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*

*Corresponding author for this work

Research output: Contribution to journalArticle

6 Citations (Scopus)

Abstract

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
Volume321
Issue number24
DOIs
StatePublished - Jun 25 2019

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Chronic Obstructive Pulmonary Disease
Hospitalization
Mortality
Atherosclerosis
National Heart, Lung, and Blood Institute (U.S.)
Vital Capacity
Health
Forced Expiratory Volume
Expert Testimony
Body Composition
Proportional Hazards Models
Cohort Studies
Outcome Assessment (Health Care)
Guidelines
Lung
Incidence

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Bhatt, S. P., Balte, P. P., Schwartz, J. E., Cassano, P. A., Couper, D., Jacobs, D. R., ... Oelsner, E. C. (2019). Discriminative Accuracy of FEV1:FVC Thresholds for COPD-Related Hospitalization and Mortality. JAMA - Journal of the American Medical Association, 321(24), 2438-2447. https://doi.org/10.1001/jama.2019.7233
Bhatt, Surya P. ; Balte, Pallavi P. ; Schwartz, Joseph E. ; Cassano, Patricia A. ; Couper, David ; Jacobs, David R. ; Kalhan, Ravi ; O'Connor, George T. ; Yende, Sachin ; Sanders, Jason L. ; Umans, Jason G. ; Dransfield, Mark T. ; Chaves, Paulo H. ; White, Wendy B. ; Oelsner, Elizabeth C. / Discriminative Accuracy of FEV1:FVC Thresholds for COPD-Related Hospitalization and Mortality. In: JAMA - Journal of the American Medical Association. 2019 ; Vol. 321, No. 24. pp. 2438-2447.
@article{612af91c2d454640abaa3f01737b044b,
title = "Discriminative Accuracy of FEV1:FVC Thresholds for COPD-Related Hospitalization and Mortality",
abstract = "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.",
author = "Bhatt, {Surya P.} and Balte, {Pallavi P.} and Schwartz, {Joseph E.} and Cassano, {Patricia A.} and David Couper and Jacobs, {David R.} and Ravi Kalhan and O'Connor, {George T.} and Sachin Yende and Sanders, {Jason L.} and Umans, {Jason G.} and Dransfield, {Mark T.} and Chaves, {Paulo H.} and White, {Wendy B.} and Oelsner, {Elizabeth C.}",
year = "2019",
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language = "English (US)",
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Bhatt, SP, Balte, PP, Schwartz, JE, Cassano, PA, Couper, D, Jacobs, DR, Kalhan, R, O'Connor, GT, Yende, S, Sanders, JL, Umans, JG, Dransfield, MT, Chaves, PH, White, WB & Oelsner, EC 2019, 'Discriminative Accuracy of FEV1:FVC Thresholds for COPD-Related Hospitalization and Mortality', JAMA - Journal of the American Medical Association, vol. 321, no. 24, pp. 2438-2447. https://doi.org/10.1001/jama.2019.7233

Discriminative Accuracy of FEV1:FVC Thresholds for COPD-Related Hospitalization and Mortality. / Bhatt, Surya P.; Balte, Pallavi P.; Schwartz, Joseph E.; Cassano, Patricia A.; Couper, David; Jacobs, David R.; Kalhan, Ravi; O'Connor, George T.; Yende, Sachin; Sanders, Jason L.; Umans, Jason G.; Dransfield, Mark T.; Chaves, Paulo H.; White, Wendy B.; Oelsner, Elizabeth C.

In: JAMA - Journal of the American Medical Association, Vol. 321, No. 24, 25.06.2019, p. 2438-2447.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Discriminative Accuracy of FEV1:FVC Thresholds for COPD-Related Hospitalization and Mortality

AU - Bhatt, Surya P.

AU - Balte, Pallavi P.

AU - Schwartz, Joseph E.

AU - Cassano, Patricia A.

AU - Couper, David

AU - Jacobs, David R.

AU - Kalhan, Ravi

AU - O'Connor, George T.

AU - Yende, Sachin

AU - Sanders, Jason L.

AU - Umans, Jason G.

AU - Dransfield, Mark T.

AU - Chaves, Paulo H.

AU - White, Wendy B.

AU - Oelsner, Elizabeth C.

PY - 2019/6/25

Y1 - 2019/6/25

N2 - 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.

AB - 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.

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