"GOLD or lower limit of normal definition? A comparison with expert-based diagnosis of chronic obstructive pulmonary disease in a prospective cohort-study".
BACKGROUND
The Global initiative for chronic Obstructive Lung Disease (GOLD) defines COPD as a fixed post-bronchodilator ratio of forced expiratory volume in 1 second and forced vital capacity (FEV1/FVC) below 0.7. Age-dependent cut-off values below the lower fifth percentile (LLN) of this ratio derived from the general population have been proposed as an alternative. We wanted to assess the diagnostic accuracy and prognostic capability of the GOLD and LLN definition when compared to an expert-based diagnosis.


METHODS
In a prospective cohort study, 405 patients aged ≥ 65 years with a general practitioner's diagnosis of COPD were recruited and followed up for 4.5 (median; quartiles 3.9; 5.1) years. Prevalence rates of COPD according to GOLD and three LLN definitions and diagnostic performance measurements were calculated. The reference standard was the diagnosis of COPD of an expert panel that used all available diagnostic information, including spirometry and bodyplethysmography.


RESULTS
Compared to the expert panel diagnosis, 'GOLD-COPD' misclassified 69 (28%) patients, and the three LLNs misclassified 114 (46%), 96 (39%), and 98 (40%) patients, respectively. The GOLD classification led to more false positives, the LLNs to more false negative diagnoses. The main predictors beyond the FEV1/FVC ratio for an expert diagnosis of COPD were the FEV1 % predicted, and the residual volume/total lung capacity ratio (RV/TLC). Adding FEV1 and RV/TLC to GOLD or LLN improved the diagnostic accuracy, resulting in a significant reduction of up to 50% of the number of misdiagnoses. The expert diagnosis of COPD better predicts exacerbations, hospitalizations and mortality than GOLD or LLN.


CONCLUSIONS
GOLD criteria over-diagnose COPD, while LLN definitions under-diagnose COPD in elderly patients as compared to an expert panel diagnosis. Incorporating FEV1 and RV/TLC into the GOLD-COPD or LLN-based definition brings both definitions closer to expert panel diagnosis of COPD, and to daily clinical practice.
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
Gülmisal
G
Güder
Susanne
S
Brenner
Christiane E
CE
Angermann
Georg
G
Ertl
Matthias
M
Held
Alfred P
AP
Sachs
Jan-Willem
JW
Lammers
Pieter
P
Zanen
Arno W
AW
Hoes
Stefan
S
Störk
Frans H
FH
Rutten
D000368:Aged; D015331:Cohort Studies; D003951:Diagnostic Errors / Q000517:prevention & control; D003955:Diagnostic Tests, Routine / Q000379:methods* / Q000592:standards*; D005541:Forced Expiratory Volume / Q000502:physiology; D006801:Humans; D008297:Male; D011379:Prognosis; D011446:Prospective Studies; D029424:Pulmonary Disease, Chronic Obstructive / Q000145:classification / Q000175:diagnosis* / Q000503:physiopathology*; D012015:Reference Standards; D012115:Residual Volume / Q000502:physiology; D012189:Retrospective Studies; D014109:Total Lung Capacity / Q000502:physiology; D014797:Vital Capacity / Q000502:physiology*