Chronic obstructive pulmonary disease guidelines in Europe: a look into the future

REVIEW Open Access Ch onic obs uc i e pulmona y disease guidelines in Eu ope: a look in o he u u e Ma c Mi a i lles 1* , Nicolas Roche 2 , João Ca doso 3 , Da id Halpin 4 , Zau bek Aisano 5 , Hannu Kankaan an a 6,7 , Vladimi Kobližek 8 , PawełŚliwiński 9 , Lei Bje me 10 , Michael Tamm 11 , F ancesco Blasi 12 and Claus F. Vogelmeie 13 Abs ac Clinical p ac ice guidelines a e ubiqui ous and a e de eloped o p o ide ecommenda ions o he managemen o many diseases, including ch onic obs uc i e pulmona y disease. The de elopmen o hese guidelines is bu densome, demanding a signi ican in es men o ime and money. In Eu ope, he majo i y o coun ies de elop hei own na ional guidelines, despi e he po en ial o o e lap o duplica ion o e o . A conce ed e o and consolida ion o esou ces be ween coun ies may alle ia e he esou ce-in ensi y o main aining indi idual na ional guidelines. Despi e signi ican esou ce in es men in o he de elopmen and main enance o clinical p ac ice guidelines, hei implemen a ion is subop imal. E ec i e s a egies o guideline dissemina ion mus be gi en mo e conside a ion, o ensu e adequa e implemen a ion and imp o ed pa ien ca e managemen in he u u e. Keywo ds: Ch onic obs uc i e pulmona y disease, Clinical p ac ice guidelines, T ea men ecommenda ions Backg ound The ul ima e ea men goals in ch onic obs uc i e pul- mona y disease (COPD) managemen emain uni o m ac oss he majo i y o na ional and in e na ional COPD clinical p ac ice guidelines (CPGs), and include educed symp oms, educed exace ba ion isk and imp o ed quali y o li e [1]. To achie e hese goals, CPGs equi e egula upda es wi h ecen and ele an s a e-o - he-a medical and scien i ic de elopmen s. Guidelines s i e o imp o e he quali y o heal hca e and o educe a ia- ions in he ea men and managemen o COPD [2]. Clinical p ac ice guidelines p o ide ecommenda ions on pa ien managemen based on a ailable e idence and, in ce ain cases, educa ed opinion whe e he e is no di - ec e idence a ailable [3]. The quali y o he a ailable e idence and he in ended audience o CPGs emain co e conside a ions o hei de elopmen [4]. In ecen yea s, CPGs ha e u he e ol ed in esponse o an inc easing ecogni ion o he need o mo e s ingen , sys ema ic app oaches when ecommending speci ic he apeu ic in e en ions o s a egies [5]. The impo ance o igo ous p ocesses o ensu e ha only accu a e and ap- p op ia e ea men ecommenda ions a e made is now well-accep ed among p o essional scien i ic socie ies. In ac , s anda ds o guide he p epa a ion o CPGs a e now a ailable [6]. Howe e , li le a en ion is a o ded o he challenges and pi alls associa ed wi h he de elopmen o such documen s. A conce ed e o be ween mul iple s akeholde s is needed o ensu e p ecise, p ac ical and up- o-da e clinical ecommenda ions o he diagnosis and op imal managemen o COPD. Guidelines mus be locally ele an ; he e o e local expe s akeholde s should o e local p oposals, while e e ing o global e idence-based documen s. This e iew a icle highligh s he challenges associa ed wi h he de elopmen and implemen a ion o na ional CPGs o COPD in Eu ope and Russia. Cu en challenges associa ed wi h he de elopmen o guidelines Impo an ad ances in he me hodologies used o he de elopmen o CPGs ha e been made in ecen yea s. These include he G ading o Recommenda ions Assess- men , De elopmen and E alua ion (GRADE) guides [7]. GRADE p o ides a anspa en , sys ema ic app oach o e iew a ailable e idence and a e i s quali y, in o de o * Co espondence: [email p o ec ed] 1 Pneumology Depa men , Uni e si y Hospi al Vall d’Heb on, Cibe de En e medades Respi a o ias (CIBERES), Ba celona, Spain Full lis o au ho in o ma ion is a ailable a he end o he a icle © The Au ho (s). 