Background

Chronic obstructive pulmonary disease (COPD) is a preventable, treatable, irreversible lung disease characterised by chronic airflow obstruction that impedes a normal breathing pattern.1 COPD, being a debilitating multisystem disease often leads to a steady decline, in terms of illness trajectory, and heavily impacts health-related quality of life (HRQol).2 3 The WHO has predicted COPD to become the third leading cause of death by 2030 considering its increase in prevalence and morbidity rate.4 5 COPD is the second leading cause of preventable hospitalisation in Australia and accounted for more than two-thirds of global respiratory fatal incidences.6 7 In Australasian research reports, 5% of all emergency department (ED) presentations included shortness of breath and 14% of these presentations were COPD.8 Acute exacerbation of COPD (AECOPD) is defined as acute variation in patient’s stable state with both respiratory and non-respiratory symptoms that demand medication changes or hospitalisation.9

Exacerbation episodes have a significant and prolonged impact on health status, HRQol, patient outcomes and the negative effects on pulmonary function decline.9 AECOPD is a common hospital presentation due to a variety of causes such as infective exacerbations, worsening disease condition, medication non-adherence, inefficient care planning, lack of education and discharge without comprehensive support plan.8 AECOPD, directly and indirectly, is associated with an increased economic burden to the health industry by hastening lung function decline, negatively affecting patients and families and increasing overall morbidity and mortality.5 Major causal factors of exacerbations include smoking, environmental and genetic factors, airway hyperactivity, chronic bronchitis and infection.1 Breathlessness, reduced activity level, malnutrition, social isolation, loss of independence, reduced HRQol and depression are some of the issues these patients tackle in their daily lives.10 COPD is a multimodal chronic disease that requires consistent interdisciplinary interventions from admission to discharge. The importance of the care and interventions provided in the hospitals may reduce readmissions and enhance HRQol in these patients and their families.11

The primary intent of publishing COPD guidelines was to facilitate an anticipated shift from the predominant emphasis of pharmacological treatment to a more holistic multidisciplinary intervention approach.12 The global initiative for chronic obstructive lung disease (GOLD), originally launched and developed by international leading experts in 1997, aims to improve HRQol and medical management around the globe.1 COPD-X plan guidelines, originally derived from GOLD, published in 2003 by Thoracic Society of Australia and New Zealand (TSANZ) and the Lung Foundation Australia (LFA) aim to promote consistent evidence-based changes in clinical practice.13 A range of interventions recommended through the published COPD guidelines such as pulmonary rehabilitation, smoking cessation, self-management of exacerbations, palliative care, psychological support or counselling for patients and families has proven to improve HRQol factors in patients with COPD.14 Advances in the management of COPD are updated quarterly in the national COPD guidelines by LFA and TSANZ.14 The prime emphasis of these guidelines is around accurate case diagnosis, functional optimisation, preventing deterioration, developing a plan of care and managing exacerbation.13 Despite the existing comprehensive recommendations, readmission rates and hospitalisations have increased in the last decade.10 11

The publication of GOLD and national clinical practice guidelines (COPD-X plan) is only the first step in a process that ends with an actual change in clinician behaviour, hence effective guideline dissemination methods cannot be overlooked.12 An Australian retrospective observational study conducted on 381 patients explored compliance with a patients’ COPD bundle of care, the results revealed 49% adherence to the established plan. This study suggested that further research is required to improve guidelines and adherence plans for patients with COPD.15 A qualitative Australian study, using semistructured interviews of nine hospital-based registrars or interns, and seven general physicians found that barriers to implementation of evidence-based recommendations for COPD plans included a lack of supportive enablers and a complexity of the behavioural change needed in patients.16 17 An identified barrier was the lack of guidelines in a readily, user-friendly and easily accessible manner with checkpoints, cues and time intervals of when they are required at point-of-care.16 The studies suggest that improvement in guideline adherence can be translated into improved patient care and HRQol in patients with COPD.

Prospective research in knowledge translation and effective ways to implement evidence into everyday clinical practice for AECOPD are imperative. Implementation of a COPD checklist and the resultant adherence conducted among respiratory ward staff in Australia had two groups of patient admissions, prechecklist implementation and postchecklist implementation.16 Adherence to the checklist used by ward medical staff in the respiratory ward identified a report of 51%.16 Concordance with COPD guideline recommendations was high overall for patient assessment and initial treatment; however, concordance was lower for longer term issues such as referral to pulmonary rehabilitation programmes (36%).16 Patients discharged from the ED had not been included in this study nor was the interdisciplinary perspective explored. The Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) cohort study was conducted in 46 EDs in Australia, New Zealand, Singapore, Hong Kong and Malaysia to explore epidemiology, clinical features, treatment outcomes, hospital length of stay and in-hospital mortality.8 The findings of this study identified most acute exacerbation patients with COPD arrive in the ED by ambulance and have increased hospitalisations’ and significant in-hospital mortality.8 A planned substudy of AANZDEM concluded compliance with COPD evidence-based guidelines is suboptimal in EDs and suggested further research is required to improve compliance with care based on published guidelines.18

