A cross-sectional survey of night-time symptoms and impact of sleep disturbance on symptoms and health status in patients with COPD

Figures & data

Table 1 Study population by country

	Total COPD, n (%)
France	314 (12.5)
Germany	402 (16.1)
Italy	180 (7.2)
Spain	336 (13.4)
UK	126 (5.0)
USA	471 (18.8)
China	675 (27.0)
Total	2,504 (100)

Abbreviation: COPD, chronic obstructive pulmonary disease.

Table 2 Patient demographics and clinical characteristics

	Overall (n=2,504)	5EU (n=1,358)	USA (n=471)	China (n=675)
Age (years)
Number of missing observations	0	0	0	0
Mean (SD)	64.6 (10.7)	65.3 (10.4)	66.6 (10.0)	62.0 (11.4)
Sex, n (%)
Number of missing observations	0	0	0	0
Male	1,629 (65.1)	959 (70.6)	260 (55.2)	410 (60.7)
Race, n (%)
Number of missing observations	4 (0.2)	4 (0.3)	0	0
Caucasian	1,691 (67.6)	1,290 (95.3)	401 (85.1)	0
African American	42 (1.7)	0	42 (8.9)	0
Hispanic	52 (2.1)	33 (2.4)	19 (4.0)	0
Asian – Indian subcontinent	8 (0.3)	5 (0.4)	3 (0.6)	0
Asian – other	10 (0.4)	4 (0.3)	6 (1.3)	0
Chinese	675 (27.0)	0	0	675 (100.0)
Other	22 (0.9)	22 (1.6)	0	0
BMI (kg/m^2)
Number of missing observations (%)	102 (4.1)	71 (5.2)	31 (6.6)	0
Mean (SD)	25.7 (4.6)	26.1 (4.4)	27.8 (6.0)	23.5 (2.9)
Employment status, n (%)
Number of missing observations	81 (3.2)	46 (3.4)	32 (6.8)	3 (0.4)
Employed	609 (25.1)	318 (24.2)	138 (31.4)	153 (22.8)
Retired	1,429 (59.0)	767 (58.5)	222 (50.6)	440 (65.5)
Homemaker	130 (5.4)	74 (5.6)	27 (6.2)	29 (4.3)
Unemployed	180 (7.4)	104 (7.9)	26 (5.9)	50 (7.4)
On long-term disability	75 (3.1)	49 (3.7)	26 (5.9)	0
Smoking status, n (%)
Number of missing observations	13 (0.5)	1 (0.1)	1 (0.2)	11 (1.6)
Current smoker	736 (29.6)	472 (34.8)	150 (31.9)	114 (17.2)
Ex-smoker	1,381 (55.4)	800 (59.0)	297 (63.2)	284 (42.8)
Never smoked	374 (15.0)	85 (6.3)	23 (4.9)	266 (40.1)
Pack-years (grouped), n (%)
Number of missing observations	93 (3.7)	52 (3.8)	29 (6.2)	12 (1.8)
<10	515 (21.4)	155 (11.9)	48 (10.9)	312 (47.1)
≥10	1,896 (78.6)	1,151 (88.1)	394 (89.1)	351 (52.9)
Proportion of patients with ACOS, n (%)
Number of missing observations	9 (0.4)	8 (0.6)	1 (0.2)	0
No asthma diagnosis	2,200 (88.2)	1,281 (94.9)	432 (91.9)	487 (72.2)
Physician-confirmed ACOS	295 (11.8)	69 (5.1)	38 (8.1)	188 (27.9)
Most recent FEV1 test score (post-bronchodilator), % predicted
Number of missing observations (%)	1,496 (59.7)	718 (52.9)	284 (60.3)	494 (73.2)
Mean (SD)	62.9 (17.8)	64.6 (17.9)	62.7 (17.3)	57.2 (16.5)
Number of COPD exacerbations in the last 12 months
Number of missing observations (%)	7 (0.3)	2 (0.1)	1 (0.2)	4 (0.6)
Mean (SD)	1.4 (2.3)	1.5 (1.8)	1.3 (1.7)	1.4 (3.2)

Abbreviations: ACOS, asthma-COPD overlap syndrome; BMI, body mass index; COPD, chronic obstructive pulmonary disease; EU, European Union; FEV₁, forced expiratory volume in 1 second; SD, standard deviation.

Table 3 Patient-reported CAT score, health status, and psychological or functional impairment