2018 Open Access This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion 4.0 In e na ional License (h p://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o he C ea i e Commons license, and indica e i changes we e made. The C ea i e Commons Public Domain Dedica ion wai e (h p://c ea i ecommons.o g/publicdomain/ze o/1.0/) applies o he da a made a ailable in his a icle, unless o he wise s a ed. Mi a i lles e al. Respi a o y Resea ch (2018) 19:11 DOI 10.1186/s12931-018-0715-1 make ecommenda ions o g aded s eng h based on he deg ee o con idence in he bene i - isk-cos a io and ap- plicabili y o he s a egies o in e es . GRADE is bes used in esponse o de ined key clinical (popula ion/in e en- ion/compa a o /ou come [PICO]) ques ions [5, 8, 9]. E idence-based CPGs should equi e minimal in e - p e a ion by end-use s, o educe he isk o bias. Howe e , his ype o CPG also ca ies inhe en d aw- backs and limi a ions, including a po en ial disconnec- ion be ween he ocus on high-quali y scien i ic e idence and eal-wo ld clinical p ac ice [10]. E idence- based guidelines may no add ess a eas whe e he e is an insu icien numbe o well-designed clinical ials (i.e. e idence), bu ye clinicians s ill equi e guidance in hese a eas [11]. While igo ous me hodologies such as he GRADE s a egy o e obus and less biased ea men ecom- menda ions, solely elying on such s ic me hodologies can also comp omise he conclusions and ex e nal alid- i y o CPGs. Using high-le el, o mal me hodology o de- elop guidelines may exclude clinically ele an s udy esul s [12]. E idence-based guidelines may educe p o- essional au onomy o clinical judgemen [11]. Fu he - mo e, he e idence included in hese g ading p ocesses is p ima ily collec ed om speci ic subse s o pa ien s who mee s ic inclusion c i e ia o pa icipa ion in la ge clinical ials: speci ically, egis a ion andomised con olled ials (RCTs) ec ui pa ien s in whom he e is he highes chance o demons a e he e icacy o es ed agen s [10]. Consequen ly, o en he esul s ob- ained do no allow de e mina ion o (i) he gene alis- abili y o esul s ob ained in selec ed popula ions, o (ii) he mos sui able a ge subg oups in e ms o bene i - isk a io. Howe e , i is well- ecognised ha signi ican he e ogenei y exis s among pa ien s wi h COPD. Olde o e y se e e COPD pa ien s, pa ien s wi h a his o y o as hma and/o alle gy, ne e smoke s o pa ien s wi h mul iple como bidi ies may no mee inclusion c i e ia and he e o e may no be ep esen ed by he e idence used o suppo mos ecommenda ions wi hin guide- lines [3, 11]. A ecen s udy by Halpin e al. epo ed ha only 27% o COPD pa ien s a e eligible o RCTs [13]. Unde - ep esen a ion o “challenging pa ien s”(i.e. hose who do no mee s ic eligibili y c i e ia, pa icu- la ly he elde ly, hose wi h signi ican como bidi ies and hose equi ing long- e m oxygen he apy) in RCTs esul s in e idence-based CPGs ha may no be ully adequa e o ensu e he op imal managemen o a signi i- can numbe o pa ien s. Con e sely howe e , guidelines which ely hea ily on consensus opinion, a he han high-quali y e idence, may be ulne able o bias and indi idual in e p e a ion [11]. To y o ind he igh balance, e idence om eal- wo ld e ec i eness s udies should be mo e hea ily conside ed in CPGs. These could include he esul s o obse a ional s udies o p agma ic ials whe e app op i- a e [10], p o ided ha hey sa is y app op ia e quali y s anda ds [14]. In ligh o his, CPGs should ideally combine bo h e idence- and opinion-based app oaches in a complemen a y and anspa en way. This can be achie ed by clea ly highligh ing sec ions ha a e e idence- based, and add essing gaps in he knowledge by educa ed opinion o ex apola ion om e icacy e idence in o he disease a eas. Fu he mo e, o signi ican conside a ion is he use o single-disease guidelines o pa ien s wi h mul- iple como bidi ies. This may be pa icula ly ele an in he case o COPD, because due o he ad anced age o he majo i y o pa ien s and he exposu e o noxious pa icles o gases, especially obacco smoking, he p e alence o co- mo bidi ies is subs an ial [15]. In addi ion, COPD and i s espi a o y consequences can exe di ec dele e ious e - ec s on o he sys ems; one example is he e ec o lung hype in la ion on hea unc ion [16]. Con e sely, some como bidi ies can inc ease he bu den o COPD; e.g., anx- ie y and dep ession can inc ease he pe cep ion o dyspnea h ough a ious mechanisms including hype en ila