Dig Dis Sci (2011) 56:19761980

DOI 10.1007/s10620-010-1542-5

ORIGINAL ARTICLE

Poorly Treated or Unrecognized GERD Reduces Quality of Life

in Patients with COPD
Ivan E. Rascon-Aguilar Mark Pamer
Peter Wludyka James Cury Kenneth J. Vega

Received: 23 July 2010 / Accepted: 18 December 2010 / Published online: 8 January 2011
Springer Science+Business Media, LLC 2011

Abstract
Background The effect of gastroesophageal reflux disease (GERD) on health-related quality of life (HRQL) in
COPD has never been assessed.
Aim To evaluate HRQL in patients with COPD alone
compared with those with both COPD and continuing
GERD symptoms.
Methods A questionnaire-based, cross-sectional survey was
performed. Subjects were recruited from the outpatient pulmonary clinics at the University of Florida Health Science
Center/Jacksonville. Included patients had an established
diagnosis of COPD. Exclusion criteria were respiratory disorders other than COPD, known esophageal disease, active
peptic ulcer disease, ZollingerEllison syndrome, mastocytosis, scleroderma, and current alcohol abuse. Those meeting
the criteria and agreeing to participate were asked to complete
the Mayo Clinic GERQ and SF-36 questionnaires, by either
personal or telephone interview. Clinically significant reflux

was defined as heartburn and/or acid regurgitation weekly.

Study patients were divided into two groups for HRQL analysis based on the GERQ response: COPD?/GERD? and
COPD only. Statistical analysis was performed using the
MannWhitneyWilcoxon T test for unequal variables and
linear regression was performed using ANOVA. All data are
expressed as mean and standard deviation.
Results Eighty-six patients completed both questionnaires. Males were 55% and COPD?/GERD? patients
comprised 37% of the study group. Compared with COPD
only, HRQL was reduced across all measures for the
COPD? GERD? patients and achieved significance for
bodily pain (P \ 0.02), mental health (P \ 0.05), and
physical component score (P \ 0.05).
Conclusion Patients with COPD and continuing GERD
symptoms have reduced HRQL in comparison with those
with COPD alone.
Keywords GERD
COPD
Quality of life

Questionnaire

I. E. Rascon-Aguilar
M. Pamer
P. Wludyka

Department of Medicine, University of Florida
College of Medicine/Jacksonville, Jacksonville, FL, USA
J. Cury
Division of Pulmonary-Critical Care Medicine, University
of Florida College of Medicine/Jacksonville, Jacksonville,
FL, USA
K. J. Vega
Division of Gastroenterology, University of Florida College
of Medicine/Jacksonville, Jacksonville, FL, USA
K. J. Vega (&)
Division of Digestive Diseases and Nutrition, University
of Oklahoma Health Sciences Center, 920 Stanton L.
Young Blvd., WP 1345, Oklahoma City, OK 73104, USA
e-mail: kenneth-vega@ouhsc.edu

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Introduction
Health-related quality of life (HRQL) is used to measure
the effect of chronic illnesses, to improve understanding of
how such illnesses interfere with a persons day-to-day
activities. Assessing HRQL in different populations can
identify subgroups with poor physical or mental health and
can guide policies or intervention to improve their health.
Interest in HRQL over the past decade has increased substantially because of recognition that patients are most
concerned about symptoms and functional status (e.g.,
ability to perform physical tasks) rather than objective
measures such as endoscopic findings or pulmonary

Dig Dis Sci (2011) 56:19761980

function test results. This is especially true in chronic or

incurable diseases [1].
The presence of gastroesophageal reflux disease
(GERD) has been shown to reduce the quality of life
compared with the general population [1]. GERD, in its
severe form, has been shown to diminish HRQL more
significantly than other chronic illnesses, for example
congestive heart failure and diabetes mellitus [2]. After
adequate treatment of GERD, HRQL measures have been
shown to improve [3, 4].
Chronic obstructive pulmonary disease (COPD) is
another disease that has been observed to reduce HRQL.
Patients with symptomatic COPD had lower scores for
HRQL than the general population [5, 6]. In a previous
report, the presence of GERD was associated with exacerbation of COPD [7]. However, the HRQL impact of
GERD symptoms in those with COPD has never been
assessed. The objective of this investigation was to investigate whether the presence of GERD symptoms affects
HRQL in patients who have COPD.

Materials and Methods

Subjects
All patients with a diagnosis of COPD presenting at the
pulmonary clinic at the University of Florida/Jacksonville,
for routine health care from January 2003 to January 2004
were eligible for the investigation. Inclusion criteria were:
FEV1/FVC B70% on pulmonary function test (PFT), age
C40 years, and a C20 pack/year history of smoking [8].
Patients were excluded if the following disorders were
present: respiratory disorders other than COPD, known
esophageal disease such as cancer, achalasia, stricture,
active peptic ulcer disease, ZollingerEllison syndrome,
mastocytosis, scleroderma, or current abuse of alcohol
defined as greater than three alcoholic drinks per day.
Consecutive patients meeting these criteria were selected
from this clinic for participation in the study. All patients
approached agreed to participate. The study was approved
by the Institutional Review Board of the University of
Florida Health Science Center/Jacksonville, and informed
consent was obtained from every volunteer.

