Estimation of mortality hazard ratios by COPD grade using a systematic review and network meta-analysis: deriving grade-, sex-, and age-specific mortality for a German COPD decision model.

Chronic Obstructive Pulmonary Disease (COPD) imposes substantial economic costs. Cost-effectiveness evaluations in COPD frequently rely on Markov (or other state-transition) models. Their accuracy relies on precise mortality probabilities by COPD grade. The aim of this systematic review was to provide evidence-based hazard ratios (HRs) for grade-specific mortality (GOLD 1-4 at baseline) and to derive grade-, age-, and sex-specific mortality probabilities for patients with COPD in Germany. A systematic PubMed and Europe PMC search was conducted for studies published between 2003 and February 2026. HRs were standardized to the reference group of normal spirometry and pooled by GOLD grade using network meta-analysis. We derived grade-specific mortality probabilities for Germany stratified by 5-year age-groups and sex by combining the pooled HRs with age- and sex-specific German period life-table mortality from the German Federal Statistical Office. Risk of bias was assessed by the Newcastle-Ottawa Scale. In total, 1,459,685 participants from 34 publications were included, with 966,144 having normal spirometry and the others classified into GOLD grades 1-4 at baseline. We found a monotonic increase in mortality with grade, with HRs (95% CIs) of 1.09 (0.97-1.22), 1.57 (1.41-1.75), 2.39 (2.03-2.83), and 4.54 (3.44-6.01) in GOLD 1-4, respectively. Estimated 1-year mortality probabilities for patients with COPD in Germany ranged from 0.15% (females, GOLD 1, ages 45-49) to 64.8% (GOLD 4, males, age ≥ 85). This study provides evidence-based mortality risks for patients with COPD in Germany, stratified by grade, age, and sex, while presenting a transferable framework for deriving similar mortality probabilities in other countries.