COPD: Journal of Chronic Obstructive Pulmonary Disease

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Quality of Life: Concept and Definition

Robert M. Kaplan & Andrew L. Ries

To cite this article: Robert M. Kaplan & Andrew L. Ries (2007) Quality of Life: Concept and
Definition, COPD: Journal of Chronic Obstructive Pulmonary Disease, 4:3, 263-271, DOI:
10.1080/15412550701480356

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COPD: Journal of Chronic Obstructive Pulmonary Disease, 4:263–271
ISSN: 1541-2555 print / 1541-2563 online
Copyright 
c 2007 Informa Healthcare USA, Inc.
DOI: 10.1080/15412550701480356

PATIENT ACTIVITY IN COPD

Quality of Life: Concept and Definition

Robert M. Kaplan1 (mkaplan@ucla.edu) and Andrew L. Ries2 (aries@ucsd.edu)
1 Departments of Health Services and Medicine, University of California, Los Angeles, Los Angeles, California;
2 Departments of Medicine and Family and Preventive Medicine, University of California, San Diego, California

ABSTRACT
This paper will consider 4 topics: (1) the definition of health-related quality of life, (2) the
measurement of health-related quality of life, (3) the relationship between exercise and health-
related quality of life in the general population, and (4) the relationship between exercise and
health-related quality of life in patients with COPD. The paper presents data from the National
Health Interview Survey, the San Diego COPD Rehabilitation Trials, and the National Emphysema
Treatment Trial (NETT).

INTRODUCTION adaptation and behavioral response are of great clinical impor-

Evidence-based reviews suggest that patients with chronic
obstructive pulmonary disease (COPD) benefit from exercise
and rehabilitation programs (1). Benefits include reduced phys-
ical and psychological symptoms (2), improved exercise toler-
ance (3), fewer hospitalizations and physician visits, and more
gainful employment (4). It has been argued that exercise en-
hances quality of life among COPD patients (5). However, there
are a variety of different definitions and measures of life qual-
ity. The purpose of this article is to review the definition and
measurement of health-related quality of life and to summarize
some of the quality of life outcomes in our research program.
Methodologies to evaluate outcomes in chronic disease differ
from those used for the assessment of acute disease. Treatments
for acute disease, particularly infections, often involve identifi-
cation of the etiology and eradication of the problem leading to
a complete cure. In chronic diseases, which are never cured, the
therapeutic goal might be to reduce disease burden. Biological
tests used to assess acute diseases usually offer an incomplete
picture for patients with COPD. Evaluating the impact of chronic
disease requires a different set of tools (6). Patient interpretation,
Keywords: COPD, Exercise, Anxiety, Activities of daily living,
Quality of life.
Correspondence to:
Robert M. Kaplan
Fred W. and Pamela K. Wasserman Professor
Chair, Department of Health Services
UCLA School of Public Health
PO Box 951772
Los Angeles, CA 90095-1772
email: rmkaplan@ucla.edu
tance. We have argued that assessment of outcomes in COPD
requires a different conceptualization known as the Outcomes
Model (7, 8). In contrast to the Traditional Biomedical Model
that requires identification of basic disease mechanism, the Out-
comes Model emphasizes all medical and social factors that may
affect the patient. Sometimes, the exact biological explanation
for disability is unknown. For example, quality-of-life (QOL)
outcomes in patients with pulmonary disease are not well pre-
dicted from measures of pulmonary function (7). The Outcomes
Model accepts that biologic pathways may never be fully under-
stood (9).
Definition of health-related quality of life
Diseases and their consequent manifestations are important
for two reasons. First, illness may shorten life expectancy. In
other words, those with specific diseases may die prematurely.
Second, diseases may cause dysfunction, as well as symptoms,
that lead to disabilities in an individual’s performance of usual
activities of daily living. Clinical studies typically refer to health
outcomes in terms of mortality (death) and morbidity (dysfunc-
tion) and sometimes to symptoms (10).
Over the last 30 years, medical and health services researchers
have developed new quantitative methods and measures to as-
sess levels of wellness. These measures are often called quality-
of-life measures. Since they are generally used exclusively to
evaluate health status in individuals with medical disorders that
impair everyday functioning or cause symptoms, we prefer the
more descriptive term ”health-related quality of life” (11).
Figure 1 summarizes the number of publications under the
topic of quality of life identified in PubMed between 1972 and
2005. In 1972, PubMed did not identify any publications under

COPD: Journal of Chronic Obstructive Pulmonary Disease September 2007 263

 Figure 1. Frequency of articles identified using the keyword “Quality of Life” in PubMed data base between 1972 and 2005.

