. 2022 Jan 10;15:47–79. doi: 10.2147/JMDH.S343277

Table 1.

TDF^a Domains and Frequency Scores with Barriers and Potential Solutions from Included Studies

Discordant Clinical Practice	TDF^a Domain	COPD^a Guidelines Uptake Barrier	COM-B^a Components	BCW^a/Study Recommendations	Solutions/Future Research Recommendations	Frequency Scores /37
Non-adherence to oxygen guideline administration³⁵ Lack of updated COPD^a GOLD^a guidelines utilisation or management in reference to publishing years³⁰ Prescription of inhaled corticoid steroids (ICS)^a discordant to guidelines (dosage and duration)¹⁸ Lack of palliative care referrals⁶¹ Delayed switch to oral treatment with steroids⁴² Lack of inhaler technique checks with COPD^a exacerbations⁴⁶ Inappropriate antibiotic prescription⁴⁴ Variations in the management of acute exacerbations of chronic obstructive pulmonary disease⁴⁷ High flow oxygen initiated in ambulances continued in ED in spite of down titration³²	Knowledge	Lack of understanding of the effects, role and dangers of oxygen therapy³⁵ Lack of familiarity of COPD^a guidelines²³^,⁵³ Lack of knowledge on updated guideline with publishing years³⁰ Difficulty prognosticating in palliative care COPD^a due to the variable disease trajectory⁶¹ Lack of awareness of the consequences of poorly controlled disease⁴⁶ Care gaps between general internists, respiratory physicians and hospitals⁴⁷ Lack of knowledge of spirometry interpretation²³^,³²^,⁵³	Capability (psychological, Physical)	Training, modeling, enablement Education and other interventions to enhance self-learning among physicians¹²^,³⁸ Introduction of hospital guidelines²¹ Implementation and education of updated guideline versions in clinical practice³⁰ Educate clinicians of the indications and contraindications for ICS^a and encourage to prescribe according to the guidelines³⁶ Education of professionals involved in the care of COPD^a patients may reduce the risk of complications of hypercapnia⁵²	Electronic care order set and prescribing at point of care^10–12^,¹⁸^,²⁰^,⁴⁷^,⁵² Informational posters¹² Training all nurses, pharmacists and allied health to share responsibility in inhaler device and technique education⁴⁹^,⁵⁸ Clinical bundles/pathways to standardise care particularly with pharmacological management¹⁸^,²⁰^,²⁹^,³³^,³⁴^,⁶⁵ Targeted health professional education for each discipline⁵⁸ Interactive educational tools, specific cue cards in clinical practice and presence of hospital clinical champions³⁸	28/37
Lack of inhaler technique checks with COPD^a exacerbation⁴⁹ Inhaler device specific guidance appears to be lacking³⁴ Lacking skills to teach device specific inhaler technique²⁸ Lack of previous experience with NIV^a initiation¹¹^,⁵²	Skills	Lack of clear and specific guidance regarding inhalation devices in current COPD^a guidelines Lack of staff education on NIV^a, ²⁹	Capability (physical)	Training, Modeling The development and validation of appropriate educational tools for inhaler technique is necessary to assist clinicians and other health-care professionals who are involved in selecting inhalation devices³³^,⁴⁹	Inhaler technique educational videos for patient education in clinical practice¹⁵ Self-learning E-modules for staff in all departments¹⁵ Training all nurses, pharmacists and allied health to share responsibility in inhaler device and technique education¹⁵^,⁴⁹ Increasing education and disseminating guidelines in the working area utilising better implementation and change management strategies¹²	10/37
Respiratory specialists and nurses adhered national guidelines more accurately over internists⁵⁰ Misalignment of prescribing with GOLD^a recommendations between respiratory physician and general physician³⁶ Lack of clinician and multidisciplinary team co-operation¹⁸^,³⁸ The role of carers was poorly recognised in end stage COPD⁶¹ Palliative care or advance care planning not offered to end stage COPD^a patients⁶¹	Social/ Professional role and identity	Lack of inter speciality communication and guidance amongst clinicians³⁶^,⁵⁰ Communication between Guideline Committees and Clinicians should be improved⁵⁶ Variability in resources and organization of hospitals, patient characteristics, process of care, and outcomes¹⁹	Opportunity (Social)	Persuasion, Enablement; Cross fertilization of knowledge and practice patterns across clinicians so that all patients could receive evidence-based care in the most efficient manner (respiratory specialist clinicians versus internists)³⁶	Admission and Discharge bundle of care to integrate primary and tertiary care²⁰ Nurse facilitated reminder system³⁵	9/37
Care gaps in the inpatient management of AECOPD^a with guidelines¹¹^,¹²^,³⁶ The prevalence of clinical depression in patients with COPD^a varies from 18% to 80%, yet not screened regularly with AECOPD^a, ⁵⁹ Screening and pharmacological treatment for clinically confirmed depression not done as part of routine care⁵⁹	Environmental context and resources (staffing, funding, other resources)	Staff time constraints and lack of enthusiasm by senior clinical staff²¹^,³⁵ Clinicians lacking time to discuss palliative care or being fearful of taking away hope⁶¹ Current health care models with insufficient communication and collaboration²⁹ Poor access, lack of Palliative care service capacity⁶¹ Lack of human resources including specialists in pulmonary rehabilitation, infrastructure, and establishment of a well-equipped pulmonary rehabilitation unit²⁹ Lack of integration of multidisciplinary team of respirology and