ion and psychological dis ess [17]. The equency and ype o como bidi ies p esen ed may be di e en in pa ien s in eal li e compa ed o hose included in RCTs [18]; he e- o e, guidance on mul imo bidi y will need o be consid- e ed in he u u e [19–21]. Guidelines a e ime-consuming and expensi e o p o- duce. Ex ensi e li e a u e e iews and de ailed analyses equi e mo e ime and esou ces han clinical and aca- demic expe s can dedica e o he de elopmen and up- da es o na ional o in e na ional CPGs [12, 22–24]. This pu s s ain on local and na ional socie ies wi h lim- i ed unding. Budge and a ailable esou ces a e impo - an ac o s o mos coun ies when de eloping and upda ing hei na ional guidelines [22]. Financial suppo om p i a e (e.g. pha maceu ical) companies may aise issues a ound po en ial con lic s o in e es [24]. New simpli ied s a egies o CPG de elopmen a e being es ed; hey combine consensus h ough a Delphi me h- odology wi h s ic applica ion o GRADE in a eas whe e consensus is no eached o ha a e subjec o a high isk o bias [25]. I adequa ely alida ed, hese s a egies could sa e signi ican ime and esou ces. An o e iew o he de elopmen al p ocesses o na ional CPGs in Eu ope and Russia is p esen ed in Table 1. The key a ge audiences o na ional and in e na ional guidelines Iden i ying he key a ge audience is a c i ical s ep in he de elopmen o CPGs. The audience is b oad, and includes heal hca e p ac i ione s wi h a ying le els o specialisa ion and expe ise, as well as non-heal hca e p o essionals [26]. Pulmonologis s, gene al p ac i ione s Mi a i lles e al. Respi a o y Resea ch (2018) 19:11 Page 2 o 9 Table 1 The de elopmen o na ional guidelines in Eu ope and Russia: pa icipan s and in ended audiences Coun y E idence sys em used O ganisa ion in ol ed in he de elopmen Pa icipan s in ol ed in he de elopmen In ended audience Re e ence Czech Republic Consensus The Czech Pneumological and Ph hisiological Socie y (CPPS) commissioned an expe g oup o d a ecommended guidelines o he managemen o s able COPD. Subsequen e isions we e u he discussed a he Na ional Consensus Con e ence. Re iewe s’commen s con ibu ed o he es ablishmen o he inal e sion. Pulmonologis s and pha macologis s Pulmonologis s ( ull e sion), in e nis s, GPs, and eme gency physicians ( educed e sion). The Czech na ional ecommenda ion was ully accep ed by he S a e Ins i u e o D ug Con ol (SUKL). [43] England NICE echnical manual me hodology (includes GRADE) Na ional Ins i u e o Heal h and Ca e Excellence (NICE) Pulmonologis s, GPs, espi a o y nu ses, physio he apis s pa ien s, NICE echnical eam (including heal h economis s), eedback om egis e ed s akeholde s (payo s, p o essional bodies, hospi als e c.) Pulmonologis s, GPs, o he specialis s, all o he heal hca e p o essionals in ol ed in ca ing o people wi h COPD, payo s and manage s h ps://www.nice.o g.uk/p ocess/ pmg20/chap e /in oduc ion- and-o e iew [44] Finland E idence-based medicine and GRADE me hodology The Cu en Ca e Guidelines we e de eloped by he Finnish Medical Socie y Duodecim in associa ion wi h a ious medical specialis socie ies. The guidelines we e p oduced wi h public unding and a e open o all heal hca e p o essionals and he gene al public, and include pa ien e sions. A la ge e iewing g oup including GPs was asked o commen on he guideline. Pulmonologis s, GPs and in e nis s Pulmonologis s, GPs, o he specialis s, all o he heal hca e p o essionals (including nu ses, physio he apis s, pha macis s) and ci izens www.kaypahoi o. i/web/english/ home [41,45] F ance (A) Posi ion pape / s a emen on pha macological ea men op imisa ion o s able COPD A es ic ed expe g oup was commissioned by he na ional socie y (SPLF) o p oduce an ini ial p oposi ion. A la ge e iewing g oup including GPs was asked o commen . Pulmonologis s and GPs Pulmonologis s and GPs [46] (B) GRADE me hod o guidelines on exace ba ions An ex ensi e mul idisciplina y g oup o expe s and end-use s was commissioned o p oduce he ini ial documen , which was commen ed on by a panel o ex e nal e iewe s. Pulmonologis s, GPs, in ensi is s, eme gency physicians, physio