the “quality of life” topic heading. However, over the next 30 addition, a mental health summary score and a physical health
years, the number of articles that use the “quality of life” key- summary score can be calculated.
word phrase grew dramatically. In 2005, PubMed identified 5345 The decision theory approach attempts to weigh the differ-
such articles. In one year from 2004 to 2005, the number of arti- ent dimensions of health in order to provide a single expres-
cles listed under the quality of life keyword grew by 10% (over sion of health status. Supporters of this approach argue that
600 articles). This rate of growth has been consistent for several
years. Quality of life is now a common outcome in studies of
patients with chronic lung disease. A PubMed search of all years Table 1. Summary of quality-of-life measures used to evaluate
crossing COPD with quality of life (in January 2007) yielded outcomes in adults with chronic lung diseases
1607 references. Adding the term “rehabilitation” still leaves
Measure Type Purposes
567 citations.
Disease Targeted Measures
Chronic Respiratory Profile Descriptive studies,
Measurement of quality of life Questionnaire clinical change
UCSD Shortness of Breath Profile/ Descriptive studies,
Quality-of-life (QOL) measures are valuable for clinical stud-
(SOBQ) Symptom- clinical change
ies for several reasons. First, QOL measures are used to quan- specific
tify the impact of a condition and to compare the effects of lung St George’s Respiratory Profile Descriptive studies,
diseases with the consequences of other chronic medical prob- Questionnaire (SGRQ) clinical change
lems. Second, QOL measures can be used to evaluate changes Generic Measures
SF-36 Profile Descriptive studies,
resulting from therapeutic intervention or the course of disease.
clinical change
Third, QOL measures are necessary as a central component of Sickness Impact Profile Profile Descriptive studies,
cost/effectiveness analysis (5). We will address each of these (SIP) clinical change
issues in the following sections. We will first consider the ratio- Nottingham Health Profile Profile Descriptive studies,
nale behind common measures that have been used to quantify (NHP) clinical change
Health Utilities Index (HUI) Decision Descriptive studies,
health-related quality of life (7, 12–14).
Theory clinical change, cost
effectiveness
Distinctions among measures EuroQol (EQ-5D) Decision Descriptive studies,
Theory clinical change, cost
Table 1 lists some of the many measures for evaluating effectiveness
quality-of-life outcomes in studies of patients with lung dis- Quality of Well-being Scale Decision Descriptive studies,
eases. The table makes several distinctions between measures. (QWB) Theory clinical change, cost
There are two major approaches to quality of life assessment: effectiveness
Health and Activities Decision Descriptive studies,
profile and decision theory. The psychometric approach is used Limitations Index (HALex) Theory clinical change, cost
to offer a profile summarizing different dimensions of quality effectiveness
of life. The best-known example of the psychometric tradition
is the Medical Outcomes Study 36-Item Short Form (SF-36) Reprinted from Kaplan RM, Ries AL. Quality of life as an outcome
(15). The SF-36 includes 8 health concepts: physical function- measure in pulmonary diseases. J Cardiopulm Rehabil Nov–Dec 2005;
25(6):321–331. Used with permission from Lippincott Williams &
ing, role-physical, bodily pain, general health perceptions, vi-
Wilkins.
tality, social functioning, role-emotional, and mental health. In

