The Value of UK Respiratory Conditions Research on Clinical Practice Guidelines from Other European Member States

Background/objectives: Research on chronic non-communicable respiratory conditions is limited. This study assessed the impact of UK medical research on other European countries development of clinical practice guidelines (CPGs), to evaluate the UK contribution to the evidence-base of European CPGs on chronic non-communicable respiratory conditions. Method: The UK contribution was determined on a fractional count basis to clinical guidelines’ citations: (1) from each of five selected (target) Member States (MS), namely France, Germany, The Netherlands, Sweden and Switzerland; and (2) from the other 25 countries (the other 23 EU MS, plus Iceland and Norway). Results: There were 6,087 cited references on 52 clinical practice guidelines published from 21 European countries. The UK contribution varied between 11% and 17% for the five target EU MSs countries for all respiratory conditions clinical guidelines. There was more foreign collaboration research on Chronic Obstructive Pulmonary Disease (COPD) (33%) than asthma (25%) with results being statistically significant. Conclusions: The study showed the importance of UK medical research contribution to the evidence-base of respiratory clinical guidelines in other European MS. Notable differences between asthma and COPD, can inform research priorities and medical progression on respiratory conditions’ clinical management. *Corresponding author: Elena Pallari, King’s College London, Institute of Psychiatry, Psychology & Neuroscience, Centre for Implementation Science, De Crespigny Park, Denmark Hill, London, SE5 8AF, United Kingdom, Tel: 02078480683; E-mail: elena.pallari@kcl.ac.uk Received November 24, 2017; Accepted December 04, 2017; Published December 11, 2017 Citation: Pallari E (2017) The Value of UK Respiratory Conditions Research on Clinical Practice Guidelines from Other European Member States . J Pulm Respir Med 7: 434. doi: 10.4172/2161-105X.1000434 Copyright: © 2017 Pallari E. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
Clinical practice guidelines (CPGs) are being increasingly used to provide recommendations based on the best available evidence to assist clinicians in effective decision-making towards the care of the patient as well as decrease variation of care [1][2][3]. Studies demonstrated that their use does change clinical practice and improve the quality of patient care, despite variations of reported outcomes [4][5][6].
Research on chronic non-communicable respiratory conditions is limited with only 0.77% of the overall biomedical research output in Europe attributed to these and 0.55% in the world between 2002 and 2013, while their disease burden accounts eight-times more [7,8]. Additionally, research in this field is unresearched with a 2.5%-4.5% funding across biomedical research and 4.3% within the European Union's (EU) seventh Framework Programme for Research and Technological Development (FP7) [8,9]. For the period 2007-2013 the UK received a total of €8.8 billion from EU, while the EU received €77.7 billion worth of UK funding [10].
Throughout Europe there are different organisations involved in the development of CPGs for a range of diseases, acute or chronic conditions. As part of a European Commission research project on the evaluation of the impact of non-communicable diseases, this short piece of research work focuses on the assessment of the extent of UK influence on the cited research evidence-base of CPGs development in other European countries. The set objectives were to identify CPGs on chronic respiratory conditions, collect their underpinning cited references and analyse the contribution of UK research in the form of evidence-base references from these guidelines. This was done for those respiratory CPGs causing the most disease burden on the average European population (see methods section).

Selection of clinical practice guidelines
For this work, the cited references underpinning the clinical care recommendations within CPGs were analysed across Europe.
(NHG) involved with all guidelines available through one electronic platform [15]. The National Board of Health and Welfare (NBHW) under the Ministry of Health and Social Affairs (Socialstyrelsen) in Sweden is responsible for the development of guidelines at the national level [11,16]. In Switzerland the process of CPGs development is decentralised with various organisations involved, and with the Swiss Respiratory Society overseeing the only CPG identified on COPD [17].
For a list of the involved organisations and identified clinical guidelines, see Table 1.
KCL graduate students were recruited and trained to identify clinical guidelines in the field of respiratory conditions for the 28 European Union Member States and three European Free Trade Association countries: Iceland, Switzerland and Norway (EUR31). The study period was 2002-2013 for the publication of the clinical guidelines; however, some of the cited references were published well before 2002, as 2013 accepted articles were published in 2014. EP then identified the cited references, downloaded their details from the Web of Science® Clarivate Analytics and using VBA programs their publication details were extracted on an Excel spreadsheet. Due to the high volume of clinical guidelines published in the EUR31 countries during 2002-2013, the work was limited to an analysis of those that dealt with diseases and disorders causing 1% or more of the European disease burden, as measured by Disability-Adjusted Life Years (DALYs) [2]. For respiratory conditions DALYs affecting the European population 2.95% are due to COPD and 1.07% due to asthma, shown in Table 2.

