Chronic Respiratory Disease

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Impact on readmission rates and mortality of a chronic obstructive pulmonary disease inpatient management guideline B J Smith, F Cheok, A R Heard, A J Esterman, A M Southcott, R Antic, P A Frith, K Hender and R E Ruffin Chronic Respiratory Disease 2004 1: 17 DOI: 10.1191/1479972304cd007oa The online version of this article can be found at: http://crd.sagepub.com/content/1/1/17

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PAPER

Impact on readmission rates and mortality of a chronic obstructive pulmonary disease inpatient management guideline BJ Smith"2'3, F Cheok4, AR Heard4, AJ Esterman5, AM Southcott, R Antic6, PA Frith7, K Hender2 and RE Ruffin' 'Department of Medicine, University of Adelaide, Australia; 2Clinical Epidemiology and Health Outcomes Unit, The Queen Elizabeth Hospital, Australia; 3Respiratory Medicine, The Queen Elizabeth Hospital, Australia; 4Epidemiology Branch, Department of Human Services, Australia;

5Department of General Practice, Flinders University, Australia;

6Respiratory Medicine, Royal Adelaide Hospital, Australia; and 7Respiratory Department, Repatriation General Hospital, Australia Aims: Chronic obstructive pulmonary disease (COPD) is a common condition associated with considerable morbidity, mortality and hospital admissions. However, published COPD management guidelines have major limitations and lack practical summaries. We aimed to optimally develop, implement, and evaluate a multidisciplinary COPD inpatient management 'ACCORD' guideline, including prompts for comprehensive day one assessments through to a discharge criteria checklist. Method: Two intervention and two control public teaching hospitals in Adelaide, South Australia, took part, with pre-intervention (721 COPD admissions over 7 months) and intervention phases (509 COPD admissions over 7 months). During the intervention stage the ACCORD guideline was placed in the case notes on the day of admission or soon after. Readmissions were categorized as either emergency or elective and compared between the study arms, as were mortality and potential confoundeis (age, gender, number of comorbidities), with Poisson regression analysis. Results: Of case notes of eligible COPD patients, 60% had the ACCORD guideline placed, of which 76% had evidence of use as judged by completion of guideline entry and tick boxes. The ACCORD guideline was associated with an increase in elective admissions and a reduction in emergency admissions in the intervention group in relation to the control group (P < 0.01), with no difference in overall admissions or death rates. Conclusions: The ACCORD guideline was associated with a shift from emergency admissions to more planned elective care, suggesting more proactive care of health problems, but without overall reduction in admissions. Chronic Respiratory Disease 2004; 1: 17-28

Key words: chronic obstructive pulmonary disease (COPD); guideline; health service utilization; protocol

Introduction Chronic obstructive pulmonary disease (COPD) is a condition of high prevalence, cost burden, and readmission and has a largely preventable component.' 2 It is Australia's fourth leading cause of death,3 with substantial direct health-care costs of over AUD$3 million per year.3 Indirect costs include absenteeism, Correspondence: Brian Smith, Director, Respiratory Department, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, South Australia, 5011 E-mail: [email protected]

early retirement and carer burden, such that the total direct and indirect costs of COPD to the Australian community have been estimated at AUD$8 million annually.2 However, there is a view that COPD is an incurable and 'self-inflicted' disease, resulting in undeserved therapeutic nihilism,2 and this view has become entrenched by lack of awareness of new and emerging treatments for COPD. Chronic obstructive pulmonary disease accounts for almost one-third of hospital separations in Australia, with an average length of stay of 5.3 days.3 Up to 76% of patients with COPD disVlay anxiety, depression, panic, confusion or neurosis.

,( Arndd 2004

10.1191/1479972304cr0J7oa


Readmission rates and mortality of COPD BJ Smith et al. 18

We have appraised published COPD management guidelines, finding a lack of optimal development and implementation processes,5 practical summaries that may be readily utilized in clinical settings, and limited uptake in actual clinical practice. Guidelines face a range of barriers that have previously been reported, including observations that clinicians practise in social units that determine behaviour,6 and prefer the advice of colleagues above recommendations of guidelines.7 The limited evidence of patient benefit from guidelines has previously been reviewed, 8 and for COPD specifically,9" 0 and optimal strategies to implement guidelines have been proposed.11"2 In 1998, the Adelaide Collaboration on Chronic Obstructive Respiratory Disease (ACCORD) was formed to develop and implement a guideline for COPD management of hospital inpatients, while attempting to address previously reported barriers to such interventions. We hypothesized that by improving inpatient care, actively seeking to identify and manage comorbidities and improving discharge planning and provision of social supports where needed, the use of the guideline would improve patient outcomes and reduce readmission rates to hospital. 5

