ST GEORGE’S RESPIRATORY QUESTIONNAIRE FOR COPD PATIENTS (SGRQ-C) Professor Paul Jones Division of Cardiac and Vascular Science St George’s, University of London London SW17 0RE
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CONTENTS 1. THE SGRQ
The SGRQ-C was developed from the SGRQ which was designed to measure healthimpairment in patients with asthma and COPD. The SGRQ is also valid for use inbronchiectasis and post tuberculosis and has been used successfully in patients withkyphoscoliosis, sarcoidosis. It is not suitable for cystic fibrosis. It is in two parts. PartI produces the Symptoms score, and Part 2 the Activity and Impacts scores. A Totalscore is also produced. 2. SGRQ-C: DIFFERENCES FROM THE SGRQ
The SGRQ-C is a shorter version derived from the original version following detailedanalysis of data from large studies in COPD. The intention was to remove the itemswith the weakest measurement properties in the original instrument, but at the sametime ensure that its scores were directly comparable with the original SGRQ. A fulldescription of this process and validation studies has been published in Chest(Meguro et al. Chest 2006;132: 456-463). The accompanying on-line supplementgives additional details concerning its development and the differences from theoriginal. ().
The SGRQ-C has been developed using COPD data only, so is valid for this disease. The validity for its use in other conditions has yet to be established, but it is unlikelyto perform very differently from the SGRQ.
1. Smaller number of items (40 compared with the original 50). 2. In a small number of items there is a reduction in the number of response
3. Change in the wording of Part 1. No specific recall period is used except for
3. STRUCTURE OF SGRQ Part 1 (Questions 1-7) addresses the frequency of respiratory symptoms. It is not designed to be a precise epidemiological tool, but to assess the patient’s perception of their recent respiratory problems. Part 2 (Questions 8-14) addresses the patient’s current state (i.e. how they are these days). The Activity score measures disturbances to daily physical activity. The Impacts score covers a range of disturbances of psycho-social function. Validation studies for the original SGRQ showed that this component relates in part to respiratory symptoms, but it also correlates quite strongly with exercise performance (6-minute walking test), breathlessness in daily life (MRC breathlessness score) and disturbances of mood (anxiety and depression). The Impacts score is, therefore, the broadest component of the questionnaires, covering the whole range of disturbances that respiratory patients experience in their lives. Note: the general scale on the front page is not part of the SGRQ or SGRQ-C, butsome investigators find it useful as an additional global measure.4. ADMINISTRATION
The questionnaire should be completed in a quiet area, free from distraction and thepatient should ideally be sitting at a desk or table. Explain to the patient why they arecompleting it, and how important it is for clinicians and researchers to understandhow their illness affects them and their daily life. Ask him or her to complete thequestionnaire as honestly as they can and stress that there are no right or wronganswers, simply the answer that they feel best applies to them. Explain that theymust answer every question and that someone will be close at hand to answer anyqueries about how to complete the questionnaire.
It is designed for supervised self-administration. This means that the patients should complete the questionnaire themselves, but someone should be available to give advice if required. It is designed to elicit the patient’s opinion of his/her health, not someone else’s opinion of it, so family, friends or members of staff should not influence the patient’s responses. If the spouse or partner has accompanied the patient they should be asked to wait in a separate area. Similarly, do not allow patients to take the SGRQ-C home to be completed since you cannot be sure that it will be completed without the help of family or friends. A recent study of the use of surrogates to complete the questionnaire has shown small but significant differences in scores obtained from the patients themselves (Santiveri et al Respiratory Medicine (2007) 101, 439–445)
Once the patient has finished, it is very important that you check the questionnaire tomake sure a response has been given to every question. If they have missed an itemreturn it to the patient for completion, before they leave.
Telephone administration of the SGRQ has been validated (Anie et al J ClinEpidemiol 1996;49:653-6.), as has computer based presentation (Meguro and Jones,unpublished), but postal administration has not. Responding to a patient’s queries regarding completion of the questionnaire
If a patient asks for help with a question, do not provide an answer for them. Thequestionnaire is designed to get an understanding of how the patient views his or herillness. It is appropriate to clarify a question but not to provide an answer. Questionsmay be read aloud if patients have difficulty with reading, but the responses must betheirs alone. If a patient gives an answer you disagree with it is not appropriate tochallenge their response or to query it. It is their view of their condition we areinterested in – no matter how strange the response!
