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BACKGROUND: Most patients with chronic obstructive pulmonary disease (COPD) in Europe are treated in primary care, but perceptions on what guides primary care physicians (PCPs) in managing patients are lacking. AIMS: To describe factors associated with the assessment by PCPs of COPD severity and those associated with impaired health status, as assessed by patient-reported outcomes. METHODS: This cross-sectional study evaluated health-related quality of life (HRQL) in 2,294 COPD patients from five European countries. The severity of COPD was clinically judged by the PCPs and GOLD stage severity was calculated using spirometry data. RESULTS: PCPs' categories of severity reflected a wider range of HRQL scores (St George's Respiratory Questionnaire (SGRQ) total score: mild 30.3; moderate 41.7; severe 55.0; very severe 66.1) than GOLD severity grading (Stage I 38.2; Stage II 41.1; Stage III 49.9; Stage IV 58.5). Multiple ordinal logistic regression models showed that factors most closely related to PCP-rated COPD severity were Medical Research Council (MRC) dyspnoea grade, forced expiratory volume in 1 second (FEV1) percent predicted, HRQL score (either SGRQ or COPD Assessment Test (CAT)), and previous hospitalisations (model generalised R2=0.45 or 0.44 (SQRQ or CAT in model, respectively); all factors p<0.0001). Factors with the highest association with HRQL scores (SGRQ or CAT) were MRC dyspnoea grade, COPD severity (PCP-rated), sputum production, and number of co-morbidities (model R2=0.46 or 0.37 (SQRQ or CAT in multiple linear regression model, respectively); all factors p<0.0001). CONCLUSIONS: PCPs successfully graded COPD severity clinically and appeared to have greater discriminative power for assessing severity in COPD than FEV1-based staging. Their more holistic approach appeared to reflect the patients' HRQL rating and was consistent across five European countries. [ABSTRACT FROM AUTHOR]