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Prognostic value of multidimensional indices in ambulatory COPD patients

      The Global Initiative for Chronic Obstructive Lung Disease (GOLD) advocates the use of multidimensional prognostic indices for staging, monitoring and guiding decision-making in chronic obstructive pulmonary disease (COPD) [
      Global strategy for the diagnosis, management and prevention of COPD, Global Initiative For Chronic Obstructive Lung Disease (GOLD).
      ]. The previous severity staging based on airflow limitation has been substituted for a grading (ABCD) system that also includes exacerbations and symptoms [
      Global strategy for the diagnosis, management and prevention of COPD, Global Initiative For Chronic Obstructive Lung Disease (GOLD).
      ]. On the other hand, comorbidities are frequent in COPD, and patients often die from other diseases than COPD. De Torres et al. found that the Body mass index (BMI), Obstruction, Dyspnea, Exercise (BODE) index had better long-term survival prediction than the GOLD ABCD categories system [
      • De Torres J.P.
      • Casanova C.
      • Marín J.M.
      • et al.
      Prognostic evaluation of COPD patients: GOLD 2011 versus BODE and the COPD comorbidity index COTE.
      ]. Also, they found that combining the BODE index with a COPD-specific comorbidity index, improved outcome prediction [
      • De Torres J.P.
      • Casanova C.
      • Marín J.M.
      • et al.
      Prognostic evaluation of COPD patients: GOLD 2011 versus BODE and the COPD comorbidity index COTE.
      ]. However, BODE index requires a six-minute walk test (6MWT) and exercise tests are personnel- and time-consuming. Therefore, this index is difficult to use in some settings, like primary care medicine. The Spanish COPD guidelines recommend the BODEX index, which replaces 6MWD with the registry of previous severe exacerbations, at least for less severe cases [
      • Miravitlles M.
      • Soler-Cataluña J.J.
      • Calle M.
      • et al.
      Spanish COPD guidelines (GesEPOC): pharmacological treatment of stable COPD. Spanish Society of Pulmonology and Thoracic Surgery.
      ]. The CODEX index (Comorbidity, Obstruction, Dyspnea, and previous severe EXacerbations) includes both variables of COPD severity and comorbidity (assessed by the age-adjusted Charlson index) and it does not require performing a 6MWT [
      • Almagro P.
      • Soriano J.B.
      • Cabrera F.J.
      • et al.
      Short- and medium-term prognosis in patients hospitalized for COPD exacerbation. The CODEX index.
      ]. Therefore, it is easy to use in clinical practice. However, it has only been validated in patients hospitalized for COPD exacerbation, and it has not been tested in ambulatory patients [
      • Almagro P.
      • Soriano J.B.
      • Cabrera F.J.
      • et al.
      Short- and medium-term prognosis in patients hospitalized for COPD exacerbation. The CODEX index.
      ]. Our hypothesis was that the BODEX index would have better survival prediction than GOLD ABCD, and that the CODEX index would improve outcome prediction, in ambulatory COPD patients.

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