The following are notes that may help you explain to patients what is required
In Part 1 of the questionnaire, emphasise to patients that you are interested inhow much chest trouble they have recently. The exact period is not important. We are looking for an impression or perception of health.
An attack of chest trouble (Part 1, Question 5) is any episode of worsesymptoms that constitutes an attack in the patient’s own judgement. Not justsevere attacks as judged by medical staff.
COPD can vary day-to-day. Part 2 is concerned with the patient’s current state(i.e. on average over ‘these days’), not necessarily just today.
For Part 1 Question 6, emphasise that you are interested in the number of gooddays that they have had.
In Part 2, Questions 8 and 14 require a single response, but Questions 9 to 13require a response to every question. It may be worth emphasising this to thepatient.
Many patients do not engage in physical activity. It is important to determinewhether this is because they do not wish to (in which case the answer would be‘False’) or cannot engage in these activities because of their chest trouble (inwhich case the answer would be ‘True’).
Responses to Questions 12 and 13 concern limitations due to breathingdifficulties and not any other problems. If the patient does not engage in anactivity for another reason, they should tick ‘False’. 5. ITEM WEIGHTS
Each questionnaire response has a unique empirically derived 'weight' (Quirk et alClin Sci 1990;79:17-21; Quirk et al Eur Respir J 1991;4:167-71).The lowest possibleweight is zero and the highest is 100. Note that, in cases where the two responseoptions to an item in the original SGRQ were combined in the SGRQ-C, the weightfor the new response option was calculated from the mean of the two that werecombined. (Note: the wording is abbreviated from that used in the questionnaire.) Question 1: I cough: Question 2: I bring up phlegm (sputum): Question 3: I have shortness of breath: Question 4: I have attacks of wheezing: Question 5:How many attacks of chest trouble have you had Question 6: How often do you have good days (with little chest trouble)? Question 7: If you have a wheeze, is it worse in the morning? Question 8: How would you describe your chest condition? Question 9: Questions about what activities usually make you feel breathless. Question 10: More questions about your cough and breathlessness. Question 11: Questions about other effects your chest trouble may have on you.
My cough or breathing is embarrassing in public
My chest trouble is a nuisance to my family, friends or neighbours
I get afraid or panic when I cannot get my breath
I feel that I am not in control of my chest problem
I have become frail or an invalid because of my chest
Question 12: Questions about how activities may be affected by your breathing.
I take a long time to get washed or dressed
I cannot take a bath or shower, or I take a long time
I walk more slowly than other people, or I stop for rests
Jobs such as housework take a long time, or I have to stop for rests
If I walk up one flight of stairs, I have to go slowly or stop
If I hurry or walk fast, I have to stop or slow down
My breathing makes it difficult to do things such as walk up hills, carry things upstairs, light gardening such as weeding, dance, play bowls or play golf
My breathing makes it difficult to do things such as carry heavy loads, dig thegarden or shovel snow, jog or walk at 5 miles per hour, play tennis or swim
Question 13: We would like to know how your chest trouble usually affects your daily life.
I cannot go out for entertainment or recreation
I cannot go out of the house to do the shopping
Question 14: Tick the statement which you think best describes how your chest affects you.
It does not stop me doing anything I would like to do
It stops me doing one or two things I would like to do
It stops me doing most of the things I would like to do
It stops me doing everything I would like to do
6. SCORING ALGORITHM
A Total and three component scores are calculated: Symptoms; Activity; Impacts.
