considered to represent COPD patients who are more symptomatic. We aimed to identify the ideal CAT score that exhibits minimal discrepancy with the mMRC score. Methods A receiver operating characteristic curve of the CAT score was generated for an mMRC scores of 1 and 2. A concordance analysis was applied to quantify the association between the frequencies of patients categorized into GOLD groups A–D using symptom cutoff points. A κ-coefficient was calculated. Results For an mMRC score of 2, a CAT score of 15 showed the maximum value of Youden’s index with a sensitivity and specificity of 0.70 and 0.66, respectively (area under the receiver operating characteristic curve [AUC] 0.74; 95% confidence interval [CI], 0.70–0.77). For an mMRC score of 1, a CAT score of 10 showed the maximum value of Youden’s index with a sensitivity and specificity of 0.77 and 0.65, respectively (AUC 0.77; 95% CI, 0.72–0.83). The κ value for concordance was highest between an mMRC score of 1 and a CAT score of 10 (0.66), followed by an mMRC score of 2 and a CAT score of 15 (0.56), an mMRC score of 2 and a CAT score of 10 (0.47), and an mMRC score of 1 and a CAT score of 15 (0.43). Conclusion A CAT score of 10 was most concordant with an mMRC score of 1 when classifying patients with COPD into GOLD groups A–D. However, a discrepancy remains between the CAT and mMRC scoring systems.
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                Author and article information

                Journal
                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                1176-9106
                1178-2005
                2015
                15 October 2015
                : 10
                : 2203-2206
                Affiliations
                [1 ]Department of Pulmonary Medicine, Hitachinaka Medical Education and Research Center, University of Tsukuba, Ibaraki, Japan
                [2 ]Department of Pulmonary Medicine, Hitachinaka General Hospital, Hitachi Ltd, Ibaraki, Japan
                [3 ]Department of Pulmonary Medicine, Graduate School of Comprehensive Human Science, University of Tsukuba, Ibaraki, Japan
                Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
                Author notes
                Correspondence: Shinji Teramoto, Hitachinaka Medical Education and Research Center, University of Tsukuba, 20-1 Hitachinaka-shi, Ishikawa-cho, Ibaraki, 312-0057, Japan, Tel +81 29 354 5111, Fax +81 29 354 5926, Email shinjit-tky@ 123456umin.ac.jp
                Correspondence: Chin Kook Rhee, Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seochogu, Seoul, 06591, Republic of Korea, Tel +82 2 2258 6067, Fax +82 2 599 3589, Email chinkook@ 123456catholic.ac.kr
                Article
                copd-10-2203
                10.2147/COPD.S94509
                4610800
                © 2015 Teramoto et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License

                The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                Letter

                Respiratory medicine

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