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Health Care Guideline:
Diagnosis and Management of Chronic Obstructive
Pulmonary Disease (COPD)
www.icsi.org
Copyright 2016 by Institute for Clinical Systems Improvement 1
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Tenth Edition/January 2016
Evidence Grading
Literature Search
The VA/DoD literature search covered the time period from January 1, 2005 to February 2014. ICSI repli-
cated this search to include January 2014 February 2015.
Additional articles were provided by work group members and discussed by the work group prior to inclusion.
GRADE Methodology
Following a review of several evidence rating and recommendation writing systems, ICSI has made a decision
to transition to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.
GRADE has advantages over other systems including the current system used by ICSI. Advantages include:
developed by a widely representative group of international guideline developers;
explicit and comprehensive criteria for downgrading and upgrading quality of evidence ratings;
clear separation between quality of evidence and strength of recommendations that includes a
transparent process of moving from evidence evaluation to recommendations;
clear, pragmatic interpretations of strong versus weak recommendations for clinicians, patients and
policy-makers;
explicit acknowledgement of values and preferences; and
explicit evaluation of the importance of outcomes of alternative management strategies.
The VA/DoD document was developed using the GRADE methodology to evaluate the overall quality of
the body of evidence (page 8 of Va/DoD guideline).
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Institute for Clinical Systems Improvement 2
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Tenth Edition/January 2016
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Institute for Clinical Systems Improvement 4
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Qualifications Table for COPD Tenth Edition/January 2016
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Institute for Clinical Systems Improvement 5
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Qualifications Table for COPD Tenth Edition/January 2016
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Institute for Clinical Systems Improvement 6
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Qualifications Table for COPD Tenth Edition/January 2016
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Institute for Clinical Systems Improvement 9
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Qualifications Table for COPD Tenth Edition/January 2016
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Institute for Clinical Systems Improvement 10
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Qualifications Table for COPD Tenth Edition/January 2016
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Institute for Clinical Systems Improvement 12
Quality Improvement Support:
Diagnosis and Management of Chronic Obstructive
Pulmonary Disease (COPD)
The Aims and Measures section is intended to provide protocol users with a menu
of measures for multiple purposes that may include the following:
population health improvement measures,
quality improvement measures for delivery systems,
measures from regulatory organizations such as Joint Commission,
measures that are currently required for public reporting,
measures that are part of Center for Medicare Services Clinician Quality
Reporting initiative, and
other measures from local and national organizations aimed at measuring
population health and improvement of care delivery.
This section provides resources, strategies and measurement for use in closing
the gap between current clinical practice and the recommendations set forth in the
guideline.
The subdivisions of this section are:
Aims and Measures
Implementation Recommendations
Implementation Tools and Resources
Implementation Tools and Resources Table
6. Increase the percentage of patients with moderate or severe COPD who have health directives in place.
Measure for accomplishing this aim:
a. Percentage of patients with moderate or severe COPD who have health care directives in place.
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Institute for Clinical Systems Improvement 15
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Aims and Measures Tenth Edition/January 2016
Measurement Specifications
Measure #1a
Percentage of COPD patients seen in emergency room for COPD-related exacerbations in one month.
Population Definition
Patients 18 years and older with COPD diagnosis.
Data of Interest
# of patients seen in emergency room for COPD-related exacerbations
# of patients with COPD
Numerator/Denominator Definitions
Numerator: Number of patients with COPD who are seen in emergency room for COPD-related exacerba-
tions in one month.
Denominator: Number of patients with COPD diagnosis.
Notes
This is an outcome measure, and improvement is noted as a decrease in the rate.
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Institute for Clinical Systems Improvement 16
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Aims and Measures Tenth Edition/January 2016
Measure #1b
Percentage of COPD patients who require hospital admission/readmission for COPD-related exacerbations
in one month.
Population Definition
Patients 18 years and older with COPD diagnosis.
Data of Interest
# of patients who were hospitalized for COPD-related exacerbations
# of patients with COPD
Numerator/Denominator Definitions
Numerator: Number of patients with COPD who were hospitalized for COPD-related exacerbations in
one month.
Denominator: Number of patients with COPD diagnosis.
Notes
This is an outcome measure, and improvement is noted as a decrease in the rate.
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Institute for Clinical Systems Improvement 17
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Aims and Measures Tenth Edition/January 2016
Measure #1c
Percentage of COPD patients with two or more hospitalizations over a 12-month period.
