Discriminative Accuracy of FEV1:FVC Thresholds for COPD-Related Hospitalization and Mortality

Published on Jun 25, 2019in JAMA51.273
· DOI :10.1001/jama.2019.7233
Surya P. Bhatt24
Estimated H-index: 24
(UAB: University of Alabama at Birmingham),
Pallavi Balte5
Estimated H-index: 5
(CUMC: Columbia University Medical Center)
+ 12 AuthorsElizabeth C. Oelsner11
Estimated H-index: 11
(Columbia University)
Importance According to numerous current guidelines, the diagnosis of chronic obstructive pulmonary disease (COPD) requires a ratio of the forced expiratory volume in the first second to the forced vital capacity (FEV 1 :FVC) of less than 0.70, yet this fixed threshold is based on expert opinion and remains controversial. Objective To determine the discriminative accuracy of various FEV 1 :FVC fixed thresholds for predicting COPD-related hospitalization and mortality. Design, Setting, and Participants The National Heart, Lung, and Blood Institute (NHLBI) Pooled Cohorts Study harmonized and pooled data from 4 US general population–based cohorts (Atherosclerosis Risk in Communities Study; Cardiovascular Health Study; Health, Aging, and Body Composition Study; and Multi-Ethnic Study of Atherosclerosis). Participants aged 45 to 102 years were enrolled from 1987 to 2000 and received follow-up longitudinally through 2016. Exposures Presence of airflow obstruction, which was defined by a baseline FEV 1 :FVC less than a range of fixed thresholds (0.75 to 0.65) or less than the lower limit of normal as defined by Global Lung Initiative reference equations (LLN). Main Outcomes and Measures The primary outcome was a composite of COPD hospitalization and COPD-related mortality, defined by adjudication or administrative criteria. The optimal fixed FEV 1 :FVC threshold was defined by the best discrimination for these COPD-related events as indexed using the Harrell C statistic from unadjusted Cox proportional hazards models. Differences in C statistics were compared with respect to less than 0.70 and less than LLN thresholds using a nonparametric approach. Results Among 24 207 adults in the pooled cohort (mean [SD] age at enrollment, 63 [10.5] years; 12 990 [54%] women; 16 794 [69%] non-Hispanic white; 15 181 [63%] ever smokers), complete follow-up was available for 11 077 (77%) at 15 years. During a median follow-up of 15 years, 3925 participants experienced COPD-related events over 340 757 person-years of follow-up (incidence density rate, 11.5 per 1000 person-years), including 3563 COPD-related hospitalizations and 447 COPD-related deaths. With respect to discrimination of COPD-related events, the optimal fixed threshold (0.71; C statistic for optimal fixed threshold, 0.696) was not significantly different from the 0.70 threshold (difference, 0.001 [95% CI, −0.002 to 0.004]) but was more accurate than the LLN threshold (difference, 0.034 [95% CI, 0.028 to 0.041]). The 0.70 threshold provided optimal discrimination in the subgroup analysis of ever smokers and in adjusted models. Conclusions and Relevance Defining airflow obstruction as FEV 1 :FVC less than 0.70 provided discrimination of COPD-related hospitalization and mortality that was not significantly different or was more accurate than other fixed thresholds and the LLN. These results support the use of FEV 1 :FVC less than 0.70 to identify individuals at risk of clinically significant COPD.
  • References (38)
  • Citations (5)
📖 Papers frequently viewed together
32 Citations
9 Citations
78% of Scinapse members use related papers. After signing in, all features are FREE.
#1Elizabeth C. Oelsner (Columbia University)H-Index: 11
#2Pallavi Balte (Columbia University)H-Index: 5
Last. R. Graham Barr (Columbia University)H-Index: 69
view all 26 authors...
6 CitationsSource
#1Paul K. Whelton (American College of Preventive Medicine)H-Index: 24
#2Robert M. Carey (American College of Preventive Medicine)H-Index: 2
Last. Jackson T. Wright (American College of Preventive Medicine)H-Index: 14
view all 21 authors...
