HEALTHCARE PROFESSIONAL USER GUIDE
Contents
1. develop psychometric tools be used The initial tem generation process Involved literature reviews physician interviews and most importantly patient input For further details on validated translations please visit www CAlestonline org Who developed the CAT The CAT was developed by a multidisciplinary group of international experts who have expertise in developing patient reported outcomes tools questionnaires The group included pulmonary specialists primary care physicians and representatives from patient bodies Patients with COPD were integral to the development and validation of the tool The CAT development was commissioned and funded by GlaxoSmithKline COPD Assessment Test Improving COPD communication improving care Using the CAT in everyday practice why who and when Why should use the CAT The CAT is a short simple questionnaire which is quick and easy for patients to complete It provides a framework for discussions with your COPD patients and should enable you and them to gain a common understanding and grading of the impact of the disease on their life It should also help you to identify where COPD has the greatest effect on the patient s health and daily life As a result you may be better informed when discussing and making management decisions with your patients and be able to ensure that his or her health status is as good as it can be For which patients is the CAT suitable2. The CAT should be used in its entirety The CAT was validated as an 8 item questionnaire and the questions should not be split up or used independently of each other This will reduce the integrity and measurement properties of the questionnaire However responses to the individual items can be used to provide you with an indication of the areas of the patient s health that are more affected than others For example one patient may have higher scores for cough and sputum whereas another may have highest scores for the items about activity or sleep Is the CAT free to use Yes The CAT will be available and free to use globally no charges will be associated with its use Is the CAT available in different languages Yes The CAT will be available in different languages However only approved translations of the CAT questionnaire should be used to ensure the validity and measurement properties of the questionnaire are maintained For further details on validated translations please visit www CATestonline org References Jones PW Harding G Berry P et al Development and first validation of the COPD Assessment Test Eur Respir 2009 34 648 54 2 World Health Statistics 2008 ISBN 978 92 4 156359 8 NLM classification WA 900 1 ISBN 978 92 4 0682740 electronic version http www who int respiratory copd World_Health_Statistics_2008 en print html 3 Jones PW Harding G Wiklund et al Improving the process and outcome of c
3. The CAT is suitable for completion by all patients diagnosed with COPD Can the CAT be used in all COPD patients irrespective of disease severity Yes The CAT has been developed and validated in COPD patients of all disease severities as defined by the Global Initiative for Chronic Obstructive Lung Disease GOLD Where and how does the CAT fit into the clinical assessment of COPD The CAT provides a reliable measure of the impact of COPD ona patient s health status It therefore provides supplementary information to that provided by other aspects of COPD clinical assessment recommended by current management guidelines i e assessment of exacerbation risk and degree of airway obstruction assessed using spirometry The CAT provides a framework for discussions with your COPD patient and should enable you and them to gain a common understanding and grading of the impact of the disease on their life lt should also help you to identify where COPD affects each patient s health and daily life most As a result you may be better informed in discussing and making management decisions with them and be able to ensure each of your COPD patient s health status is as good as it can be Does the CAT replace spirometry No The CAT is not a diagnostic tool Spirometry is essential for the diagnosis of COPD The CAT and spirometry are complementary measures which can be used together in the clinical assessment of a patients COPD to ensure th
4. User Guide which is based upon our current knowledge of the CAT In this we include a first method of grading impact of COPD by CAT scores and provide a simple outline of potential management considerations actions We provide these broad recommendations with the recognition that these may change as more evidence becomes available and clinicians gain more experience with the CAT The guide is presented in the form of frequently asked questions in order to make it as accessible and applicable to your everyday practice as possible As we learn more this guidance will be developed and refined further We look forward to hearing about your experiences using the CAT In your practice in the near future a iii Professor Paul Jones Professor Christine Jenkins London UK Sydney Australia Dr Otto Bauerle Merida Mexico On behalf of the CAT Development Steering Group What is the CAT The CAT is a validated short and simple patient completed questionnaire which has been developed for use in routine clinical practice to measure the health status of patients with COPD Despite the small number of component items it covers a broad range of effects of COPD on patients health Why has the CAT been developed COPD represents a major burden on patients and healthcare systems Despite the fact that it is projected to become the third leading cause of death by 2030 2 communicating the impact of COPD can be difficult and this can