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psychometrically based physical and mental health summary measures, and a preference-based health utility index.
Also obtained by the SF-36 are composite summary scores
of physical (PCS) and mental (MCS) quality of life to
obtain a more general sense of the HRQL. This HRQL
instrument has been validated previously and used in over
4,000 publications including those on either COPD and
GERD [6, 10]. The GERQ was developed and validated by
Locke and colleagues as a surrogate for a diagnostic physician interview [11]. It consists of 80 items and assesses
the presence of heartburn and acid regurgitation with the
occurrence of other symptoms (chest pain, dysphagia,
upper respiratory symptoms), and its effects on health care
utilization; it has been used twice previously in patients
with GERD and COPD [7, 12].
Protocol
Eligible subjects meeting the inclusion criteria and agreeing to participate then completed both SF-36 and GERQ
instruments. These questionnaires were either self administered or answered over the telephone. GERD-positive
patients were identified by the GERQ as having weekly
heartburn or acid regurgitation. Study patients were then
divided into two groups for HRQL analysis based on the
GERQ response, COPD with GERD symptoms versus
those with COPD alone. Demographic information,
comorbid conditions, and active medications were also
collected for all subjects.
Statistical Analysis
The minimum sample size required to detect a 25% difference in HRQL between groups (COPD with GERD
symptoms versus COPD alone) was calculated using a
confidence level of 95% and a power of 0.8. The sample
size needed for each group was 28 patients. The two groups
were compared using the MannWhitneyWilcoxon twosample test. All data are expressed as mean and standard
deviation. Multiple regression analysis was performed with
the ANOVA test for quality of life variables. Differences
between groups were considered significant if P \ 0.05.
Statistical analysis was performed with SAS 9.1 statistical
analysis software.

Survey Instruments
Results
The surveys used in this investigation were the Short Form36 (SF-36) HRQL and the Mayo Clinic gastroesophageal
reflux (GERQ) questionnaires. The SF-36 HRQL instrument was developed by Ware and associates [9]. It is a
general health survey consisting of 36 questions. It yields
an eight scale profile of functional health, well being,

Study Population and Demographics

A total of 91 patients were enrolled in the investigation. Of
those, five did not complete both surveys leaving 86 patients
for analysis. The study patients were then divided into two

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Dig Dis Sci (2011) 56:19761980

Table 2 Patient comorbidities
Comorbidities
Anemia
Barretts esophagus
CAD
Valvular heart disease

Fig. 1 Patient selection diagram for quality-of-life analysis

Table 1 Patient demographic data

Number of
patients
2
2
14

GERD (-)
N = 54

P value

Age (mean SD)

66.0 9.9

68.8 7.0

0.16

% Male (N)

59.0% (19)

53.7% (29)

0.65

% Tobacco use (N)

25.0% [8]

18.5% [10]

0.58

FEV1 (mean SD)

45.9% 16.0% 40.7% 17.6% 0.16

BMI (mean SD)

27.4 6.2

26.3 5.9

0.41

0
0
28.13

Percent
GERD3.77

P value
0.2661

3.77

0.2661

9.43

0.024
0.111

7.55

Diabetes mellitus

11

12.5

13.21

0.925

Depression

11

12.5

13.21

0.925

Hypertension
Arthritis

39
25

43.75
25

47.17
30.19

0.759
0.606

Skin cancer

Peptic ulcer disease

9.38

Hypercholesterolemia 15

GERD (?)
N = 32

Percent
GERD?

21.8

1.89

0.43

11.32

0.777

15.09

0.426

9.43

0.604

Congestive heart
failure

6.25

Hypothyroidism

3.13

3.77

0.875

Osteoporosis

3.77

0.266

Anxiety

6.25

5.66

0.91

Bradycardia

3.13

1.89

0.715

Arrhythmia

3.13

7.55

0.401

EtOH drinks/week,
(mean SD)

1.2 0.80

1.3 0.75

0.62

Atrial fibrillation
Back pain

3
1

3.13
3.13

3.77
0

0.875
0.195

Coffee 240 cc/week

(mean SD)

1.5 2.1

1.0 1.1

0.25

Hip fracture

1.89

0.43

Bipolar disorder

1.89

0.43

CVA

1.89

0.43

Headache

1.89

0.43

groups on the basis of their responses to the GERQ: 32 with

COPD and GERD, 54 with COPD alone (Fig. 1). Patient
demographics are shown in Table 1. There were no statistically significant differences in age, gender, tobacco use,
mean FEV1% predicted, body mass index (BMI), alcoholic
drinks per week, or coffee consumption between the two
groups. With regard to the presence of co-morbid illnesses,
the COPD and GERD symptom group had an increased
frequency of coronary artery disease only in comparison
with the COPD alone group (P = 0.024, Table 2).
Health-Related Quality of Life Measures
A comparison of the eight different HRQL measures
between GERD?/COPD? and COPD alone can be seen in
Table 3. Patients with COPD and GERD symptoms had a
diminished HRQL compared with those with COPD alone
for all measures. This achieved significance for bodily
pain, mental health, and the PCS score.
Multiple regression analysis showed that both the presence of GERD and a low FEV1 were significant predictors
of a diminished PCS score. All other variables including
age, gender, body mass index, alcohol or tobacco intake,
and use of proton pump inhibitors (PPI), histamine 2
receptor antagonists (H2RA), or antacids did not affect