Data processing
The details of the cited references within the clinical guidelines were prepared as a series of search statements on Excel, including keywords from the title, publication year and author and run against the Web of Science (WoS). Their full bibliographic details were downloaded as text files from the WoS and were then converted by means of a VBA program into an Excel spreadsheet. An additional VBA program was used for an analysis of the addresses on each paper, and the fractional count of each country was tabulated in a separate column of the spreadsheet. The titles of the papers were matched to those of cited papers in the respiratory clinical guidelines and other details including address, publication year, journal and funding information was recorded.

Data analysis
The main analyses performed was of the contribution of the UK to cited papers in the respiratory clinical guidelines in the following way: These comparisons were designed to show the contribution of the UK in context on a fractional count basis (adding up to 100%). For example, a paper with two French addresses and one German one would be counted 1 each for FR and DE on integer counting, but 0.67 and 0.33 respectively on fractional counting. However, there are some papers that do not have addresses, meaning that the number of classified papers in the results section on the Tables does not correspond to the overall number of cited research papers (left-hand column "Papers", on "Total") as these were excluded from any analysis.

Comparator analysis
The UK percentage presence in the respiratory conditions research was determined for the world excluding each of the five target EU MSs and the other 25 EU MSs. These percentages were then compared with the UK contributions to papers cited by the RESPI clinical guidelines to these MSs. All data were calculated on a fractional count as this gives a better understanding to the actual contribution of the UK to other countries' guidelines.

Results
The results presented are for the UK contribution to CPGs published by the five target Member States and by the other Member there was a CPG on COPD, this was not included in the analysis as the cited references were a few (n=20) and although included other clinical practice guidelines from other countries including the UK, it would not reach any meaningful results among the hundreds of analysed references.  States as a group. This was done for both respiratory conditions' clinical guidelines collectively and for the two respiratory conditions, asthma and chronic obstructive pulmonary disease (COPD) separately. The results presented are on a fractional count basis. There were 52 clinical guidelines on two respiratory conditions, asthma and COPD, in 18 European countries with a total number of 6,087 cited references, as shown in Table 1.

Overall respiratory conditions
On overall respiratory conditions, the other nine EU MSs are Austria, Belgium, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, Hungary, Lithuania, Portugal, Romania and Spain. Table 3 shows raw values and UK contribution on a fractional count basis. The UK contribution to other EU Member States clinical guidelines shows that about one in six research papers is cited in a country's own clinical guidelines portfolio as shown in Tables 3-5. The UK contribution is in terms of a percentage presence of different countries (Tables 4 and 5). This is higher than the five target EU MSs collectively (column other 4) and higher than the rest of the EU MSs' contribution. However, the European contribution to UK guidelines was less than that of the USA or the Rest of the World (RoW). The presence of different countries as a percentage of foreign collaboration, shows that UK is higher than the other four EU MSs, but almost equal to the rest of Europe collectively, and less than the rest of the world or the US, shown in Table 4.

Asthma
On asthma, the other six EU MSs are Croatia, Czech Republic, Finland, Hungary, Lithuania, Portugal, Romania and Spain. Table  6 shows raw values and UK contribution on a fractional count basis. The UK contribution is in terms of a percentage presence of different countries (Tables 7 and 8). The UK contribution to other EU Member States clinical guidelines varies between 11-19% of research papers cited in a country's own clinical guidelines portfolio as shown in Tables  7 and 8. For asthma, this is higher than own country's contribution, and higher than the five target EU MSs collectively (column other 4) but less than the rest of the EU MSs' contribution ( Table 7). The UK contribution though, is less than the Rest of the World or the United States and is also comparable on foreign contribution too (Table 8).

