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Original Study
Redefining Cut-Points for High Symptom Burden of the Global Initiative for Chronic Obstructive Lung Disease Classification in 18,577 Patients With Chronic Obstructive Pulmonary Disease

https://doi.org/10.1016/j.jamda.2017.09.003Get rights and content

Abstract

Background

Patients with chronic obstructive pulmonary disease (COPD) can be classified into groups A/C or B/D based on symptom intensity. Different threshold values for symptom questionnaires can result in misclassification and, in turn, different treatment recommendations. The primary aim was to find the best fitting cut-points for Global initiative for chronic Obstructive Lung Disease (GOLD) symptom measures, with an modified Medical Research Council dyspnea grade of 2 or higher as point of reference.

Methods

After a computerized search, data from 41 cohorts and whose authors agreed to provide data were pooled. COPD studies were eligible for analyses if they included, at least age, sex, postbronchodilator spirometry, modified Medical Research Council, and COPD Assessment Test (CAT) total scores.

Main outcomes

Receiver operating characteristic curves and the Youden index were used to determine the best calibration threshold for CAT, COPD Clinical Questionnaire, and St. Georges Respiratory Questionnaire total scores. Following, GOLD A/B/C/D frequencies were calculated based on current cut-points and the newly derived cut-points.

Findings

A total of 18,577 patients with COPD [72.0% male; mean age: 66.3 years (standard deviation 9.6)] were analyzed. Most patients had a moderate or severe degree of airflow limitation (GOLD spirometric grade 1, 10.9%; grade 2, 46.6%; grade 3, 32.4%; and grade 4, 10.3%). The best calibration threshold for CAT total score was 18 points, for COPD Clinical Questionnaire total score 1.9 points, and for St. Georges Respiratory Questionnaire total score 46.0 points.

Conclusions

The application of these new cut-points would reclassify about one-third of the patients with COPD and, thus, would impact on individual disease management. Further validation in prospective studies of these new values are needed.

Section snippets

Methods

This is a pooled analysis of concurrent cohort studies assessing mMRC and multidimensional evaluation systems in COPD. To identify the original cohorts, we performed a computerized search in the database Medline/Pubmed for reports published from the first CAT publication (September 2009) to June 2015.11 D.S., S.H-W., or M.S. approached the corresponding authors to gather information about their readiness to partake and the availability of a minimum required set of individual data of patients

Results

Overall, 337 reports were identified, of which 63 were eligible (Figure 1). Forty-five author groups were able and willing to participate. Finally, 41 datasets were included in the patient level pooled analysis. At the time of inclusion, 3 articles were published with the dataset of the COPD History Assessment In SpaiN (CHAIN) cohort,14 3 articles used the Adelphi Respiratory Disease Specific Program dataset (one of which is from another subcohort15 than the other 2 articles16, 17), 1 author

Discussion

Healthcare professionals should be aware of the fact that the choice of symptom measure influences classification, and, in turn, also specific treatment recommendation in patients with COPD. Using mMRC ≥2 points as a reference, a CAT cut-point of 18 points, CCQ cut-point of 1.9 points, and SGRQ cut-point of 46.0 points reached the highest agreement. Implementation of these newly derived cut-points will influence the management of individual patients and the design and interpretation of clinical

Conclusions

To objectively define a symptom burden score equivalent to a mMRC dyspnea grade of 2 or higher, a CAT total score of ≥18 points, a CCQ total score of ≥1.9 points, or a SGRQ total score of ≥46 points should be used. Following this grading, about one-third of the patients in GOLD groups B/D are re-classified to GOLD groups A/C. This implies that guidelines committees may consider adapting our evidence-based cut-points of symptom measures.

Acknowledgments

The authors thank all the patients who participated. In addition, they thank J. Jarkovsky, J. Svancara, and M. Svoboda for their help with data collection and validation within the Czech Multicenter Research Database of Severe COPD. Furthermore, the authors acknowledge Nasrin Moghimi, Shilan Mohammadi, Farhad Sabershahraki, and Daem Roshani for their valuable help during the original study performed in the Tohid Hospital. Subsequently, the authors thank R. Casamor for helping with the On-Sint

References (80)

  • N. Kwon et al.

    Validity of the COPD assessment test translated into local languages for Asian patients

    Chest

    (2013)
  • S.D. Lee et al.

    The COPD assessment test (CAT) assists prediction of COPD exacerbations in high-risk patients

    Respir Med

    (2014)
  • I. Ladeira et al.

    The overall impact of COPD (CAT) and BODE index on COPD male patients: Correlation?

    Revista Portuguesa de Pneumologia

    (2015)
  • M. Miravitlles et al.

