Description of the condition

Chronic obstructive pulmonary disease (COPD) is a ‘common, preventable and treatable condition that is characterised by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious gases and particles’ (GOLD 2017). Cigarette smoke is the biggest risk factor for the development of COPD, especially in middle‐income to high‐income countries (Decramer 2012; WHO 2017a). The airflow limitation characteristic of COPD is detected through spirometry testing (GOLD 2017). Diagnosis and assessment of COPD severity are based on the ratio of post‐bronchodilator forced expiratory volume in one second (FEV₁) to forced vital capacity (FVC). A ratio < 0.7 suggests airflow limitation consistent with COPD (GOLD 2017). Another approach involves the use of lower limit of normal values as cut‐offs for COPD diagnosis, in contrast to the fixed cut‐off value of 0.7 (Culver 2012). The four stages of GOLD (Global Initiative for Chronic Obstructive Lung Disease; GOLD I to IV), which categorises patients according to % FEV₁ predicted, are commonly used to assess severity of COPD (GOLD 2017). The ABCD grading system assesses COPD symptoms, along with exacerbation frequency and severity (GOLD 2017).

Prevalence of COPD varies widely from 0.2% to 37% according to country, population, age group analysed and method of diagnosis used (such as spirometry and other classification methods according to symptoms) (Rycroft 2012). The actual prevalence of COPD is likely to be higher than reported in studies owing to widespread underdiagnosis of the condition in some parts of the world (Koblizek 2016). Approximately 80% of COPD cases confirmed by spirometry were previously undiagnosed (Koblizek 2016).

Chronic obstructive pulmonary disease is widely acknowledged as a major health problem associated with substantial burden on morbidity, mortality and healthcare resources (Decramer 2012; Toelle 2013). It is the fourth leading cause of death in the world and is projected to be the third leading cause by 2030, accounting for 8.6% of deaths globally (WHO 2008). Chronic and progressive respiratory symptoms, such as dyspnoea and cough with sputum production, are frequently experienced by patients with COPD (GOLD 2017). The disease is aggravated by acute exacerbations of the disease, which reduce quality of life in affected patients (Decramer 2003; Doll 2005) and result in extensive use of healthcare services. Potential psychological effects of the condition such as anxiety and depression, along with systemic manifestations and comorbidities (such as ischaemic heart disease, congestive heart failure, diabetes and lung cancer), can contribute to loss of quality of life (Decramer 2012; Doll 2005; Putcha 2015).

Description of the intervention

New developments in therapeutics and changes in the evidence base for treatments occur over time. Treatment guidelines and strategies change accordingly. It is acknowledged that professionals from all health fields should invest in educational opportunities that give them up‐to‐date knowledge and skills so they can provide best patient care (WHO 2017b). The term ‘continuing professional development’ (CPD) is used to describe the "process by which health professionals keep updated to meet the needs of patients, the health service, and their own professional development" (Peck 2000). This includes "continuous acquisition of new knowledge, skills, and attitudes to enable competent practice" (Peck 2000). Health professional registration boards and regulatory bodies in many countries mandate CPD for legislated revalidation and recertification of practitioners (Peck 2000). Continuing education (CE) is an integral part of CPD. Types of CE for different health professions are named accordingly, for example, continuing medical education (CME), continuing nursing education (CNE) and continuing pharmacy education (CPE). Recently, continuing interprofessional education (CIPE) has been recognised as a distinct branch of CE (Owen 2013).

Educational activities provided in CE/CPD programs vary in terms of educational media (i.e. format used to deliver educational content, e.g. printed materials, videotapes, audiotapes, podcasts, online materials), method of delivery (e.g. live sessions vs Internet or other technology‐based sessions), educational technique (specific educational tools used to deliver media, such as small group learning, lectures and simulation) and exposure (duration and frequency of the activity) (Moores 2009). Activities can be categorised as (1) ‘live' or external activities, such as courses, seminars, meetings, conferences and audio and video presentations, (2) internal activities, including practice‐based activities, case conferences, grand rounds, journal clubs, teaching and consultation with peers and colleagues, and (3) ‘enduring' materials (print, CD‐ROM or Web‐based materials, with testing or assessment) (Peck 2000). Educational interventions can consist of individual activities or may involve multiple activities, and can be didactic, interactive or a mixture of both (Davis 1999).

How the intervention might work

It is assumed that CE for health professionals improves healthcare practice and, thereby, health outcomes for patients receiving care (Forsetlund 2009). The effectiveness of continuing education can be analysed in three areas: competence, performance and patient health status (Lloyd 1979). Reviews have shown that CE can improve knowledge, performance skills, attitudes and behaviour of health professionals, as well as patient healthcare outcomes (Bloom 2005; Cervero 2015; Robertson 2003). Additionally, more specific reviews of the effectiveness of different CE formats have been conducted. Reviews of online CME have shown positive effects on professional practice and satisfaction (Thepwongsa 2014), and reviews of CE meetings, including conferences, workshops and rounds, have shown beneficial effects on both professional practice and patient healthcare outcomes (Forsetlund 2009). In contrast, didactic presentations and distribution of printed information have been shown to provide little or no benefit in changing physician practice (Bloom 2005).