Methods

Study design and participants The ACCORD guideline was developed using a combination of evidence from available literature and local input, involving extensive consultation with a range of health professionals, including physicians, general practitioners, nurses and allied health professionals. A steering committee, including representatives from these health professional groups, health economists, epidemiologists, and a patient advocate, met regularly. We utilized reVorted recommendations on guideline development and implementation, 13 with consideration of the complexities of changing clinical behaviour7 Input was also obtained from international guidelines experts, including site visits (see Acknowledgements) and Ethics Committee approval was obtained from all participating institutions. The guideline was designed to facilitate management of COPD from admission assessment through to discharge readiness, which was based on specified criteria. Management recommendations related to effective treatment (including evidence-based use of drugs and planning for pulmonary rehabilitation), prevention (including vaccination and smoking cessation) as well as identification of major comorbidities (including depression, cor pulmonale, overlap syndrome/ obstructive sleep apnoea and malnutrition).

The final guideline was an eight-page document comprising a referral screen to prompt referrals to allied health, social work, psychiatry, and a management and discharge plan, which included respiratory assessment, infection, comorbidities, patient and carer knowledge, and resuscitation directives. Related to each section were management suggestions for Day 1 and Day 2 onwards with corresponding discharge criteria. The guideline included a one-page summary of the evidence to support the recommendations with full information available in a resource folder on all wards. A dyspnoea assessment sheet and a feedback sheet on the usefulness of the guideline were also included. The full guideline is shown in Appendix 1. The final guideline was endorsed at an interactive multidisciplinary workshop (with 100 attendees) using audience response technology. Figure 1 outlines the study design (a separate prepost samples nonequivalent intervention study) and study numbers. Four public teaching hospitals across Adelaide, South Australia, the population of which is around 1.1 million, were included in the study, two assigned as 'control' hospitals and two as 'intervention' hospitals. The ACCORD guideline was introduced to the two intervention hospitals through site visits by ACCORD nurse researchers, by group meetings, and one-to-one sessions with medical officers, nurses and allied health professionals involved in the care of COPD patients. During the 13 months of the study there were 1240 tracked admissions for COPD across the participating hospitals; however, 10 patients died on the same day as their index admission and have been excluded, leaving 1230 admissions; 721 during the preintervention phase (May to late November 1998) and 509 during the intervention phase (late November 1998 to June 1999). The index admission was defined as the first admission for an individual during the phase. Patients had a single index admission during each phase, but could have been included in both phases this applied to 111 patients, hence the total 1230 admissions relates to I 1 19 unique patients. Eligible subjects were identified by research assistants from daily hospital admission records on the basis of a primary diagnosis of COPD (from a list of descriptions matching those of ICD-10 codes J438, J439, J441, J448, J449, J960, J961 and J969).14 Usual care was provided to all subjects during the pre-intervention phase and to those in control hospitals during the intervention phase. The study protocol recommended that a copy of the ACCORD guideline be placed in the case notes of patients at the two intervention hospitals on the day of admission, or as soon as practicable after admission by the nurse researchers. Copies of the guideline were available in each ward

Chrric Rspratory [isase


-


Figure

1

ACCORD study design and numbers.

for clinicians to access if the guideline had not been placed. The design allowed for a comparison of subjects in control vs. intervention hospitals during the intervention phase, adjusted for pre-intervention differences between the two groups of hospitals. The two outcome measures were 1) readmission rate, and 2) death rate. A readmission was defined as a readmission to the same hospital as the index admission within the phase (pre-intervention or intervention). Readmission rate was defined as the total number of readmissions (each patient could have several readmissions) per patient-days on trial. The latter was calculated as time from index admission to end of phase or death if the patient died. Readmissions were identified from hospital separation databases and were further categorized as emergency (unplanned) or elective (planned). The elective admissions were pre-planned either before the initial discharge or at subsequent clinic follow-up and usually entailed a specific procedure. A death was defined as any death occurring within the same phase as the index admission. Death rate was defined as deaths per patient-days on trial. Participants who were in both the pre-intervention and intervention phases were omitted from the analysis. Deaths were identified by cross matching index COPD admissions with death registry data. Other data collected and included as potential confounding variables were age, gender and type of index admission (emergency/elective) and number of comorbidities (defined as the number of ICD- 10 discharge diagnoses coded in addition to the primary diagnosis).

group patients were required for each control group patient.