5. contribute to undermanagement of COPD in a significant proportion of people who may suffer increased disability and reduced quality of life as a result The care of COPD patients can only be optimised if there is a reliable standardised measure of the overall effect of disease on each patient s health Unfortunately commonly used lung function measurements such as FEV do not reflect the full impact of COPD The COPD Assessment Test CAT the basics As a result there is a need for a simple to use tool which can measure A structured rigorous scientific approach was then used in the item the effect of COPD on the patients health and enhance understanding reduction process to select the best items and generate the final between patients and physicians of the disease s impact in order to 8 item questionnaire tients optimally and reduce the burden of di h cas un nn The CAT has been initially validated in prospective studies conducted as possible The CAT has been developed to meet this need ae in the USA and Europe but we believe that it is globally applicable A validation study is currently Development of the COPD Assessment Test CAT ongoing in China The CAT has been translated and validated for use in How was the CAT developed The development of the CAT has involved Bi O E E 55 Only validated translations well accepted methodologies used to Ay of the CAT should i 1 i
6. HEALTHCARE PROFESSIONAL USER GUIDE COPD Assessment Test Expert guidance on frequently asked questions Issue September 2009 USERGUIDE Introducing the COPD Assessment Test CAT The COPD Assessment Test CAT Is a new patient completed instrument that has been designed to provide a simple and reliable measure of health status in COPD It will complement existing approaches such as FEV measurement in assessing COPD patients by providing a simple method of quantifying the impact of COPD on the patient s health The CAT has undergone a rigorous scientific development process and the first validation studies show that it has properties very similar to much more complex health status questionnaires such as the St Georges Respiratory Questionnaire SGRQ that are used in research studies It takes only a fraction of the time to complete however making it suitable for routine use Further validation studies are underway in Europe USA and Asia Throughout its development we have understood from discussions with primary care physicians pulmonary specialists and patient groups from around the world that the precise way the CAT will be used will vary by healthcare setting and country However we felt that some initial guidance for healthcare professionals on how to use and interpret CAT scores would be helpful as soon as the CAT became publicly available As such we have developed this the first edition of the CAT
7. aire can then provide a framework for your consultation Where can l access the CAT questionnaire You can download the CAT questionnaire from www CA Testonline org Will patients require much instruction to complete the CAT The content of the CAT questionnaire has been driven by COPD patients It comprises 8 simple questions that most patients should be able to understand and answer easily You should not need to assist patients to complete it In fact it is much better if they complete this independently How frequently should the CAT be used in patients The optimal frequency for completing the CAT is still to be determined by actual use in clinical practice Until further data is available on this the expert development committee would recommend that patients routinely complete the CAT questionnaire every 3 6 months What is the scoring range of the CAT The CAT has a scoring range of 0 40 What do CAT scores and changes in CAT scores mean The implication of CAT scores needs to be considered in relation to an individual s disease severity Patients with more severe COPD as defined by GOLD would be expected to have higher CAT scores than patients with milder disease although many studies have shown that the relationship between GOLD stage measured by FEV and health status scores is generally very weak This is one of the reasons that the CAT was developed and also why the assessment of health status and GOLD stag
8. are in COPD development of a standardised assessment tool Prim Care Resp J 2009 18 3 208 15 4 Jones PW Health status measurement in chronic obstructive pulmonary disease Thorax 2001 56 880 7 Q U NOTES COPD Assessment Test Improving COPD communication improving care www CATestonline org supported by an educational grant from GlaxoSmithKline COPD Assessment Test and CAT logo is a trademark of the GlaxoSmithKline group of companies 2009 GlaxoSmithKline All rights reserved C 09 134 Date of preparation September 2009
9. at they are being optimally managed Can use the CAT to diagnose COPD No The CAT is a scientifically developed tool for measurement of health status It is not a diagnostic instrument unlike FEV measurement which is needed to confirm the diagnosis of COPD as well as to assess the degree of airway obstruction Will the CAT help me make management decisions regarding any co morbidities which my COPD patients may also have No The CAT is a disease specific tool to measure the impact of COPD on patients It will not provide an assessment of co morbid conditions or provide information to help guide any management decisions for co morbid conditions How does the CAT compare with other health status measures used in COPD The CAT has very similar discriminative properties to the much more complex SGRQ suggesting that it will be able to measure the impact of COPD on the health of individual patients in a similar way However the CAT is much simpler and quicker to complete Practical use of CAT When do give the CAT to my patients to complete Experts involved in the development of the CAT recommend that you ask a COPD patient to complete a CAT questionnaire when they arrive for a check up appointment for their COPD or immediately before attending Completion of the CAT takes only a couple of minutes and patients could complete it whilst waiting to see you or at home prior to consultation The completed CAT questionn
