Combining the Pulmonary Rehabilitation Decisional Score with the Bode Index and Clinical Opinion in Assigning Priority for Pulmonary Rehabilitation

Figures & data

Figure 1. Panel A shows PRDS score distribution with respect to clinical evaluation at entry for each type of “setting” (LP, HP and VHP; for both LP vs. VHP and HP vs. VHP p < 0.0001); Panel B refers to BI distribution with respect to clinical evaluation at entry for each type of “setting” (LP, HP and VHP; for both LP vs. VHP and HP vs. VHP, p < 0.0001). Legend: The horizontal lines represent PRDS or BI decisional values. Box plots refer to median value and interquartile ranges. Circles indicate outliers.

Table 1. Distribution of patient population according to PRDS, BI and Clinical decision (CD)

(n = 124 subjects)	LP rehab	HP rehab	VHP rehab
CD evaluations, n	41	37	46
PRDS evaluations, n	39	46	39
BI evaluations, n	41	43	40

Legend: CD: clinical decision, LP rehab: Low Priority rehabilitation, HP rehab: High Priority rehabilitation, VHP rehab: Very High Priority rehabilitation

Table 2. Concordance between clinical decision, PRDS, BI in terms of Specificity (concordance in indicating LP, i.e. all real negative), Sensitivity (concordance in indicating HP or VHP, i.e. all real positive) and Efficiency (total concordance).

Evaluations	Specificity	Sensitivity	Efficiency	p
PRDS vs. CD	51.2%	78.3%	69.3%	<0.001
BODE vs. CD	53.7%	77.1%	69.3%	<0.001
PRDS vs. BODE	75.6%	90.4%	85.5%	<0.0001

Legend: CD: clinical decision; HP: High Priority rehabilitation; LP: Low Priority rehabilitation, VHP: Very High Priority rehabilitation

Table 3. Details for data which were differently evaluated by the tools: comparison of PRDS and BI with clinical decision and between PRDS and BI

Evaluations	EFFICIENCY = Concordance (n)	Underprescription LP cases in HP or VHP groups for reference method (n)			Overprescription HP or VHP cases in LP group for reference method (n)
			LP vs HP	LP vs VHP		HP vs LP	VHP vs LP
PRDS vs. CD	86/124	18/124	17 (11 CDL)	1	20/124	16 (3 CDL)	4
BI vs. CD	86/124	19/124	17 (4 CDL)	2 (1 CDL)	19/124	12 (4 CDL)	7
PRDS vs. BI	106/124	8/124	7 (6 CDL)	1 (1 CDL)	10/124	10 (5 CDL)	0

Legend: underprescription (loss of positive patients = loss of sensitivity) or overprescription (loss of negative patients = loss of specificity) considering all interactions between tools; CD: clinical decision; HP: High Priority rehabilitation; LP: Low Priority rehabilitation; VHP: Very High Priority rehabilitation

Table 1 appendix: Efficiency, underprescription and overprescription of PRDS vs BI.

Evaluations	Efficiency = concordance (n)	Underprescription LP cases in HP or VHP groups for reference method (n)			Overprescription HP or VHP cases in LP group for reference method (n)
			LP vs. HP	LP vs. VHP		HP vs. LP	VHP vs. LP
PRDS vs. BI	106/124	8/124	7^a (6 CDL)	1 (1 CDL)	10/124	10^b (5 CDL)	0

^a The only patient with PRDS UNDERPRECRIPTION vs. BI and with PRDS not CDL was Patient n. 80: PRDS LP (score = 3) and BI HP (Index = 4). This patient was characterized by critical FEV1 (40%), BMI = 21, MRC = 1 and Comorbidities = 1. So the different classification obtained in PRDS and BI was due to the presence of critical FEV1 (with an impact specially on BI) and the absence of critical values for PRDS-only items (generating a low PRDS score).

^b The 5 patients with PRDS OVERPESCRIPTION vs. BI not CDL were HP with a score from 14 to 16 on the PRDS and LP with Index 1 or 2 on BI. They were all characterized by non critical values for respiratory function: FEV1 values (from 65 to 77), MRC (0–1) and 6MWT (from 300 to 689) generating a low BI with LP classification. But they presented critical values in several PRDS-only items (such as number of exacerbations, smoking status, comorbidities, anxiety/depression, limitations in physical activity) with an impact on the PRDS score determining HP classification.

Figure 2. Correlation plot between PRDS score and BI. Patients graded for PR priority by Clinical Decision, are allocated in different sectors of the plot on the basis of PRDS and BODE PR priority. Legend: cases are represented as signs in a scatter plot. Different signs and colors have been used for the three groups of rehabilitation priority according to CD: group 1 (white circle) for LP; group 2 (grey triangle) for HP and group 3 (black circle) for VHP. The oblique black line is the Regression line PRDS score (y) versus BI (x). Horizontal blue lines identify PRDS score limits (continue for LP-HP and dashed for HP-VHP). Vertical blue lines identify BI limits (continue for LP-HP and dashed for HP-VHP). The four blue lines split the plot into nine different sectors indicating PR priority by PRDS and BI: A. Discordance VHP PRDS-LP BI; B. Discordance HP PRDS-LP BI; C. Concordance LP; D. Discordance VHP PRDS-HP BI; E. Concordance HP; F. Discordance LP PRDS-HP BI; G. Concordance VHP; H. Discordance HP PRDS-VHP BI; I. Discordance LP PRDS-VHP BI.

Figure 1 appendix shows clinical evaluation at entry for each type of “setting” (LP, HP and VHP) and the corresponding PRDS score and BI. Single dots represent cases (filled shapes for PRDS and empty form for BI) and black lines represent the median values within the group. Grey box defines areas for BI score: ≤2 white; 2–6 dots; ≥6 white; black arrows indicate cut off (for PRDS scores).