A Review of Quality of Care Evaluation for the Palliation of Dyspnea

Abstract

Assessment and management of dyspnea has emerged as a priority topic for quality evaluation and improvement. Evaluating dyspnea quality of care requires valid, reliable, and responsive measures of the care provided to patients across settings and diseases. As part of an Agency for Healthcare Research and Quality Symposium, we reviewed quality of care measures for dyspnea by compiling quality measures identified in systematic searches and reviews. Systematic reviews identified only three existing quality measurement sets that included quality measures for dyspnea care. The existing dyspnea quality measures reported by retrospective evaluations of care assess only four aspects: dyspnea assessment within 48 hours of hospital admission, use of objective scales to rate dyspnea severity, identification of management plans, and evidence of dyspnea reduction. To begin to improve care, clinicians need to assess and regularly document patient's experiences of dyspnea. There is no consensus on how dyspnea should be characterized for quality measurement, and although over 40 tools exist to assess dyspnea, no rating scale or instrument is ideal for palliative care. The panel recommended that dyspnea assessment should include a measure of intensity and some inquiry into the associated bother or distress experienced by the patient. A simple question into the presence or absence of dyspnea would be unlikely to help guide therapy, as complete relief of dyspnea in advanced disease would not be anticipated. Additional knowledge gaps include standards for clinical dyspnea care, assessment in the cognitively impaired, and evaluation of effectiveness of dyspnea care for patients with advanced disease.

An Official American Thoracic Society Statement: Update on the Mechanisms, Assessment, and Management of Dyspnea

“…Johnson and colleagues categorized measures primarily according to whether they were unidimensional or multidimensional (178). Others have suggested categorizations of intensity or severity, situational or functional impact, effects on health-related quality of life or health status, and qualitative descriptors (179,180).…”

Ensuring Breathing Comfort at the End of Life: The Integral Role of the Critical Care Nurse

“…Using a visual analog scale for dyspnea permits a unidimensional assessment of dyspnea intensity if the patient can point to a line. 10 In one study, 11 persons with chronic obstructive pulmonary disease preferred a vertical orientation of a dyspnea visual analog scale.…”

Opioids for refractory dyspnea

“…To evaluate the efficacy of therapy on the impact of dyspnea in ambulatory patients, multidimensional instruments (e.g., the self-administered computerized transition dyspnea index) are more responsive than unidimensional rating scales (e.g., Medical Research Council scale) [74]. Patients should be asked to routinely and regularly rate their breathlessness as part of a comprehensive care plan, and this information should be documented in the medical record [1,75].…”