Glenn N. Levine, MD, FACC, FAHA, Chair Patrick T. O’Gara, MD, MACC, FAHA, Chair-Elect Jonathan L. Halperin, MD, FACC, FAHA, Immediate Past Chair Sana M. Al-Khatib, MD, MHS, FACC, FAHA Joshua A. Beckman, MD, MS, FAHA Kim K. Birtcher, MS, PharmD, AACC Biykem Bozkurt, MD, PhD, FACC, FAHA
1,268 CitationsSource
#1Yunus Çolak (Copenhagen University Hospital)H-Index: 7
#2Shoaib Afzal (Copenhagen University Hospital)H-Index: 25
Last. Peter LangeH-Index: 74
view all 5 authors...
A presumed consequence of using a fixed ratio for the definition of airflow limitation (AFL) has been overdiagnosis among older individuals and underdiagnosis among younger individuals. However, the prognosis of younger individuals with potentially underdiagnosed AFL is poorly described. We hypothesised that potential underdiagnosis of AFL at a younger age is associated with poor prognosis. We assigned 95 288 participants aged 20–100 years from the Copenhagen General Population Study into the fo...
5 CitationsSource
#1Surya P. Bhatt (UAB: University of Alabama at Birmingham)H-Index: 24
3 CitationsSource
#1Spyridon Fortis (UoC: University of Crete)H-Index: 6
#2Michael Eberlein (UIHC: University of Iowa Hospitals and Clinics)H-Index: 25
Last. Alejandro P. Comellas (UIHC: University of Iowa Hospitals and Clinics)H-Index: 2
view all 4 authors...
Introduction We compared the predictive value of prebronchodilator and postbronchodilator spirometry for chronic obstructive pulmonary disease (COPD) features and outcomes. Methods We analysed COPDGene data of 10 192 subjects with smoking history. We created regressions models with the following dependent variables: clinical, functional and radiographic features, and the following independent variables: prebronchodilator airflow obstruction (PREO) and postbronchodilator airflow obstruction (POST...
5 CitationsSource
#1Joan B. Soriano (UAM: Autonomous University of Madrid)H-Index: 69
#2Amanuel Alemu Abajobir (UQ: University of Queensland)H-Index: 25
Last. E. Theo VosH-Index: 107
view all 125 authors...
Summary Background Chronic obstructive pulmonary disease (COPD) and asthma are common diseases with a heterogeneous distribution worldwide. Here, we present methods and disease and risk estimates for COPD and asthma from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2015 study. The GBD study provides annual updates on estimates of deaths, prevalence, and disability-adjusted life years (DALYs), a summary measure of fatal and non-fatal disease outcomes, for over 300 diseases and ...
300 CitationsSource
#1C. Vogelmeier (University of Marburg)H-Index: 11
#2Gj. Criner (TU: Temple University)H-Index: 63
Last. Alvar Agusti (University of Barcelona)H-Index: 90
view all 22 authors...
This Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 report focuses primarily on the revised and novel parts of the document. The most significant changes include: (1) the assessment of chronic obstructive pulmonary disease has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and...
652 CitationsSource
#1Akshay Sood (UNM: University of New Mexico)H-Index: 25
#2Hans Petersen (LRRI: Lovelace Respiratory Research Institute)H-Index: 18
Last. Yohannes Tesfaigzi (LRRI: Lovelace Respiratory Research Institute)H-Index: 31
view all 7 authors...
Background Spirometrically-defined chronic obstructive pulmonary disease (COPD) is considered progressive but its natural history is inadequately studied. We hypothesized that spirometrically-defined COPD states could undergo beneficial transitions.
10 CitationsSource
#1Elizabeth C. Oelsner (Columbia University)H-Index: 11
#2Laura R. LoehrH-Index: 38
Last. R. Graham Barr (Columbia University)H-Index: 69
view all 12 authors...
Rationale: One in 12 adults has chronic obstructive pulmonary disease or asthma. Acute exacerbations of these chronic lower respiratory diseases (CLRDs) are a major cause of morbidity and mortality. Valid approaches to classifying cases and exacerbations in the general population are needed to facilitate prevention research.Objectives: To assess the feasibility, reproducibility, and performance of a protocol to identify CLRD cases and exacerbations triggering emergency department (ED) visits or ...