COPD
On COPD, the other nine EU MSs are Austria, Belgium, Bulgaria, Czech Republic, Denmark, Finland, Hungary, Lithuania and Spain. Table 9 shows the raw values and UK contribution on a fractional count basis. The UK contribution is in terms of a percentage presence of different countries (Tables 10 and 11). The UK contribution to other EU Member States clinical guidelines varies between 11-19% of research papers cited in a country's own clinical guidelines portfolio as shown in Tables 10 and 11. For asthma, this is higher than own country's contribution or than the five target EU MSs collectively (column other 4) but less than the rest of the EU MSs' contribution (     contribution though, is less than the Rest of the World or the United States and is also comparable on foreign contribution too (Table 11).

Comparison of UK's presence on CPG references with its presence in respiratory conditions research
The UK percentage contribution to the evidence base of clinical guidelines from five target EU MS (Germany, France, Netherland, Sweden and Switzerland), and other continental European countries, is shown on Table 12 for all respiratory conditions, asthma and COPD.

Variation of UK participation with time
Some of the references on the clinical guidelines go back before the start of the study year 2002. Therefore, to examine the variation of UK participation with time and assess the impact on research citation in the CPGs, the UK cited research papers were classified into six broad five-year periods: before 1990, 1990-1994, 1995-1999, 2000-2004, 2005-2009, 2010-2014 for the three NCD fields as shown in Table 13. The participation of the UK in the CPGs decreased slightly with time for all respiratory conditions. For asthma, particularly there has been a great decrease of UK research in the European clinical guidelines evidence base. For COPD, there was a drop between 1995-1999 but then a sharp increase and during the last five-year period an increase.

Discussions
This study was set to examine the research landscape of Europe in the form of UK influence on clinical guidelines' development. There is a substantial percentage contribution from UK institutions underpinning clinical practice guidelines' recommendations. This contribution of UK research to other EU MS's research is even greater on CPGs than research paper output as indicated by the ratios in Table 12. Perhaps this difference could indicate the important relevance of UK research as applied in the form of recommendations than other conventional research output measures. A limitation of this study though is the lack of examination of the contribution of European Member States' research on the UK clinical practice guidelines. A future piece of research work could be the examination of the UK CPGs for the contribution from individual European countries in the underpinned research evidence-base and the establishment of further impact on formed recommendations. This in particular could be of interest, as from 2010-2014 there has been a decrease on the UK contribution to asthma research and slightly more on COPD from the previous five years. This may indicate the need to strike a balance between research attention between asthma and COPD and even the consideration of other conditions like emphysema, bronchitis or cystic Fibrosis (which were not included in this study). The clinical importance of such a shift in the trend of the cited research evidence-base for clinical practice may be due to a potential shift towards new or experimental treatments      tackling COPD. Although this cannot be inferred in this study, a previous study demonstrated that the citation of asthma research in European CPGs was more clinical than COPD [7] while research reported on newspaper stories was more basic than that of COPD [8]. Also, the latter study [8] demonstrated a heavily reporting research on asthma than COPD despite the reverse image presented by the disease burden afflicted by the European population. However, with limited funding, such research practices may even lead to further variation between countries' CPG focus and even greater disparities between the different respiratory conditions.

Conclusions
This study assessed the UK contribution to the evidence-base of other European countries' respiratory conditions' clinical practice guidelines. The UK contribution to the evidence-base of respiratory clinical guidelines was about a sixth for the five key European Member States and for the rest of the EU. The study showed the importance of UK medical research to healthcare in other European MS based on evidence-based recommendations. The UK participation in the clinical guidelines' references decreased slightly over time for asthma but increased for COPD. The extent of this impact on clinical practice though remains unknown. It would be of interest to see how such studies contributing to evidence-based recommendations are influencing clinical practice or patient outcomes. Assessing the adherence or implementation of such evidence-based recommendations from these various European respiratory conditions guidelines and comparing their impact in practice can have further implications for research, finding and collaboration. Potential implications of the current findings are that UK medical research is important for healthcare in other EU MS, so they have an interest in ensuring that it is not adversely affected by the UK's departure from the EU.