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Orjola Shahaj,1 Anne Meiwald,1 Krishnan Puri Sudhir,1 Rupert Gara-Adams,1 Peter Wark,2 Alexis Cazaux,3 Abelardo Elizondo Rios,4 Sergey N Avdeev,5 Elisabeth J Adams1 1Aquarius Population Health, London, UK; 2Respiratory and Sleep Medicine, John Hunter Hospital, New Castle, Australia; 3Pulmonary and Respiratory Medicine, Universidad Nacional de Cordoba, Cordoba, Argentina; 4Intensive Pneumology, Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico; 5Respiratory Medicine, Sechenov First Moscow State Medical University, Moscow, RussiaCorrespondence: Elisabeth J Adams, Aquarius Population Health, Unit 29 Tileyard Studios, London, N7 9AH, UK, Tel +44 207 993 2930, Email elisabeth.adams@aquariusph.comPurpose: Chronic obstructive pulmonary disease (COPD) poses a significant global health burden despite being largely preventable and treatable. Despite the availability of guidelines, COPD care remains suboptimal in many settings, including high-income countries (HICs) and upper-middle-income countries (UMICs), with varied approaches to diagnosis and management. This study aimed to identify common and unique barriers to COPD care across six countries (Australia, Spain, Taiwan, Argentina, Mexico, and Russia) to inform global policy initiatives for improved care.Methods: COPD care pathways were mapped for each country and supplemented with epidemiological, health-economic, and clinical data from a targeted literature review. Semi-structured interviews with 17 respiratory care clinicians were used to further validate the pathways and identify key barriers. Thematic content analysis was used to generate the themes.Results: Six themes were common in most HICs and UMICs: “Challenges in COPD diagnosis”, “Strengthening the role of primary care”, “Fragmented healthcare systems and coordination challenges”, “Inadequate management of COPD exacerbations”, “Limited access to specialized care” and, “Impact of underfinanced and overloaded healthcare systems”. One theme, “Insurance coverage and reimbursement challenges”, was more relevant for UMICs. HICs and UMICs differ in patient and healthcare provider awareness, primary care involvement, spirometry access, and availability of specialized care. Both face issues with healthcare fragmentation, guideline adherence, and COPD exacerbation management. In addition, UMICs also grapple with resource limitations and healthcare infrastructure challenges.Conclusion: Many challenges to COPD care are the same in both HICs and UMICs, underscoring the pervasive nature of these issues. While country-specific issues require customized solutions, there are untapped possibilities for implementing global respiratory strategies that support countries to manage COPD effectively. In addition to healthcare system-level initiatives, there is a crucial need for political prioritization of COPD to allocate the essential resources it requires.Keywords: COPD, barriers, qualitative research, healthcare systems, global policy

Anne Meiwald,1 Rupert Gara-Adams,1 Aleix Rowlandson,1 Yixuan Ma,1 Henrik Watz,2 Masakazu Ichinose,3 Jane Scullion,4 Tom Wilkinson,5,6 Mohit Bhutani,7 Georgie Weston,1 Elisabeth J Adams1 1Aquarius Population Health, London, UK; 2Pulmonary Research Institute, LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Schleswig-Holstein, Germany; 3Academic Center, Osaki Citizen Hospital, Miyagi, Japan; 4Bush & Co, Northamptonshire, UK; 5Faculty of Medicine, Southampton University, Southampton, Hampshire, UK; 6Respiratory and Allergy, NIHR Southampton Biomedical Research Centre, Southampton, Hampshire, UK; 7Department of Medicine, University of Alberta, Edmonton, Alberta, CanadaCorrespondence: Elisabeth J Adams, Aquarius Population Health, Unit 29 Tileyard Studios, London, N7 9AH, UK, Tel +44 (0)207 993 2930, Email elisabeth.adams@aquariusph.comBackground: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. A comprehensive and detailed understanding of COPD care pathways from pre-diagnosis to acute care is required to understand the common barriers to optimal COPD care across diverse health systems.Methods: Country-specific COPD care pathways were created for four high-income countries using international recommendations and country-specific guidelines, then populated with published epidemiological, clinical, and economic data. To refine and validate the pathways, semi-structured interviews using pre-prepared discussion guides and country-specific pathway maps were held with twenty-four primary and secondary care respiratory healthcare professionals. Thematic analysis was then performed on the interview transcripts.Results: The COPD care pathway showed broad consistency across the countries. Three key themes relating to barriers in optimal COPD management were identified across the countries: journey to diagnosis, treatment, and the impact of COVID-19. Common barriers included presentation to healthcare with advanced COPD, low COPD consideration, and sub-optimal acute and chronic disease management. COVID-19 has negatively impacted disease management across the pathway but presents opportunities to retain virtual consultations. Structural factors such as insurance and short duration of appointments also impacted the diagnosis and management of COPD.Conclusion: COPD is an important public health issue that needs urgent prioritization. The use of Evidenced Care Pathways with decision-makers can facilitate evidence-based decision making on interventions and policies to improve care and outcomes for patients and reduce unnecessary resource use and associated costs for the healthcare provider/payer.Keywords: health policy, COPD management, COPD diagnosis, exacerbations, qualitative, pathway mapping