264 September 2007 COPD: Journal of Chronic Obstructive Pulmonary Disease

psychometric methods fail to consider that different health prob-
lems are not of equal concern. A minor itch is a symptom and
coughing up blood is also a symptom. However, the importance
of a minor itch and coughing blood are not equal. Simple symp-
tom counts may miss the severity or impact of more serious
complaints. A cough, for example, might result in a low overall
score if it disrupts usual activities of daily living.
In an experimental trial using the psychometric approach,
some aspects of quality of life may improve while others may
worsen. For example, a medication might reduce coughing, but
increase skin problems or reduce energy. When components of
outcome change in different directions, an overall subjective
evaluation is often used to integrate the components and offer a
summary of whether the patient is better or worse off. The deci-
sion theory approach attempts to provide an overall single mea-
sure of quality of life that integrates subjective function states,
preferences for these states, morbidity, and mortality. The profile
methods do not offer a single number that is indexed between
death and perfect health.
In addition to the distinction between psychometric and de-
cision theory approaches, measures can be classified as either
generic (top of Table 1) or disease targeted (bottom of Table
1). Generic measures can be used with any population, while
disease targeted measures are used for patients with a particular
diagnosis. Finally, measures can be separated by the purposes of
their use. Most measures can be used to characterize populations
and to study clinical changes. However, cost-effectiveness anal-
ysis requires a generic measure of benefit that scales outcomes
on a metric ranging from death to perfect health. Thus, only
generic, decision theory based measures can be used to evaluate
cost-effectiveness.
A more detailed discussion of the different measures is avail-
able elsewhere (5). Readers interested in more detailed reviews
may also consult Shumaker and Berzon (16), Walker and Rosser
(17) and McDowell and Newell (18). The American Thoracic
Society maintains a website www.atsqol.org that summarizes
quality-of-life measures that can be used in outcomes research
for lung disease. The site lists measures by disease and offers
references on their use.
The next sections concentrate on example generic and dis-
ease specific measures that have been applied in our research
program.
Decision theory approaches
Some approaches to the measurement of health-related qual-
ity of life combine measures of morbidity and mortality to ex-
press health outcomes in units analogous to years of life. The
years of life measure can be adjusted for diminished quality of
life associated with diseases or disabilities (19).
Measures of health outcome should consider future as well as
current health status. Lung cancer, for example, may have very
little impact on current functioning but may have a substantial
impact on life expectancy and functioning in the future. Today,
a person with a malignant tumor in a lung may be functioning
very much like a person with a chest cold. However, the cancer
patient is more likely to remain or become dysfunctional, or
COPD: Journal of Chronic Obstructive Pulmonary Disease
to die prematurely. Comprehensive expressions of health status
need to incorporate estimates of future outcomes as well as to
measure current status (9).
Quality-of-life data can be used to help evaluate the cost-
effectiveness or cost/utility of health-care programs. Cost stud-
ies have gained in popularity because health-care costs have
grown so rapidly in recent years. Not all health-care interven-
tions equally return benefit for the expended dollar. Objective
cost studies might guide policymakers toward an optimal and eq-
uitable distribution of scarce resources. Cost-effectiveness anal-
ysis typically quantifies the benefits of a health-care intervention
in terms of years of life, or quality-adjusted life-years (QALYs).
Cost/utility is a special use of cost-effectiveness that weights
observable health states by preferences or utility judgments of
quality (20). In cost/utility analysis, the benefits of medical care,
surgical interventions, or preventive programs are expressed in
terms of common QALYs (21).
If a man dies of COPD at age 60 and we expected him to
live to age 80, we might conclude that the disease precipitated
20 lost life-years. If 100 men died at age 60 (and also had a
life expectancy of 80 years), we might conclude that 2000 (100
men × 20 years) life-years had been lost. Yet, death is not the
only relevant outcome of lung disease. COPD might also cause
long term consequences and diminished quality of life. Quality-
adjusted life-years take into consideration such consequences.
For example, a disease that reduces quality of life by one-half
will take away 0.5 QALY over the course of each year. If the
disease affects 2 people, it will take away one year (2 × 0.5)
over each year. A medical treatment that improves quality of
life by 0.2 for each of 5 individuals will result in the equivalent
of 1 QALY if the benefit persists for one year. This system has
the advantage of considering both benefits and side effects of
programs in terms of the common QALY units.
Of the several different approaches for obtaining quality-
adjusted life years, most are similar (22). The most com-
monly used methods are the EuroQol (EQ-5D), the Health Util-
ities Index (HUI), the Quality of Well-being Scale (QWB),
and the Health and Activities Limitations Index. In this re-
port, we emphasize the Quality of Well-being Scale because
it has been applied most often in outcomes studies of COPD
patients.
Quality of well-being scale
The QWB combines preference-weighted values for symp-
toms and functioning. The preference weights were obtained by
ratings of 856 people from the general population. These judges
rated the desirability of health conditions in order to place each
on the continuum between death (0.00) and optimum health
(1.00). Symptoms are assessed by questions that ask about the
presence or absence of different symptom complexes. Function-
ing is assessed by a series of questions designed to record func-
tional limitations over the previous 3 days, within three separate
domains (Mobility, Physical Activity, and Social Activity). The
4 domain scores are combined into a total score that provides
a numerical point-in-time expression of well-being that ranges