Population Definition
Patients 18 years and older with COPD diagnosis.
Data of Interest
# of patients who were hospitalized two or more times
# of patients with COPD
Numerator/Denominator Definitions
Numerator: Number of patients with COPD who were hospitalized for COPD-related exacerbations two
or more times over a 12-month period.
Denominator: Number of patients with COPD diagnosis.
Notes
This is an outcome measure, and improvement is noted as a decrease in the rate.
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Institute for Clinical Systems Improvement 18
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Aims and Measures Tenth Edition/January 2016
Measure #2a
Percentage of patients with a diagnosis of COPD who had spirometry testing to establish COPD diagnosis.
Population Definition
Patients 18 years and older with COPD diagnosis.
Data of Interest
# of patients who had spirometry testing to establish COPD diagnosis
# of patients with COPD
Numerator/Denominator Definitions
Numerator: Number of patients with COPD who had spirometry testing to establish COPD diagnosis.
Denominator: Number of patients with COPD diagnosis.
Notes
This is a process measure, and improvement is noted as an increase in the rate. Check for quality of spirom-
etry reading on a case-by-case basis.
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Institute for Clinical Systems Improvement 19
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Aims and Measures Tenth Edition/January 2016
Measure #3a
Percentage of patients with COPD who are asked about smoking and smoking exposure at every visit with
clinician.
Population Definition
Patients age 18 years and older with COPD diagnosis.
Data of Interest
# of patients with COPD who are asked about smoking and smoking exposure at every visit with clinician
# of patients with COPD
Numerator/Denominator Definitions
Numerator: Number of patients with COPD who are asked about smoking and smoking exposure at every
visit with clinician.
Denominator: Number of patients with COPD.
Notes
This is a process measure, and improvement is noted as an increase in the rate.
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Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Aims and Measures Tenth Edition/January 2016
Measure #3b
Percentage of patients with COPD who are smokers who have assessment of readiness to attempt smoking
cessation.
Population Definition
Patients 18 years and older with COPD diagnosis and smokers.
Data of Interest
# of patients who have assessment of readiness to attempt smoking cessation
# of patients with COPD and smokers
Numerator/Denominator Definitions
Numerator: Number of patients with COPD and smokers who have assessment of readiness to attempt
smoking cessation.
Denominator: Number of patients with COPD diagnosis and smokers.
Notes
This is a process measure, and improvement is noted as an increase in the rate.
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Institute for Clinical Systems Improvement 21
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Aims and Measures Tenth Edition/January 2016
Measure #3c
Percentage of COPD patients who are smokers who receive a smoking cessation intervention.
Population Definition
Patients 18 years and older with COPD diagnosis and smokers.
Data of Interest
# of patients who receive a smoking cessation intervention
# of patients with COPD and smokers
Numerator/Denominator Definitions
Numerator: Number of patients with COPD and smokers who receive a smoking cessation intervention.
Denominator: Number of patients with COPD diagnosis and smokers.
Notes
This is a process measure, and improvement is noted as an increase in the rate.
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Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Aims and Measures Tenth Edition/January 2016
Measure #3d
Percentage of patients with COPD and smokers who quit smoking (100% quit-rate goal).
Population Definition
Patients 18 years and older with COPD diagnosis and smokers.
Data of Interest
# of patients who quit smoking
# of patients with COPD and smokers
Numerator/Denominator Definitions
Numerator: Number of patients with COPD and smokers who quit smoking.
Denominator: Number of patients with COPD diagnosis and smokers.
Notes
This is an outcome measure, and improvement is noted as an increase in the rate. The target goal for quit
rate is 100%.
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Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Aims and Measures Tenth Edition/January 2016
Measure #4a
Percentage of patients with COPD who are prescribed appropriate therapy, including:
appropriate vaccinations per CDC schedule
long-term oxygen assessment and prescription for long-term home oxygen for those who are hypoxic
and meet criteria
short-acting bronchodilator (when needed)
long-acting bronchodilator (when needed)
corticosteroids (when needed)
Population Definition
Patients 18 years and older with COPD diagnosis.