10. e are complementary Research is currently ongoing to define ranges of CAT score severity and to better understand the minimal clinically relevant change often referred to as the Minimum Clinically Important Difference or MCID in a CAT score from one visit to the next However based on the strong correlation of the CAT with the SGRQ we currently believe that a difference or change of 2 or more units suggests a clinically significant difference or change in health status We emphasise that this needs to be confirmed by further scientific studies but we are confident that it is a reasonable indicative value of the MCID based upon current knowledge Due to the strong correlation between the CAT and the SGRQ tt is possible to map CAT scores to specific SGRQ Items Four descriptive scenarios have been developed to provide you with pictures of the type of patient associated with different levels of CAT score The content of these is based solely on the appropriate items in the SGRQ They are for illustrative purposes only since each patient will vary in the way COPD affects him or her but the scenarios may be useful in providing you with the broad clinical picture of the impact of COPD associated with different levels of CAT score In addition for each scenario the CAT Development Steering Group has proposed some potential management considerations Very high Their condition stops them doing everything they want to do and they
11. ever recover fully Therefore another potential application of the CAT may be to assess the degree of recovery following an acute exacerbation by re assessing the CAT score 2 3 months after the event Will be able to assess response to therapy with the CAT We know that the CAT has good repeatability which is similar to that for the FEV and based upon our current knowledge we believe that the relative size of its response to therapy will also be similar to that of the FEV For these reasons we think that the CAT will be like the FEV a reliable method of assessing response to therapy in groups of patients but less reliable for assessing whether an Individual patient has had a worthwhile response to a specific therapy That will always require a thorough individual assessment taking a number of factors into account Including change in CAT score However the CAT will provide a measure of the individual patients health that will be very useful in initial assessment and for following medium to long term trends It should also provide a prognostic measure of future health resource use In individual patients Data analysis is currently ongoing to confirm this The design of the CAT may also allow clinicians to readily identify areas of a patient s health that are more severely impaired than others such as mood daytime physical function or sleep Can just use a few of the questions included in the CAT No
12. never have any good days If they can manage to take a bath or shower It takes them a long time They cannot go out of the house for shopping or recreation or do their housework Often they cannot go far from their bed or chair They feel as if they have become an invalid COPD stops them doing most things that they want to do They are breathless walking around the home and when getting washed or dressed They may be breathless when they talk Their cough makes them tired and their chest symptoms disturb their sleep on most nights They feel that exercise is not safe for them and every thing they do seems too much effort They are afraid and panic and do not feel in control of their chest problem Patient has significant room for improvement In addition to the guidance for patients with low and medium impact CAT scores consider e Referral to specialist care if you are a primary care physician Also consider e Additional pharmacological treatments e Referral for pulmonary rehabilitation e Ensuring best approaches to minimising and managing exacerbations Medium 10 20 COPD is one of the most important problems that they have They have a few good days a week but cough up sputum on most days and have one or two exacerbations a year They are breathless on most days and usually wake up with chest tightness or wheeze They get breathless on bending over and can only walk up a flight of stairs slowly They either do their h
13. ousework slowly or have to stop for rests Patient has room for improvement optimise management In addition to the guidance provided for patients with low impact CAT scores consider e Reviewing maintenance therapy Is it optimal e Referral for pulmonary rehabilitation e Ensuring best approaches to minimising and managing exacerbations e Reviewing aggravating factors is the patient still smoking gt 30 gt 20 10 Most days are good but COPD causes a few problems and stops people doing one or two things that they would like to do They usually cough several days a week and get breathless when playing sports and games and when carrying heavy loads They have to slow down or stop when walking up hills or if they hurry when walking on level ground They get exhausted easily e Smoking cessation e Annual influenza vaccination Reduce exposure to exacerbation risk factors e Therapy as warranted by further clinical assessment What effect does an exacerbation have on CAT scores We already know that CAT scores in patients with moderate severe exacerbations are approximately 5 unrts higher than in those who are not exacerbating Based on what we know from other studies this is likely to be the size of change in CAT score when a patient gets an exacerbation Research studies have shown that it may take many weeks for patients to recover fully from a single moderate severe exacerbation and some patients may n
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