Description of the condition
Chronic obstructive pulmonary disease (COPD) is a respiratory syndrome characterized by progressive, partially reversible airway obstruction and lung hyperinflation [
1,
2]. This leads to progressive shortness of breath, limitation of daily activities and worsening health-related quality of life, as well as increasingly frequent and severe exacerbations [
1]. It is most often caused by exposure to tobacco smoke [
3], but is also associated with air pollution and biomass [
3] and occupational exposures to dusts and chemicals [
3]. The disease is significantly underdiagnosed [
4,
5], leading to difficulty in estimating prevalence at both the international and national level. Estimates for worldwide prevalence of COPD range from 4 to 20 % [
4]. Similar trends can be seen in Canada where approximately 4 % of Canadians self-report as being diagnosed [
5], but estimates based on airflow obstruction suggest a prevalence between 12 and 17 % depending on diagnostic criteria [
5]. Data from Europe is less readily available as estimates for Europe in general are out of date [
6]. However, statistics from the UK also point to underdiagnoses as 1 million people live with diagnosed COPD while another 2 million are undiagnosed [
7].
COPD has significant consequences. It is the fourth leading cause of death in Canada [
8] and the third leading cause of death in the USA. In 2009, COPD caused 8 million physician office visits, 1.5 million ED visits, 715,000 hospitalizations and 133,965 deaths in the USA [
9]. In 2010, costs for COPD in the US were projected to be $49.9 billion [
10]. Exacerbations of COPD (AECOPD) account for most of the morbidity. In Canada alone, the cost of moderate and severe exacerbations has been estimated to be $646–$736 million per year [
11]. In the UK, direct costs of COPD are estimated at £800 million [
12]. In order to minimize the burden of COPD, high-quality guidelines have been developed [
1,
13‐
16]. These guidelines generally specify disease identification through spirometry, management through a combination of smoking cessation, vaccination, pharmacologic therapy, physical activity, prevention and optimal management of AECOPD [
1,
17]. When implemented, these steps have shown substantial increases in patient quality of life, as well as a reduction in healthcare utilization [
18].
Although these results are promising, evidence suggests that the creation of guidelines in isolation is inadequate [
19‐
21] as passive dissemination of guidelines rarely results in meaningful changes in practice [
14,
22,
23]. Estimates across the healthcare environment suggest that 30–40 % of patients do not receive treatments with proven effectiveness [
24], although guideline uptake varies across areas of care [
25].
Description of the intervention
One proposed method of minimizing this gap is the implementation of clinical pathways (CPWs). CPWs, also known as ‘integrated care pathways’, ‘critical pathways’, ‘care plans’ or ‘checklists’, are tools used by health professionals to guide evidence-based practice and improve the interaction between health services. They bring the best available evidence to a range of healthcare professionals by adapting guidelines to a local context and detailing the essential steps in the assessment and care of patients [
26,
27]. Evidence suggests that CPWs are commonly implemented and studied in hospitals [
28]. However, work analyzing the extent of CPW implementation and evaluation in primary care is still underway [
29].
Evidence exists to support the general use of CPWs to change behaviour and improve quality of care [
20,
21,
30‐
32]. Less evidence is available to establish the effectiveness of CPWs for the management of COPD. This is demonstrated in a previous systematic review focused on in-hospital management of AECOPD which utilized a comprehensive search strategy but only identified four studies which met the inclusion criteria [
33]. The systematic review described in this protocol follows the preferred reporting items for systematic review and meta-analysis (PRISMA) methodology, as outlined in the PRISMA protocols (PRISMA-P) checklist (see Additional file
1) and will improve the current knowledge base regarding the development and implementation of CPWs for COPD.