Data of Interest
# of patients who are prescribed appropriate therapy
# of patients with COPD
Numerator/Denominator Definitions
Numerator: Number of patients with COPD who are prescribed appropriate therapy, including:
appropriate vaccinations per CDC schedule
long-term oxygen assessment and prescription for long-term home oxygen for those who
are hypoxic and meet criteria
short-acting bronchodilator (when needed)
long-acting bronchodilator (when needed)
corticosteroids (when needed)
Denominator: Number of patients with COPD diagnosis.
Notes
This is a process measure, and improvement is noted as an increase in the rate.
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Institute for Clinical Systems Improvement 24
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Aims and Measures Tenth Edition/January 2016
Measure #5a
Percentage of patients with moderate or severe COPD who have been referred to a pulmonary rehabilitation
or exercise program.
Population Definition
Patients 18 years and older with COPD diagnosis.
Data of Interest
# of patients referred to a pulmonary rehabilitation or exercise program
# of patients with COPD
Numerator/Denominator Definitions
Numerator: Number of patients with moderate or severe COPD referred to a pulmonary rehabilitation or
exercise program.
Denominator: Number of patients with moderate or severe COPD.
Notes
This is a process measure, and improvement is noted as an increase in the rate.
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Institute for Clinical Systems Improvement 25
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Aims and Measures Tenth Edition/January 2016
Measure #6a
Percentage of patients with moderate or severe COPD who have health care directives in place.
Population Definition
Patients 18 years and older with COPD diagnosis.
Data of Interest
# of patients who have health care directives in place
# of patients with moderate or severe COPD
Numerator/Denominator Definitions
Numerator: Number of patients with moderate or severe COPD who have health care directives in place.
Denominator: Number of patients with moderate or severe COPD.
Notes
This is a process measure, and improvement is noted as an increase in the rate.
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Institute for Clinical Systems Improvement 26
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Tenth Edition/January 2016
Implementation Recommendations
Prior to implementation, it is important to consider current organizational infrastructure that address the
following:
System and process design
Training and education
Culture and the need to shift values, beliefs and behaviors of the organization. In addition, this
document was developed for the VA system and may not always be generalizable to all health care
systems.
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Institute for Clinical Systems Improvement 27
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Tenth Edition/January 2016
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Supporting Evidence:
Diagnosis and Management of Chronic Obstructive
Pulmonary Disease (COPD)
Abascal-Bolado B, Novotny PJ, Sloan JA, et al. Forecasting COPD hospitalization in the clinic: optimizing
the chronic respiratory questionnaire. Int J Chron Obstruct Pulmon Dis 2015;10:2295-301.
Bajaj A, Rathor P, Sehgal V, Shetty A. Efficacy of noninvasive ventilation after planned extubation: a
systematic review and meta-analysis of randomized controlled trials. Heart & Lung 2015;44:150-57.
Blakemore A, Dickens C, Guthrie E, et al. Depression and anxiety predict health-related quality of life
in chronic obstructive pulmonary disease: systematic review and meta-analysis. Int J Chron Obstruct
Pulmon Dis 2014;9:501-12.
Bollmeier SG, Prosser TR. Combination of fluticasone furoate and vilanterol for the treatment of chronic
obstructive pulmonary disease. Ann Pharmacother 2014;48:250-57.
Borge CR, Hagen KB, Mengshoel AM, et al. Effects of controlled breathing exercises and respiratory
muscle training in people with chronic obstructive pulmonary disease: results from evaluating the quality
of evidence in systematic reviews. BMC Pulm Med 2014;14:184.
DiSantostefano RL, Sampson T, Le HV, et al. Risk of pneumonia with inhaled corticosteroid versus
long-acting bronchodilator regimens in chronic obstructive pulmonary disease: a new-user cohort study.
PLoS One 2014;9:e97149.
Goossens LM, Leimer I, Metzdorf N, et al. Does the 2013 GOLD classification improve the ability to
predict lung function decline, exacerbations and mortality: a post-hoc analysis of the 4-year UPLIFT
trial. BMC Pulm Med 2014;14:163.
Gupta N, Pinto LM, Morogan A, Bourbeau J. The COPD assessment test: a systematic review. Eur
Respir J 2014;44:873-84.
Hardie JA, Buist AS, Vollmer WM, et al. Risk of over-diagnosis of COPD in asymptomatic elderly never-
smokers. Eur Respir J 2002;20:1117-22.
Holmedahl NH, verland B, Fondenes O, et al. Sleep hypoventilation and daytime hypercapnia in stable
chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2014;9:265-75.