Statistical analysis

Results

Sample size required

Sample size calculations were based on expected differences

in death and readmission rates. Two intervention

a) Death rates: based on a chi-square test with a 0.050 two-sided significance level and 80% power to detect the difference between a death rate in the control group of 33% compared with a death rate of 20% in the intervention group (relative risk of 0.70), 132 patients were required in the control group and 264 patients in the intervention group. b) Readmission rates: assuming 198 patients in each group then a sample this size would allow a difference of 198 readmissions in the control group over the sixmonth period, compared with 192 readmissions in the intervention group (a reduction of 3%) to be statistically significant, based on a Poisson z-test with 80% power and a 0.05 two-sided significance level. Because of potential clustering effects within hospitals and the overlap of some patients between the preintervention and intervention phases, a minimum sample size of 500 patients was set for each phase. For both death and readmission rates, crude comparison of rates and 95% confidence intervals for the rate ratios were undertaken by Poisson regression analysis. Adjustment for potential confounding variables was also undertaken by Poisson regression analysis, with allowance made for clustering by hospital and individual. The phase/group interaction term was used as a test of intervention effect, a significance level of P < 0.05 being set for statistical significance. All analyses were undertaken using the Stata 7.0 statistical software.15

Survey of case notes demonstrated that the ACCORD guideline was placed in 60% of case notes of eligible COPD patients. Table 1 describes age, gender and numwv.RAiwmauLnm.


Readmission rates and mortality of COPD BJSmithetal. 20

ber of comorbidities, based upon discharge coding by ICD-10 practices, for all intervention and control patients. Of these, 76% of ACCORD guideline sheets had some evidence of use, according to use of entry and tick boxes on the ACCORD guideline sheets.

Analysis of readmission rates Table 2 shows the readmission rates for each phase for intervention and control hospital groups for all readmissions, emergency readmissions and elective readmissions. In both study groups, there was a statistically significant increase in readmission rates between the pre-intervention and intervention phases. However, for the intervention group the increase was in the elective readmissions, whereas for the control group the increase was

in

emergency readmissions.

Poisson regression analysis with adjustment for clustering by hospital, age, gender and patient identifier, and time on trial demonstrated a similar pattern of results.

Death rates Death rates for each phase for intervention and control groups are presented in Table 3. Participants who were

in both the pre-intervention and intervention phases were omitted, leaving 11 19 individuals in the analysis. Table 3 shows that whereas in the intervention group there was a trend for a decreased death rate between the two phases (P = 0.053), there was no change in death rates for the control group. Poisson regression analysis with adjustment for potential confounders, time on trial, showed no statistically significant effect by the intervention. Length of stay There was no significant difference between baseline and active length of stay for any hospital. Factors that were associated with an increase in length of stay were female gender (P < 0.05), number of comorbidities (P < 0.001) and hospital (P < 0.001).

Discussion The increase in admissions generally, regardless of intervention, is likely to relate to overall seasonal bed availability. However, the increase in unplanned readmissions in control hospitals, in contrast to elective admissions in ACCORD intervention hospitals, suggests

Table 1 Companrson of control and intervention characteristics, in relation to baseline and active phases of the study Study group Baseline control