	Overall (n=2,504)	5EU (n=1,358)	USA (n=471)	China (n=675)
8-item CAT score
Number of missing observations (%)	136 (5.4)	93 (6.8)	42 (8.9)	1 (0.1)
Mean (SD)	21.7 (8.1)	20.5 (8.4)	20.4 (8.6)	24.8 (6.1)
8-item CAT score (grouped), n (%)
Number of missing observations	136 (5.4)	93 (6.8)	42 (8.9)	1 (0.1)
0–9	208 (8.8)	140 (11.1)	58 (13.5)	10 (1.5)
10–19	631 (26.7)	409 (32.3)	120 (28.0)	102 (15.1)
20–29	1,126 (47.6)	525 (41.5)	185 (43.1)	416 (61.7)
30–40	403 (17.0)	191 (15.1)	66 (15.4)	146 (21.7)
EQ-5D-3L index score
Number of missing observations (%)	85 (3.4)	47 (3.5)	38 (8.1)	0
Mean (SD)	0.7 (0.3)	0.7 (0.3)	0.8 (0.2)	0.8 (0.3)
Psychological or functional impairment, n (%)
Number of missing observations	51 (2.0)	30 (2.2)	20 (4.2)	1 (0.1)
Constant lack of energy	1,047 (42.7)	484 (36.5)	170 (37.7)	393 (58.3)
Tiredness through lack of sleep	896 (36.5)	377 (28.4)	126 (27.9)	393 (58.3)
Sickness	343 (14.0)	35 (2.6)	33 (7.3)	275 (40.8)
Nervousness or anxiety	668 (27.2)	299 (22.5)	109 (24.2)	260 (38.6)
Feelings of sadness or depression	335 (13.7)	186 (14.0)	59 (13.1)	90 (13.4)
Difficulty expressing your feelings	177 (7.2)	86 (6.5)	27 (6.0)	64 (9.5)
Embarrassment about your condition	336 (13.7)	194 (14.6)	61 (13.5)	81 (12.0)
Scared and worried about your condition	578 (23.6)	306 (23.0)	112 (24.8)	160 (23.7)
Feelings of irritability	442 (18.0)	259 (19.5)	85 (18.9)	98 (14.5)
None of them	515 (21.0)	348 (26.2)	130 (28.8)	37 (5.5)

Abbreviations: CAT, COPD assessment test; COPD, chronic obstructive pulmonary disease; EQ-5D-3L, EuroQol five-dimension questionnaire; EU, European Union; SD, standard deviation.

Table 4 Jenkins Sleep Evaluation Questionnaire (JSEQ) findings

	Overall (n=2,504)	5EU (n=1,358)	USA (n=471)	China (n=675)
JSEQ score (0–20)
Mean (SD)	6.1 (4.8)	6.1 (5.0)	5.4 (4.7)	6.3 (4.6)
How often in the past 4 weeks did you: have trouble falling asleep? n (%)
(0) Not at all	669 (26.7)	386 (28.4)	171 (36.3)	112 (16.6)
(1) 1–3 days	768 (30.7)	427 (31.4)	134 (28.5)	207 (30.7)
(2) 4–7 days	551 (22.0)	293 (21.6)	90 (19.1)	168 (24.9)
(3) 8–14 days	264 (10.5)	141 (10.4)	39 (8.3)	84 (12.4)
(4) 15–21 days	142 (5.7)	65 (4.8)	26 (5.5)	51 (7.6)
(5) 22–28 days	110 (4.4)	46 (3.4)	11 (2.3)	53 (7.9)
Mean (SD) score	1.5 (1.4)	1.4 (1.3)	1.3 (1.3)	1.9 (1.5)
How often in the past 4 weeks did you: wake up several times per night? n (%)
(0) Not at all	618 (24.7)	343 (25.3)	136 (28.9)	139 (20.6)
(1) 1–3 days	772 (30.8)	424 (31.2)	146 (31.0)	202 (29.9)
(2) 4–7 days	524 (20.9)	273 (20.1)	103 (21.9)	148 (21.9)
(3) 8–14 days	297 (11.9)	162 (11.9)	46 (9.8)	89 (13.2)
(4) 15–21 days	159 (6.4)	87 (6.4)	25 (5.3)	47 (7.0)
(5) 22–28 days	134 (5.4)	69 (5.1)	15 (3.2)	50 (7.4)
Mean (SD) score	1.6 (1.4)	1.6 (1.4)	1.4 (1.3)	1.8 (1.5)
How often in the past 4 weeks did you: have trouble staying asleep (including waking up earlier than normal)? n (%)
(0) Not at all	735 (29.4)	388 (28.6)	164 (34.8)	183 (27.1)
(1) 1–3 days	684 (27.3)	375 (27.6)	144 (30.6)	165 (24.4)
(2) 4–7 days	565 (22.6)	309 (22.8)	90 (19.1)	166 (24.6)
(3) 8–14 days	274 (10.9)	160 (11.8)	42 (8.9)	72 (10.7)
(4) 15–21 days	142 (5.7)	76 (5.6)	20 (4.3)	46 (6.8)
(5) 22–28 days	104 (4.2)	50 (3.7)	11 (2.3)	43 (6.4)
Mean (SD)	1.5 (1.4)	1.5 (1.4)	1.2 (1.3)	1.7 (1.5)
How often in the past 4 weeks did you: wake up after your usual amount of sleep feeling tired and worn out? n (%)
(0) Not at all	810 (32.4)	345 (25.4)	143 (30.4)	322 (47.7)
(1) 1–3 days	665 (26.6)	367 (27.0)	127 (27.0)	171 (25.3)
(2) 4–7 days	477 (19.1)	296 (21.8)	84 (17.8)	97 (14.4)
(3) 8–14 days	280 (11.2)	182 (13.4)	57 (12.1)	41 (6.1)
(4) 15–21 days	178 (7.1)	104 (7.7)	46 (9.8)	28 (4.2)
(5) 22–28 days	94 (3.8)	64 (4.7)	14 (3.0)	16 (2.4)
Mean (SD)	1.5 (1.4)	1.7 (1.4)	1.5 (1.4)	1.0 (1.3)

Note: No patients included had missing JSEQ data.