September 2007 265
from zero (0) for death to one (1.0) for asymptomatic optimum
functioning.
The QWB has been used in numerous clinical trials and stud-
ies to evaluate medical and surgical therapies in conditions such
as chronic obstructive pulmonary disease (23), HIV (24, 25),
cystic fibrosis (26, 27), diabetes mellitus (28), atrial fibrillation
(29), lung transplantation (30), arthritis (31, 32), end-stage re-
nal disease (33), cancer (34), depression (35, 36), and several
other conditions (22). Further, the method has been used for
health resource allocation modeling and has served as the basis
for an innovative experiment on rationing of health care by the
state of Oregon (37, 38). Studies have also demonstrated that the
QWB is responsive to clinical change derived from surgery (30)
or medical therapies in conditions such as rheumatoid arthritis
(39), AIDS (25) and cystic fibrosis (26). The self-administered
form of the QWB (QWB-SA) was developed more recently.
It has been shown to be highly correlated with the interviewer
administered QWB and to retain the psychometric properties
(40). General information about the QWB can be found at:
http://orpheus.ucsd.edu/famed/hoap/MEASURE.html
Integrating cost with outcome data
While treatment programs provide health benefits, they also
have costs. Resources are limited, and good policy requires that
they be used wisely. Methodologies for estimating costs have
now become standardized (21). From an administrative perspec-
tive, cost estimates include all costs of treatment and any costs
associated with caring for side effects of treatment. Typically,
economic discounting is applied to adjust for using current as-
sets to achieve a future benefit. From a social perspective, costs
are broader and may include, for example, costs of family mem-
bers staying off work to provide care. Comparing treatment pro-
grams for a given population with a given medical condition,
cost-effectiveness is measured as the change in costs of care
for the program compared to the existing therapy or program,
relative to the change in health measured in a standardized unit
such as the quality-adjusted life year (QALY). The difference
in costs over the difference in effectiveness is the incremental
cost/effectiveness and is usually expressed as the cost/QALY.
Since the objective of all therapeutic interventions is to produce
QALYs, the cost/QALY ratio can be used to show the relative
health benefits from investing in different programs (22).
Rehabilitation service providers must compete with other
health care providers for limited resources. In order to compete
successfully, it will be necessary to document that behavioral
services provide a benefit to the consumer. One of the advan-
tages of using QALY outcomes is that the common metric al-
lows for comparisons among very different types of services.
All providers in the health-care system have the common ob-
jectives of increasing length of life and improving quality of
life. General quality-of-life outcomes, such as QALYs, allow
evaluations of the relative value of investing in each of these
specialties in comparison to the resources that they use. Several
different governments have proposed allocating resources based
on formal cost-effectiveness evaluations (38). For example, the
266 September 2007 COPD: Journal of Chronic Obstructive Pulmonary Disease
Australian government now requires evidence of effectiveness,
as do a variety of European governments. In Ontario Canada
Quality-Adjusted Life Years have been considered as a basis for
formulary decisions (41). Similar proposals have been consid-
ered in the United Kingdom (42). The use of QALYs has in-
creased dramatically in recent years. Just a decade ago QALYs
were rarely cited in the medical literature. Today, QALYs are
identified in nearly 300 articles per year.
For most clinical outcome studies, it is advisable to include
disease-targeted approaches in addition to generic measures of
health outcome. These measures are typically more sensitive to
changes in a particular disease or illness process. One example of
a measure designed specifically for COPD patients is the UCSD
Shortness of Breath Questionnaire.
UCSD shortness of breath
questionnaire (SOBQ)
The SOBQ is self-administered and asks subjects (43) to
rate their breathlessness for 21 various daily activities (plus 3
overall items) on a 6-point scale from none at all (0) to severe (4)
to maximal or unable to do because of breathlessness (5). For
activities that they do not typically perform, respondents are
expected to estimate their breathlessness for that activity. The
21 activities of daily living (ADLs) are grouped according to
factor analysis into 4 categories of ADLs: Rest and Light ADLs
(Factor 1), 8 questions; Moderate ADLs (Factor 2), 5 questions;
Walking (Factor 3), 4 questions; and Strenuous ADLs (Factor
4), 4 questions. The score on each of the 24 items is summed to
produce an overall summary score.
The QWB-SA and the UCSD SOBQ have been applied in a
variety of investigations of physical activity in COPD patients.
These include population studies, observational investigations,
and clinical trials. The following sections review some of these
applications.
ESTIMATION OF HEALTH-RELATED
QUALITY OF LIFE AND PHYSICAL
ACTIVITY IN THE POPULATION
A variety of methods have been used to estimate the rela-
tionship between health-related quality of life and self-reported
physical activity in the adult population. One effort involves the
use of the National Health Interview Survey (NHIS). In collabo-
ration with John Anderson from the University of California, San
Diego we built a data set that allows imputation of the QWB for
the NHIS for the years 1989–2002. This unique data set includes
more than 2,000,000 cases. Details of the method are published
elsewhere (44). The analysis suggests a systematic relationship
between the number of episodes of vigorous activity and esti-
mated QWB score. There is a systematic relationship between
physical activity and QWB score up to about 3–5 episodes of
self-reported vigorous physical activity per week. Those who
are unable to engage in vigorous activity have the lowest QWB
scores. Interestingly, there is a slight drop-off in QWB scores
for those who engage in vigorous activities 7 or more times per
 Figure 2. Mean imputed QWB score for National Health Interview Survey (NHIS) respondents who reported differing numbers of sessions of
vigorous activity per week. Data from merged NHIS file 1989–2002.

