title: Clinical practice guidelines: barriers to durability after effective early implementation.
abstract: BACKGROUND
  Clinical practice guidelines in general (General-CPG) may reduce variation in clinician performance and improve patient outcomes. Short-term evaluation is now routine, but demonstration of early successful implementation does not necessarily ensure longer-term effectiveness.
  
  
  OBJECTIVE
  To assess adherence to chronic obstructive pulmonary disease (COPD)-CPG recommendations at the Royal Melbourne Hospital (RMH), 2 years after successful implementation. To identify barriers to sustained success of General-CPG.
  
  
  METHODS
  A multi-faceted evaluation was performed to document: (i) current adherence to COPD management recommendations (medical record audit); (ii) awareness of attitudes towards and barriers for the use of COPD-CPG and General-CPG (staff survey, focus groups and key informant interviews) and (iii) access to and quality of available General-CPG (internet review and random sample General-CPG evaluation.
  
  
  RESULTS
  Adherence to COPD-CPG recommendations was highly variable. Adherence was higher in the Emergency Department than the general wards and for specific therapeutic recommendations. It was lower for non-pharmacological therapy and for recommendations relating to processes of care. Most health professionals were in favour of General-CPG. Barriers to use of General-CPG were in keeping with previous literature reports. Organizational issues including high levels of staff turnover and lack of integration of General-CPG into hospital quality frameworks were highlighted as major barriers. Hospital intranet access and presentation of General-CPG identified lack of consistency in terminology and presentation.
  
  
  CONCLUSIONS
  Short-term effectiveness of COPD-CPG implementation did not ensure sustained success. Departmental organizational behaviours and organizational system barriers are major factors influencing durability.
authors.affiliation: Clinical Epidemiology & Health Service Evaluation Unit, The Royal Melbourne Hospital, Parkville, Victoria, Australia. caroline.brand@mh.org.au
authors.forename: C
authors.initials: C
authors.lastname: Brand
authors.forename: F
authors.initials: F
authors.lastname: Landgren
authors.forename: A
authors.initials: A
authors.lastname: Hutchinson
authors.forename: C
authors.initials: C
authors.lastname: Jones
authors.forename: L
authors.initials: L
authors.lastname: Macgregor
authors.forename: D
authors.initials: D
authors.lastname: Campbell
mesh_terms: D000368:Aged; D002983:Clinical Competence; D005260:Female; D019983:Guideline Adherence; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D010819:Physician's Role; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D029424:Pulmonary Disease, Chronic Obstructive / Q000628:therapy; D011795:Surveys and Questionnaires