Each component of the questionnaire is scored separately:
6.1 Sum the weights for all items with a positive response SYMPTOMS COMPONENT
This consists of all the questions in Part 1. The weights for Questions 1-7 aresummed. A single response is required to each item. If multiple responses are givento an item, the weights for the multiple positive responses should be averaged thenadded to the sum. This is a better approach than losing the data set and thistechnique was for calculating scores used in the original validation studies forpatients who gave multiple responses. (Clearly a better approach is to prevent suchmultiple responses occurring). ACTIVITY COMPONENT
This is calculated from the summed weights for the positive responses to itemsQuestions 9 and 12 in Part 2 of the questionnaire. IMPACTS COMPONENT
This is calculated from Questions 8, 10, 11, 13, 14 in Part 2 of the questionnaire. Theweights for all positive responses to items in Questions 10, 11, 13 are summedtogether with the responses to the single item that should have been checked(ticked) in Questions 8 and 14. In the case of multiple responses to either of theseitems, the average weight for the item should be calculated. TOTAL SCORE
The Total score is calculated by summing the weights to all the positive responses ineach component. 6.2 Calculate the score
The score for each component is calculated separately by dividing the summedweights by the maximum possible weight for that component and expressing theresult as a percentage:
Score = 100 x Summed weights from all positive items in that component
Sum of weights for all items in that component
The Total score is calculated in similar way:
Score = 100 x Summed weights from all positive items in the questionnaire
Sum of weights for all items in the questionnaire
Sum of maximum possible weights for each component and Total:
Total (sum of maximum for all three components)
(Note: these are the maximum possible weights that could be obtained for the worstpossible state of the patient). 6.3 Handling missing items
It is better not to miss items and any missing items are the fault of the investigator,not the patient. We have examined the effect of missing items and recommend thefollowing methods:
Missed items are treated as if the answer was in the negative. A maximum of onemissed item is permitted for this section.
The following approach may be used. Items in Questions 9, 10, 11, 12, 13 all requirea response of either ‘True’ or ‘False’. If neither box is ticked, the item should becoded as ‘missing’. The weight for that item should then be removed from the totalpossible for that component (and the total score). Based on an analysis of the effectof missing data on calculated scores in the original SGRQ, this method will bereliable for handling up to 3 missed items for the Activity component (items inQuestions 9 and 12) and up to 5 items for the Impacts component (items inQuestions 8, 10, 11, 13, 14). 6.4 Converting SGRQ-C scores to be comparable to SGRQ scores
Scores for SGRQ-C, calculated as described above, need a small arithmeticadjustment to make them directly comparable to those obtained with the SGRQ. Symptoms: SGRQ score = (SGRQ-C x 0.99) + 0.94 units
Activity: SGRQ score = (SGRQ-C x 0.87) +7.01 units
Impacts: SGRQ score = (SGRQ-C x 0.88) +2.18 units
Total: SGRQ score = (SGRQ-C x 0.90) + 3.10 units
7. EXCEL-BASED SCORING SYSTEM 8. SGRQ SCORES IN HEALTHY SUBJECTS
Means (95% confidence intervals) for SGRQ scores in normal subjects with nohistory of respiratory disease
A full range of normative values for a general population studied in Spain can befound in Ferrer et al Eur Respir J 2002;19:405-413. 9. CLINICALLY SIGNIFICANT DIFFERENCE IN SGRQ SCORE
The threshold for a clinically significant difference between groups of patients and forchanges within groups of patients is four units. Note this is an indicative value (thethreshold is not 4.0). As with all measurements there is biological variation, samplingerror and measurement error. Four units is an average value obtained in differentgroups of patients. Estimation of clinical thresholds, their use and implications arediscussed in much greater detail in Jones P.W. Eur Respir J 2002;19:398-404 andJones P.W. Journal of COPD 2005;2:75-79.
Note: A responder analysis using the 4 unit threshold may be suitable in someanalyses. Such estimates, including the Number Needed to Treat (NNT), appear tobe relatively insensitive to small differences in the value used for the threshold forclinical significance. (Jones P.W. Eur Respir J 2002;19:398-404 and Norman et alMed Care 2001;39:1039-47).
