Determinants of delayed care-seeking during acute exacerbations of chronic obstructive pulmonary disease: protocol for a systematic review and meta-analysis

INTRODUCTION: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are major drivers of hospitalisation, readmission and mortality. Patient delay, the interval between the onset or recognition of exacerbation symptoms and the first contact with a healthcare professional, represents a potentially modifiable part of the overall prehospital delay. Existing evidence on why people with COPD delay seeking care is fragmented, based on heterogeneous definitions of delay and limited sets of predictors, and has not yet been synthesised within a coherent theoretical framework. This protocol describes a systematic review and meta-analysis to identify determinants of delayed care-seeking during AECOPD, structured by Andersen's Behavioural Model of Health Service Use. METHODS AND ANALYSIS: We will include observational analytic studies (prospective or retrospective cohort, case-control and cross-sectional designs) involving adults (≥18 years) with physician-diagnosed COPD who have experienced at least one AECOPD. The primary outcome is delayed care-seeking, defined as the time interval between onset or recognition of exacerbation symptoms and first contact with a healthcare professional or facility; studies must report a clear definition of "delay" and provide effect estimates (or sufficient data to calculate them) for associations between candidate determinants and delayed presentation or delay duration. Determinants of interest will be mapped onto Andersen's predisposing, enabling and need-related domains. We will search PubMed, Web of Science, CINAHL, Cochrane Library and EMBASE from database inception to the date of the final search, supplemented by grey literature searching, backward reference list screening and forward citation tracking, without restrictions on country or, where feasible, language. Two reviewers will independently perform study selection and data extraction and will assess risk of bias using study design-specific critical appraisal tools appropriate to cohort, case-control and cross-sectional studies. Where at least three studies report comparable effect measures for the same determinant-outcome pair, random-effects meta-analyses will be conducted; otherwise, findings will be synthesised narratively. Certainty of evidence for key associations will be graded using the grading of recommendations assessment, development and evaluation approach adapted for observational and prognostic evidence. ETHICS AND DISSEMINATION: Ethical approval is not required for this systematic review and meta-analysis, as it will use data extracted exclusively from published studies and other publicly available sources, with no involvement of individual participants or identifiable personal data. The findings of this review will be disseminated through publication in a peer-reviewed journal and presentation at relevant academic and clinical conferences. The results are expected to inform clinicians, nurses and policymakers about key determinants of delayed care-seeking during AECOPD, and to support the development of theory-informed, targeted interventions aimed at promoting timely healthcare utilisation. PROSPERO REGISTRATION NUMBER: This study has been registered in the PROSPERO (CRD420251244791).