Editorials

Using COPD Guidelines to Improve Patient Care

Am Fam Physician. 2006 Feb 15;73(4):590-591.

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The worldwide chronic obstructive pulmonary disease (COPD) epidemic affects nearly 600 million people and accounts for more than 2.2 million deaths each year.1 Airflow obstruction makes COPD an even greater health burden because it independently contributes to the morbidity and mortality of coexisting chronic conditions, such as ischemic heart disease.2 Not surprisingly, more than 15 professional societies have published clinical practice guidelines about COPD during the past decade3; however, the content and format of these guidelines are variable, and some experts say that to improve patient care, these efforts must be better coordinated.4,5

All COPD guidelines aim to improve health care processes and outcomes, decrease practice variation, and optimize resources.6 Although effective guidelines are developed systematically to be used easily in busy practices and to ensure scientifically valid outcomes, guidelines alone cannot improve patient care. Physicians must be committed to guideline dissemination and implementation for patient outcomes to improve.

The three-part mission of COPD guidelines includes systematic development, dissemination, and implementation. However, until recently, most COPD guideline developers have created hard-to-adopt, non-explicit recommendations using informal consensus methods or expert opinion.4,5 Most have only disseminated their guidelines through publication in subspecialty journals rather than reaching frontline physicians through multiple media and forums. And most guideline developers have not created effective implementation strategies. Consequently, little evidence has shown that COPD guidelines have affected health care processes or improved respiratory health.4

The future, however, appears promising. COPD has increasingly been recognized as an enormous health burden worldwide. The Global Initiative for Chronic Obstructive Lung Disease (GOLD), a collaboration of the World Health Organization, National Institutes of Health, and the National Heart, Lung, and Blood Institute, was formed as an organized international alliance aimed at creating an evidence-based set of practice parameters.7 The GOLD guideline developers update their recommendations regularly using systematic reviews of the literature and grading of the evidence. Also, the GOLD developers have designed dissemination and implementation strategies for their guideline efforts. Recent joint COPD guidelines from the European Respiratory Society and American Thoracic Society are in concordance with the GOLD recommendations; they are provided in Web-based format with patient education materials to promote dissemination and implementation.8 The British Thoracic Society COPD guidelines use evidence-based techniques and correspond well with GOLD guidelines.9 And, as demonstrated by Dewar and Curry’s review of the diagnosis of COPD in this issue of American Family Physician,10 experts in primary care have joined the international effort to disseminate a congruent set of international evidence-based recommendations to primary care physicians.

COPD guidelines are evolving toward a more robust and effective future because of well-coordinated worldwide efforts to standardize recommendations and improve implementation strategies. Family physicians will remain on the leading edge of practice improvement efforts, because 70 percent of patients with COPD seek care from primary care physicians rather than pulmonary specialists. How well these patients do in the future depends on how effectively physicians can incorporate evidence-based COPD guidelines into their everyday clinical practices.

The Author

JOHN E. HEFFNER, M.D., is professor and executive medical director at the Medical University of South Carolina, Charleston.

Address correspondence to John E. Heffner, M.D., 169 Ashley Ave., P.O. Box 250332, Charleston, SC 29425 (e-mail: heffnerj@musc.edu). Reprints are not available from the author.

REFERENCES

1. Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. Lancet. 1997;349:1498–504.

2. Sin DD, Man SF. Why are patients with chronic obstructive pulmonary disease at increased risk of cardiovascular diseases? The potential role of systemic inflammation in chronic obstructive pulmonary disease. Circulation. 2003;107:1514–9.

3. Heffner JE. Chronic obstructive pulmonary disease: on an exponential curve of progress. Respir Care. 2002;47:586–607.

4. Heffner JE, Ellis R. The guideline approach to chronic obstructive pulmonary disease: how effective?. Respir Care. 2003;48:1257–66.

5. Lacasse Y, Ferreira I, Brooks D, Newman T, Goldstein RS. Critical appraisal of clinical practice guidelines targeting chronic obstructive pulmonary disease. Arch Intern Med. 2001;161:69–74.

6. Audet AM, Greenfield S, Field M. Medical practice guidelines: current activities and future directions. Ann Intern Med. 1990;113:709–14.

7. Fabbri LM, Hurd SS. for the GOLD Scientific Committee Global Strategy for the diagnosis, management and prevention of COPD: 2003 update. Eur Respir J. 2003;22:1–2.

8. American Thoracic Society. Standards for the diagnosis and management of patients with COPD. Accessed online July 18, 2005, at: http://www.test.thoracic.org/copd/.

9. National Collaborating Centre for Chronic Conditions. Chronic obstructive pulmonary disease. National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax. 2004;59(suppl 1):S1–232.

10. Dewar M, Curry RW Jr. Chronic obstructive pulmonary disease: diagnostic considerations. Am Fam Physician. 2006;73:669–76.677–8.


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