10. LIST OF SGRQ-C TRANSLATIONS AVAILABLE FROM SGUL
SGRQ-C translations have been produced as a result of collaboration between St George’s University of London and the following agencies:- (1) MAPI Research Institute * ) and (2) Oxford Outcomes ◊ ( Argentina Australia English for Australia * Lithuania Bulgaria ◊ Mexico Spanish for Mexico * Canada French for Canada * ◊ Netherlands Chile Spanish for Chile ◊ New Zealand English for NZ ◊ Czech ◊ Norway ◊ Denmark ◊ Philippines * Estonia Estonian ◊ Portugal * Russia ◊ Finland Finnish * Slovakia * Slovenia ◊ South Africa Germany * Spain ◊ Hungary * 11. LIST OF SGRQ TRANSLATIONS AVAILABLE FROM SGUL - This list is given since where no SGRQ-C version is available, only a small amount of additional translation would be necessary.
Most of the translations have been produced as a result of collaboration between St George’s University of London and the following agencies:- (1) MAPI Research Institute* () (2) Health Research Associates (3) these translations have followed the backtranslation process but have not been through full international harmonisation (4) ◊ Translated and validated by Dr. Mohamed Metwally, MD, FCCP, Assistant Professor of Chest Diseases, Assiut University, Egypt New Zealand Norwegian* Arabic ◊ Philippines* Hungarian* Australia Icelandic* Portuguese* Romanian* Russian* Serbian* Singapore Slovakian* Bulgarian* Indonesian Slovenian* South Africa Spanish for Italian* Croatian* Japanese* Swedish* English (UK) Thailand* Lithuanian* Turkish* Malaysia Ukrainian* Farsi Vietnamese Netherlands Finnish* 12. SELECTED BIBLIOGRAPHY Major source references
Jones PW, Quirk FH, Baveystock CM. The St George's Respiratory Questionnaire.
Jones PW, Quirk FH, Baveystock CM, Littlejohns P. A self-complete measure for
chronic airflow limitation - the St George's Respiratory Questionnaire. Am Rev Respir Dis1992;145:1321-7.
Meguro M, Barley EA, Spencer S, Jones PW. Development and validation of an
improved COPD-specific version of the St George's Respiratory Questionnaire. Chest2006;132: 456-463. Other references
Quirk FH, Jones PW. Patients' perception of distress due to symptoms and effects of
asthma on daily living and an investigation of possible influential factors. Clin Sci1990;79:17-21.
Quirk FH, Baveystock CM, Wilson RC, Jones PW. Influence of demographic and
disease related factors on the degree of distress associated with symptoms and restrictionson daily living due to asthma in six countries. Eur Respir J 1991;4:167-71.
Jones PW, the Nedocromil Sodium Quality of Life Study Group. Quality of Life,
symptoms and pulmonary function in asthma: long-term treatment with nedocromil sodiumexamined in a controlled multicentre trial. Eur Respir J 1994;7:55-62.
Anie KA, Jones PW, Hilton SR, Anderson HR. A computer-assisted telephone
interview technique for assessment of asthma morbidity and drug use in adult asthma. JClin Epidemiol 1996;49:653-6.
Ketelaars CAJ, Sclösser MAG, Mostert R, Huyer Abu-Saad H, Halfens RJG, Wouters
EFM. Determinants of health-related quality of life in patients with chronic obstructivepulmonary disease. Thorax 1996;51:39-43.
Okubadejo AA, Jones PW, Wedzicha JA. Quality of life in patients with chronic
obstructive pulmonary disease and severe hypoxaemia. Thorax 1996;51(1):44-7.
10. Renwick DS, Connolly MJ. Impact of obstructive airways disease on quality of life inolder adults. Thorax 1996;51:520-5.
11. Jones PW, Bosh TK. Changes in quality of life in COPD patients treated withsalmeterol. Am J Resp Crit Care Med 1997;155:1283-9.
12. Wilson CB, Jones PW, O'Leary CJ, Cole PJ, Wilson R. Validation of the St George'sRespiratory Questionnaire in Bronchiectasis. AJRCCM 1997;156:536-41.
13. Osman LM, Godden DJ, Friend JAR, Legge JS, Douglas JG. Quality of life andhospital re-admission in patients with chronic obstructive pulmonary disease. Thorax1997;52:67-71.
