***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Better self management could improve quality of life ( QoL ) and reduce hospital admissions in chronic obstructive pulmonary disease ( COPD ) , but the best way to promote it remains unclear . AIM To explore the feasibility , effectiveness and cost effectiveness of a novel , layperson-led , theoretically driven COPD self-management support programme . DESIGN AND SETTING Pilot r and omised controlled trial in one UK primary care trust area . METHOD Patients with moderate to severe COPD were identified through primary care and r and omised 2:1 to the 7-week-long , group intervention or usual care . Outcomes at baseline , 2 , and 6 months included self-reported health , St George 's Respiratory Question naire ( SGRQ ) , EuroQol , and exercise . RESULTS Forty-four per cent responded to GP invitation , 116 were r and omised : mean ( st and ard deviation [ SD ] ) age 69.5 ( 9.8 ) years , 46 % male , 78 % had unscheduled COPD care in the previous year . Forty per cent of intervention patients completed the course ; 35 % attended no sessions ; and 78 % participants completed the 6-month follow-up question naire . Results suggest that the intervention may increase both QoL ( mean EQ-5D change 0.12 ( 95 % confidence interval [ CI ] = -0.02 to 0.26 ) higher , intervention versus control ) and exercise levels , but not SGRQ score . Economic analyses suggested that with thresholds of £ 20 000 per quality -adjusted life-year gained , the intervention is likely to be cost-effective . CONCLUSION This intervention has good potential to meet the UK National Institute for Health and Clinical Excellence criteria for cost effectiveness , and further research is warranted . However , to make a substantial impact on COPD self-management , it will also be necessary to explore other ways to enable patients to access self-management education Aims : The main objective of this study was to investigate whether a comprehensive self-management programme , including self-treatment guidelines for exacerbations and a fitness programme , is an efficient treatment option for chronic obstructive pulmonary disease ( COPD ) patients . Method : We r and omly allocated 248 COPD patients to either self-management  ( 127 ) or usual care ( 121 ) . Data on preference-based utilities ( EuroQol-5D ) , health-related quality of life ( HRQoL ) , health-care re source use and productivity losses associated with exacerbations were prospect ively collected . Quality -adjusted life years ( QALYs ) were calculated . The economic analysis took the societal perspective and the observation period was one year . Results : As we observed that the groups were equally effective in terms of QALYs and HRQoL ( SGRQ ) , we described a cost minimization analysis only . The self-management programme-specific costs amounted to 6642 per patient . In the base-case cost analysis , the incremental cost difference amounted to 838 per patient per year in favour of usual care . When only direct medical costs were included , the incremental annual cost of self-managementrelative to usual care was 179 per person per year . If time costs for the fitness programme were set to zero , the costs for self-management diminished to 542 . Sensitivity analysis showed that these results were robust to changes in the underlying assumptions . Conclusion : We conclude that the COPE self-management programme is not an efficient treatment option for moderate to severe COPD patients who rate their HRQoL relatively high . The programme was twice as expensive as usual care and had no measurable beneficial effects on QALYs or Objectives Pulmonary rehabilitation ( PR ) provides benefit for patients with chronic obstructive pulmonary disease ( COPD ) in terms of quality of life ( QoL ) and exercise capacity ; however , the effects diminish over time . Our aim was to evaluate a maintenance programme for patients who had completed PR . Setting Primary and secondary care PR programmes in Norfolk . Participants 148 patients with COPD who had completed at least 60 % of a st and ard PR programme were r and omised and data are available for 110 patients . Patients had greater than 20 pack year smoking history and less than 80 % predicted forced expiratory volume in 1 s but no other significant disease or recent respiratory tract infection . Interventions Patients were r and omised to receive a maintenance programme or st and ard care . The maintenance programme consisted of 2 h ( 1 h individually tailored exercise training and 1 h education programme ) every 3 months for 1 year . Primary and secondary outcome measures The Chronic Respiratory Question naire ( CRQ ) ( primary outcome ) , endurance shuttle walk test ( ESWT ) , EuroQol ( EQ5D ) , hospital anxiety and depression score ( HADS ) , body mass index ( BMI ) , body fat , activity levels ( overall score and activity diary ) and exacerbations were assessed before and after 12 months . Results There was no statistically significant difference between the groups for the change in CRQ dyspnoea score ( primary end point ) at 12 months which amounted to 0.19 ( −0.26 to 0.64 ) units or other domains of the CRQ . There was no difference in the ESWT duration ( −10.06 ( −191.16 to 171.03 ) seconds ) , BMI , body fat , EQ5D , MET-minutes , activity rating , HADS , exacerbations or admissions . Conclusions A maintenance programme of three monthly 2 h sessions does not improve outcomes in patients with COPD after 12 months . We do not recommend that our maintenance programme is adopted . Other methods of sustaining the benefits of PR are required . Trial registration number NCT00925171 The Global Initiative for Chronic Obstructive Lung Disease ( GOLD ) serves as a guide to treat and manage different severity classes of patients with COPD . It was suggested that the five categories of FEV1 % predicted ( GOLD 0–4 ) , can be applied for selecting different therapeutic approaches . However , validation of these selective properties is very poor . To determine the relevance of the GOLD staging system for estimating the severity of clinical problems , GOLD 2 ( n=70 ) and GOLD 3 ( n=65 ) patients were drawn from a prospect i ve cohort of patients with COPD and evaluated crosssectionally by a newly developed Nijmegen Integral Assessment Framework ( NIAF ) . The NIAF is a detailed assessment of a wide range of aspects of health status ( HS ) . Significant , though small , differences were found in Static Lung Volumes , Exercise Capacity , Subjective Pulmonary Complaints , Subjective Impairment , and Health-Related QoL , besides Airflow of course . Moreover , overlap between scores of these five HS sub-domains was substantial , indicating small clinical relevance for discernment . No significant differences were found in nine other aspects of HS . It is concluded that GOLD stages do not discriminate in any aspect of HS other than airflow obstruction , and therefore do not help the clinician in deciding which treatment modalities are appropriate STUDY OBJECTIVES To examine electrocardiographic findings after short- and long-term tiotropium therapy in patients with chronic obstructive pulmonary disease ( COPD ) , and to establish previously reported symptomatic efficacy . DESIGN R and omized , double-blind , placebo-controlled , parallel-group study . SETTING Twelve outpatient investigational centers in the United States . PATIENTS One hundred ninety-six patients with COPD . INTERVENTIONS Patients received either tiotropium 18 mug once/day or placebo , delivered by the H and iHaler device . MEASUREMENTS AND MAIN RESULTS Electrocardiography ( predose and 5 min postdose ) and 24-hour Holter monitoring were performed at baseline and after 8 and 12 weeks of treatment with tiotropium 18 microg once/day or placebo . Efficacy measures ( spirometry , global COPD ratings , scores on the EuroQol Health Question naire [ EQ-5D ] , albuterol inhaler as needed ) were included to demonstrate that the study population exhibited the characteristic improvements observed in previous tiotropium studies . Mean baseline forced expiratory volume in 1 second ( FEV1 ) was 1.03 L. Mean changes in heart rate from baseline were similar in both groups . No differences were noted in the percentage of patients developing rhythm or conduction abnormalities detected with electrocardiography or Holter monitoring . Frequency of premature beats and mean maximal changes in PR , QRS , QT , QTcB , and QTcF intervals were similar in both groups . No patients developed new-onset QT or QTc intervals greater than 500 msec , and no differences were noted in the percentage of patients developing new QT prolongation less than 30 msec , 30 - 60 msec , or greater than 60 msec . At 12 weeks , predose and postdose improvements in FEV1 were 184 and 265 ml , respectively , with tiotropium versus placebo ( p<0.001 ) . Physician and patient