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Mortality and Exacerbations by Global Initiative for Chronic Obstructive Lung Disease Groups ABCD: 2011 Versus 2017
Rachel N Criner1, Wassim W Labaki2, Elizabeth A Regan3
1Department of Internal Medicine, University of Michigan, Ann Arbor.
Insights
The 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) ABCD grouping, focusing on exacerbations, shows similar predictive power for exacerbation rates but lower mortality discrimination compared to the 2011 GOLD guidelines which included FEV1.
Area of Science:
- Pulmonology
- Clinical Epidemiology
- Respiratory Medicine
Background:
- The Global Initiative for Chronic Obstructive Lung Disease (GOLD) updated its ABCD grouping criteria for COPD risk stratification.
- The 2011 GOLD guidelines incorporated FEV1 and exacerbation history, while the 2017 guidelines emphasize exacerbation history and dyspnea.
Purpose of the Study:
- To compare the predictive performance of the GOLD 2011 and 2017 ABCD classifications for mortality and exacerbation rates.
- To evaluate the impact of revised GOLD guidelines on COPD patient stratification using the COPDGene® cohort.
Main Methods:
- Utilized data from the COPDGene® study, including 4469 participants.
- Applied Cox models for all-cause mortality and zero-inflated Poisson models for longitudinal exacerbations.
- Compared ABCD group distributions and predictive accuracy (AUC) between GOLD 2011 and 2017 systems.
Main Results:
- Significant differences in patient distribution between GOLD 2011 and 2017 ABCD groups were observed (Kappa=0.67).
- Both systems identified Group D as having the highest mortality risk, with similar hazard ratios.
- The GOLD 2011 system demonstrated superior mortality discrimination (AUC 0.68 vs. 0.66) compared to the GOLD 2017 system.
Conclusions:
- The GOLD 2017 ABCD classification maintains similar predictive power for COPD exacerbations compared to the 2011 guidelines.
- The GOLD 2017 classification shows reduced discriminatory ability for all-cause mortality relative to the GOLD 2011 guidelines.
- Revisiting the inclusion of FEV1 in COPD risk stratification may be warranted for improved survival prediction.
Abstract:
Background: The Global initiative for chronic Obstructive Lung Disease (GOLD) ABCD groupings were recently modified. The GOLD 2011 guidelines defined increased risk as forced expiratory volume in 1 second (FEV1) < 50% predicted or ≥ 2 outpatient or ≥ 1 hospitalized exacerbation in the prior year, whereas the GOLD 2017 guidelines use only exacerbation history. We compared mortality and exacerbation rates in the Genetic Epidemiology of COPD Study cohort (COPDGene®) by 2011 (exacerbation history/FEV1 and dyspnea) versus 2017 (exacerbations and dyspnea) classifications. Methods: Using data from COPDGene®, we tested associations of ABCD groups with all-cause mortality (Cox models, adjusted for age, sex, race and comorbidities) and longitudinal exacerbations (zero-inflated Poisson models). Results: In 4469 individuals (mean age 63.1 years, 44% female), individual distributions in 2011 versus 2017 systems were: A, 32.0% versus 37.0%; B, 17.6% versus 36.3%; C, 9.4% versus 4.4%; D, 41.0% versus 22.3%; (observed agreement 76% [expected 27.8%], Kappa 0.67, p<0.001). Individuals in group D-2011 had 1.1 ± 1.6 exacerbations/year (mean ± standard deviation [SD]) versus 1.4 ± 1.8 for D-2017 (median follow-up 3.7 years). Using group A as reference, for both systems, mortality (median follow-up 6.8 years) was highest in group D (D-2011, [hazard ratio] HR 5.2 [95% confidence interval (CI) 4.2, 6.4]; D-2017, HR 5.5 [4.5, 6.8]), lowest for group C (HR 1.9 [1.4, 2.6] versus HR 1.9 [1.3, 2.8]) and intermediate for group B (HR 2.6 [2.0, 3.4] versus HR 3.4 [2.8, 4.1]). GOLD 2011 had better mortality discrimination (area under the curve [AUC] 0.68) than GOLD 2017 (AUC 0.66, p<0.001 for comparison) but similar exacerbation rate prediction. Conclusions: Relative to the GOLD 2011 consensus statement, discriminate predictive power of the 2017 ABCD classification is similar for exacerbations but lower for survival.
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