14. Hajiro T, Nishimura K, Tsukino M, Ikeda A, Koyama H, Izumi T. Comparison ofdiscriminative properties among disease-specific questionnaires for measuring health-related quality of life in patients with chronic obstructive pulmonary disease. AmericanJournal of Respiratory & Critical Care Medicine 1998;157(3 Pt 1):785-90.
15. Seemungal TAR, Donaldson GC, Paul EA, Bestall JC, Jefferies DJ, Wedzicha JA. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonarydisease. Am J Respir Crit Care Med 1998;157:1418-22.
16. Wijkstra PJ, Jones PW. Quality of life in patients with chronic obstructive pulmonarydisease. Eur Respir Monogr 1998;3(7):235-46.
17. Barley EA, Jones PW. A comparison of global questions versus health statusquestionnaires as measures of the severity and impact of asthma. European RespiratoryJournal 1999;14(3):591-6.
18. Carone M, Bertolotti G, Anchisi F, Zotti AM, Donner PW, Jones PW. Analysis of factorsthat chararacterize health impairment in patients with chronic respiratory failure. Eur RespirJ 1999;13:1293-300.
19. Jones PW. Health status in chronic obstructive pulmonary disease. Eur Respir Rev1999;9:169-72.
20. Burge PS, Calverley PMA, Jones PW, Spencer PW, Anderson JA, Maslen TK. Randomised, double blind, placebo controlled study of fluticasone proprionate in patientswith moderate to severe chronic obstructive pulmonary disease. BMJ 2000;320:1297-303.
21. Griffiths TL, Burr ML, Campbell IA, Lewis-Jenkins V, Mullins J, Shiels K, et al. Resultsat 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlledtrial. Lancet 2000;355(9201):362-8.
22. Jones PW. Impact of lower respiratory tract infections on health status. Seminars inRespiratory and Critical Medicine 2000;21:107-11.
23. Spencer S, Calverley PMA, Burge PS and Jones PW. Health status deterioration inpatients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med2001;163:122-8.
24. Jones PW. Health status measurement in chronic obstructive pulmonary disease. Thorax 2001;56:880-7.
25. Jones PW. Interpreting thresholds for a clinically significant changes in health status inasthma and COPD. Eur Respir J 2002;19:398-404.
26. Ferrer M, Villasante C, Alonso J, Sobradillo V, Gabriel R, Vilagut G, et al. Interpretation of quality of life scores from the St. George’s Respiratory Questionnaire. EurRespir J 2002;19:405-413.
27. Domingo-Salvany A, Lamarca R, Ferrer M, Garcia-Aymerich J, Alonso J, Félez M, etal. Health-related quality of life and mortality in male patients with chronic obstructivepulmonary disease. Am J Respir Crit Care Med 2002;166:680-685.
28. Oga T, Nishimura K, Tsukino M, Sato S, Hajiro T. Analysis of the factors related tomortality in chronic obstructive pulmonary disease. Am J Respir Crit Care Med2003;167:544-549.
29. Stolk J, Ng WH, Bakker ME, Reiber JHC, Rabe KF, Putter H. Stoel BC. Correlationbetween annual change in health status and computer tomography derived lung density insubjects with alpha1-antitrypsin deficiency. Thorax 2003, 58: 1027-30
30. Gudmundsson G, Gislason T, Janson C, Lindberg E, Hallin R, Ulrik CS, Brøndum E,Nieminen MM, Aine T and Bakke P. Risk factors for rehospitalisation in COPD: role ofhealth status, anxiety and depression. Eur Respir J 2005; 26: 414–419
31. Jones PW. St George's Respiratory Questionnaire: MCID. Journal of COPD 2005;2:75-79.
32. Broekhuizen, R. Wouters EFM, Creutzberg E.C. Schols A.M.W.J. Raised CRP levelsmark metabolic and functional impairment in advanced COPD. Thorax 2006; 61: 17-22
33. Santiveri C, Espinalt M, Carrasco FXD, Marin A, Miguel E, Jones PW. Evaluation ofmale COPD patients’ health status by proxies. Respir Med;101:439-445.
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