Chest

Chest

Volume 156, Issue 5, November 2019, Pages 864-877
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Original Research: COPD
Effects of Clinical Pathways for COPD on Patient, Professional, and Systems Outcomes: A Systematic Review

Part of this article has been presented earlier (Plishka C, Rotter T, Kinsman L, et al. Systematic Rev. 2016;5:135).
https://doi.org/10.1016/j.chest.2019.04.131Get rights and content

Background

COPD has a substantial burden seen in both patient quality of life and health-care costs. One method of minimizing this burden is the implementation of clinical pathways (CPWs). CPWs bring the best available evidence to a range of health-care professionals by adapting guidelines to a local context and detailing essential steps in care.

Methods

A systematic review was conducted to address the following question: What are the effects of CPWs for COPD on patient-, professional-, and systems-level outcomes? The review used methods outlined by the Cochrane Collaboration. We included all studies that met our operational definition for CPWs and focused on COPD. All studies were evaluated for risk of bias, and all data regarding patient, professional, and systems outcomes were extracted.

Results

The search strategy identified 497 potentially relevant titles. Of these, 13 studies were included in the review. These studies reported a total of 398 outcomes, with sufficient data for meta-analysis of five outcomes: complications, length of stay, mortality, readmissions, and quality of life. Results showed statistically significant reductions in complications, readmissions, and length of stay but did not show changes in mortality or quality of life.

Conclusions

This systematic review reveals evidence to suggest that CPWs for COPD have the potential to reduce complications, readmissions, and length of stay without negatively influencing mortality or quality of life. However, quality of evidence was generally low. The authors therefore acknowledge that results should be interpreted with caution and note the need for additional research in this area.

Section snippets

Description of the Condition

COPD is a respiratory disease characterized by progressive, partially reversible airway obstruction and lung hyperinflation.1, 2 This leads to progressive shortness of breath, limitation of daily activities, worsening health-related quality of life, and increasingly frequent and severe exacerbations.1 The disease is significantly underdiagnosed,3, 4 leading to difficulty in estimating prevalence at both the international and national levels. Estimates for worldwide prevalence of COPD range from

Materials and Methods

The current review follows the methodology outlined in a previously published review protocol.32 Methods are based on the guidelines provided by the Cochrane Collaboration.33 For brevity, this section only outlines the authors who completed each task and notes changes from the protocol.32 Due to the nature of this research, ethics approval was not required.

Screening

The search regarding CPWs in primary care resulted in 312 potentially relevant search hits, and the search regarding CPWs in hospitals resulted in 257 potentially relevant search hits. Hand-searching identified an additional six potentially relevant articles. Together, this approach resulted in a total of 575 search hits. Of these, 78 were duplicates, leaving 497 potentially relevant hits.

All search hits were screened independently by two reviewers (C. T. P. and Adegboyega Lawal, MPH).

Discussion

An overview of findings along with the justification for quality of evidence ratings is presented in Table 3. These findings suggest that CPWs for COPD have the potential to reduce complications (very low quality of evidence), reduce readmissions (high quality of evidence), and reduce length of stay (low quality of evidence). Furthermore, they did not point toward changes in mortality (low quality of evidence) or quality of life (low quality of evidence).

Conclusions

The current systematic review objectively found a number of benefits resulting from the implementation of CPWs for COPD. The results reveal high-quality evidence suggesting that CPWs for COPD have the potential to reduce readmissions. In addition, there is low-quality evidence to suggest that CPWs may reduce complications and length of stay regarding COPD. Finally, the evidence does not point to positive or negative changes to mortality rate or patient quality of life. Although these findings

Acknowledgments

Author contributions: D. D. M. and T. R. act as the guarantor of this research and take responsibility for the integrity of the work as a whole, from inception to published article. C. T. P., D. D. M., E. D. P., and T. R. made substantial contributions to conception and design. C. T. P., D. D. M., T. R., and S.-K. A. F. made substantial contributions to the acquisition of data. C. T. P., D. D. M., E. D. P., M. R. H., and T. R. made substantial contributions to analysis and interpretation of

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    • Cited by (0)

    FUNDING/SUPPORT: The protocol and systematic review have been supported by the Lung Health Institute of Canada.

    ∗

    Collaborators from the Saskatchewan COPD CPWs Research Group are listed in the Acknowledgments.

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