9 CitationsSource
#1Prescott G. Woodruff (UCSF: University of California, San Francisco)H-Index: 52
#2R. Graham Barr (Columbia University)H-Index: 69
Last. MeiLan K. Han (UM: University of Michigan)H-Index: 51
view all 17 authors...
BackgroundCurrently, the diagnosis of chronic obstructive pulmonary disease (COPD) requires a ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) of less than 0.70 as assessed by spirometry after bronchodilator use. However, many smokers who do not meet this definition have respiratory symptoms. MethodsWe conducted an observational study involving 2736 current or former smokers and controls who had never smoked and measured their respiratory symptoms using the COP...
198 CitationsSource
Cited By5
#1Spyridon Fortis (UI: University of Iowa)H-Index: 6
#2Alejandro P. Comellas (UI: University of Iowa)H-Index: 24
Last. Emily S. Wan (Brigham and Women's Hospital)H-Index: 20
view all 8 authors...
One quarter of individuals with Preserved Ratio Impaired Spirometry (PRISm) will develop airflow obstruction, but there are no established methods to identify these individuals. We examined the utility of FVC/TLC in identifying features of obstructive lung disease. The ratio of post-bronchodilator FVC and TLCCT from chest CT (FVC/TLCCT) among current and former smokers with PRISm (FEV1/FVC ≥ 0.7 and FEV1 < 80%) in COPDGene was used to stratify subjects into quartiles: very high, high, low, and v...
#1Pallavi Balte (CUMC: Columbia University Medical Center)H-Index: 5
#2Paulo M. Chaves (FIU: Florida International University)H-Index: 2
Last. A. Newman (University of Pittsburgh)H-Index: 150
view all 17 authors...
Importance Chronic bronchitis has been associated with cigarette smoking as well as with e-cigarette use among young adults, but the association of chronic bronchitis in persons without airflow obstruction or clinical asthma, described as nonobstructive chronic bronchitis, with respiratory health outcomes remains uncertain. Objective To assess whether nonobstructive chronic bronchitis is associated with adverse respiratory health outcomes in adult ever smokers and never smokers. Design, Setting,...
1 CitationsSource
#1Sateesh Sakhamuri (UWI: University of the West Indies)H-Index: 3
#2Terence A. R. Seemungal (UWI: University of the West Indies)H-Index: 23
AbstractThe GOLD 2020 updates added more lucidity on the treatment of COPD. However, few diagnostic dilemmas still exist. Research is needed on the use of the CAT score in assessing symptoms for th...
#1Xiaoxia Han (HFHS: Henry Ford Health System)H-Index: 5
#1Xiaoxia Han (HFHS: Henry Ford Health System)
Last. Yilong Zhang (MSD: Merck & Co.)
view all 2 authors...
#1Surya P. Bhatt (UAB: University of Alabama at Birmingham)H-Index: 24
#2Joseph E. Schwartz (CUMC: Columbia University Medical Center)H-Index: 94
Last. Elizabeth C. Oelsner (CUMC: Columbia University Medical Center)H-Index: 11
view all 3 authors...
#1Martin R. Miller (University of Birmingham)H-Index: 30
#2Sanja StanojevicH-Index: 26
#1Jean Bourbeau (MUHC: McGill University Health Centre)H-Index: 53
#2Mohit Bhutani (U of A: University of Alberta)H-Index: 10
Last. Darcy D. Marciniuk (U of S: University of Saskatchewan)H-Index: 33
view all 12 authors...
AbstractIn this guideline update, we highlight important and new findings related to pharmacological therapy of chronic obstructive pulmonary disease (COPD) that should change clinical practice and...
#1Carlos Alberto de Castro Pereira (UNIFESP: Federal University of São Paulo)H-Index: 20
#2Maria Raquel Soares (UNIFESP: Federal University of São Paulo)H-Index: 6
Last. Andrea GimenezH-Index: 4
view all 3 authors...