Hoult, Johanna

Abstract Background Anxiety and depression have been reported in patients with fibrotic interstitial lung disease (f-ILD) and may be detected or evaluated with use of patient reported outcome measures (PROMs). The Generalized Anxiety Disorder-7 (GAD-7) is a screening tool for general anxiety, and the Patient Health Questionnaire (PHQ-9) is a screening tool for depression. We hypothesize that anxiety and depression in f-ILD may be independently associated with increased self-reported dyspnea and decreased physical activity. Methods This was a prospective observational cohort study conducted at a tertiary care institution. Patients with f-ILD were electronically sent PROMs to be completed at study enrollment, three months and six months. Patients also wore an activity monitor (ActiGraph) for 7 days at each time point. Included PROMs were the Modified Medical Research Council dyspnea scale (mMRC), GAD-7, and PHQ-9. The primary outcome was physical activity defined by average steps per day at each timepoint. Two sided, two sample t- tests were used to compare mean mMRC scores between participants with and without anxiety and depression. Mixed effects linear regression models with each patient as a random effect were used to evaluate the association between PROMS and physical activity. Models were adjusted for age, sex, FVC, and timepoint. Results Forty-eight patients were enrolled (mean age 69, female 46%, mean forced vital capacity (FVC%) 80%) and 45 completed baseline PROM and activity measures. In our cohort, 22 (46%) had background clinical anxiety and 17 (31%) had depression. In those with anxiety, 59% were classified as moderate and 2% as severe, while 47% were classified as moderate and 1% as severe in those with depression. Higher mMRC dyspnea scores were associated with both anxiety (1.955, p = 0.058) and depression (2.118, p = 0.022). Results from regression models indicated a one-point increase in GAD7, PHQ-9, and mMRC was associated with decrease in physical activity as defined by steps per day) ([GAD: -272 steps, p = 0.022], [PHQ-9: -188 steps, p = 0.014], [mMRC: -741 steps, p = 0.007]). Conclusions Patients with f-ILD and clinical anxiety and depression reported greater dyspnea and decreased measured physical activity. This abstract is funded by: None

Abstract Rationale: Patients with fibrotic interstitial lung (f-ILD) disease often have decreased physical activity (PA) due to high symptom burden, with shortness of breath, cough, anxiety, and fatigue affecting health-related quality of life (HR-QOL). Previously undiagnosed anxiety and depression has been described in f-ILD though contributing factors remain unknown. We hypothesize that significant rates of disease-related anxiety and depression may be detected but not persist, representing situational or short-term responses to disease burden. We also hypothesize that real-world PA is an important contributor to or reflection of HR-QOL and associated with selected patient-reported outcome measures (PROMs). Methods: This was a single-center prospective observational cohort enrolling adult patients with established f-ILD. PROM questionnaires were sent electronically to patients at study enrollment and 3 months. These included the Modified Medical Research Council (mMRC), Fatigue Severity Scale (FSS), Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Self-Management Ability Scale-30 (SMAS-30), and abbreviated Prolife of Mood States (POMS). PA was defined as mean number of steps per day over a 7-day period as measured by at-home Actigraphy, obtained at enrollment and 3 months (within 2 weeks of completing PROM questionnaires). Results: Forty five patients were included (mean age 69, female 49 %, non-IPF f-ILD 78%, mean forced vital capacity 77%). Baseline GAD-7 anxiety scores were ‘moderate’ in 45% and ‘severe’ in 5%. PHQ-9 depression scores were ‘moderately severe’ in 30% and ‘severe’ in 5%. Mean GAD-7 and PHQ scores were no different at baseline and three months (GAD7 10.18 vs 10, P = 0.653; PHQ-9 12.82 vs 13.32, P = 0.294). mMRC, FSS, and SMAS-30 scores were associated with daily step activity. A one-point increase in mMRC or FSS (greater dyspnea or fatigue) was associated with a decrease in daily steps of 1400 [CI: (-2000, -600), ] or 90 steps [CI: (-160, -15))], respectively. A one-point increase in SMAS-30 (greater self-management) was associated with an increase of 108 steps per day [CI: (25, 190-0.38) ]. Anxiety, depression, and mood did not appear to be associated with step activity GAD-7-4.5 (P = 0.982), PHQ-9-211.5 (P = 0.13), POMS -36.5 (P = 0.096). Conclusions: Clinical symptoms of anxiety and depression are prevalent in patients with f-ILD and do not appear diminished or improved in the short term. Dyspnea, fatigue, and self-management ability are associated with real-world measures of physical activity.

