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Measurement of psychophysiologic response variables in chronic bronchitis and emphysema
RESEARCH BRIEFS
36
Award, #5F31 NU-05554-02, Division of Nursing, HRSA DHHS. Address reprint requests to Martha S. Pitzer, RN, PhD, Assistant Professor, The Ohio State University, College of Nursing, 1585 Nell Ave, Columbus, OH 43210. © 1990 by W.B. Saunders Company. 0897-1897190/0301-0007505.00/0
Measurement of Psychophysiologic Response Variables in Chronic Bronchitis and Emphysema Linda E. Moody
ALID AND RELIABLE instruments to measure response variables in clinical research trials and in the clinical area will permit assessment of interventions and outcome responses (Guyatt, Bombardier, & Tugwell, 1986). The Chronic Disease Assessment Tool (CDAT) is used to assess psychophysiologic variables, functional status, and quality of life in adults with chronic bronchitis and emphysema (CBE). It was developed by Moody (1988), who modified scales from a number of established instruments that have been shown in previous research with CBE, cancer, arthritis, and other chronic diseases to have acceptable validity and reliability. The new instrument contains both'new and modified scales and is comprehensive in the.measurement of psychophysiologic variables. The instrument was piloted in a sample o f 21 subjects with CBE. Based on pilot data, a few items were modified to improve clarity. In this develoPment stage, two pulmonary nurse experts and one pulmonary epidemiologist reviewed the CDAT for content validity, yielding a total content validity index of .94 for all items (Waltz,:Strickland, & Lenz, 1984). The CDAT was then used in a cross-sectional study of 45 subjects with CBE at the Gerontology Research Center, National Institute on Aging (NIA). The CDAT (Pans 1 and 2) includes the following sections and scales.
V
Part 1
Pan 1 of the CDAT contains 106 self-report items and five sections, A through E. The questionnaire is administered by pencil and paper to
subjects who are usually able to complete it within 25 to 30 minutes. Section A: General Health and Medical History
Questions in this section are used to measure the subject's perceived health status, degree of disability from lung disease, and length of known diagnosis of lung disease. The subject's perceived degree of dyspnea, acute and chronic, is measured by a dyspnea visual analog scale (dyspnea severity) (Guyatt et al., 1986) and the American Thoracic Society Grade of Breathlessness Scale (GBS) (Brown,' 1985). Section B: Environmental Risk (Air Quality and Active and Passive Tobacco Exposure)
This section measures the degree of past and current exposure to tobacco (active and passive), the subject's assessment of an allergic response, and the ventilation and quality of air in the home (Task Force on Health Risk Assessment, 1986). Section C: Health Impact Measurement Survey
This section of the CDAT was modified from the Arthritis Impact Measurement Survey (AIMS) (Liang, Larson, Cullen, & Schwartz, 1985) and the Chronic Disease Respiratory Questionnaire (CDRQ) (Guyatt, Walter, & Geoff, 1987). The Health Impact Measurement Survey (HIMS) contains the following scales: functional status (mobility, physical activity, dexterity, household activity, activities of daily living), cognitive ability, anxiety, depression, social support, dyspnea index, mastery, health status, and other health problems. These scales are seven-point adjectival response scales that are designed to be administered at various intervals to assess responses. They were also used to cross-validate the scales in Section A that are scaled differently: visual analog scale and a six-point graded scale. Section D: Quality of Life Index
The quality of life scale is a five-item index that has been used extensively in cancer research and has established validity and reliability within standard limits, .89 or higher (Spitzer et al., 1981). A total score is assigned for the quality of life index. Scores range from 0 (poor) to 10 (high).
