NIHR Evidence for COPD exacerbations

The sit-to-stand test may predict the risk of hospitalisation for COPD exacerbations 

NIHR Evidence for COPD exacerbations

What’s the issue? 

Figures from the NHS show that more than 128,000 patients in the UK were admitted to hospital for COPD exacerbations in 2016-17. The vast majority (97%) were unscheduled emergencies. Aside from increasing costs for the healthcare system, 4.3 per cent of these patients died in hospital, with a further 2.8 per cent dying within one month of discharge. 

Identifying these high-risk patients with COPD could help inform clinical decision-making and target interventions. Interventions that may reduce the risk of exacerbation include vaccination, optimisation of inhaled therapies and exercise-based therapies.  

The BODE Index, which includes the six-minute walk test (6MWT), is a physical performance assessment that can predict long-term outcomes for patients with COPD. However, the National Institute of Clinical Excellence (NICE) 2018 guidelines recommend against its use in primary care because it is time-intensive and challenging to carry out. 

In 2016-17 for COPD exacerbations of hospital admissions 97% were unscheduled emergencies

This study aimed to identify alternative and simpler assessments to identify COPD patients at risk of exacerbation. These include the short physical performance battery (SPPB), which is widely used to assess the health of elderly people. 

What’s new? 

Hospital data from 714 patients with stable COPD, who were taking part in the long-term observational ERICA study, were analysed. The researchers looked at several physical performance measurements, including the SPPB and its three individual components (walking speed, balance, and five repetitions of sit-to-stand), and the 6MWT. They estimated how well these measures predicted patients’ risk of hospitalisation due to COPD exacerbation, and the length of their hospital stay. 

Over five years, 291 of the 714 patients were admitted to hospital because of a COPD exacerbation. Some were admitted more than once; there were 762 of these hospitalisations in all.

The researchers found that: 

  • a worse SPPB performance was linked with a higher risk of hospitalisation for COPD exacerbation and an increased length of stay 
  • the SPPB and sit-to-stand test were easier to carry out than the 6MWT and performed almost as well in predicting the risk of hospitalisation for COPD exacerbation 
  • the SPPB, and sit-to-stand component, performed as well as the 6MWT in predicting the length of hospital stay in these patients. 

    Why is this important? 

    This study suggests that the SPPB, or its sit-to-stand component as a standalone, is a quick, simple and practical way of carrying out risk assessments of patients with COPD in primary and secondary care settings.  

    These tests could provide a practical alternative to the 6MWT to aid decision-making for individual patients. The sit-to-stand component can be performed almost anywhere in less than five minutes. This would be much easier to implement in the clinic, where professionals are short of time, than the 6MWT – which takes around 30 minutes and requires access to a flat, uninterrupted 30m track.  

    This simple way to assess risk could help doctors to ensure that patients with COPD receive appropriate interventions to help prevent lengthy hospital stays, potentially reducing their risk of death. 

    What’s next? 

    The authors propose that the sit-to-stand test should be adopted as a routine measure in the care pathway for patients with COPD, potentially as part of the annual COPD review. They say its use can help identify at-risk patients and facilitate better-informed resource planning. 

    If the results can be replicated in larger cohorts and/or different geographical populations over longer follow-up periods, the researchers hope that the current guidelines will be updated to recommend that clinicians use this approach to identify patients with COPD at greater risk of hospitalisation, enabling prompt intervention. 

    Research on COPD exacerbations is part of a current James Lind Alliance Priority Setting Partnership, which is prioritising further research focusing on preventing and managing COPD exacerbations.  

    Expert view: 

    Lucy Gardiner Regional networks lead, Association of Chartered Physiotherapists in Respiratory Care (ACPRC) and teaching fellow at the University of Birmingham 

    Significant numbers of people with COPD in the UK are admitted to hospital with exacerbations affecting their health and quality of life. We know that pulmonary rehabilitation can improve functional abilities and quality of life; which is demonstrated in recommended measures of physical performance amongst others. These measures are not necessarily used routinely in other clinical settings, such as during a hospital stay, respiratory clinic review, or GP review. The reported predictive quality of the sit-to-stand test, has the potential to facilitate more timely and targeted care which may assist in preventing the need for admission.  

    In order for the sit-to-stand test to be an effective tool in preventing admissions, an integrated approach (primary and secondary care) is needed. Provision of community respiratory care remains variable across the UK. Areas with multi-disciplinary integrated teams may be able to implement effective use of the tool with relative ease. Other areas may be reliant on annual COPD reviews provided by GP practices which would require training of staff, and utility may be more limited.  

    Where needed, the sit-to-stand test may have an additional role in categorising and/or prioritising patients in secondary care clinics and pulmonary rehabilitation services. 

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    You may be interested to read 

    The full NIHR Alert and additional expert commentary published on 9 June 2020

    The full paper: Fermont JM et al.  Risk assessment for hospital admission in patients with COPD; a multi-centre UK prospective observational study.  PLoS One. 2020;15:e0228940 

    Fermont JM, and others. Short physical performance battery as a practical tool to assess mortality risk in chronic obstructive pulmonary disease. Age and Ageing. 2020.  Accepted for publication on 29 May 2020 

    Hopkinson NS, and others. Chronic obstructive pulmonary disease: diagnosis and management: summary of updated NICE guidance. BMJ. 2019;366:l4486 

    Kon SS, and others. Gait speed and readmission following hospitalisation for acute exacerbations of COPD: a prospective study. Thorax. 2015;70:1131-1137 

    Conflict of interest 

    GSK was involved in funding this research. 


    This work was supported by the NIHR Biomedical Research Centres at Cambridge and Nottingham, the UK Medical Research Council, the British Heart Foundation, Health Data Research UK. 

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