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

Dionne E. Smid, Frits M.E. Franssen, Maria Gonik, Marc Miravitlles, Ciro Casanova, Borja G. Cosio, Pilar de Lucas-Ramos, Jose M. Marin, Cristina Martinez, Isabel Mir, Joan B. Soriano, Juan P. de Torres, Alvar Agusti, Nart B. Atalay, Julia Billington, Afroditi K. Boutou, Stefanie Brighenti-Zogg, Emma Chaplin, Samantha Coster, James W. DoddSelina Dürr, Alberto Fernandez-Villar, Miriam T.J. Groenen, Miguel Guimarães, Karel Hejduk, Victoria Higgins, Nicholas S. Hopkinson, Nobuyuki Horita, Sarah Houben-Wilke, Daisy J.A. Janssen, Melissa Jehn, Rudolf Joerres, Annika Karch, Julia L. Kelly, Yu-Il Kim, Hiroshi Kimura, Vladimir Koblizek, Janwillem H. Kocks, Samantha S.C. Kon, Namhee Kwon, Inês Ladeira, Sang-Do Lee, Joerg D. Leuppi, Nicholas Locantore, José L. Lopez-Campos, William D-C Man, Lana Maricic, Laura Mendoza, David Miedinger, Florin Mihaltan, Seigo Minami, Thys van der Molen, Trevor J. Murrells, Nienke Nakken, Yu Nishijima, Ian J. Norman, Barbora Novotna, Denis E. O'Donnell, Yoshitaka Ogata, Eanes D. Pereira, James Piercy, David Price, Chaicharn Pothirat, Natya Raghavan, Thomas Ringbaek, Dimitar Sajkov, Naseh Sigari, Sally Singh, Mark Small, Guilherme F. da Silva, Rebecca J. Tanner, Ioanna G. Tsiligianni, Baykal Tulek, Nikolaos Tzanakis, Lowie E.G.W. Vanfleteren, Henrik Watz, Katherine A. Webb, Emiel F.M. Wouters, Guogang G. Xie, Masanori Yoshikawa, Martijn A. Spruit

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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.
Original languageEnglish
Pages (from-to)1097.e11-1097.e24
Number of pages24
JournalJournal of the American Medical Directors Association
Issue number12
Early online date20 Nov 2017
Publication statusPublished - 1 Dec 2017


  • COPD
  • GOLD
  • health status
  • clinical significance


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