Baseline intervention

Active control

Active intervention

Total

n

%

n

S

n

%

n

%

n

%

Gender Female Male Total

102 116 218

47 53 100

215 294 509

42 58 100

75 100 175

43 57 100

106 232 338

31 69 100

498 742 1240

40 60 100

Age (years) < 50 50-59 60-69 70-79 80+ Total

10 25 52 93 38 218

5 11 24 43 17 100

18 51 114 194 132 509

4 10 22 38 26 100

9 14 48 62 42 175

5 8 27 35 24 100

20 35 73 133 77 338

6 10 22 39 23 100

57 125 287 482 289 1240

5 10 23 39 23 100

4 9 12 14 12 16 10 4 5 7 8 100

11 41 59 83 81 65 57 41 23 14 34 509

2 8 12 16 16 13 11 8 5 3 7 100

7 10 12 15 22 17 18 16 17 12 29 175

4 6 7 9 13 10 10 9 10 7 17 100

4 23 46 50 50 38 42 28 16 12 29 338

1 7 14 15 15 11 12 8 5 4 9 100

30 94 143 179 179 154 138 93 67 53 110 1240

2 8 12 14 14

Number of comorbid conditions 0 8 1 20 2 26 3 31 4 26 34 5 6 21 7 8 11 8 9 15 10+ 18 Total 218

Chroric nsfratory Dsse


12

11 8 5 4

9 100

Readmission rates and mortality of COPD BJ Smith et al. 21 Table 2 Readmission rates of control and intervention study groups, in relation to baseline and active phases of the study Readmissions Type of readmission

Phase

Hospital group

All

Pre-intervention

Intervention Control Intervention Control

Intervention Emergency

Pre-intervention

Intervention Elective

Pre-intervention Intervention

Intervention Control Intervention Control Intervention Control Intervention Control

per patient days on trial

305/51672 113/20227 279/34633 123/15631 253/51672 99/20227 164/34633 110/15631 52/51672 14/20227 115/34633 13/15631

Readmission rate per 100 days on trial

Rate ratio

95% CIfor RR

0.59 0.56 0.81 0.79

1.06

0.85-1.31

0.616

1.02

0.83-1.26

0.828

0.49 0.49 0.47 0.70

1.00

0.79-1.26

0.957

0.67

0.53-0.86

0.001

1.45

0.81-2.62

0.211

3.99

2.25-7.08

0.10 0.07 0.33 0.08

Significance

< 0.00

Table 3 Death rates during the pre-intervention and intervention stages of the study, according to control and intervention study groups. Hospital

Deaths per patient

Phase

group

days on trial

Death rate per 100 days on trial

Risk ratio

95% Cl for RR

Significance

Pre-intervention

Intervention Control Intervention Control

87/43638 31/16314 49/34633 30/15631

0.20 0.19 0.14 0.19

1.05

0.70-1.58

0.818

0.74

0.47-1.16

0.186

Intervention

ongoing reactive health-care delivery is transformed into more proactive management of COPD and associated comorbidities, arguably through the use of the ACCORD guideline. We demonstrated no benefit associated with the intervention in terms of statistically significant changes in mortality, although there was a trend to reduced deaths in the intervention hospitals from the pre-intervention phase to the intervention phase. The results of the current study must be interpreted in the context of its potential limitations, which may affect the outcomes of the study and its generalizability. The COPD patients were enrolled among those admitted to the major teaching hospitals in Adelaide, and may not be representative of the general COPD population. Precise use of the guideline is not known. Although the guideline was not placed in 40% of eligible COPD case notes, staff practice may have been influenced by general awareness of the ACCORD guideline through care of other COPD patients and ACCORD education efforts. Nonuse of entry and tick boxes does not exclude ACCORD guideline recommendation influence. This suggestion is supported by the lack of difference between intention-to-treat and per-protocol analysis. The most common reason for nonplacement of the guideline was incomplete or inaccurate admission diagnosis. Brief admissions, particularly over

weekends, were less likely to have the guideline placed by the research assistants, which also raises resource implications for the future. The mention of COPD at discharge as a primary or secondary diagnosis in 92% of those patients who entered our study emphasizes the effectiveness in the recruiting process. However, there are a large number of patients in whom COPD was not related to the primary admission diagnosis but was a potential comorbidity that would need to be targeted to have universal adoption of the guidelines. This has substantial resource implications and perhaps emphasizes the need to have targeted application of guidelines. Misclassification of the diagnosis of COPD is likely at times with mismatching of ACCORD placement to suitable COPD patients, reducing the chances of demonstrating a positive benefit of the guideline. The four hospitals cannot be assumed to have similar baseline practices, and dividing into two intervention and two control hospitals may be a limitation of this study. Unmeasured benefits may have accrued by the facilitated detection and management of depression and anxiety, as well as the longer term management of comorbidities such as hypoxia-associated cor pulmonale, obstructive sleep apnoea, and prevention of pneumococcus by vaccination. Such benefits may not be measurable within a short period of study. 16 An anal-

