Background:
Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable lung disease. COPD makes it harder for a person to get air in and out of the lungs. Symptoms include shortness of breath, cough, excess phlegm and wheezing. COPD can cause a huge impact on a person's life and lead to poor health.
Question:
What evidence exists for educational interventions delivered to health professionals managing COPD in primary care?
Search strategy:
To find relevant studies, we searched six online databases, trial registries and the reference list of included studies, retrieving studies published up until May 2021.
Selection criteria:
We included randomised controlled trials (RCTs) or studies of similar design comparing a group of health professionals or patients (or both) receiving an intervention with a group receiving usual care (no intervention) or receiving a different intervention. We included trials that studied educational interventions aimed at any health professionals involved in the management of COPD in primary care.
Main results:
We identified 38 studies, 36 of which tested interventions versus usual care, and seven of which compared two or more different types of interventions. A range of simple to complex interventions were used across the studies, including education provided to health professionals via sessions, workshops or online modules (31 studies), provision of practice support tools or tool kits (10 studies), provision of COPD clinical practice guidelines (nine studies) and training on lung function tests (five studies).
The studies we identified were very different in terms of who received the interventions, what interventions people received, where the interventions were delivered, and how and when the outcomes were measured. Due to these differences and problems with how the trials were conducted, we mostly considered the overall quality of the evidence to be low or very low.
Based on the current evidence, we were unable to determine the effects of educational interventions for health professionals on the proportion of COPD diagnoses confirmed with lung function tests, the proportion of patients with COPD who participated in pulmonary rehabilitation (specialised education and exercises to improve breathing) and the proportion of patients with COPD who were prescribed medications for their lungs/breathing that were consistent with recommended guidelines. However, the available evidence does suggest that educational interventions for health professionals probably improve influenza (flu) vaccination rates among patients with COPD and patient satisfaction with care.
Author's conclusions:
It was unclear whether educational interventions improved COPD management in primary care, including COPD diagnosis confirmed with lung function tests, participation in pulmonary rehabilitation and prescribing of guideline-recommended respiratory medication. However, educational interventions for health professionals may improve influenza vaccination rates and patient satisfaction with care. Interventions and outcomes varied greatly among studies, and there were problems regarding how the trials were conducted, which may have affected their results. Further high-quality studies are necessary to determine the effectiveness of educational interventions for health professionals managing COPD in primary care.
The evidence of efficacy was equivocal for educational interventions for health professionals in primary care on the proportion of COPD diagnoses confirmed with spirometry, the proportion of patients with COPD who participate in pulmonary rehabilitation, and the proportion of patients prescribed guideline-recommended COPD respiratory medications. Educational interventions for health professionals may improve influenza vaccination rates among patients with COPD and patient satisfaction with care. The quality of evidence for most outcomes was low or very low due to heterogeneity and methodological limitations of the studies included in the review, which means that there is uncertainty about the benefits of any currently published educational interventions for healthcare professionals to improve COPD management in primary care. Further well-designed RCTs are needed to investigate the effects of educational interventions delivered to health professionals managing COPD in the primary care setting.
Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable health condition. COPD is associated with substantial burden on morbidity, mortality and healthcare resources.
To review existing evidence for educational interventions delivered to health professionals managing COPD in the primary care setting.
We searched the Cochrane Airways Trials Register from inception to May 2021. The Register includes records from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED) and PsycINFO. We also searched online trial registries and reference lists of included studies.
We included randomised controlled trials (RCTs) and cluster‐RCTs. Eligible studies tested educational interventions aimed at any health professionals involved in the management of COPD in primary care. Educational interventions were defined as interventions aimed at upskilling, improving or refreshing existing knowledge of health professionals in the diagnosis and management of COPD.
Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data and assessed the risk of bias of included studies. We conducted meta‐analyses where possible and used random‐effects models to yield summary estimates of effect (mean differences (MDs) with 95% confidence intervals (CIs)). We performed narrative synthesis when meta‐analysis was not possible. We assessed the overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were: 1) proportion of COPD diagnoses confirmed with spirometry; 2) proportion of patients with COPD referred to, participating in or completing pulmonary rehabilitation; and 3) proportion of patients with COPD prescribed respiratory medication consistent with guideline recommendations.
We identified 38 studies(22 cluster-RCTs and 16 RCTs) involving 4936 health professionals (reported in 19/38 studies) and 71,085 patient participants (reported in 25/38 studies). Thirty-six included studies evaluated interventions versus usual care; seven studies also reported a comparison between two or more interventions as part of a three- to five-arm RCT design.
A range of simple to complex interventions were used across the studies, with common intervention features including education provided to health professionals via training sessions, workshops or online modules (31 studies), provision of practice support tools, tool kits and/or algorithms (10 studies), provision of guidelines (nine studies) and training on spirometry (five studies). Health professionals targeted by the interventions were most commonly general practitioners alone (20 studies) or in combination with nurses or allied health professionals (eight studies), and the majority of studies were conducted in general practice clinics.
We identified performance bias as high risk for 33 studies. We also noted risk of selection, detection, attrition and reporting biases, although to a varying extent across studies.
The evidence of efficacy was equivocal for all the three primary endpoints evaluated: 1) proportion of COPD diagnoses confirmed with spirometry (of the four studies that reported this outcome, two supported the intervention); 2) proportion of patients with COPD who are referred to, participate in or complete pulmonary rehabilitation (of the four studies that reported this outcome, two supported the intervention); and 3) proportion of patients with COPD prescribed respiratory medications consistent with guideline recommendations (12 studies reported this outcome, the majority evaluated multiple drug classes and reported a mixed effect). Additionally, the low quality of evidence and potential risk of bias make the interpretation more difficult.
Moderate-quality evidence (downgraded due to risk of bias concerns) suggests that educational interventions for health professionals probably improve the proportion of patients with COPD vaccinated against influenza (three studies) and probably have little impact on the proportion of patients vaccinated against pneumococcal infection (two studies).
Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on the frequency of COPD exacerbations (10 studies).
There was a high degree of heterogeneity in the reporting of health-related quality of life (HRQoL). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on HRQoL overall, and when using the COPD-specific HRQoL instrument, the St George's Respiratory Questionnaire (at six months MD 0.87, 95% CI -2.51 to 4.26; 2 studies, 406 participants, and at 12 months MD -0.43, 95% CI -1.52 to 0.67, 4 studies, 1646 participants; reduction in score indicates better health).
Moderate-quality evidence suggests that educational interventions for health professionals may improve patient satisfaction with care (one study).
We identified no studies that reported adverse outcomes.