he apis s and nu ses Pulmonologis s, GPs, in ensi is s, eme gency physicians, physio he apis s and nu ses [47] Ge many Consensus The Ge man Respi a o y Socie y (DGP) and he Ge man Ai way League (AWL) commissioned an expe g oup o de elop a guideline o he diagnosis, assessmen and managemen o COPD. Pulmonologis s Pulmonologis s, GPs, in ensi is s, eme gency physicians, physio he apis s, nu ses and pa ien s Vogelmeie CF e al. Pneumologie 2017; in p epa a ion I aly Consensus The documen was p epa ed by a wo king g oup appoin ed by he h ee majo na ional espi a o y socie ies (AIMAR, AIPO and SIMeR) and he I alian Socie y o Gene al Medicine (SIMG). Rep esen a i es o he I alian Minis y o Heal h and AGE.NA.S. we e in ol ed as ex e nal independen obse e s o ensu e e hical, social and solida i y p inciples. Pulmonologis s and GPs Pulmonologis s and o he specialis s wo king ei he inside o ou side he hospi al se ing, GPs, o he heal hca e p o essionals, pa ien associa ions, and ins i u ions a na ional, egional, o local le el [48] Mi a i lles e al. Respi a o y Resea ch (2018) 19:11 Page 3 o 9 Table 1 The de elopmen o na ional guidelines in Eu ope and Russia: pa icipan s and in ended audiences (Con inued) Coun y E idence sys em used O ganisa ion in ol ed in he de elopmen Pa icipan s in ol ed in he de elopmen In ended audience Re e ence Poland Consensus Polish Respi a o y Socie y Pulmonologis s Pulmonologis s and a sho e sion o GPs [49] Po ugal Consensus Na ional Heal h Au ho i y (DGS) commissioned an expe g oup, including Na ional Physicians O ganiza ion (OM) and Po uguese Respi a o y Socie y (SPP) ep esen a i es, o p oduce a guidance documen . Pulmonologis s All Physicians o he Na ional Heal h Se ice (SNS) [50] Russia E idence-based medicine and consensus Russian Respi a o y Socie y and Russian Minis y o Heal h. Pulmonologis s Pulmonologis s, GPs, o he heal hca e p o essionals, pa ien associa ions, and ins i u ions a na ional, egional, o local le el [51] Spain GRADE and consensus 11 medical scien i ic socie ies and he Na ional Associa ion o Pa ien s. Pulmonologis s, GPs, in e nal medicine, ehabili a o s, nu ses, physio he apis s, ge ia icians, eme gency specialis s and pa ien s Pulmonologis s, GPs, in e nal medicine and eme gency specialis s [52] Sweden (A) E idence-based medicine and consensus Swedish Medical P oduc s Agency (MPA) Pulmonologis s, GPs, alle gologis s and physio he apis s Pulmona y specialis s, GPs and in e nal medicine specialis s h ps://lakemedels e ke .se/ upload/halso-och-sjuk a d/be handlings ekommenda ione / K onisk _obs uk i _lungsjukdom _KOL_behandlings ekommen da ion.pd [53] (B) E idence-based medicine and GRADE The Swedish Na ional Boa d o Heal h and Wel a e Pulmonologis s, GPs, alle gologis s and physio he apis s Pulmona y specialis s, GPs and in e nal medicine specialis s [54] Swi ze land Consensus The Swiss Socie y o Pneumology (SGP) commissioned an expe g oup including pulmonologis s om all i e Uni e si y Hospi als in Swi ze land, a ep esen a i e om a REHAB Clinic and a leas one ep esen a i e om each Language Region in Swi ze land Swiss medical doc o s (membe s o he Foede a io Medico um Hel e ico um [FMH]) Pulmonologis s, GPs, in e nal medicine and specialis s [55] Abb e ia ions:GP gene al p ac i ione , GRADE g ading o ecommenda ions assessmen , de elopmen and e alua ion Mi a i lles e al. Respi a o y Resea ch (2018) 19:11 Page 4 o 9 (GPs), o he heal hca e p o essionals, pa ien s, payo s and policy-make s a e he p ima y audiences o COPD guidelines. Al hough no di ec ly in ol ed in he deli e y o pa- ien ca e, heal hca e payo s, policy-make s and egu- la o y agencies also comp ise he eade ship o CPGs. Recommenda ions ha elie e he bu den o disease (e.g. educe he equency o se e i y o cos ly exace - ba ions) o s a egies o encou age ea ly diagnosis in COPD pa ien s can be o conside able bene i o payo s. Payo s ely on CPGs and obus e icacy e i- dence in o de o make in o med decisions on und- ing and eimbu semen policies o speci ic he apies [27, 28]. Policy-make s also need CPGs o de elop ad- equa e p e en