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

      , MD a , b , , MD, PhD c , , MD, PhD d , , MD, PhD e , f , g , , MD h , i , j , , MD, PhD k , , MD l , m , , MD n , , MD o , , MPH p , , MPH q , , PhD q , , MD, PhD r , , PhD s , , MD, PhD t , , PharmD, PhD a ,
      American College of Chest Physicians
      chronic obstructive, consensus, developing countries, pulmonary disease, reference standards, GACD, Global Alliance for Chronic Diseases, GNI, gross national income, GOLD, Global Initiative for Chronic Obstructive Lung Disease, HIC, high-income countries, IOM, Institute of Medicine, LMIC, low- and middle-income countries, PRISMA, preferred reporting items for a systematic review and meta-analysis

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          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).


          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).


          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.

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          Most cited references37

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          PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation

          Scoping reviews, a type of knowledge synthesis, follow a systematic approach to map evidence on a topic and identify main concepts, theories, sources, and knowledge gaps. Although more scoping reviews are being done, their methodological and reporting quality need improvement. This document presents the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist and explanation. The checklist was developed by a 24-member expert panel and 2 research leads following published guidance from the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network. The final checklist contains 20 essential reporting items and 2 optional items. The authors provide a rationale and an example of good reporting for each item. The intent of the PRISMA-ScR is to help readers (including researchers, publishers, commissioners, policymakers, health care providers, guideline developers, and patients or consumers) develop a greater understanding of relevant terminology, core concepts, and key items to report for scoping reviews.
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            GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.

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              Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the Global Burden of Diseases Study 2015

              Summary Background Exposure to ambient air pollution increases morbidity and mortality, and is a leading contributor to global disease burden. We explored spatial and temporal trends in mortality and burden of disease attributable to ambient air pollution from 1990 to 2015 at global, regional, and country levels. Methods We estimated global population-weighted mean concentrations of particle mass with aerodynamic diameter less than 2·5 μm (PM2·5) and ozone at an approximate 11 km × 11 km resolution with satellite-based estimates, chemical transport models, and ground-level measurements. Using integrated exposure–response functions for each cause of death, we estimated the relative risk of mortality from ischaemic heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, lung cancer, and lower respiratory infections from epidemiological studies using non-linear exposure–response functions spanning the global range of exposure. Findings Ambient PM2·5 was the fifth-ranking mortality risk factor in 2015. Exposure to PM2·5 caused 4·2 million (95% uncertainty interval [UI] 3·7 million to 4·8 million) deaths and 103·1 million (90·8 million 115·1 million) disability-adjusted life-years (DALYs) in 2015, representing 7·6% of total global deaths and 4·2% of global DALYs, 59% of these in east and south Asia. Deaths attributable to ambient PM2·5 increased from 3·5 million (95% UI 3·0 million to 4·0 million) in 1990 to 4·2 million (3·7 million to 4·8 million) in 2015. Exposure to ozone caused an additional 254 000 (95% UI 97 000–422 000) deaths and a loss of 4·1 million (1·6 million to 6·8 million) DALYs from chronic obstructive pulmonary disease in 2015. Interpretation Ambient air pollution contributed substantially to the global burden of disease in 2015, which increased over the past 25 years, due to population ageing, changes in non-communicable disease rates, and increasing air pollution in low-income and middle-income countries. Modest reductions in burden will occur in the most polluted countries unless PM2·5 values are decreased substantially, but there is potential for substantial health benefits from exposure reduction. Funding Bill & Melinda Gates Foundation and Health Effects Institute.

                Author and article information

                American College of Chest Physicians
                08 October 2020
                February 2021
                08 October 2020
                : 159
                : 2
                : 575-584
                [a ]Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, the Netherlands
                [b ]Department of Pulmonary Diseases, National Center of Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
                [c ]UCL Respiratory, University College London, United Kingdom
                [d ]Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Madrid, Spain
                [e ]Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD
                [f ]Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
                [g ]Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD
                [h ]Woolcock Institute of Medical Research, Sydney, Australia
                [i ]South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
                [j ]Division of Thoracic Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
                [k ]University of Medicine and Pharmacy ‘Grigore T. Popa’ Iasi (UMF Iasi), Iasi, Romania
                [l ]Biomedical Research Unit, A.B. PRISMA, Lima, Peru
                [m ]Universidad de San Martin de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru; and the Universidad Cientifica del Sur, Facultad de Ciencias de la Salud, Lima, Peru
                [n ]Department of Medicine, Makerere Lung Institute, Kampala, Uganda
                [o ]Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
                [p ]ARK Foundation, Dhaka, Bangladesh
                [q ]University of Sydney, Faculty of Medicine and Health, Australia
                [r ]Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga Portugal; ICVS/3B’s, PT Government Associate Laboratory, Braga/Guimarães, Portugal
                [s ]University of Groningen, University Medical Center Groningen, Department of Health Sciences, Unit of Global Health, Netherlands
                [t ]Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
                Author notes
                [] CORRESPONDENCE TO: Job F. M. van Boven, PharmD, PhD j.f.m.van.boven@ 123456rug.nl
                © 2020 The Authors

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

                COPD: Original Research

                Respiratory medicine
                chronic obstructive,consensus,developing countries,pulmonary disease,reference standards,gacd, global alliance for chronic diseases,gni, gross national income,gold, global initiative for chronic obstructive lung disease,hic, high-income countries,iom, institute of medicine,lmic, low- and middle-income countries,prisma, preferred reporting items for a systematic review and meta-analysis


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