Objective: Health coaching has the potential to improve self-management abilities (SM) in patients with Chronic Obstructive Pulmonary Disease (COPD). Patient engagement with health care providers has a beneficial effect on patient outcomes. We examined the association of patient engagement with the health coach on SM abilities in patients with COPD. Methods: We analyzed the association between the degree of engagement measured by the Working Alliance Inventory (WAI-SR) and the SM measured by the Self-Management-Ability-Scale-30 (SMAS-30) at the end of a COPD health coaching intervention. Results: The cohort included 146 moderate to severe COPD patients. The WAI-SR total score was 85% of the maximum possible scores indicating a high degree of engagement between the health coach and the patients. The WAI-SR Task and Bond domains were positively associated with SM abilities after adjusting for lung function (FEV1 %) and depression symptoms (PHQ-2). Conclusion: The degree of engagement between a health coach and patients is associated with the perception of SM abilities in patients with COPD. Our results may inform self-management intervention and clinical practice.

Abstract Rationale Quality of life (QoL) matters the most to patients with chronic obstructive pulmonary disease (COPD) and is associated with healthcare usage and survival. Pulmonary rehabilitation is the most effective intervention in improving QoL but has low uptake and adherence. Home-based programs are a proposed solution. However, there is a knowledge gap on effective and sustainable home-based programs impacting QoL in patients with COPD. Objectives To determine whether remote patient monitoring with health coaching improves the physical and emotional disease-specific QoL measured by the Chronic Respiratory Questionnaire (CRQ). Methods This multicenter clinical trial enrolled 375 adult patients with COPD, randomized to a 12-week remote patient monitoring with health coaching (n = 188) or wait-list usual care (n = 187). Primary outcomes include physical and emotional QoL measured by the CRQ summary scores. Prespecified secondary outcomes included the CRQ domains: dyspnea, CRQ-fatigue, CRQ-emotions, CRQ-mastery, daily physical activity, self-management abilities, symptoms of depression/anxiety, emergency room/hospital admissions, and sleep. Results Participant age: 69 ± 9 years; 59% women; forced expiratory volume in 1 second percent predicted: 45 ± 19. At 12 weeks, there was a significant and clinically meaningful difference between the intervention versus the control group in the physical and emotional CRQ summary scores: change difference (95% confidence interval): 0.54 points (0.36–0.73), P < 0.001; 0.51 (0.39–0.69), P < 0.001, respectively. In addition, all CRQ domains, self-management, daily physical activity, sleep, and depression scores improved (P < 0.01). CRQ changes were maintained at 24 weeks. Conclusions Remote monitoring with health coaching promotes COPD wellness and behavior change, given its effect on all aspects of QoL, self-management, daily physical activity, sleep, and depression scores. It represents an effective option for home-based rehabilitation. Clinical trial registered with clinicaltrials.gov (NCT 03480386).

BACKGROUND: Pulmonary rehabilitation is an effective treatment for patients with COPD, but patient uptake and adherence to the current offering of center-based pulmonary rehabilitation is modest due to transportation, access, poverty, and frailty, and even more so in the context of the COVID pandemic. Home-based options have been proposed and were found noninferior to center-based rehabilitation; however, there is a lack of home-based programs, and more understanding is needed. We aimed to test the feasibility, uptake, and adherence to a home-based program for COPD rehabilitation with health coaching. METHODS: We conducted a randomized trial with a wait-list controlled design to evaluate the effects of a home-based program with health coaching on breathlessness in subjects with moderate to severe COPD unable to attend the regular pulmonary rehabilitation program. The 8-week intervention consisted of video-guided exercises to be done 6 times a week and captured with a computer tablet. Health coaching was done weekly over the telephone to review subject activity and symptoms and to provide an opportunity for the subject to define their weekly goals. The primary outcomes were uptake, adherence, and Chronic Respiratory Questionnaire (CRQ) Dyspnea Domain. Secondary outcomes were self-management abilities and CRQ Emotions-Mastery-Fatigue. RESULTS: 154 subjects with moderate to severe COPD were randomized. Subject adherence was 86% to the proposed 6-times a week exercise routine. There ( P = .062) was no significant difference in breathlessness (CRQ dyspnea). There was a significant improvement in self-management abilities ( P < .001). The results of the qualitative interviews showed high levels of acceptability of the program. CONCLUSIONS: The tested home-based rehabilitation program with health coaching was feasible, highly acceptable, showed a high degree of adherence, and improved self-management abilities. This study offers seminal information for home-based rehabilitation programs to design alternative options of rehabilitation to individuals with COPD that cannot attend to the well-established center-based pulmonary rehabilitation. (ClinicalTrials.gov registration NCT02557178.)