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PCS score. In contrast, in those with COPD and GERD

symptoms, the PCS does not improve as dramatically with
increasing FEV1.
Also, multiple regression analysis of the mental component summary score (MCS) showed that use of antacids,
H2 receptor antagonists, and their combination were predictors of a diminished MCS. Other variables, including
PPI use, age, gender, PFT, BMI, and alcohol or tobacco
use, did not affect MCS score. As noted in Fig. 2, most of
the study subjects were on some form of antireflux medication, however, only MCS was affected by the type of
medication used.

Discussion
HRQL has been assessed previously in patients with either
COPD or GERD alone, and indicated that each resulted in
decreased HRQL compared with healthy subjects [1, 6].
Adequate treatment of GERD is known to improve HRQL
[3, 4]. The objective of this investigation was to document
the effect of GERD symptoms in COPD patients on HRQL.

Dig Dis Sci (2011) 56:19761980

Table 3 Health-related quality
of life in COPD patients with
and without GERD symptoms

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HRQL measure

GERD?/COPD?
(N = 32, mean SD)

Physical function

24.7 19.6

33.8 24.6

0.07

30.8 28.5

42.4 30.6

0.07

Bodily pain

51.7 28.8

66.7 27

General health

35.8 22

42.5 24.5

0.15

37.1 20.4

42.7 21

0.22

Social function

58.2 23.3

64.1 29.7

0.32

Role emotional function

63.3 34.8

71 35.6

0.37

Mental health

60.5 23

71.3 20.9

\0.03
\0.05

PCS summary score

29.3 9.3

33.8 10.2

MCS summary score

44.8 13.6

48.5 13.2

3(2)

13(7)
6(5)

Antacid
s

\0.02

Vitality

PPIs

18(9)

P value

Role physical function

11(2)
No therapy = 25(4)

COPD only
(N = 54, mean SD)

3(1)

7(2)

H2RAs

Numbers in ( ) = GERD + patients

Fig. 2 Use of antireflux medication by each group

The results of our study indicate that HRQL is reduced in

patients with both COPD and GERD symptoms compared
with patients with COPD alone. This decrease was noted in
all measures of HRQL and achieved statistical significance
for bodily pain, mental health, and physical component
summary score.
Patients who suffer from COPD have a higher prevalence of GERD symptoms than observed in the general
population, suggesting that COPD patients should be
evaluated for GERD symptoms to improve care of these
patients [7, 12, 13]. Because patients with COPD and
GERD symptoms have a lower HRQL than those with
COPD alone, treatment with antireflux medication may
help improve the quality of life of these patients. However,
most patients with both COPD and GERD symptoms in our
study had continuing symptoms despite some type of
antireflux medication use. This signifies that these individuals were being treated suboptimally at the time of
survey completion and could benefit from more aggressive
medical therapy.

0.215

The decrease in HRQL for patients with both COPD and

GERD symptoms was significant for bodily pain, mental
health, and PCS score. Other measures indicated diminished quality of life but only approached statistical significance. With regard to the other summary score (MCS), the
use of specific antireflux medication (H2RA/antacids) was
associated with a lower score in those with GERD and
COPD compared with those using PPI. This suggests the
presence of poorly controlled reflux, because it is well
understood that H2RAs and antacids do not control reflux
symptoms as well as PPI [16]. Therefore, it is apparent that
GERD symptoms affect both PCS and MCS significantly,
especially when poorly controlled.
Evaluation of comorbidity frequency between the two
groups revealed a higher rate of coronary artery disease, as
reported on the survey by patients in the COPD and GERD
symptom group. Unfortunately, how the diagnosis was
made in that group is unknown. It is also well recognized
that patients with GERD may present with chest pain,
serving as a confounder in the overall health assessment
[14, 15]. Presently, it is unclear that COPD and GERD
symptom patients have a higher rate of CAD compared
with those with COPD alone. Further study will be needed
to assess the significance of this finding.
One of our major limitations was the sample size, which
was only enough to observe a significant difference in
HRQL in two of eight measures, with a trend towards
diminished HRQL in the remaining categories. Assessing a
larger population may clarify this observation. Another
limitation is the possibility of recall bias, common to
studies involving surveys, especially when long-term
memory is used.

Conclusion
In summary, this investigation indicates that the presence
of continuing GERD symptoms in those with COPD

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Dig Dis Sci (2011) 56:19761980

reduces HRQL compared with COPD alone. To improve

HRQL, further investigation assessing intervention to
reduce the frequency of GERD symptoms in those with
COPD is warranted.
Conflict of interest
this manuscript.

No conflict of interest exists for all authors of

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