The Cascade of Care in the Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

BackgroundThe gaps between evidence-based recommendations and real-world practice for management of chronic obstructive pulmonary disease (COPD) have been poorly characterised. We aimed to describe the progress of patients with COPD through the cascade of care.MethodsWe performed five systematic reviews and meta-analyses of observational studies evaluating the diagnosis and treatment of patients with COPD. We searched MEDLINE, Embase, CINAHL, Global Health, and the Cochrane Library for studies, published between January 2000 and December 2018, that reported data on the following five main components of patient care: diagnosis using spirometry, pharmacotherapy, smoking cessation, vaccination, and pulmonary rehabilitation. A random effects model was used to identify the proportion of patients with COPD completing each step in the cascade.FindingsWe identified 18, 32, 15, 48, and 36 studies for diagnosis, pharmacotherapy, smoking cessation, vaccination, and pulmonary rehabilitation components, respectively. Major gaps in the cascade included: assignment of a diagnosis of COPD among people with airflow obstruction and respiratory symptoms (29·7% [95% CI 13·1 – 54·3%]), adherence to maintenance inhalers up to 12 months (proportion of days covered: 30·9% [95% CI 18·3 – 47·1%]; medication possession ratio: 29·7% [95% CI 20·3 – 41·3%]), vaccination against S.pneumoniae (37·9% [95% CI 24·9 – 53·0%]), and referral for pulmonary rehabilitation (20·4% [95% CI 9·2 – 39·3%]).InterpretationSubstantial gaps were identified between evidence and practice for patients along the cascade of care for COPD. Further policies and actions are needed to address these gaps and reduce the global burden of COPD.FundingAustralian National Health and Medical Research Council.