internal medicine ward physicians and allied health team members³⁶ Communication difficulties between doctors and nurses⁶⁵ Practical issues related to space and place for prescribing oxygen³²^,³⁸ Evidence for effectiveness of a specific pharmacological therapy for treating COPD^a related depression is still limited⁵⁹	Opportunity (physical)	Environmental restructuring, persuasion, Incentivisation Patient centred and coordinated interdisciplinary care across Primary, acute and community sectors³⁸ Integrated, multidisciplinary services, are urgently required to address the unmet needs of people and carers with advanced COPD³¹ COPD^a quality initiative framework for systematic follow-up of guideline to avoid variance of practice¹⁵^,⁶⁵ Care pathway implementation improves adherence with guidelines¹⁹, Pharmacological and non-pharmacological treatment options with cognitive behavioural based therapies, education, patient centred programmes⁵⁹	Automatic electronic linkage between hospital and community¹⁵ Simple preformatted order sets may be readily integrated into the diverse electronic health record platforms that currently exist across different hospitals¹⁰^,¹²^,⁴⁷^,⁵⁴ Message alerts on computer login screens¹¹^,¹²^,²⁰^,²⁴	16/37
Oxygen prescribing practices non adherent to guidelines³² Difficulty remembering updated guidelines³⁰	Memory attention	Difficulty recalling all delivery devices and management modality from COPD^a guidelines¹¹^,¹²^,⁴¹	Capability (psychological)	Environmental restructuring, Enablement, Education Point of care checklist in respiratory wards have improved guideline adherence¹² Health professional education and self-learning resources³⁸ Decision-making algorithms (including electronic systems) and reminders at the time of consultation, and continuous quality assurance programmes⁵⁴	Admission bundle with electronic prescribing system²⁰ Easy access to guidelines in clinical areas¹² Electronic order sets^10–12^,¹⁸^,²⁰, ³³^,⁴⁷^,⁵⁴	8/37
Lack of adherence to long-acting bronchodilators (LABD^a)³⁶^,⁴⁶ Poor concordance with AECOPD^a guidelines was observed in terms of antibiotic prescribing⁴⁸ Lack of prevention of future exacerbations with particular attention to smoking cessation, current vaccination knowledge of current therapy including inhaler technique and self-management²² Inconsistent pharmacotherapy adherence with GOLD^a guidelines⁴⁸ Poor compliance and variability in clinician practice with NIV^a, bronchodilators and systemic steroids in the emergency department¹¹^,¹²^,⁴¹ Systemic corticosteroid regimens used in clinical practice are administered for much longer periods and at higher doses than recommended in guidelines¹⁸^,³⁷^,⁴² Low utilisation of pulmonary rehabilitation¹⁰^,¹²^,²⁰^,³³^,³⁶^,⁵²^,⁶⁵ Lack of implementation of vaccination¹⁰^,²⁹ Unvaccinated patients not vaccinated in the acute setting¹⁵ Low utilisation of spirometry and ABG^a for COPD^a diagnosis²²^,²³^,³¹^,³²^,⁵²	Behavioural regulation	Failure to adhere to GOLD^a guidelines LABD^a prescription¹⁵^,⁴³ Suboptimal understanding of guideline recommendations lack of perceived treatment benefit, low self-efficacy and time constraints⁴⁹ Poor uptake of evidence by clinicians¹²^,²³ Varying standards of PR^a program and access²³^,³⁶	Capability (Psychological)	Modeling, Enablement Initiation and management of patients on LABD^a to prevent exacerbations³⁶^,⁴⁶ Dedicated AECOPD^a pathway may improve antibiotic selection, and help to drive compliance with guidelines¹⁹^,³⁴^,⁴⁷^,⁶⁵ Further research and implementation strategies recommended to study reasons behind discordant antibiotic prescribing practice⁴⁷ Well-structured screening protocol or program-based multimodality COPD^a care service should be developed¹² ED^a short stay unit pathways and access to community follow-up care with primary care or specialist clinics, disease specific outreach services¹¹^,²³ Guidelines were more specifically targeted to the process of emergency care may be more meaningful to ED^a clinicians¹¹^,²³ Rehabilitation professionals and social supporters can make rehabilitation more long-lasting and facilitate people with COPD^a to participate in activity by motivating and encouraging them, reducing their fears and reinforcing the benefits of activity participation²⁰^,⁵² Physicians should collaborate with hospital authorities to establish smoking cessation teams and pulmonary rehabilitation units²⁹ Integrated care pathway to improve non- pharmacological treatment in COPD^a, ¹⁸ Improve adherence to guidelines including clinical bundle services²⁴ Dedicated and holistic bundles of care for AECOPD^a have been implemented in the United Kingdom and have been demonstrated to improve patient management²⁰^,²⁴ Pro-forma aided COPD^a management in concordance to guidelines significantly improves the standards of care in COPDa patients in the EDa, ¹¹^,⁴¹ Evidence-based electronic order sets improved compliance with clinical practice guidelines^10–12^,¹⁸^,²⁰^,³³^,⁴⁷^,⁵⁴	Electronic order sets^10–12^,¹⁸^,²⁰, ³³^,⁴⁷^,⁵⁴ Evaluation audits and targeted health professional education for each discipline⁵⁸	36

Abbreviations: ^aTDF, theoretical domains framework; BCW, behavior change wheel; COM-B, capability, opportunity, motivation; COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative Obstructive Lung Disease; AECOPD, acute exacerbation of COPD; NIV, non-invasive ventilation; ABG, arterial blood gas; LABD, long‑acting bronchodilators; ICS, inhaled corticosteroids; PR, pulmonary rehabilitation; ED, emergency department.