ion s a egies and o build pa hways o ca e [29]. Guidelines a e hea ily ega ded by egula- o y au ho i ies, which may impac he design o clinical ials. This is o signi ican impo ance when egula o y au ho i ies adop he de ini ion o diagnos- ic c i e ia used by a pa icula guideline when de in- ing he equi emen s o no el d ugs, he eby (and pe haps inad e en ly) in luencing he design o clinical ials [30]. Who is in ol ed in he de elopmen o CPGs? Guidelines ha a e in ended o widesp ead use in clin- ical p ac ice should include ele an s akeholde s a a i- ous and app op ia e s ages o he de elopmen p ocess, which may encou age imp o ed implemen a ion and ad- he ence o he ecommenda ions h ough an inc eased sense o owne ship [31, 32]. Al hough i may no be ap- p op ia e o all s akeholde s o ake an ac i e ole in he de elopmen p ocess om he beginning, ce ain g oups may pa icipa e in he d a ing o ecommenda ions o a he e iew s ages. Academic o clinical expe in ol emen in guideline p epa a ion should include GPs, pulmonologis s, nu ses and physio he apis s whe e app op ia e [31]. As he ma- jo i y o COPD ca e is adminis e ed by GPs, hei in- ol emen in guideline de elopmen may d i e inc eased p ima y ca e physician-specialis communica ion and in- eg a ion, which is c ucial in he managemen o COPD, pa icula ly when pa ien e e al is necessa y. Inpu om nu ses, ca diologis s, physio he apis s and die i- cians may also add alue and clinical expe ise o guide- lines in he pa hways o ca e [26]. Impo an ly, guidelines should in ol e all “end-use s”, including pa ien s, non-expe p ac i ione s and payo s o ensu e ha he guidelines add ess he igh ques ions om a amily o socie y pe spec i e. C i ically, his may also help o inco po a e pa ien p e e ences in o he guidelines. Inc eased in ol emen may encou age pa- ien s o play a mo e ac i e ole in hei heal hca e managemen [33]. A s anda dised pan-Eu opean guideline; is his ealis ic? Duplica e e o s a e made ac oss Eu ope, wi h indi id- ual coun ies in es ing signi ican esou ces in o he de- elopmen o CPGs [34]. Ins i u ional collabo a ion and consolida ion o e o s may signi ican ly educe he cumbe some na u e o guideline de elopmen and equen upda es [35]. Fu he mo e, a ia ions in indi idual se s o guidelines will ine i ably con inue unless collabo a ion is encou aged and op imised be- ween coun ies. These a ia ions, howe e mino , ha e he po en ial o mislead o con use p ac icing heal hca e p o essionals [10]. Mos na ional guidelines in Eu ope ha e been in lu- enced o a ying ex en s by GOLD. Mo eo e , GOLD 2017 [36] will likely impac u u e e isions o Eu opean na ional guidelines in a mo e owa ds mo e pe sonalised ea men o COPD. The GOLD s a egy also ca ies a majo posi i e ad an age in ha he documen is upda ed annually wi h he mos ecen and ele an li - e a u e and s udies; howe e , no o mal e alua ion o e idence (i.e. GRADE o simila ) is pe o med. In addi ion, since by i s de ini ion, GOLD aims o p o ide a global s a egy documen , some ecommenda ions may no be di ec ly (i.e. wi hou any adap a ion) applicable in some a eas o con ex s. As mos coun ies do no ha e he esou ces o acili a e an annual upda e o hei na- ional guidelines, each coun y has he oppo uni y o adop speci ic sec ions o GOLD ha a e locally ele an . Such p ocesses could be acili a ed by igh e collabo - a ion be ween GOLD commi ees and egional, na ional o local ini ia i es. Owing o he impo ance o na ional guidelines, coupled wi h he in e na ional a ailabili y o he GOLD 2017 docu- men , he e may be po en ial o he de elopmen o an in e media y documen be ween he wo. This could com- p ise a single de ailed “umb ella”e idence base suppo ing common p inciples bu wi h an adap a ion o ecommen- da ions o e lec local p ac ices. Indi idual sensi i i ies could he e o e be acili a ed wi hin his common adap - able empla e. Na ional eimbu semen policies, a ailabil- i y o esou ces and/o egula o y legisla ion may cause guideline ecommenda ion and p esc ip ion de ia ions be ween coun ies. In b ie , i s -line ea men ecom- menda ions (a he class le el) and seconda y