COPD exacerbations and their management were explored in an Ireland hospital through a prospective before and after study. Following the education of staff and the implementation of a COPD care bundle, the outcome for 51 consecutive patients was analysed. Bundle of care improved the delivery of care for patients with COPD. However, care indicators did not suggest or assess interdisciplinary services (pulmonary rehabilitation, smoking cessation, self-management education, dietician or psychosocial support).19 Spirometry and non-invasive ventilation are two other variables identified in the treatment plan by another retrospective audit of frequent patients with COPD presenting in an Australian ED.20 Imperative evidence collectively resulting from these studies have suggested exploring barriers and enablers of holistic COPD assessment and management could be beneficial in providing holistic care options for patients with COPD. Decreased awareness, familiarity, low concordance, suboptimal primary, secondary and tertiary care provided by health professionals have immensely affected HRQol in patients with COPD.11 16 18

COPD is a multimodal disease, where interdisciplinary care holds a pivotal role in reducing COPD exacerbations.21–23 Current evidence reports doctors, nurses and interdisciplinary health professionals in Australia, do not consistently adhere to COPD guidelines.8 14 24 25 Bartels et al26 postulate from their 1-year retrospective study in Canada that patients with COPD discharged from EDs have a significantly higher risk of readmission due to variability in treatment as less than 50% of patients with AECOPD in their study, who presented to ED received recommended COPD therapy.26 Exploring the barriers and enablers for interdisciplinary team members to provide holistic care as per COPD guidelines (medical, physical, psychological, social, spiritual and palliation) is crucial.18 27 Interdisciplinary care has proven to significantly optimise functionality and prevent deterioration in patients with COPD, which subsequently reduces hospital admissions and hospital days per person.16 21 Initiation of consistent interdisciplinary healthcare interventions for patients with COPD will extrude any implementation gap and prevent readmissions.21

Low concordance is indubitably associated with low awareness of clinical guidelines and role confusion that may subsequently lead to suboptimal clinical care for patients in primary, secondary and tertiary care.17 25 According to an observational study in Australia, COPD guidelines developed with detailed processes and a plethora of international evidence are not well adhered to, where the study also reports a lack of clinician knowledge nationally and internationally.16 Globally, the results of this review with implementation recommendations will avail interdisciplinary clinicians treating patients with COPD and clinical decision-makers. Existence of the guidelines alone does not often aid patients with better health outcomes; hence, exploration of the contributing factors to the already established lack of concordance through this review is in need. Existing evidence and reviews have ascertained that a lack of COPD guideline concordance will increase ED readmissions, imploring the need to better examine contributing factors inhibiting recommended clinical practice.

Implementation research suggests better implementation of guideline demand interdisciplinary clinical behavioural change in an individual and collective manner.28 Theoretical Domains Framework (TDF) had aimed to deliver a comprehensive and theory-informed advanced methodology to help identify the fundamentals of non-concordance behaviour among interdisciplinary professional.28 Integrating theoretical framework will assist cross-disciplinary implementation and research synthesis to create specific recommendations for local, national and international health systems.28 29 A preliminary search of the topic showed a lack of knowledge, skills, environmental and beliefs of health professionals contribute to lack of concordance. TDF allows researchers to explore, understand and target clinician behaviour change interventions to provide recommendations to improve concordance.30 This theoretical scaffolding allows identification and accumulation of salient determinants from existing evidence towards a lack of COPD guidelines adherence to 14 domains.31 The 14 domains according to Cane et al are (1) knowledge, (2) skills, (3) social influences, (4) memory, attention and decision processes, (5) behavioural regulation, (6) professional/social role and identity, (7) beliefs about capabilities, (8) belief about consequences, (9) optimism, (10) intentions, (11) goals, (12) emotion, (13) environmental context and resources and (14) reinforcement (see table 1).29 Any determinants that do not fit within the existing domains will be organised into an ‘others’ domain.

Framework synthesis of data allows robust filtration of evidence from multiple sources to provide better implementation strategies and clinical behaviour change solutions to COPD guideline concordance.30 31 TDF was originally developed to identify determinants and influences on health professionals behaviour to inform better implementation efforts.28 29 A further benefit of TDF is its linkage to behaviour change techniques which may provide an early identification of implementation issues associated with clinician behaviour to recommend intervention designs (see table 1).28 29 This systematic review will identify the contributing factors to the lack of COPD guidelines concordance from the time of admission in the hospital to discharge. Given the scarcity of research in interdisciplinary guidelines concordance with COPD, the proposed mixed methods approach will enable all available evidence to be incorporated into the review.

Ethics and dissemination

Ethics approval is not required for this study as all data are obtained from publicly available studies. Knowledge and interpretations from this review will provide recommendations towards prominent implementation strategies to increase COPD guideline concordance. The results of this study will be presented before industry stakeholders, interdisciplinary clinicians and appropriate future conferences to develop and assist with implementation initiatives.