Challenges in the Implementation of Chronic Obstructive Pulmonary Disease Guidelines in Low- and Middle-Income Countries: An Official American Thoracic Society Workshop Report

Abstract

There is a substantial burden of chronic respiratory diseases, including chronic obstructive pulmonary disease (COPD), in lowand middle-income countries (LMICs). LMICs have particular challenges in delivering cost-effective prevention, diagnosis, and management of COPD. Optimal care can be supported by effective implementation of guidelines. This American Thoracic Society workshop considered challenges to implementation of COPD guidelines in LMICs. We make 10 specific recommendations: 1) relevant organizations should provide LMIC-specific COPD management guidance; 2) patient and professional organizations must persuade policy-makers of the importance of lung function testing programs in LMICs; 3) healthcare education and training should emphasize the early-life origins of COPD; 4) urgent action is required by governments to reduce airborne exposures, including exposures to tobacco smoke and indoor and outdoor air pollution; 5) guidance for COPD in LMICs should explicitly link across Essential Medicine Lists and the World Health Organization package of essential noncommunicable disease interventions for primary health care in low-resource settings and should consider availability, affordability, sustainability, and cost-effective use of medicines; 6) the pharmaceutical industry should work to make effective COPD and tobacco-dependence medicines globally accessible and affordable; 7) implementation of locally adapted, cost-effective pulmonary rehabilitation programs should be an international priority; 8) the World Health Organization Global Action Plan for the Prevention and Control of Noncommunicable Diseases should specify how improvements in respiratory health will be achieved; 9) research funders should increase the proportion of funding allocated to COPD in LMICs; and 10) the respiratory community should leverage the skills and enthusiasm of earliercareer clinicians and researchers to improve global respiratory health.

Quality Standard Position Statements for Health System Policy Changes in Diagnosis and Management of COPD: A Global Perspective

“…However, while treatment guidelines and recommendations [ 1 , 10 , 11 ] are intended to optimize case management, their global implementation remains inadequate [ 12 – 18 ], resulting in substantial gaps in the standard of clinical care. The dissemination and adaptation of guidelines is particularly lacking in low- and middle-income countries where the feasibility of implementing integrated disease management approaches remains limited [ 19 – 21 ]. Although guideline-directed treatment may afford clinical benefits to patients with COPD, guidelines rarely drive systemic policy change, or change practice across primary, secondary, and tertiary care.…”

Guideline based knowledge and practice of physicians in the management of COPD in a low‐ to middle‐income country

“…These factors were in line with a report from the American Thoracic Society on challenges in implementing COPD guidelines in LMIC. 15 Thus, overcoming those barriers by proper training and supply of resources in LMIC like Nepal can help increase the physician's practice level in COPD and reflect their knowledge.…”

“…As recommended, the concerned authority and government should develop evidence‐based diagnostic tools, such as screening questionnaires and mobilise locally available resources like peak flow meters (PFMs) to diagnose COPD. 15 These methods can be cost‐effective and readily available in LMIC when there is limited access to spirometry. Training should still be given to medical physicians in the proper use of PFM.…”

TB and COPD in low-income settings: a collision of old foes

“…Notwithstanding some controversy over the definition and diagnosis of COPD in LMICs, the Global Burden of Disease Study estimates suggest that LMICs account for 71% of the global burden of COPD, 84% of COPD deaths and 84% of the disability adjusted life years lost in relation to COPD 6. Between a third and a fifth of COPD in LMICs occurs in non-smokers and the heterogenous causes of fixed airway obstruction among adults in LMICs are increasingly recognised 7. The data presented here, together with findings from the BOLD Study and other work, suggest that TB has a role in driving airway obstruction in LMICs.…”