week (see Figure 2). It is worth noting that because of the very
large sample size, all differences are statistically significant.

Exercise endurance in patients with COPD

We have conducted several studies involving rehabilitation
for patients with chronic lung disease. One of these experiments
randomly assigned 119 COPD patients to either comprehensive
rehabilitation or to an education control group. Pulmonary reha-
bilitation consisted of 12 4-hour sessions distributed over an 8-
week period. The content of the sessions was education, physical
and respiratory care, psychosocial support, and supervised exer-
cise. The education control group attended 4 2-hour sessions that
were scheduled twice per month. These education sessions did
not include any individual instruction or exercise training. Top-
ics included medical aspects of COPD, pharmacy use, breathing
techniques and a variety of interviews about smoking, life events
and social support. Lectures covered pulmonary medicine, phar-
macology, respiratory therapy, and nutrition. Outcome measures
included lung function, maximum and endurance exercise toler-
ance, symptoms of perceived breathlessness, perceived fatigue,
self-efficacy for walking, Centers for Epidemiologic Studies De-
pression (CES-D) score, and the Quality of Well-being scale.
The patients were evaluated at the baseline and then again after
2, 6, 12, 24, 36, 48, and 60 months.
Figure 3 shows the differences between those in pulmonary
rehabilitation and the education control groups over the first
year of the study. The top portion of the figure shows changes in
exercise endurance. Those randomly assigned to rehabilitation
had significantly higher endurance at 2, 6, and 12 months. This
Figure 3. In comparison to patients randomly assigned to educa-
is complemented by differences in breathlessness where those tion, those participating in pulmonary rehabilitation demonstrated
in the rehabilitation program were less breathless at the end significantly greater endurance (top panel), and less breathless-
of the treadmill exercise after 2, 6, and 12 months. Similarly, ness (center panel) and fatigue (bottom panel) over a 12-month
patients in the rehabilitation group were significantly lower in follow-up. Reprinted with permission from Ries AL, Kaplan RM,
Limberg TM, Prewitt LM. Effects of pulmonary rehabilitation on
perceived muscle fatigue at each follow-up period (lower section
physiologic and psychosocial outcomes in patients with chronic ob-
of Figure 4) (45). structive pulmonary disease. Ann Intern Med 1995; 122(11):823–
There were no differences between groups for measures of 832.
lung function, depression, or general quality of life. However,