ww.CRqcuffd.aom



ysis was possible of the presence of psychiatric 'caseness' in this study, by objective means, using the General Health Questionnaire, 17,18 completed by a sample of study patients (n = 530) during their index admission, and a comparison could be made to the recording of depression in the discharge coding. Over 50% of patients met the caseness criteria for the anxiety and insomnia subscale, while 30% met the severe depression subscale criteria. However, only 4.5% of patients had an anxiety diagnosis recorded as a comorbid condition, with clinical depression rarely appearing (0.4%), despite being identified for a third of patients by objective criteria. Quality of life measurements would be important in this patient group; however, questionnaire burden in frail elderly subjects was a major limitation in our pilot attempts. In the development of our ACCORD guideline, we committed to obtaining extensive input from a range of health professionals and potential guideline users. Although this addressed the need for local input as recommended, it resulted in an eight-page ACCORD guideline. This was considered unwieldy and an impediment to effective implementation by health professionals who participated on post-study feedback. Future guidelines for COPD management may be more successful if they target a smaller number of key clinical issues for which the evidence is strongest, such as pulmonary rehabilitation, which has the ability to reduce subsequent health-care utilization. 19,20 Future projects could also consider closer integration of guidelines with usual clinical practice by incorporation into case note progress sheets, electronic medical records, online interactive guidelines, or patient-driven guidelines. Despite the likely impact of a dilution in study outcomes due to the factors described above, we were able to demonstrate excess burden in terms of emergency readmissions, which in turn is likely to impact on reduced quality of life and increased service use among COPD patients for whom guidelines, as recommended by the ACCORD, were not actively promoted.

Acknowledgements This study was funded by grants from the South Australian Department of Human Services and the National Health and Medical Research Council of Australia. The authors thank the ACCORD Steering Committee members, the Pharmaceutical Alliance, and staff of Adelaide teaching hospitals for their contribution in implementing the ACCORD project. Also, Dr Chris

Wise, Director of Practice Guideline Implementation, University of Michigan Medical School, and Dr Jeremy Grimshaw, Cochrane Effective Practice and Organisation of Care Group, Health Services Research Unit, University of Aberdeen, contributed through local site visits to facilitate development and implementation of the ACCORD guideline.

References 1. Cydulka RK, McFadden ER Jr, Emerman CL, Sivinski LD, Pisanelli W, Rimm AA. Patterns of hospitalization in elderly patients with asthma and chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1997; 156(6): 1807-12. 2. Burdon J, Edwards R. The chronic obstructive pulmonary disease strategy. Intern Med J 2002; 32(3): 64-65. 3. Australian Institute of Health and Welfare. Australia's Health 2000: the seventh biennial health report ofthe Australian Institute of Health and Welfare. Canberra: AIHW, 2000. 4. Frith P, McKenzie D, Pierce R. Management of chronic obstructive pulmonary disease in the twenty-first century. Intern Med J 2001; 31(9): 508-11. 5. Smith B, Hender K, Frith P, Crockett A, Cheok F, Spedding S. Systematic assessment of clinical practice guidelines for the management of chronic obstructive pulmonary disease. Respir Med 2003; 97: 37-45. 6. Cook D, Ricard J, Reeve B et al. Ventilator circuit and secretion management strategies: A Franco-Canadian survey. Crit Care Med 2000; 28: 3547-54. 7. Borbas C, Morris N, McLaughlin B, Asinger R, Gobel F. The role of clinical opinion leaders in guideline implementation and quality improvement. Chest 2000; 118(2): 24S-32S. 8. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342(8883): 1317-22. 9. Ferguson GT. Recommendations for the management of COPD. Chest 2000; 117(2): 23S-28S. 10. Hackner D, Tu G, Weingarten S, Mohsenifar Z. Guidelines in pulmonary medicine: a 25-year profile. Chest 1999; 116(4): 1046-62. 11. Feder G, Eccles M, Grol R, Griffiths C, Grimshaw J. Using clinical guidelines. Br Med J 1999; 318(7185): 728-30. 12. Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. Br Med J 1998; 317: 465-68. 13. Cabana MD, Rand CS, Powe NR et al. Why don't physicians follow clinical practice guidelines?: a framework for improvement. JAMA 1999; 282(15): 1458-65. 14. National Centre for Classification in Health. The international statistical classification of diseases and related health problems, 10th revision, Australian Modification (ICD-10-AM). Sydney: NCCH, University of Sydney, 1998. 15. STATA statistical software, Version Release 7.0, College Station, TX: Stata Corporation, 2001. 16. Haycox A, Bagust A, Walley T. Clinical guidelines - the hidden costs. Br Med J 1999; 318: 391-93. 17. Goldberg DP. Manual of the general health questionnaire. Windsor (UK): NFER Publishing Company, 1978. 18. Goldberg DP, Williams P. Users' guide to the general health questionnaire. Windsor (UK): NFER-Nelson, 1988. 19. Lacasse Y, Guyatt GH, Goldstein RS. The components of a respiratory rehabilitation program: a systematic overview. Chest 1997; 111(4): 1077-88. 20. Tiep BL. Disease management of COPD with pulmonary rehabilitation. Chest 1997; 112(6): 1630-56.

