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      GOLD Classifications, COPD Hospitalization, and All-Cause Mortality in Chronic Obstructive Pulmonary Disease: The HUNT Study

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          The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has published three classifications of COPD from 2007 to 2017. No studies have investigated the ability of these classifications to predict COPD-related hospitalizations. We aimed to compare the discrimination ability of the GOLD 2007, 2011, and 2017 classifications to predict COPD hospitalization and all-cause mortality.

          Patients and Methods

          We followed 1300 participants with COPD aged ≥40 years who participated in the HUNT Study (1995–1997) through to December 31, 2015. Survival analysis and time-dependent area under receiver operating characteristics curves (AUC) were used to compare the discrimination abilities of the GOLD classifications.


          Of the 1300 participants, 522 were hospitalized due to COPD and 896 died over 20.4 years of follow-up. In adjusted models, worsening GOLD 2007, GOLD 2011, or GOLD 2017 categories were associated with higher hazards for COPD hospitalization and all-cause mortality, except for the GOLD 2017 classification and all-cause mortality (p trend=0.114). In crude models, the AUCs (95% CI) for the GOLD 2007, GOLD 2011, and GOLD 2017 for COPD hospitalization were 63.1 (58.7–66.9), 60.9 (56.1–64.4), and 56.1 (54.0–58.1), respectively, at 20-years’ follow-up. Corresponding estimates for all-cause mortality were 57.0 (54.8–59.1), 54.1 (52.1–56.0), and 52.6 (51.0–54.3). The differences in AUCs between the GOLD classifications to predict COPD hospitalization and all-cause mortality were constant over the follow-up time.


          The GOLD 2007 classification was better than the GOLD 2011 and 2017 classifications at predicting COPD hospitalization and all-cause mortality.

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          Most cited references 20

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          The 2011 revision of the global strategy for the diagnosis, management and prevention of COPD (GOLD)--why and what?

          The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has published a strategy for diagnosis and for management of chronic obstructive pulmonary disease (COPD) since 2001 and this has formed the basis for numerous national and regional guidelines. We describe the background for the 2011 revision of the GOLD document. The GOLD document is updated annually and revised every 5 years based on published research as well as an evaluation by an expert panel of how to best formulate and disseminate knowledge on COPD. The GOLD 2011 revision states that spirometry is required for making a clinical diagnosis of COPD. At the same time, the document has less emphasis on spirometric evaluation of disease severity and launches a combined assessment taking symptoms, spirometry and history of exacerbations into account. This is matched with initial treatment for COPD where smoking cessation, pulmonary rehabilitation and physical activity in general are given high priority followed by pharmacologic treatment guided by the novel assessment scheme. Comorbidities are often present in COPD and the GOLD 2011 revision gives some guidance in how to manage these as well as how to manage COPD in the presence of comorbidities. A more clinically oriented GOLD document will hopefully improve assessment and management of COPD. © 2012 Blackwell Publishing Ltd.
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            Mortality prediction in chronic obstructive pulmonary disease comparing the GOLD 2007 and 2011 staging systems: a pooled analysis of individual patient data.

            There is no universal consensus on the best staging system for chronic obstructive pulmonary disease (COPD). Although documents (eg, the Global Initiative for Chronic Obstructive Lung Disease [GOLD] 2007) have traditionally used forced expiratory volume in 1 s (FEV1) for staging, clinical parameters have been added to some guidelines (eg, GOLD 2011) to improve patient management. As part of the COPD Cohorts Collaborative International Assessment (3CIA) initiative, we aimed to investigate how individual patients were categorised by GOLD 2007 and 2011, and compare the prognostic accuracy of the staging documents for mortality.
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              Comparison of 2011 and 2007 Global Initiative for Chronic Obstructive Lung Disease guidelines for predicting mortality and hospitalization.

              The GOLD (Global Initiative for Chronic Obstructive Lung Disease) 2011 update on chronic obstructive pulmonary disease (COPD) bases disease classification on level of dyspnea, exacerbation history, and FEV1, whereas the previous GOLD categorized disease severity according to FEV1 only. Information on how the new classification predicts long-term hospitalizations and mortality is limited. To examine how GOLD 2011 predicts hospitalizations and mortality over an 8-year period and to assess differences in predictive ability between GOLD 2011 and GOLD 2007. In the GenKOLS study, 912 patients with COPD (FEV1/FVC < 0.7 and FEV1 < 80% predicted) aged 40 to 91 years were clinically examined. Patients answered questionnaires and performed lung function testing in 2003-2005. The population was followed for 8 years regarding hospitalizations (all-cause, respiratory) and mortality (all-cause, respiratory, cardiovascular). We performed logistic regression and receiver operating curve analyses for GOLD 2007 and GOLD 2011 with estimations of area under the curve (AUC) to compare the different classifications. Twenty percent of patients were classified as GOLD 2011 group A (mild), 30% as group B, 6% group as C, and 44% as group D (very severe). Patients in GOLD 2011 group D had odds ratios of 4.1 (95% confidence interval [CI], 2.5-6.7), 9.6 (95% CI, 3.4-27.0), and 3.0 (95% CI, 0.7-13.2) relative to group A for all-cause, respiratory, and cardiovascular mortality, respectively, and 3.8 (95% CI, 2.4-5.9) and 13.0 (95% CI, 6.6-25.6) for all-cause and respiratory hospitalizations, respectively. Associations were similar also for GOLD 2007. The adjusted AUC values for GOLD 2011 and GOLD 2007 were 0.82/0.82 for respiratory mortality (P = 0.87) and 0.77/0.76 for respiratory hospitalizations (P = 0.51). The predictive ability of GOLD 2011 did not differ significantly from GOLD 2007 in terms of hospitalizations and mortality.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of Chronic Obstructive Pulmonary Disease
                31 January 2020
                : 15
                : 225-233
                [1 ]Department of Public Health and Nursing, NTNU Norwegian University of Science and Technology , Trondheim, Norway
                [2 ]Centre for Clinical Documentation and Evaluation (SKDE), Northern Norway Regional Health Authority , Tromsø, Norway
                [3 ]Department of Circulation and Medical Imaging, NTNU Norwegian University of Science and Technology , Trondheim, Norway
                [4 ]Clinic of Thoracic and Occupational Medicine, St. Olavs Hospital, Trondheim University Hospital , Trondheim, Norway
                [5 ]Medical Research Council Integrative Epidemiology Unit, Department of Population Health Sciences, Bristol Medical School, University of Bristol , Bristol, UK
                [6 ]Population Health Sciences, University of Bristol , Bristol, UK
                [7 ]School of Epidemiology and Public Health, University of Ottawa , Ottawa, Canada
                [8 ]HUNT Research Centre, Department of Public Health and Nursing, NTNU Norwegian University of Science and Technology , Levanger, Norway
                [9 ]K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, NTNU Norwegian University of Science and Technology , Trondheim, Norway
                Author notes
                Correspondence: Laxmi Bhatta Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU Norwegian University of Science and Technology , P.O. Box 8905, MTFS, TrondheimNO-7491, Norway Email

                These authors contributed equally to this work

                © 2020 Bhatta et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (

                Page count
                Figures: 2, Tables: 3, References: 37, Pages: 9
                Original Research

                Respiratory medicine

                gold grades, abcd groups, copd hospitalization, mortality, area under curve, auc


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