Hsu KY, Lin JR, Lin MS, et al. The modified medical research council dyspnoea scale is a good indi-
cator of health-related quality of life in patients with chronic obstructive pulmonary disease. Singapore
Med J 2013;54:321-27.
Jcome C, Marques A. Pulmonary rehabilitation for mild COPD: a systematic review. Respir Care
2014;59:588-94.
Karbasi-Afshar R, Aslani J, Ghanei M. Efficacy and safety of inhaler steroids in COPD patients:
Systematic review and meta-analysis of randomized placebo-controlled trials. Caspian J Intern Med
2014;5:130-36.
Liu Y, Shi H, Sun X, et al. Benefits of adding fluticasone propionate/salmeterol to tiotropium in COPD:
a meta-analysis. Eur J Int Med 2014;25:491-95.
Lundell S, Holmer A, Brje R, et al. Telehealthcare in COPD: a systematic review and meta-analysis
on physical outcomes and dyspnea. Resp Med 2015;109:11-26.
Mathioudakis AG, Chatzimavridou-Grigoriadou V, Evangelopoulou E, et al. Comparative mortality risk
of tiotropium administered via handihaler or respimat in COPD patients: are they equivalent? Pulm
Pharmacol Ther 2014a;28:91-97.
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Institute for Clinical Systems Improvement 31
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
References Tenth Edition/January 2016
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Institute for Clinical Systems Improvement 32
Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Tenth Edition/January 2016
Collaborative Conversation
A collaborative approach towards decision-making is a fundamental tenet of Shared Decision-Making (SDM).
The Collaborative Conversation is an interprofessional approach that nurtures relationships; enhances
patients knowledge, skills and confidence as vital participants in their health; and encourages them to
manage their health care. Within a Collaborative Conversation, the perspective is that the patient, rather
than the clinician, knows which course of action is most consistent with the patients values and preferences.
Use of Collaborative Conversation elements and tools is even more necessary to support patient, care
clinician and team relationships when patients and families are dealing with high stakes or highly charged
issues. A diagnosis of a life-limiting illness is one example of such a circumstance.
The overall objective for the Collaborative Conversation approach is to create an environment in which
the patient, family and care team work collaboratively to reach and carry out a decision that is consistent
with the patients values and preferences, along with the best available evidence. A rote script, completed
form or checklist does not constitute this approach. Rather it is a set of skills employed appropriately for
the specific situation. These skills need to be used artfully to address all aspects of the person involved in
making a decision: cognitive, affective, social and spiritual.
Key communication skills help build the collaborative conversation approach. These skills include (Adapted
from OConnor, Jacobsen Decisional Conflict: Supporting People Experiencing Uncertainty about Options
Affecting their Health [2007], and Bunn H, OConnor AM, Jacobsen MJ Analyzing decision support and
related communication [1998, 2003])
1. Listening skills
Encourage patient to talk by providing prompts to continue such as go on, and then? and uh huh
or by repeating the last thing a person said, Its confusing.
Paraphrase content of messages shared by patient to promote exploration, clarify content and
to communicate that the persons unique perspective has been heard. The clinician should use their
own words rather than just parroting what they heard.
Reflection of feelings usually can be done effectively once trust has been established. Until the clini-
cian feels that trust has been established, short reflections at the same level of intensity expressed by
the patient without omitting any of the messages meaning are appropriate. Reflection in this manner
communicates that the clinician understands the patients feelings and may work as a catalyst for
further problem solving. For example, the clinician identifies what the person is feeling and responds
back in his or her own words like this: So, youre unsure which choice is the best for you.
Summarize the persons key comments and reflect them back to the patient. The clinician should
condense several key comments made by the patient and provide a summary of the situation. This
assists the patient in gaining a broader understanding of the situation rather than getting mired
down in the details. The most effective times to do this are midway through and at the end of the
conversation. An example of this is You and your family have read the information together,
discussed the pros and cons, but are having a hard time making a decision because of the risks.
Perception checks ensure that the clinician accurately understands a patient or family member
perspective, and may be used as a summary or reflection. They are used to verify that the clinician
is interpreting the message correctly. The clinician can say, So you are saying that youre not
ready to make a decision at this time. Am I understanding you correctly?