Chroric Pospratory Disse



Appendix 1: The ACCORD Management and Discharge Plan ACCORD MANAGEMENT AND DISCHARGE PLAN

Adelaide

UR 10.2T

PATIENT LABEL

C..ollaboration Unit Record

C-hrmonic

No.:

rn

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Given NamesI_

DRspirasty Dk

Sex:

Date of Birth:

as W.

The ACCORD is an alliance. between

Rspatory visions across the adult

te

teachinghospitals inAdelaide and representatives ofa rangeof disciplines. The Management and Discharge Plan is designed to guide the care of patients- with Chronic Obstructive Pulmonary Disease from admission through t discharge. The Refeal Sreen and Dyspnoea Assessment assstin the implemenation the Plan.

*

The Plan aims to improve the

*

qualiy

of-life of patients (and their carers),

and reduce the need for readmission, by asessing and managing the physical as wellas psychologica and social factors which contributed to ent., 'admission. the,

This isthe first phase -ofthedevelopment of this document. It combines: the avaiable evidence and epert opinion on best practice. Any comments you may have on the use of the Plan, its contents and any suggested improvements would be welcome for ongoing development

*

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Note:

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Readmission rates and mortality of COPD BJ Smith et al. 26 LhR 'No.

__--. Sum

flyspuota A~~ssessment

4

NSTRUCUTONS

rm ..:_ t3isea-an

-admisin

Li

._.................

:

-=.....

DOB:

Ask the patient the folownag qutestions: On

anur

__

b-Std

-t QI and QIl: to estalish theprevious *S fia bestpdyspnoea scores I Q2b: to establish cumnt (admission) dyspnoea scors : Q l2aand ;:: Atdishre _/ _ : *Q and Q2hb: to establish current (discharge) dyspnoeda scores __ SCORESSHOULD RBE REC:ORDED IN THlEMANAGEMEiNTAND DISCHARGE PLANI NO-TIE: If thepatient haslnot coinpleted arn of these tas.ks ask ':O you think th at yUr shortness

of breath would interferewith..

_

__________________

I

E) .... -".Y..................... Best irevious -e(reodd ON

Admission NtLY) I t ast three months, when your breathing was at its best hwsho ofbreath ster you? (re-cord. biheso~

QIa

SCORE 4

Extrmiely Quite a bit

3

Nodetrately

M

2

A Alittle

I

at----- ----------a-l -------l.

QI I, Inthe lastthree ~months, whenl your breaIlhing wasAa at its, best, did your -sh.ortnesso breath interferWetw ? (record highst)

Being at rest

7 6

TaWking or eating Mo40ving in and out of bed

4 3

Shwering or dreSssing WAlking a very short distance eA.g ao a room

i

0 2:! Wal¢:kiashordistance e.g. around tewhouse s ____________ :Walkin a longLdistce .g. to the6 .1 j: ) spnoea DURING Dsharge Stay (recorded l Hospital ONAdmissionANMat In:,eneral.how shortof breath have you 1b tday(rtcordhihe): SCORE :

4

Extremetly. .Q.:

.

uite a bit

2 I 0 (fib lg wr b hasyo ]: Today.

Moderately f\i t

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Sh-owering or dressing srosa troonm Waking a very shoti distancei the house short distance e.g. around Wa king

4

Dyptip

at

Moving

15

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