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

Surya P. Bhatt, Pallavi P. Balte, Joseph E. Schwartz, Patricia A. Cassano, David Couper, David R. Jacobs, Ravi Kalhan, George T. O'Connor, Sachin Yende, Jason L. Sanders, Jason G. Umans, Mark T. Dransfield, Paulo H. Chaves, Wendy B. White, Elizabeth C. Oelsner

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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 (FEV1: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 FEV1: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 FEV1: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 FEV1: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 24207 adults in the pooled cohort (mean [SD] age at enrollment, 63 [10.5] years; 12990 [54%] women; 16794 [69%] non-Hispanic white; 15181 [63%] ever smokers), complete follow-up was available for 11077 (77%) at 15 years. During a median follow-up of 15 years, 3925 participants experienced COPD-related events over 340757 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 FEV1: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 FEV1:FVC less than 0.70 to identify individuals at risk of clinically significant COPD.

Original languageEnglish (US)
Pages (from-to)2438-2447
Number of pages10
JournalJAMA - Journal of the American Medical Association
Issue number24
StatePublished - Jun 25 2019

Bibliographical note

Funding Information:
Funding/Support: Dr Bhatt is supported by NIH

Funding Information:
grant K23 HL133438. Dr Oelsner is supported by NIH grants R21 HL129924 and K23 HL130627. The Atherosclerosis Risk in Communities (ARIC) study has been funded in whole or in part with federal funds from NIH, NHLBI, and the Department of Health and Human Services (contract numbers: HHSN268201700001I, HHSN268201700002I, HHSN268201700003I, HHSN268201700005I, and HHSN268201700004I). The Cardiovascular Health Study (CHS) was supported by contracts HHSN268201200036C, HHSN268200800007C, HHSN268201800001C, N01HC55222, N01HC85079, N01HC85080, N01HC85081, N01HC85082, N01HC85083, N01HC85086, and grants U01HL080295 and U01HL130114 from NHLBI, with an additional contribution from the National Institute of Neurological Disorders and Stroke. Additional support was provided by R01AG023629 from the National Institute on Aging (NIA). The Health, Aging and Body Composition (Health ABC) study was funded by NIA contracts N01-AG-6-2101, N01-AG-6-2103, N01-AG-6-2106, NIA grant R01-AG028050, National Institute of Nursing Research grant R01-NR012459, and supported in part by the intramural research program at NIA. the Multi-Ethnic Study of Atherosclerosis study was funded by NIH/NHLBI grants R01-HL-077612, R01-HL-093081, RC1-HL-100543, N01-HC-95159, N01-HC-95160, N01-HC-95161, N01-HC-95162, N01-HC-95163, N01-HC-95164, N01-HC-95165, N01-HC-95166, N01-HC-95167, N01-HC-95168 and N01-HC-95169.

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© 2019 American Medical Association. All rights reserved.


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