Gaps in COPD Guidelines of Low- and Middle-Income Countries: A Systematic Scoping Review

Abstract

Background: Guidelines are critical for facilitating cost-effective COPD care. Development and implementation in low-and middle-income countries (LMICs) is challenging. To guide future strategy, an overview of current global COPD guidelines is required.

Research question: We systematically reviewed national COPD guidelines, focusing on worldwide availability and identification of potential development, content, context, and quality gaps that may hamper effective implementation.

Study design and methods: Scoping review of national COPD management guidelines. We assessed: (1) global guideline coverage; (2) guideline information (authors, target audience, dissemination plans); (3) content (prevention, diagnosis, treatments); (4) ethical, legal, and socio-economic aspects; and (5) compliance with the eight Institute of Medicine (IOM) guideline standards. LMICs guidelines were compared with those from high-income countries (HICs).

Results: Of the 61 national COPD guidelines identified, 30 were from LMICs. Guidelines did not cover 1.93 billion (30.2%) people living in LMICs, whereas only 0.02 billion (1.9%) in HICs were without national guidelines. Compared with HICs, LMIC guidelines targeted fewer health-care professional groups and less often addressed case finding and co-morbidities. More than 90% of all guidelines included smoking cessation advice. Air pollution reduction strategies were less frequently mentioned in both LMICs (47%) and HICs (42%). LMIC guidelines fulfilled on average 3.37 (42%) of IOM standards, compared with 5.29 (66%) in HICs (P < .05). LMICs scored significantly lower compared with HICs regarding conflicts of interest management, updates, articulation of recommendations, and funding transparency (all, P < .05).

Interpretation: Several development, content, context, and quality gaps exist in COPD guidelines from LMICs that may hamper effective implementation. Overall, COPD guidelines in LMICs should be more widely available and should be transparently developed and updated. Guidelines may be further enhanced by better inclusion of local risk factors, case findings, and co-morbidity management, preferably tailored to available financial and staff resources.

Keywords: chronic obstructive; consensus; developing countries; pulmonary disease; reference standards.

Figure 1

World map showing countries with and without COPD guidelines. Light blue: high-income country without country guideline; dark blue: high- income country with guideline; light red: low- and middle- income country without guideline; red: low- and middle-income country with guideline.

Figure 2

Overview of target audience of COPD guidelines around the world. ∗Significant difference, P < .05; GPs = general practitioners; HICs = high-income countries; LMICs = low- and middle-income countries.

Figure 3

Overview of coverage of COPD management recommendations met by COPD guidelines in high-income countries and low- and middle-income countries. ∗Significant difference, P < .05. HICs = high-income countries; inf = influenza; LMICs = low-and middle-income countries; pneu = pneumococcal.

Figure 4

IOM guideline quality standards met by COPD guidelines in high-income countries and low- and middle-income countries. HIC = high-income countries; IOM = Institute of Medicine; LMIC = low-and middle-income countries.