global COPD ratings and the EQ-5D visual analog scale scores were improved with tiotropium ( p<0.05 ) ; as-needed albuterol was reduced by 25 % relative to placebo ( p<0.05 ) . CONCLUSION Tiotropium provided spirometric and symptomatic benefits in patients with COPD and was not associated with evidence of electrocardiographic changes in heart rate , rhythm , QT intervals , or conduction Objective To assess the cost-effectiveness of a structured education pulmonary rehabilitation programme ( SEPRP ) for chronic obstructive pulmonary disease ( COPD ) relative to usual practice in primary care . The programme consisted of group-based sessions delivered jointly by practice nurses and physiotherapists over 8 weeks . Design Cost-effectiveness and cost-utility analysis alongside a cluster r and omised controlled trial . Setting 32 general practice s in Irel and . Participants 350 adults with COPD , 69 % of whom were moderately affected . Interventions Intervention arm ( n=178 ) received a 2 h group-based SEPRP session per week over 8 weeks delivered jointly by a practice nurse and physiotherapist at the practice surgery or nearby venue . The control arm ( n=172 ) received the usual practice in primary care . Main outcome measures Incremental costs , Chronic Respiratory Question naire ( CRQ ) scores , quality -adjusted life years ( QALYs ) gained estimated using the generic EQ5D instrument , and expected cost-effectiveness at 22 weeks trial follow-up . Results The intervention was associated with an increase of € 944 ( 95 % CIs 489 to 1400 ) in mean healthcare cost and € 261 ( 95 % CIs 226 to 296 ) in mean patient cost . The intervention was associated with a mean improvement of 1.11 ( 95 % CIs 0.35 to 1.87 ) in CRQ Total score and 0.002 ( 95 % CIs −0.006 to 0.011 ) in QALYs gained . These translated into incremental cost-effectiveness ratios of € 850 per unit increase in CRQ Total score and € 472 000 per additional QALY gained . The probability of the intervention being cost-effective at respective threshold values of € 5000 , € 15 000 , € 25 000 , € 35 000 and € 45 000 was 0.980 , 0.992 , 0.994 , 0.994 and 0.994 in the CRQ Total score analysis compared to 0.000 , 0.001 , 0.001 , 0.003 and 0.007 in the QALYs gained analysis . Conclusions While analysis suggests that SEPRP was cost-effective if society is willing to pay at least € 850 per one-point increase in disease-specific CRQ , no evidence exists when effectiveness was measured in QALYS gained . Trial Registration Current Controlled Trials IS RCT N52 403 063 Background Chronic obstructive pulmonary disease ( COPD ) is associated with increased mortality and poor health-related quality of life ( HRQoL ) compared with the general population . The objective of this study was to identify clinical characteristics which predict mortality and very poor HRQoL among the COPD population and to develop a Bayesian prediction model . Methods The data consisted of 738 patients with COPD who had visited the Pulmonary Clinic of the Helsinki and Turku University Hospitals during 1995–2006 . The data set contained 49 potential predictor variables and two outcome variables : survival ( dead/alive ) and HRQoL measured with a 15D instrument  ( very poor HRQoL < 0.70 vs. typical HRQoL ≥ 0.70).In the first phase of model validation we r and omly divided the material into a training set ( n = 538 ) , and a test set ( n = 200 ) . This procedure was repeated ten times in r and om fashion to obtain independently created training sets and corresponding test sets . Modeling was performed by using the training set , and each model was tested by using the corresponding test set , repeated in each training set . In the second phase the final model was created by using the total material and eighteen most predictive variables . The performance of six logistic regressions approaches were shown for comparison purpose s. Results In the final model , the following variables were associated with mortality or very poor HRQoL : age at onset , cerebrovascular disease , diabetes , alcohol abuse , cancer , psychiatric disease , body mass index , Forced Expiratory Volume ( FEV1 ) % of predicted , atrial fibrillation , and prolonged QT time in ECG . The prediction accuracy of the model was 77 % , sensitivity 0.30 , specificity 0.95 , positive predictive value 0.68 , 
    Output:
    
Meta-analyses of COPD stages utility values showed influence of airway obstruction on utility value .