    Factors associated with depression and severe depression in patients with COPD

    Respir Med

    (2014)
  • M.J. Sillen et al.

    Heterogeneity in clinical characteristics and comorbidities in dyspneic individuals with COPD GOLD D: Findings of the DICES trial

    Resp Med

    (2013)
  • A.S. Buist et al.

    International variation in the prevalence of COPD (the BOLD Study): A population-based prevalence study

    Lancet

    (2007)
  • C.F. Vogelmeier et al.

    Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report: GOLD executive summary

    AJRCCM

    (2017)
  • P.W. Jones et al.

    Comparisons of health status scores with MRC grades in COPD: Implications for the GOLD 2011 classification

    Eur Respir J

    (2013)
  • S. Wilke et al.

    The 2014 updated GOLD strategy: A comparison of the various scenarios

    JCOPDF

    (2014)
  • S. Holt et al.

    Little agreement in GOLD category using CAT and mMRC in 450 primary care COPD patients in New Zealand

    NPJ Prim Care Respir Med

    (2014)
  • A. Agusti et al.

    FAQs about the GOLD 2011 assessment proposal of COPD: A comparative analysis of four different cohorts

    Eur Respir J

    (2013)
  • C.H. Lee et al.

    Chronic obstructive pulmonary disease (COPD) assessment test scores corresponding to modified Medical Research Council grades among COPD patients

    Korean J Intern Med

    (2015)
  • I.G. Tsiligianni et al.

    Investigating sensitivity, specificity, and area under the curve of the Clinical COPD Questionnaire, COPD Assessment Test, and Modified Medical Research Council scale according to GOLD using St George's Respiratory Questionnaire cutoff 25 (and 20) as reference

    Int J Chron Obstruct Pulmon Dis

    (2016)
  • S.S. Kon et al.

    The clinical chronic obstructive pulmonary disease questionnaire: Cut point for GOLD 2013 classification

    Am J Respir Crit Care Med

    (2014)
  • P.W. Jones et al.

    Development and first validation of the COPD Assessment Test

    Eur Respir J

    (2009)
  • A.S. Pickard et al.

    Comparison of health-related quality of life measures in chronic obstructive pulmonary disease

    Health Qual Life Outcomes

    (2011)
  • W.J. Youden

    Index for rating diagnostic tests

    Cancer

    (1950)
  • D. Price et al.

    Management of COPD in the UK primary-care setting: An analysis of real-life prescribing patterns

    Int J Chron Obstruct Pulmon Dis

    (2014)
  • G.F. da Silva et al.

    Comparison of face-to-face interview and telephone interview administration of COPD assessment test: A randomized study

    Qual Life Res

    (2014)
  • G.P. da Silva et al.

    Portuguese-language version of the COPD Assessment Test: Validation for use in Brazil

    J Bras Pneumol

    (2013)
  • J. Han et al.

    Breathlessness or health status in chronic obstructive pulmonary disease: The impact of different definitions

    COPD

    (2015)
  • I. Grzelewska-Rzymowska et al.

    Stratification of patients with COPD according to the 2011 GOLD report

    Pneumonologia i Alergologia Polska

    (2014)
  • R. Zhang et al.

    Comparison of symptom and risk assessment methods among patients with chronic obstructive pulmonary disease

    Chin Med J

    (2014)
  • L.M. Paulin et al.

    Occupational exposures are associated with worse morbidity in patients with chronic obstructive pulmonary disease

    Am J Respir Crit Care Med

    (2015)
  • E. Gimeno-Santos et al.

    The PROactive instruments to measure physical activity in patients with chronic obstructive pulmonary disease

    Eur Respir J

    (2015)
  • O.K. Kurt et al.

    Pentraxin 3 as a novel biomarker of inflammation in chronic obstructive pulmonary disease

    Inflammation

    (2015)
  • R.W. Dal Negro et al.

    Sensitivity of the COPD assessment test (CAT questionnaire) investigated in a population of 681 consecutive patients referring to a lung clinic: The first Italian specific study

    Multidiscip Respir Med

    (2014)
  • Y.I. Hwang et al.

    A Validation Study for the Korean Version of Chronic Obstructive Pulmonary Disease Assessment Test (CAT)

    Tuberc Respir Dis

    (2013)
  • Y. Zhang et al.

    The COPD assessment test correlates well with the computed tomography measurements in COPD patients in China

    Int J Chron Obstruct Pulmon Dis

    (2015)
  • P. Stoll et al.

    Imbalance of dendritic cell co-stimulation in COPD

    Respir Res

    (2015)
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    Funding information is detailed in Appendix A.

    All authors have completed the ICMJE uniform disclosure form. Conflict of interest information is detailed in Appendix B.

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