COPD: Journal of Chronic Obstructive Pulmonary Disease September 2007 267

 Figure 4. QWB scores for patients who maintained physical activity (walking) on a regular or an irregular basis following pulmonary rehabilitation.
Reprinted from Heppner PS, Morgan C, Kaplan RM, Ries AL. Regular walking and long-term maintenance of outcomes after pulmonary
rehabilitation. J Cardiopulm Rehabil Jan–Feb. 2006; 26(1):44–53. Used with permission from Lippincott Williams & Wilkins.
both groups experienced reductions in quality of life. For
exercise variables, benefits tended to relapse toward baseline
after 18 months of follow - up. In other words, activity changes
are not well maintained over the course of time. The trial did not
show significant changes in quality of life as measured using the
QWB.
In a more recent study, 160 patients with chronic lung dis-
ease participated in a comprehensive rehabilitation program. In
comparison to baseline, there was a significant improvement in
quality of life as measured by the QWB, following the rehabil-
itation program. At the end of the program the patients were
randomly assigned to a program designed to improve compli-
ance and maintenance of the rehabilitation lessons or to routine
follow-up. Outcome measures included quality of life, symp-
toms, healthcare utilization, measures of pulmonary function,
measures of psychological function, and survival.
All patients were evaluated prior to the pulmonary rehabili-
tation and then again after the 8-week program had been com-
pleted. Following the second evaluation, patients were evaluated
at 6 months, 12 months, and 24 months. In an analysis by Hep-
pner and colleagues, the patients were further divided into those
who were regular walkers and those who walked irregularly.
Regular walking was defined as walking most days or every sin-
gle day while irregular walking was defined as walking some
days, rarely, or never. The core psychosocial measures included
the QWB scale, the UCSD Shortness of Breath questionnaire
and a measure of self-efficacy for walking. Quality-of-life re-
sults are summarized in Figure 4. Regular walkers maintained
better QWB quality-of-life scores than irregular walkers. Simi-
larly, those who walked on an irregular basis had more shortness
of breath than those who walked on a regular basis (46).
Our group has produced other evidence that walking compli-
ance is related to better health outcomes. In one of our ear-
lier studies, COPD patients were randomly assigned to one
of five groups. One group underwent an intervention designed
268 September 2007 COPD: Journal of Chronic Obstructive Pulmonary Disease
to increase compliance with physical activity using cognitive-
behavior modification. Cognitive-behavior modification com-
bines traditional behavior modification with cognitive therapy.
Cognitive-behavior modification is believed to be superior to
either the behavior modification alone or the cognitive compo-
nent alone. The second and third groups received a behavioral
and a cognitive intervention, respectively. The fourth group got
attention while the fifth group received no treatment. All patients
were evaluated at baseline and followed over the course of 12
weeks.
Cumulative time spent walking was measured using patient
reports in a diary. Those in the cognitive-behavior modification
group accumulated significantly more walking time than those
in control groups. Compliance with physical activity was associ-
ated with changes in endurance as evaluated on a treadmill after
12 weeks. Further, these changes in endurance were associated
with changes on the QWB scale. All 3 groups experiencing a
cognitive or behavioral intervention showed improvements on
the QWB while those in the 2 control groups declined on the
QWB (47). Cost-effectiveness analysis demonstrated that the
behavioral activity interventions were a reasonable use of re-
sources in relation to other alternatives in health care (48).
Correlational studies of exercise
tolerance and QOL
A variety of other evidence supports relationships between
measures of exercise endurance and measures of health-related
quality of life. The UCSD trials demonstrated systematic rela-
tionships between the QWB and the 6-minute walk at 6-month
follow-up (49). There were similar relationships between the 6-
minute endurance walk and the UCSD Shortness of Breath ques-
tionnaire. Perhaps more important are relationships between
changes in exercise performance and changes in outcomes.
Figure 5a compares patients who decreased their performance
 Figure 5. Changes in QWB (left panel) and SOBQ (right panel) for patients who either increased or decreased 6-minute walking endurance
during the first year following pulmonary rehabilitation.
on the 6-minute walk between baseline and 12-month follow-up
and those who increased their performance.
As the figure shows, those who increased their endurance im-
proved their QWB scores by about 0.03 units. Studies using the
QWB suggest that a change of 0.03 units is a meaningful clinical
difference. It is equivalent to the benefits of cataract surgery or
the medical treatment of rheumatoid arthritis. Figure 5b shows
that those who improved their 6-minute walk performance had
significantly greater improvements on the UCSD Shortness of
Breath questionnaire.
Data from the National Emphysema Treatment Trial (NETT)
offer similar results. The NETT evaluated patients on a variety of
measures at baseline and again after completion of the rehabilita-