Despite dissemination of evidence‐based guidelines and the availability of resources, evidence still suggests suboptimal management of COPD in primary care. Underutilisation of spirometry in COPD diagnosis is a key problem identified in the primary care setting (Abramson 2012; Walters 2011; Zwar 2011), leading to misdiagnosis and underdiagnosis. Lack of spirometry referral for high‐risk patients is a major barrier to improved patient outcomes, as it delays treatment of patients with potential COPD and associated symptoms (Drexel 2011). In addition, adherence to recommended management guidelines by health professionals is poor. Approximately one in four adults 40 years of age or older, with known risk factors for COPD, have airway obstruction consistent with COPD diagnosis (Drexel 2011; Zhou 2010). Even though the prevalence of COPD is high in primary care, the condition remains undertreated compared with less morbid and asymptomatic conditions such as hypertension (Barr 2009). Various studies have identified deviations from recommended pharmacological treatment guidelines by primary care professionals (Glaab 2012; Jones 2008; Price 2014). It is also very common for evidence‐based non‐pharmacological components of guidelines to be omitted from COPD management (Bourbeau 2008; Johnston 2012; Jones 2008; Price 2014).

Although review authors found good evidence showing benefits for patients with COPD of non‐pharmacological management components such as pulmonary rehabilitation, smoking cessation support and vaccinations, these components are commonly absent from COPD management. It is important that health professionals are adequately educated on the benefits of these and their routine use in practice. Smoking cessation is integral, regardless of disease severity (GOLD 2017), with quitting smoking shown to slow rate of lung function decline, preserve remaining lung function and delay onset of disability (Anthonisen 1994; Anthonisen 2002; GOLD 2017; Tashkin 1996). Knowing patients’ smoking habits and recording smoking status and smoking information are essential for identifying high‐risk patients and providing appropriate smoking cessation support to delay progression of COPD and worsening of symptoms (Jimenez‐Ruiz 2015; Vasankari 2011). Influenza vaccination has been shown to reduce risks of exacerbation, hospitalisation and death among patients with COPD (GOLD 2017; Nichol 1994; Poole 2006), and the incidence of community‐acquired pneumonia in younger patients with COPD with FEV₁ < 40% predicted or comorbidities was reduced after pneumococcal vaccination (Alfageme 2006; GOLD 2017).

Studies have shown beneficial effects of training and education on health professional knowledge and practices surrounding COPD diagnosis and treatment. A one‐hour training session on national COPD guidelines provided to hospital physicians was shown to improve the percentage of individuals correctly given a diagnosis of COPD and ability of physicians to correctly grade COPD severity and correctly prescribe COPD treatment (Cai 2015). A four‐day spirometry and COPD interactive training programme with Web assistance provided to community pharmacists was shown to improve identification of high‐risk individuals and performance of spirometry to identify airflow obstruction (Castillo 2015). Participation in an educational programme on COPD in Denmark primary care was shown to improve FEV₁ recording in patient files, smoking cessation counselling provision, referral to pulmonary rehabilitation and appropriate prescribing of inhaled corticosteroids (Ulrik 2010). Another study looking at a one‐day interactive COPD CME/CE programme for 351 primary care clinicians in the United States showed improvement in clinician self‐confidence, knowledge of COPD and implementation of clinical change after completion of the programme (Adams 2012).

Why it is important to do this review

The worsening burden of COPD calls for critical review and assessment of the efficacy of different interventions aimed at case finding and diagnosing COPD, controlling COPD symptoms, preventing exacerbations and maintaining quality of life. Education of health professionals involved in the management of COPD may fill existing practice gaps in COPD recognition and management.

Although numerous original studies and reviews have surrounded the effectiveness of educational interventions targeted at patients, less work has been done in reviewing the evidence behind educational interventions targeted at health professionals involved in the management of COPD. Patients are usually extensively treated in the primary care setting (with general practitioners serving as the main health professionals providing care for most patients with COPD (Koblizek 2016)) before moving into secondary and tertiary care as the condition progresses. However, evidence of suboptimal management in the primary care setting has aroused concern, and awareness and use of evidence‐based guidelines are known to be low (Adams 2012). Therefore, it is important that primary care health professionals involved in COPD management are clinically up‐to‐date and well educated so they can provide high‐quality primary care services to affected patients (Fletcher 2007).

We will conduct this review to assess the effectiveness of education provided to doctors, and of educational interventions provided to the wide range of health professionals who play important roles in COPD diagnosis and ongoing management. Different healthcare workers provide different components of care to patients with COPD. The roles of nurses, pharmacists and allied health professionals, such as physiotherapists, are becoming increasingly important with availability of new therapeutic agents and increasing awareness of the benefits of pulmonary rehabilitation programmes. Growing interest in COPD management involving interprofessional collaboration among health professions and multidisciplinary team‐based care has led to studies investigating both patient‐related outcomes and health professional practices (Chavannes 2009; Kruis 2010; Kruis 2014; Zwar 2012). Improving knowledge and skills related to optimal COPD management amongst all health professionals practising in primary care could further improve guideline adherence, health professional practice and patient‐related outcomes.