ecommen- da ions could be included wi hin he common guideline, wi h local al e na i e sugges ions added a a local le el in line wi h local policy and scien i ic socie ies. To suppo he in oduc ion and implemen a ion o a common, adap able Eu opean guideline, a pan- Eu opean guideline de elopmen esou ce eposi o y could be compiled as a suppo ool. Mo eo e , di e - en sec ions o a guideline dedica ed o a speci ic heal hca e p ac i ione ole may boos implemen a ion ac oss clinical p ac ice. Mi a i lles e al. Respi a o y Resea ch (2018) 19:11 Page 5 o 9 The e is po en ial o signi ican alle ia ion o ime and budge cons ain s h ough a conce ed, collabo a- i e e o be ween Eu opean coun ies. Who should ake he lead du ing such a collabo a ion emains o be discussed, bu i is likely ha he Eu opean Respi a o y Socie y (ERS) is in he bes posi ion o lead such a p o- jec . The ERS is commi ed o he de elopmen o high quali y CPGs [37], and ei he alone o in conce wi h sis e socie ies such as he Ame ican Tho acic Socie y (ATS), has also deli e ed e idence-based CPGs o he managemen o COPD [38, 39]. De eloping a Eu opean collabo a ion would be bes achie ed h ough he ERS and na ional socie ies, ag eeing on a common me hod- ology. Tigh links wi h he GOLD g oup could also be use ul o sha e e ie ed e idence and inc ease eac i i y, allowing a con inuous upda e and adap a ion p ocess. Can COPD guidelines be simpli ied? The e is an appa en con adic ion be ween he expo- nen ial inc ease in he scien i ic knowledge o COPD complexi y (pheno ypes, endo ypes, como bidi ies e c.) and he need o simpli ied ea men pa hways. Com- plex aw da a needs o be agg ega ed and ansla ed in o meaning ul, use ul in o ma ion o suppo ecommenda- ions o new ea men s [29]. Algo i hms may be help ul o guide COPD he apy in a simple, s epwise and coo di- na ed manne [40]. Such algo i hms need o be lexible and con inuously e ol ing in o de o emain up- o-da e and clinically ele an . Impo an ly, he a ailabili y o al- go i hms does no nega e he need o scien i ic p inci- ples, and he ole o clinical judgemen should always be acknowledged. Conside a ions o e ec i e guideline dissemina ion Once inalised, he CPGs should be sha ed in many ways o ensu e op imal dissemina ion. F eely accessible online publishing o he guidelines is impo an . A way o wa d could be o amalgama e CPGs on all diseases in o one single po al ha is accessible by all physicians, o he heal hca e p o essionals and he gene al public ee o cha ge. This has been done in Finland by he gene al Medical Socie y Duodecim Cu en Ca e Guideline sys em whe e guidelines on mo e han 100 diseases a e colla ed on a single online po al and used by mos heal hca e p o essionals [41]. Also, p esen ing he guide- lines a local, na ional and in e na ional cong esses may inc ease awa eness amongs a my iad o heal hca e p ac- i ione s. Fu he mo e, inno a i e me hods o in o m ele an end-use s o CPGs could be conside ed e.g. e- mail blas s o social media communica ions. Plain language summa ies may also p o e help ul o guide pa- ien s and hei ela i es on a ailable ea men s. A sho pocke e sion should be made a ailable o all physicians o acili a e quick and easy access du ing pa ien consul a ions. Use ul ea men algo i hms should be a ailable on an easily-na igable websi e. Using sma echnology may also imp o e he implemen a ion o guidelines. Such applica ions may also ha e a place wi hin al eady-exis ing clinical in eg a ed managemen sys ems such as GP p ac ice compu e so wa e. The inal p esen a ion o he ecommenda ions should also be ca e ully conside ed. Succinc and concise ec- ommenda ions p esen ed in an easily-diges ible o ma such as ables o cha s should be conside ed o busy heal hca e p ac i ione s [10]. Conclusions E idence-based CPGs a e igo ous by hei e y na u e, bu a e di icul o implemen in eal-li e clinical p ac ice [11]. Some sugges ions o imp o emen in he de elop- men and implemen a ion o COPD CPGs a e p esen ed in Table 2. The au ho s sugges ha an ideal COPD guideline documen should comp ise a ai balance be- ween e idence-based and expe