tion program. Changes in 6-minute walking scores were divided
into quintiles. There was a systematic relationship between level
of improvement on the 6-minute walk and changes in the QWB.
In particular, there is a difference between those in the first and
fifth quintiles of 6-minute walking time. This difference was
about 0.04 QWB units. The relationship between quintiles of
improvement in 6-minute walk and scores on the UCSD-SOBQ
were also linear and quite systematic. For the QWB, the differ-
ences of about 0.04 exceed the estimated MCID for the QWB
of 0.03 units (7). Comparing patients in the first and fifth quin-
tiles, this improvement translates into about 1 QALY for each
25 patients who obtain maintain the benefit for one year.
SUMMARY
Data summarized in this paper suggest that quality of life is
an important outcome for patients with COPD. Quality-of-life
measures help calibrate the effect of treatment. Standardized
quality of life measures can allow the estimation of the treat-
ment effect size. Sometimes, it is valuable to compare the size
of the treatment effect in relation to alternative interventions.
COPD: Journal of Chronic Obstructive Pulmonary Disease
Measures, such as the QWB, can be translated into a standard-
ized unit of outcome that can be reported in terms of quality
adjusted life-years. These estimates can be useful in studies of
treatment cost-effectiveness.
Data from a variety of studies suggest that improvements in
exercise endurance are associated with improvements in quality
of life. Unfortunately, long-term compliance with physical activ-
ity is often poor. Better methods for enhancing compliance with
exercise interventions are needed. Correlational studies show a
clear relationship between compliance with physical activity and
quality-of-life outcomes for patients with COPD. These studies
do not allow us to determine whether the association is causal.
Future studies, including more systematic experimental trials,
are needed to evaluate the impact of physical activity interven-
tions upon quality-of-life outcomes for patients with COPD.
REFERENCES
1. Puhan MA, Scharplatz M, Troosters T, Steurer J. Respiratory
rehabilitation after acute exacerbation of COPD may reduce risk
for readmission and mortality—A Systematic Review. Respir Res
Jun 8 2005; 6(1):54.
2. Resnikoff PM, Ries AL. Maximizing functional capacity. Pul-
monary rehabilitation and adjunctive measures. Respir Care Clin
N Am Sep 1998; 4(3):475–492.
3. Puhan MA, Schunemann HJ, Frey M, Scharplatz M, Bachmann
LM. How should COPD patients exercise during respiratory re-
habilitation? Comparison of exercise modalities and intensities to
treat skeletal muscle dysfunction. Thorax May 2005; 60(5):367–
375.
4. Goldstein RS. Health resource utilization and rehabilitation.
Monaldi Arch Chest Dis Jul–Sep 2003; 59(3):244–249.
5. Kaplan RM, Ries AL. Quality of life as an outcome measure
in pulmonary diseases. J Cardiopulm Rehabil Nov–Dec 2005;
25(6):321–331.
6. Holman H, Lorig K. Patients as partners in managing chronic
disease. Partnership is a prerequisite for effective and efficient
September 2007 269
 health care [editorial; comment]. BMJ (Clinical Research Ed.)
2000; 320(7234):526–527.
7. Kaplan RM, Ries AL, Reilly J, Mohsenifar Z. Measurement of
health-related quality of life in the national emphysema treatment
trial. Chest Sep 2004; 126(3):781–789.
8. Kaplan RM. Two pathways to prevention. Amer Psychol 2000;
55(4):382–396.
9. Kaplan RM. The Ziggy theorem: toward an outcomes-
focused health psychology. Health Psychol 1994; 13(6):451–
460.
10. Kaplan RM. Behavior as the central outcome in health care. Amer
Psychol 1990; 45(11):1211–1220.
11. Kaplan RM, Bush JW. Health-related quality of life measurement
for evaluation research and policy analysis. Health Psychol 1982;
1:61–80.
12. Bourbeau J, Maltais F, Rouleau M, Guimont C. French-
Canadian version of the Chronic Respiratory and St George’s Res-
piratory questionnaires: an assessment of their psychometric prop-
erties in patients with chronic obstructive pulmonary disease. Can
Respir J Oct 2004; 11(7):480–486.
13. Dimitrov D, Rumrill PD. Multivariate methods in rehabilitation.
Work 2005; 24(2):205–212.
14. Schmier JK, Halpern MT, Higashi MK, Bakst A. The quality of
life impact of acute exacerbations of chronic bronchitis (AECB): a
literature review. Qual Life Res Mar 2005; 14(2):329–347.
15. Ware JE, Jr., Gandek B. Overview of the SF-36 Health Survey
and the International Quality of Life Assessment (IQOLA) Project.
J Clin Epidemiol 1998; 51(11):903–912.
16. Shumaker SA, Berzon R. The International Assessment of
Health-Related Quality of Life: Theory, Translation, Measurement
and Analysis. New York: Oxford; 1995.
17. Walker SR, Rosser R. Quality of Life Assessment: Key Issues
in the 1990s. Dordrecht; Boston: Kluwer Academic Publishers;
1993.
18. McDowell I, Newell C. Measuring Health: A Guide to Rating
Scales and Questionnaires. 2nd ed. New York: Oxford University
Press; 1996.
19. Kaplan RM, Feeny D, Revicki DA. Methods for assessing rela-
tive importance in preference based outcome measures. In: Joyce
CRB, Hannah M, McGee E, et al., editors. Individual Quality of
Life: Approaches to Conceptualisation and Assessment. Amster-
dam, Netherlands; 1999:135–149.
20. Kaplan RM, Groessl EJ. Cost/effectiveness analysis in behavioral
medicine. J Consult Clin Psychol 2007; in press.
21. Gold MR. Cost-Effectiveness in Health and Medicine. New York:
Oxford University Press; 1996.
