Quantifying a Vital Symptom: Large-scale Inpatient Dyspnea Measurement

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PROJECT SUMMARY Shortness of breath (Dyspnea) is both a predictor of life-threatening illness and a common symptom that causes suffering if not adequately managed. Pain is routinely assessed in accredited healthcare institutions; dyspnea is not. We hypothesize that routine measurement of dyspnea can be a powerful tool to predict problems, target interventions, and manage discomfort; we will test this thesis in a very large cohort of hospitalized patients. Dyspnea is one the strongest predictors of death in a variety of narrow disease populations (e.g., cardiac disease, gastrointestinal cancer, and COPD), but surprisingly little is known about the prevalence, severity, and predictive value of dyspnea in the general hospital population. In the present proposal, bedside nurses will perform standardized dyspnea assessments at the time of admission in 45,000 newly hospitalized patients and will assess dyspnea twice each day over the course of the hospital stay in 12,000 of these patients. Dyspnea will be measured as a continuous variable, rather than a binary yes/no variable. In 2,000 of these patients with significant dyspnea at admission, research staff will make more detailed multidimensional dyspnea measurements, tracking dyspnea through the course of hospitalization. These cohorts - linked to detailed electronic medical record data -- will add critical information to the body of knowledge by answering several key questions: (1) In a large cohort of newly hospitalized patients, does dyspnea measurement independently predict future outcomes that are important to patients and the healthcare system (e.g., death, development of critical illness, readmission, patient satisfaction)? (Very preliminary results suggest a large increase in risk if dyspnea is greater than 3/10.) Risk predictions could be used to target closer monitoring on the basis of risk - such follow-up might include more frequent assessment for needed changes in therapy, symptom management, and pro-active planning for end-of-life issues. (2) What is the prevalence, incidence, severity, and time course of dyspnea in hospitalized patients? Do some diseases have typical temporal patterns of dyspnea? Are particular qualities of dyspnea associated with greater emotional burden or greater morbidity? (3) What is the burden of dyspnea measurement on health care providers? (4) What constitutes adequate treatment of dyspnea in the view of patients? This project will provide a novel evidence base for policymakers to use in setting goals for dyspnea treatment in hospitalized patients and incorporating dyspnea assessment into standard hospital practice. Standardizing the assessment of pain has changed how we think about the patient's experience of pain. We hypothesize that standardized dyspnea assessment will have a similar effect on our appreciation of the patient's experience, and will also have dramatic prognostic value. This concept suggests a large opportunity for improving care with minimal cost.