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Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
ICSI Shared Decision-Making Model Tenth Edition/January 2016
2. Questioning Skills
Open and closed questions are both used, with the emphasis on open questions. Open questions ask
for clarification or elaboration and cannot have a yes or no answer. An example would be, What
else would influence you to choose this? Closed questions are appropriate if specific information
is required, such as Does your daughter support your decision?
Other skills such as summarizing, paraphrasing, and reflection of feeling can be used in the ques-
tioning process so that the patient doesnt feel pressured by questions.
Verbal tracking, referring back to a topic the patient mentioned earlier, is an important foundational
skill (Ivey & Bradford-Ivey). An example of this is the clinician saying, You mentioned earlier
3. Information-Giving Skills
Providing information and providing feedback are two methods of information giving. The
distinction between providing information and giving advice is important. Information giving
allows a clinician to supplement his or her knowledge and helps to keep the conversation patient
centered. Giving advice, on the other hand, takes the attention away from the patients unique goals
and values, and places it on those of the clinician.
Providing information can be sharing facts or responding to questions. An example is If we look
at the evidence, the risk is Providing feedback gives the patient the clinicians view of the
patients reaction. For instance, the clinician can say, You seem to understand the facts and value
your daughters advice.
Table 1
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Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
ICSI Shared Decision-Making Model Tenth Edition/January 2016
The Collaborative Conversation Map is the heart of this process. The Collaborative Conversation Map
can be used as a stand-alone tool that is equally applicable to clinicians and patients, as shown in Table 2.
Clinicians use the map as a clinical workflow. It helps get the shared decision-making process initiated and
provides navigation for the process. Care teams can use the Collaborative Conversation to document team
best practices and to formalize a common lexicon. Organizations can build fields from the Collaborative
Conversation Map in electronic medical records to encourage process normalization. Patients use the
map to prepare for decision-making, to help guide them through the process and to share critical informa-
tion with their loved ones.
Table 2
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Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
ICSI Shared Decision-Making Model Tenth Edition/January 2016
Copyright 2012, 2016 by Institute for Clinical Systems Improvement. All rights reserved.
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Institute for Clinical Systems Improvement 38
Disclosure of Potential Conflicts of Interest:
Diagnosis and Management of Chronic Obstructive
Pulmonary Disease (COPD)
ICSI has long had a policy of transparency in declaring potential conflicting and
competing interests of all individuals who participate in the development, revision
and approval of ICSI guidelines and protocols.
In 2010, the ICSI Conflict of Interest Review Committee was established by the
Board of Directors to review all disclosures and make recommendations to the board
when steps should be taken to mitigate potential conflicts of interest, including
recommendations regarding removal of work group members. This committee
has adopted the Institute of Medicine Conflict of Interest standards as outlined in
the report, Clinical Practice Guidelines We Can Trust (2011).
Where there are work group members with identified potential conflicts, these are
disclosed and discussed at the initial work group meeting. These members are
expected to recuse themselves from related discussions or authorship of related
recommendations, as directed by the Conflict of Interest committee or requested
by the work group.
The complete ICSI policy regarding Conflicts of Interest is available at
http://bit.ly/ICSICOI.
Funding Source
The Institute for Clinical Systems Improvement provided the funding for this
guideline revision. ICSI is a not-for-profit quality improvement organization
based in Bloomington, Minnesota. ICSI's work is funded by the annual dues
of the member medical groups and three sponsoring health plans in Minnesota.
Individuals on the work group are not paid by ICSI but are supported by their
medical group for this work.
ICSI facilitates and coordinates the guideline development and revision process.
ICSI, member medical groups and sponsoring health plans review and provide
feedback but do not have editorial control over the work group. All recommenda-
tions are based on the work group's independent evaluation of the evidence.
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Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD)
Disclosure of Potential Conflicts of Interest Tenth Edition/January 2016
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Institute for Clinical Systems Improvement 41
Document History and Development:
Diagnosis and Management of Chronic Obstructive
Pulmonary Disease (COPD)
Document Drafted
Jan Jun 2000
First Edition
Dec 2001
Second Edition
Jan 2003
Third Edition
Jan 2004
Fourth Edition
Begins Jan 2005
Fifth Edition
Jan 2006
Sixth Edition
Feb 2007
Seventh Edition
Feb 2009
Eighth Edition
Begins Apr 2011
Ninth Edition
Apr 2013
Tenth Edition
The next revision will be no later than January 2021.
Begins Jan 2016
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Institute for Clinical Systems Improvement 43