22. Kaplan RM, Ganiats TG, Sieber WJ, Anderson JP. The Quality
of Well-Being Scale: critical similarities and differences with SF-
36 [see comments]. Inter J Qual Health Care 1998; 10(6):509–
520.
23. Kaplan RM, Atkins CJ, Timms R. Validity of a quality of well-being
scale as an outcome measure in chronic obstructive pulmonary
disease. J Chron Dis 1984; 37(2):85–95.
24. Kaplan RM, Patterson TL, Kerner DN, Atkinson JH, Heaton
RK, Grant I. The Quality of Well-Being scale in asymptomatic HIV-
infected patients. HNRC Group. HIV Neural Behavioral Research
Center. Qual Life Res 1997; 6(6):507–514.
25. Kaplan RM, Anderson JP, Patterson TL. Validity of the Quality of
Well-Being Scale for persons with human immunodeficiency virus
infection. HNRC Group. HIV Neurobehavioral Research Center.
Psychosom Med 1995; 57(2):138–147.
26. Orenstein DM, Pattishall EN, Nixon PA, Ross EA, Kaplan RM.
Quality of well-being before and after antibiotic treatment of pul-
monary exacerbation in patients with cystic fibrosis. Chest 1990;
98(5):1081–1084.
27. Orenstein DM, Kaplan RM. Measuring the quality of well-
being in cystic fibrosis and lung transplantation. The impor-
270 September 2007 COPD: Journal of Chronic Obstructive Pulmonary Disease
tance of the area under the curve. Chest 1991; 100(4):1016–
1018.
28. Kaplan RM, Hartwell SL, Wilson DK, Wallace JP. Effects of
diet and exercise interventions on control and quality of life in
non-insulin-dependent diabetes mellitus. J Gen Intern Med 1987;
2(4):220–228.
29. Ganiats TG, Palinkas LA, Kaplan RM. Comparison of Qual-
ity of Well-Being scale and Functional Status Index in pa-
tients with atrial fibrillation. Medical Care. 1992; 30(10):958–
964.
30. Squier HC, Ries AL, Kaplan RM. Quality of well-being predicts
survival in lung transplantation candidates. Amer J Respir Crit Care
Med 1995; 152(6 Pt 1):2032–2036.
31. Kaplan RM, Schmidt SM, Cronan TA. Quality of well be-
ing in patients with fibromyalgia. J Rheum 2000; 27(3):785–
789.
32. Kaplan RM, Alcaraz JE, Anderson JP, Weisman M.
Quality-adjusted life years lost to arthritis: effects of gender,
race, and social class. Arthritis Care Res 1996; 9(6):473–
482.
33. Rocco MV, Gassman JJ, Wang SR, Kaplan RM. Cross-sectional
study of quality of life and symptoms in chronic renal disease pa-
tients: the Modification of Diet in Renal Disease Study. Am J Kid
Dis 1997; 29(6):888–896.
34. Kaplan RM. Quality of life assessment for cost/utility studies in
cancer. Cancer Treat Rev 1993; 19 Suppl A(1):85–96.
35. Pyne JM, Patterson TL, Kaplan RM, et al. Preliminary longitudi-
nal assessment of quality of life in patients with major depression.
Psychopharmacol Bull 1997; 33(1):23–29.
36. Pyne JM, Patterson TL, Kaplan RM, Gillin JC, Koch WL, Grant I.
Assessment of the quality of life of patients with major depression.
Psychiat Serv 1997; 48(2):224–230.
37. Kaplan RM. California Policy Seminar. Allocating Health Re-
sources in California: Learning from the Oregon Experiment.
Berkeley, CA: California Policy Seminar; 1993.
38. Kaplan RM. Value judgment in the Oregon Medicaid experiment.
Med Care 1994; 32(10):975–988.
39. Bombardier C, Ware J, Russell IJ, Larson M, Chalmers A, Read
JL. Auranofin therapy and quality of life in patients with rheumatoid
arthritis. Results of a multicenter trial. Am J Med 1986; 81(4):565–
578.
40. Kaplan RM, Sieber WJ, Ganiats TG. The Quality of Well-being
Scale: Comparison of the interviewer-administered version with a
self-administered questionnaire. Psychol Health 1997;12(6):783–
791.
41. Detsky AS. Economics and cost-effectiveness in evaluating the
value of cardiovascular therapies. Terminology I would like to see
disappear. Am Heart J 1999; 137(5):S51–52.
42. Williams A. Cochrane Lecture. All cost effective treatments should
be free. or, how Archie Cochrane changed my life! J Epidemiol
Comm Health 1997; 51(2):116–120.
43. Eakin EG, Resnikoff PM, Prewitt LM, Ries AL, Kaplan RM. Vali-
dation of a new dyspnea measure: the UCSD Shortness of Breath
Questionnaire. University of California, San Diego. Chest 1998;
113(3):619–624.
44. Anderson JP. Activity limitations reported in the National Health
Interview Survey: an anomaly and its effect on estimates of na-
tional well-being. American J Publ Health Jul 2001; 91(7):1135–
1136.
45. Ries AL, Kaplan RM, Limberg TM, Prewitt LM. Effects of pul-
monary rehabilitation on physiologic and psychosocial outcomes
in patients with chronic obstructive pulmonary disease. Ann Intern
Med Jun 1 1995; 122(11):823–832.
46. Heppner PS, Morgan C, Kaplan RM, Ries AL. Regular walk-
ing and long-term maintenance of outcomes after pulmonary
rehabilitation. J Cardiopulm Rehabil Jan–Feb 2006; 26(1):44–
53.
47. Atkins CJ, Kaplan RM, Timms RM, Reinsch S, Lofback K.
Behavioral exercise programs in the management of chronic
obstructive pulmonary disease. J Consult Clin Psychol Aug 1984;
52(4):591–603.
48. Toevs CD, Kaplan RM, Atkins CJ. The costs and effects of be-
havioral programs in chronic obstructive pulmonary disease. Med
Care Dec 1984; 22(12):1088–1100.
49. Ries AL, Kaplan RM, Myers R, Prewitt LM. Maintenance after
pulmonary rehabilitation in chronic lung disease: a randomized
trial. Am J Respir Crit Care Med Mar 15 2003; 167(6):880–888.
50. Ries AL, Kaplan RM, Limberg TM, Prewitt LM. Effects of pul-
monary rehabilitation on physiologic and psychosocial outcomes
in patients with chronic obstructive pulmonary disease. Ann Intern
Med 1995; 122(11):823–832.

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