37
RESEARCHBRIEFS
Section E : Demographic Data
This section includes standard demographic items (gender, age, occupation, work status, and formal education) that are used only in summary form to profile the population studied. Part 2
Part 2 of the CDAT is used as a data collection tool for the clinician/researcher to record results of the physical assessment and pulmonary function tests. Items in the section on pulmonary assessment assess type of pulmonary disease, disease history, chronicity of disease, treatment regimen, and education of the patient about Chronic Obstructive Pulmonary Disease (COPD) management. Also included are results from the spirometry test and maximum inspiratory pressure test that are evaluated in accordance with the standards set forth by the American Thoracic Society (1987). A brief clinical exam is used to verify the subject's pulmonary status. RESULTS
From the NIA study, coefficient alpha reliability indexes (Waltz, Strickland, & L e n z , 1984) were calculated for scales in Part I and found to be sufficiently high, ranging from .65 to .96. Significance
The CDAT holds potential for assisting researchers and clinicians in measuring psychophysiologic responses, functional status, and quality of life, not only for CBE but for other chronic diseases. The CDAT can be modified for type of disease entity. A study is currently underway with a community-based population of subjects with CBE to further test the CDAT with a larger sample. This study adds new knowledge to and broadens the work of other researchers in the measurement of functional status and quality of life for individuals with CBE. The CDAT facilitates assessment of the impact of disease severity and symptom severity (dyspnea, fatigue, and depression) on functional status and quality of life of individuals affected by this progressive, chronic lung disease. The CDAT can be used in clinical trials to evaluate patients' responses to research protocols by measuring outcome variables such as health care use (emergency department visits or hospitalizations
for respiratory distress), disease severity, depression, anxiety, mastery, environmental risk, functional status, and quality of life. Future Research
The occurrence of chronic illness and disability are costly and mutually frustrating for patients and their health care providers (Costa & McCrae, 1988). The magnitude of dyspnea, fatigue, and depression as clinical problems that occur in many chronic diseases (arthritis, heart disease, osteoporosis), and the documented ineffectiveness of existing therapeutic interventions for symptom management provide a c o m p e l l i n g rationale for developing instruments to measure outcome responses and responses to interventions. The symptom triad of dyspnea, fatigue, and depression are important response variables that need to be measured in the clinical environment and in research protocols (Gift, 1987; Guyatt, et al., 1987). Randomized clinical trials are needed to test the effectiveness of various interventions for improving symptom management, functional status, and quality of life in CBE. The CDAT can be used to further examine the complex interactions of psychophysiologic and environmental factors and effects on functional status and quality of life in those who suffer from chronic diseases. ACKNOWLEDGMENTS
Dr. Moody was on IntergovernmentalPersonnel Agreement (IPA) assignmentat the NationalInstitute of Aging, Baltimore, MD whilethis studywas conductedand acknowledgesthe helpful consultationof the followingresearchersat NIA: Drs. Kathleen McCormick,BernardEngel, David Anderson, Paul Costa, and Robert McCrae. Gratitude is expressed to Lori Frank and Monteray Jackson for assistance in data collection and Drs. Virginia Carded and Audrey Gift for reviewing the CDAT for content validity. REFERENCES
American Thoracic Society, Medical Section of the American Lung Association (1987). Standardization of spirometry1987 update. American Review Respiratory Disease, 136, 1285-1298. Brown, M. (1985). Selecting an instrument to measuredyspnea. Oncology Nursing Forum, 12, 98-100. Costa, P., & McCrae, R. (1988, in press). Personality, stress, and coping: Some lessons from a decade of research. In K.S. Markides & C.L. Cooper (Eds.), Aging, stress, social support, and health. New York: Wiley. Gift, A. (1987). Dyspnea:A clinical perspective.Scholarly Inquiryfor Nursing Practice, 1, 73-85. Guyatt, G., Bombardier, C., & Tugwell, P. (1986). Mea-
38
suring disease-specific quality of life in clinical trials. Canadian Medical Association Journal, 134, 889-895. Guyatt, G., Walter, S., & Geoff, N. (1987). Measuring change over time: Assessing the usefulness of evaluative instruments. Journal of Chronic Disease, 40, 171-178. Liang, M., Larson, M., Cullen, K., & Schwartz, J. (1985). Comparative measurement efficiency and sensitivity of five health status instruments for arthritis research. Arthritis and Rheumatism, 28, 542-547. Moody, L. (1988). Psychophysiologic respo~es of adults with chronic lung disease. Gainesville, FL: University of Florida, Grant Proposal to Division of Sponsored Research, University of Florida. Spitzer, W.O., Dobson, J.H., Chesterman, E., Levi, L, Shepherd, R., Battista, R., & Catchlove, B. (1981). Measuring the quality of life of cancer patients. Journal of Chronic Disease, 34, 585-597.
RESEARCH BRIEFS
Task Force on Health Risk Assessment (U.S. Department of Health and Human Services) (1986). Determining risks to health. Dover, MS: Auburn House Publishing Company. Waltz, C., Strickland, O., & Lenz, E. (1984). Measurement in nursing research. Philadelphia: F.A. Davis.
