Facilitators and barriers to the implementation of chronic obstructive pulmonary disease screening: a systematic synthesis based on the CFIR framework

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable chronic airway disease characterized by persistent airflow limitation and associated with high prevalence, high disability rates, and a substantial disease burden[1-3]. The latest data from the Global Burden of Disease study indicate that COPD has become the third leading cause of death worldwide[2, 4]. According to the Global Burden of Disease Study 2023, there were approximately 16.61 million incident cases of COPD worldwide in 2023, with 214 million prevalent cases and nearly 3.42 million deaths[2]. In China, the prevalence of COPD is 8.6% among adults aged ≥20 years and 13.7% among those aged ≥40 years, affecting an estimated 100 million patients nationwide[3, 5]. COPD causes approximately 1 million deaths each year in China, imposing a heavy disease burden[2, 3]. However, in stark contrast to its high prevalence, COPD prevention and control in China have long faced the dilemma of “three highs and three lows”: high prevalence, high mortality, and high disease burden, alongside low public awareness, low spirometry testing rates, and low standardized treatment rates at the primary care level[6]. Available data indicate that public awareness of COPD in China remains below 10%, with fewer than 3% of patients aware of their condition and approximately 90% never having received a confirmed diagnosis[7]. Screening plays a pivotal role in the early detection and intervention of COPD[8-10]. According to data released by the National Health Commission of China, only 4.5% of residents aged 40 years and older have undergone pulmonary function testing[11]. In China, initial screening using questionnaires such as the COPD-SQ is recommended for community populations, and individuals with positive screening results should undergo spirometry for diagnostic confirmation[12-15]. However, primary healthcare facilities in China commonly face practical barriers such as a lack of spirometry equipment, a shortage of trained personnel, and inadequate technical training, which prevent a substantial number of early-stage COPD patients from receiving timely diagnosis and intervention[6]. Although Chinese clinical guidelines recommend COPD screening and specify appropriate screening tools, the implementation of screening remains far from adequate. In September 2024, the National Health Commission of China issued the Specification for Health Services for Patients with Chronic Obstructive Pulmonary Disease (Trial), incorporating COPD patient health management into the National Basic Public Health Service Program. This policy initiative provides an important opportunity to advance COPD screening, but it also places higher demands on the implementation capacity of primary healthcare institutions. The Consolidated Framework for Implementation Research (CFIR) is one of the most widely used theoretical frameworks in the field of implementation science. It was originally proposed by Damschroder et al. in 2009 and updated in 2022[1]. The updated 2022 version was adopted in this study; accordingly, the term “innovation” is used throughout to refer to the domain formerly labeled “intervention characteristics.” The CFIR categorizes the factors influencing implementation outcomes into five core domains: the innovation, the outer setting, the inner setting, individual characteristics, and the implementation process. This framework provides researchers with a unified theoretical language to systematically identify and analyze barriers and facilitators during the implementation process[1, 16]. In recent years, studies on chronic respiratory disease screening have also begun to apply the CFIR to examine the implementation of screening programs[17, 18]. Raghavan and colleagues employed the CFIR framework to develop a semi-structured interview guide and systematically explored, from the perspectives of both patients and healthcare providers, the barriers to and facilitators of the suboptimal implementation of core measures recommended in COPD clinical practice guidelines, such as spirometry[1]. Substantial efforts have been made to explore COPD screening in China. In 2017, a large-scale validation study was conducted among community residents to evaluate the accuracy of COPD screening tools[19]. However, research by Chinese scholars has focused primarily on the development and validation of screening tools, with insufficient attention paid to practical implementation[20]. For instance, an ongoing qualitative study in China is exploring stakeholders’ attitudes toward and perceptions of COPD screening, with the aim of identifying the key barriers to and facilitators of implementing COPD screening in primary care settings[21]. However, inadequate COPD screening remains a global challenge. Globally, few studies have examined the factors influencing the real-world implementation of screening from an implementation science perspective. In contrast to our group’s previous bibliometric analysis of COPD screening research in China[20] and the ongoing qualitative exploration of stakeholder perceptions[21], the present study synthesizes multinational evidence and quantifies the distribution of implementation determinants across the five CFIR domains. Therefore, this study aims to systematically review the published literature on COPD screening implementation in China and worldwide; identify, code, and analyze the barriers to and facilitators of implementation within the CFIR framework; and summarize the distribution and reporting frequency of different influencing factors. By systematically synthesizing the available evidence, we hope to provide a theoretical basis for developing targeted implementation strategies and to offer practical guidance for advancing early screening and early diagnosis of COPD.