Purpose: GOLD 2019 proposed a novel treatment decision tool for follow-up based on the predominant trait (exacerbation or dyspnea) of patients, alongside treatment escalation and de-escalation strategies. This study was designed to provide an up-to-date snapshot of patient and disease characteristics, treatment pathways, and healthcare resource use (HRU) in COPD in real life, and comprehensively examine patients considering GOLD 2019 recommendations.Patients and Methods: This mixed design, observational, multicenter (14 pulmonology clinics) study included all patients with a documented COPD diagnosis (excluding asthma-COPD overlap [ACO]) for >12 months, aged >40 years at diagnosis who had a COPD-related hospital visit, spirometry test and blood eosinophil count (BEC) measurement under stable conditions within the 12 months before enrollment between February and December 2020. Data were collected cross-sectionally from patients and retro-spectively from hospital medical records. Results: This study included 522 patients (GOLD group A: 17.2%, B: 46.4%, C: 3.3%, D: 33.1%), of whom 79.5% were highly symptomatic and 36.2% had high risk of exacerbation. Exacerbations (n = 832; 46.6% moderate, 25.5% severe) were experienced by 57.5% of patients in the previous 12 months. Inter-rater agreement between investigators and patients regarding the reason for visit was low (Kappa coefficient: 0.338, p = 0.001). Inhaled treatment was modified in 88 patients at index, mainly due to symptomatic state (31.8%) and exacerbations (27.3%); treatment was escalated (57.9%, mainly switched to LABA+LAMA+ICS), inhaler device and/or active ingredient was changed (36.4%) or treatment was de-escalated (5.7%). 27% had >1 hospital overnight stay over 12 months. Emergency department visits and days with limitation of daily activities were higher in group D (p < 0.001). Conclusion: Despite being on-treatment, many patients with COPD experience persistent symptoms and exacerbations requiring hospital-related HRU. A treatable trait approach and holistic disease management may improve outcomes by deciding the right treatment for the right patient at the right time.