From the College of Nursing, University of Florida, Gainesville, FL. Linda E. Moody, PhD, FAAN: Professor, College of Nursing, University of Florida, Gainesville, FL. Address reprint requests to Linda E. Moody, PhD, FAAN, Professor, College of Nursing, Box J-187, University of Florida, Gainesville, FL 32610. © 1990 by W.B. Saunders Company. 0897-189719010301-0007505.00/0
36
Award, #5F31 NU-05554-02, Division of Nursing, HRSA DHHS. Address reprint requests to Martha S. Pitzer, RN, PhD, Assistant Professor, The Ohio State University, College of Nursing, 1585 Nell Ave, Columbus, OH 43210. © 1990 by W.B. Saunders Company. 0897-1897190/0301-0007505.00/0
Measurement of Psychophysiologic Response Variables in Chronic Bronchitis and Emphysema Linda E. Moody
ALID AND RELIABLE instruments to measure response variables in clinical research trials and in the clinical area will permit assessment of interventions and outcome responses (Guyatt, Bombardier, & Tugwell, 1986). The Chronic Disease Assessment Tool (CDAT) is used to assess psychophysiologic variables, functional status, and quality of life in adults with chronic bronchitis and emphysema (CBE). It was developed by Moody (1988), who modified scales from a number of established instruments that have been shown in previous research with CBE, cancer, arthritis, and other chronic diseases to have acceptable validity and reliability. The new instrument contains both'new and modified scales and is comprehensive in the.measurement of psychophysiologic variables. The instrument was piloted in a sample o f 21 subjects with CBE. Based on pilot data, a few items were modified to improve clarity. In this develoPment stage, two pulmonary nurse experts and one pulmonary epidemiologist reviewed the CDAT for content validity, yielding a total content validity index of .94 for all items (Waltz,:Strickland, & Lenz, 1984). The CDAT was then used in a cross-sectional study of 45 subjects with CBE at the Gerontology Research Center, National Institute on Aging (NIA). The CDAT (Pans 1 and 2) includes the following sections and scales.
V
Part 1
Pan 1 of the CDAT contains 106 self-report items and five sections, A through E. The questionnaire is administered by pencil and paper to
subjects who are usually able to complete it within 25 to 30 minutes. Section A: General Health and Medical History
Questions in this section are used to measure the subject's perceived health status, degree of disability from lung disease, and length of known diagnosis of lung disease. The subject's perceived degree of dyspnea, acute and chronic, is measured by a dyspnea visual analog scale (dyspnea severity) (Guyatt et al., 1986) and the American Thoracic Society Grade of Breathlessness Scale (GBS) (Brown,' 1985). Section B: Environmental Risk (Air Quality and Active and Passive Tobacco Exposure)
This section measures the degree of past and current exposure to tobacco (active and passive), the subject's assessment of an allergic response, and the ventilation and quality of air in the home (Task Force on Health Risk Assessment, 1986). Section C: Health Impact Measurement Survey
This section of the CDAT was modified from the Arthritis Impact Measurement Survey (AIMS) (Liang, Larson, Cullen, & Schwartz, 1985) and the Chronic Disease Respiratory Questionnaire (CDRQ) (Guyatt, Walter, & Geoff, 1987). The Health Impact Measurement Survey (HIMS) contains the following scales: functional status (mobility, physical activity, dexterity, household activity, activities of daily living), cognitive ability, anxiety, depression, social support, dyspnea index, mastery, health status, and other health problems. These scales are seven-point adjectival response scales that are designed to be administered at various intervals to assess responses. They were also used to cross-validate the scales in Section A that are scaled differently: visual analog scale and a six-point graded scale. Section D: Quality of Life Index
The quality of life scale is a five-item index that has been used extensively in cancer research and has established validity and reliability within standard limits, .89 or higher (Spitzer et al., 1981). A total score is assigned for the quality of life index. Scores range from 0 (poor) to 10 (high).