opinion-based ecom- menda ions whe e de ini i e e idence is una ailable. Fo anspa ency, each ecommenda ion should clea ly s a e whe he i is suppo ed by e idence o based on expe opinion and clinical judgemen . The key a ge medical audience o COPD guidelines include pulmonologis s and GPs, wi h pa ien s, payo s and policy-make s also comp ising he in ended audi- ence. All end-use s should be in ol ed in he de elop- men o guidelines. Fo mally assessing wha hey expec om he guidelines and which ba ie s may impede hei implemen a ion could help o e come cu en insu i- ciencies in ou ine ca e o COPD pa ien s. Some guideline de elope s s uggle o p o ide he ne- cessa y esou ces o suppo he de elopmen and/o Table 2 Sugges ions o imp o emen in he de elopmen and implemen a ion o COPD guidelines De elopmen o CPG mus be based on a alida e me hod o e alua ion and g ading o e idence (GRADE o simila ) In a eas in which GRADE may no be applied, consensus o opinion-based ecommenda ions should be inco po a ed A clea iden i ica ion o e idence-based and consensus-based ecommenda ions is manda o y o anspa ency Clea and simple algo i hms a e necessa y o in e p e a ion and implemen a ion All s akeholde s mus pa icipa e in CPGs de elopmen A common Eu opean guideline could be used as a e e ence and can be adap ed o local heal h sys ems The Eu opean Respi a o y Socie y could be he pla o m o gene a e and discuss na ional Eu opean CPGs Dissemina ion and adhe ence is c ucial and new echnologies may help o his objec i e New s udies a e equi ed o e alua e he impac o CPGs on clinical and economic ou comes in COPD Mi a i lles e al. Respi a o y Resea ch (2018) 19:11 Page 6 o 9 egula upda e o hei guidelines. Fu he mo e, i is pos- sible ha no all aspec s o in e na ional guidelines will be di ec ly ele an o all local pa ien s. In his ega d, imp o ed collabo a ion be ween Eu opean coun ies and he ERS may be bene icial, whe e a single in e media y s a egy documen o he managemen o COPD should be conside ed. This documen could encompass some o e a ching high-le el common p inciples, wi h he im- po an oppo uni y o local adap a ion. This may sig- ni ican ly educe he cos s and esou ces associa ed wi h guideline de elopmen o many coun ies. Al hough he majo i y o COPD managemen is con- duc ed by GPs, amilia i y o guidelines amongs gene al p ac i ione s is subop imal. App oxima ely 24% o gen- e al p ac i ione s ha e epo ed ha hey a e no amilia wi h he GOLD s a egy o COPD [42]. Quick and easy access o guidelines on a websi e o sma phone is impo an o maximise guideline imple- men a ion. A quickly- and easily-unde s andable ea - men algo i hm may help o simpli y COPD guidelines. The algo i hm mus be lexible and con inually e ol ing in acco dance wi h new esea ch and e idence. The e is s ill a pauci y o knowledge on he e ec o adequa e COPD guideline implemen a ion on disease managemen and pa ien ou comes. Fu he s udies a e wa an ed o add ess his gap in he li e a u e. Abb e ia ions ATS: Ame ican Tho acic Socie y; COPD: Ch onic obs uc i e pulmona y disease; CPG: Clinical p ac ice guidelines; ERS: Eu opean Respi a o y Socie y; GOLD: Global Ini ia i e o Ch onic Obs uc i e Lung Disease; GP: Gene al p ac i ione ; GRADE: G ading o Recommenda ions Assessmen , De elopmen and E alua ion; PICO: Popula ion/in e en ion/compa a o / ou come ques ion; RCT: Randomised con olled ial Acknowledgmen s The au ho s hank Gillian La elle, PhD, o No a is P oduc Li ecycle Se ices (Dublin, I eland), o p o iding medical w i ing suppo o his a icle, which was unded by No a is Pha ma AG, Basel, Swi ze land in acco dance wi h Good Publica ion P ac ice (GPP3) guidelines (h p://www.ismpp.o g/gpp3). The au ho s also hank P o esso Ba olome Celli (Bos on, US) o b inging he de ini ion o a guideline by he US Depa men o Ve e ans A ai s o hei a en ion. Funding None o he au ho s ecei ed paymen o compensa ion o he de elopmen o his a icle. Medical w i ing suppo was unded by No a is Pha ma AG, Basel, Swi ze land. A ailabili y o da a and ma e ials No applicable Au ho s’con ibu ions All au ho s made subs an ial con ibu ions