Abbreviations: EU, European Union; JSEQ, Jenkins Sleep Evaluation Questionnaire; SD, standard deviation.

Figure 1 Frequency of night-time symptoms reported in Europe and the USA during the last 4 weeks by (A) physicians and (B) patients.

Abbreviation: EU, European Union.

Table 5 EQ-5D-3L multivariate modeling showing logistic (perfect health versus non-perfect health patients) and linear (non-perfect health patients only) regression

	5EU	USA	China
Logistic regression (perfect health versus non-perfect health patients)
JSEQ score
Number of observations	1,136	294	400
Odds ratio (95% CI)	1.27 (1.18, 1.36)	1.23 (1.12, 1.38)	1.19 (1.10, 1.28)
P-value	<0.001	<0.001	<0.001
Linear regression of JSEQ score (non-perfect health patients only)
With EQ-5D score
Number of observations	923	276	270
Coefficient	0.019	0.007	0.008
P-value	<0.001	<0.001	0.055
With 7-item CAT score (excluding sleep item)
Number of observations	1,098	357	404
Coefficient	0.695	0.725	0.224
P-value	<0.001	<0.001	0.001

Notes: Perfect health was defined as an EQ-5D-3L score of 1 and non-perfect health <1. For the logistic regression, an odds ratio of >1 represented the change in odds of a non-perfect health for a unit increase in JSEQ score. For the linear regression of JSEQ score with EQ-5D, a positive coefficient was associated with a patient with worse health status (lower EQ-5D score). A higher/lower value of the coefficient indicated a greater effect of the variable.

Abbreviations: CAT, COPD assessment test; CI, confidence interval; COPD, chronic obstructive pulmonary disease; EQ-5D-3L, EuroQol five-dimension questionnaire; EU, European Union; JSEQ, Jenkins Sleep Evaluation Questionnaire.

Table 6 Current treatment for COPD

	Overall (n=2,504)	5EU (n=1,358)	USA (n=471)	China (n=675)
Physician type responsible for treatment decisions, n (%)
Number of missing observations	11 (0.4)	4 (0.3)	7 (1.5)	0
PCP only	799 (32.0)	584 (43.1)	215 (46.3)	n/a
Specialist involvementa	1,694 (68.0)	770 (56.9)	249 (53.7)	675 (100)
Current treatment regimen,b n (%)
Number of missing observations	5 (0.2)	2 (0.1)	2 (0.4)	1 (0.1)
Short-acting onlyc	156 (6.2)	72 (5.3)	44 (9.4)	40 (5.9)
ICS	116 (4.6)	22 (1.6)	10 (2.1)	84 (12.5)
LAMA	335 (13.4)	253 (18.7)	76 (16.2)	6 (0.9)
LABA	115 (4.6)	83 (6.1)	5 (1.1)	27 (4.0)
ICS + LABA (fixed or free)	761 (30.5)	266 (19.6)	140 (29.9)	355 (52.7)
ICS + LAMA	33 (1.3)	19 (1.4)	14 (3.0)	0
LAMA + LABA	151 (6.0)	142 (10.5)	6 (1.3)	3 (0.5)
ICS + LAMA + LABA (fixed or free)	618 (24.7)	457 (33.7)	150 (32.0)	11 (1.6)
Other (no inhaled maintenance medication)	214 (8.6)	42 (3.1)	24 (5.1)	148 (22.0)
Current treatment chosen by the physician for improvement in night-time symptom relief, n (%)
Number of missing observations	424 (16.9)	258 (19.0)	161 (34.2)	5 (0.7)
Not night-time symptom relief	983 (47.3)	614 (55.8)	167 (53.9)	202 (30.2)
Night-time symptom relief	1,097 (52.7)	486 (44.2)	143 (46.1)	468 (69.9)
Current COPD treatment chosen by the physician for improvement in daytime symptom relief, n (%)
Number of missing observations	424 (16.9)	258 (19.0)	161 (34.2)	5 (0.7)
Not daytime symptom relief	714 (34.3)	441 (40.1)	118 (38.1)	155 (23.1)
Daytime symptom relief	1,366 (65.7)	659 (59.9)	192 (61.9)	515 (76.9)

Notes:

a Pulmonologist or equivalent; hospital-based respiratory specialist in China.

b ± short-acting products.

c SABA, SAMA, or SABA/SAMA.

Abbreviations: COPD, chronic obstructive pulmonary disease; EU, European Union; ICS, inhaled corticosteroid; LABA, long-acting β₂-agonist; LAMA, long-acting muscarinic antagonist; n/a, not applicable; PCP, primary care physician; SABA, short-acting β₂-agonist; SAMA, short-acting muscarinic antagonist.