37
RESEARCHBRIEFS
Section E : Demographic Data
This section includes standard demographic items (gender, age, occupation, work status, and formal education) that are used only in summary form to profile the population studied. Part 2
Part 2 of the CDAT is used as a data collection tool for the clinician/researcher to record results of the physical assessment and pulmonary function tests. Items in the section on pulmonary assessment assess type of pulmonary disease, disease history, chronicity of disease, treatment regimen, and education of the patient about Chronic Obstructive Pulmonary Disease (COPD) management. Also included are results from the spirometry test and maximum inspiratory pressure test that are evaluated in accordance with the standards set forth by the American Thoracic Society (1987). A brief clinical exam is used to verify the subject's pulmonary status. RESULTS
From the NIA study, coefficient alpha reliability indexes (Waltz, Strickland, & L e n z , 1984) were calculated for scales in Part I and found to be sufficiently high, ranging from .65 to .96. Significance
The CDAT holds potential for assisting researchers and clinicians in measuring psychophysiologic responses, functional status, and quality of life, not only for CBE but for other chronic diseases. The CDAT can be modified for type of disease entity. A study is currently underway with a community-based population of subjects with CBE to further test the CDAT with a larger sample. This study adds new knowledge to and broadens the work of other researchers in the measurement of functional status and quality of life for individuals with CBE. The CDAT facilitates assessment of the impact of disease severity and symptom severity (dyspnea, fatigue, and depression) on functional status and quality of life of individuals affected by this progressive, chronic lung disease. The CDAT can be used in clinical trials to evaluate patients' responses to research protocols by measuring outcome variables such as health care use (emergency department visits or hospitalizations
for respiratory distress), disease severity, depression, anxiety, mastery, environmental risk, functional status, and quality of life. Future Research
The occurrence of chronic illness and disability are costly and mutually frustrating for patients and their health care providers (Costa & McCrae, 1988). The magnitude of dyspnea, fatigue, and depression as clinical problems that occur in many chronic diseases (arthritis, heart disease, osteoporosis), and the documented ineffectiveness of existing therapeutic interventions for symptom management provide a c o m p e l l i n g rationale for developing instruments to measure outcome responses and responses to interventions. The symptom triad of dyspnea, fatigue, and depression are important response variables that need to be measured in the clinical environment and in research protocols (Gift, 1987; Guyatt, et al., 1987). Randomized clinical trials are needed to test the effectiveness of various interventions for improving symptom management, functional status, and quality of life in CBE. The CDAT can be used to further examine the complex interactions of psychophysiologic and environmental factors and effects on functional status and quality of life in those who suffer from chronic diseases. ACKNOWLEDGMENTS
Dr. Moody was on IntergovernmentalPersonnel Agreement (IPA) assignmentat the NationalInstitute of Aging, Baltimore, MD whilethis studywas conductedand acknowledgesthe helpful consultationof the followingresearchersat NIA: Drs. Kathleen McCormick,BernardEngel, David Anderson, Paul Costa, and Robert McCrae. Gratitude is expressed to Lori Frank and Monteray Jackson for assistance in data collection and Drs. Virginia Carded and Audrey Gift for reviewing the CDAT for content validity. REFERENCES
American Thoracic Society, Medical Section of the American Lung Association (1987). Standardization of spirometry1987 update. American Review Respiratory Disease, 136, 1285-1298. Brown, M. (1985). Selecting an instrument to measuredyspnea. Oncology Nursing Forum, 12, 98-100. Costa, P., & McCrae, R. (1988, in press). Personality, stress, and coping: Some lessons from a decade of research. In K.S. Markides & C.L. Cooper (Eds.), Aging, stress, social support, and health. New York: Wiley. Gift, A. (1987). Dyspnea:A clinical perspective.Scholarly Inquiryfor Nursing Practice, 1, 73-85. Guyatt, G., Bombardier, C., & Tugwell, P. (1986). Mea-
38
suring disease-specific quality of life in clinical trials. Canadian Medical Association Journal, 134, 889-895. Guyatt, G., Walter, S., & Geoff, N. (1987). Measuring change over time: Assessing the usefulness of evaluative instruments. Journal of Chronic Disease, 40, 171-178. Liang, M., Larson, M., Cullen, K., & Schwartz, J. (1985). Comparative measurement efficiency and sensitivity of five health status instruments for arthritis research. Arthritis and Rheumatism, 28, 542-547. Moody, L. (1988). Psychophysiologic respo~es of adults with chronic lung disease. Gainesville, FL: University of Florida, Grant Proposal to Division of Sponsored Research, University of Florida. Spitzer, W.O., Dobson, J.H., Chesterman, E., Levi, L, Shepherd, R., Battista, R., & Catchlove, B. (1981). Measuring the quality of life of cancer patients. Journal of Chronic Disease, 34, 585-597.
RESEARCH BRIEFS
Task Force on Health Risk Assessment (U.S. Department of Health and Human Services) (1986). Determining risks to health. Dover, MS: Auburn House Publishing Company. Waltz, C., Strickland, O., & Lenz, E. (1984). Measurement in nursing research. Philadelphia: F.A. Davis.
From the College of Nursing, University of Florida, Gainesville, FL. Linda E. Moody, PhD, FAAN: Professor, College of Nursing, University of Florida, Gainesville, FL. Address reprint requests to Linda E. Moody, PhD, FAAN, Professor, College of Nursing, Box J-187, University of Florida, Gainesville, FL 32610. © 1990 by W.B. Saunders Company. 0897-189719010301-0007505.00/0