o he d a ing and c i ical e iew o all s ages o his a icle. All au ho s ha e gi en inal app o al o he e sion o be published and ag ee o be accoun able o all aspec s o his wo k. E hics app o al and consen o pa icipa e No applicable Consen o publica ion No applicable Compe ing in e es s Ma c Mi a i lles has ecei ed speake ees om Boeh inge Ingelheim, Chiesi, Cipla, Mena ini, G i ols and No a is, and consul ing ees om Boeh inge Ingelheim, GlaxoSmi hKline, Geb o Pha ma, CLS Beh ing, No a is and G i ols. Nicolas Roche epo s g an s om Boeh inge Ingelheim, P ize and No a is, and pe sonal ees om Boeh inge Ingelheim, No a is, Te a, GSK, As aZeneca, Chiesi, Mundipha ma, Cipla, P ize , Sano i, Sandoz, 3 M, Zambon. João Ca doso epo s pe sonal ees om No a is, and has ecei ed hono a ia o scien i ic ad ice and/o lec u e ees om As aZeneca, Boeh inge Ingelheim, GSK, Mundipha ma and No a is. Da id Halpin epo s pe sonal ees om No a is. Zau bek Aisano and Michael Tamm ha e no con lic s o in e es o decla e. Hannu Kankaan an a epo s pe sonal ees om Almi all, As aZeneca, Chiesi, GSK, Boeh inge Ingelheim, Lei as-Takeda, MSD, No a is, Mundipha ma, Medi h, ResMed Finland, Roche and O ion Pha ma. He also epo s non- inancial suppo om Almi all, As aZeneca and In e mune, and g an s om As aZeneca. Vladimi Kobližek epo s pe sonal ees om As aZeneca, Angelini, Boeh inge Ingelheim, GSK, No a is, Pulmonx, Sandoz and Mundipha ma. He also epo s g an s om As aZeneca, GSK and No a is. PawełŚliwiński epo s pe sonal ees om Boeh inge Ingelheim, Chiesi, G i ols, No a is, Roche and Te a, and non- inancial suppo om Boeh inge Ingelheim and Chiesi. Lei Bje me epo s ha he has ecei ed hono a ia o a ending ad iso y boa ds o gi ing lec u es om As aZeneca, Boeh inge Ingelheim, Chiesi, GSK, No a is and Te a. F ancesco Blasi epo s pe sonal ees and g an s om As aZeneca, Baye , Chiesi, Mena ini, G i ols, P ize and Zambon, and pe sonal ees om GSK, Guido i and No a is. Claus F. Vogelmeie epo s pe sonal ees and g an s om As aZeneca, Boeh inge Ingelheim, Chiesi, GlaxoSmi hKline, G i ols, Mundipha ma, No a is and Takeda. He also epo s pe sonal ees om Almi all, Cipla, Be lin Chemie/Mena ini, CSL Beh ing and Te a, and g an s om he Ge man Fede al Minis y o Educa ion and Resea ch (BMBF) Compe ence Ne wo k As hma and COPD (ASCONET), Baye Sche ing Pha ma AG, MSD and P ize . Publishe ’sNo e Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in published maps and ins i u ional a ilia ions. Au ho de ails 1 Pneumology Depa men , Uni e si y Hospi al Vall d’Heb on, Cibe de En e medades Respi a o ias (CIBERES), Ba celona, Spain. 2 Se ice de Pneumologie e Soins In ensi s Respi a oi es, Hôpi al Cochin (AP-HP), Uni e si y Pa is Desca es (EA2511), Pa is, F ance. 3 Hospi al de San a Ma a, Cen o Hospi ala de Lisboa Cen al, Uni e sidade No a de Lisboa, Lisbon, Po ugal. 4 Royal De on and Exe e Hospi al, Exe e , UK. 5 Pulmonology Depa men , Pulmonology Resea ch Ins i u e, Russian Na ional Medical Uni e si y, Moscow, Russia. 6 Depa men o Respi a o y Medicine, Seinäjoki Cen al Hospi al, Seinäjoki, Finland. 7 Facul y o Medicine and Li e Sciences, Uni e si y o Tampe e, Tampe e, Finland. 8 Depa men o Pneumology, Uni e si y Hospi al H adec K alo e, Facul y o Medicine in H adec K alo e, Cha les Uni e si y in P ague, H adec K alo e, Czech Republic. 9 2nd Depa men o Respi a o y Medicine, Ins i u e o Tube culosis and Lung Diseases, Wa saw, Poland. 10 Depa men o Respi a o y Medicine & Alle gology, Skåne Uni e si y Hospi al, Lund, Sweden. 11 Clinic o Pulmona y Medicine and Respi a o y Cell Resea ch, Uni e si y Hospi al, Basel, Swi ze land. 12 Depa men o Pa hophysiology and T ansplan a ion, Uni e si y o Milan, and Depa men o In e nal Medicine, Respi a o y Uni and Adul Cys ic Fib osis Cen e , Fondazione IRCCS Cà G anda Ospedale Maggio e Policlinico, Milan, I aly. 13 Depa men o Medicine, Pulmona y and C i ical Ca e Medicine, Uni e si y Medical Cen e Giessen and Ma bu g, Philipps-Uni e si y Ma bu g, Membe o he Ge man Cen e o Lung Resea ch (DZL), Ma bu g, Ge many. 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