Two-year exacerbation history predicts COPD risk best Any moderate or severe COPD flare in the past 2 years best predicted high flare risk.
*Prospective cohort prediction study; Level 2 (OCEBM).

Citation

Bhatt SP, Adibi A, Bodduluri S, et al. American Journal of Respiratory and Critical Care Medicine. 2026;212(8):1721-1729. doi:10.1093/ajrccm/aamag118

Background

Preventing chronic obstructive pulmonary disease flares depends on identifying patients at high future risk. Current guidance often uses a 1-year history of at least 2 moderate or 1 severe flare, but this cutoff has limited supporting evidence.

Patients

Adults with chronic obstructive pulmonary disease in 2 prospective cohorts: COPDGene (n=3035) and NOVELTY (n=3080). COPDGene excluded major lung disease other than chronic obstructive pulmonary disease or asthma and required airflow obstruction; NOVELTY used physician diagnosis.

Intervention

Risk classification using 18 prior flare-history categories, varying by number, severity, and 1-year versus 2-year recall.

Control

Current standard: at least 2 moderate or at least 1 severe flare in the prior year.

Outcome

Primary outcome: at least 2 moderate or at least 1 severe flare in the next 12 months. Prediction was assessed with area under the curve (0.5 to 1.0; higher is better) and net benefit.

Follow-up Period

Three to 4 years, depending on cohort and analysis.

Results

Cohort Best predictor Area under curve Improvement versus current standard
COPDGene Any moderate or severe flare in past 2 years 0.69 (95% CI 0.67 to 0.71) Δ 0.03 (95% CI 0.01 to 0.05)
NOVELTY Any moderate or severe flare in past 2 years 0.87 (95% CI 0.85 to 0.88) Δ 0.12 (95% CI 0.10 to 0.15)

Decision analysis also favored 2-year recall across clinically plausible treatment thresholds. At a 20% risk threshold, the 2-year “any flare” rule yielded about 21 more correct treatment decisions per 1000 in COPDGene and 18 more per 1000 in NOVELTY than the current standard. Analyses used complete cases.

Limitations

This was not a treatment trial, so it cannot prove that changing therapy based on the new rule improves outcomes. Medication use was not adjusted. Treatment thresholds for chronic obstructive pulmonary disease prevention are not firmly established. Missing data were handled by complete-case analysis.

Funding

Government grants; COPD Foundation industry board; AstraZeneca funded NOVELTY.

Clinical Application

Consider reviewing 2-year flare history; any moderate or severe flare may justify closer monitoring and treatment reassessment.