title: Which chronic obstructive pulmonary disease care recommendations have low implementation and why? A pilot study.
abstract: BACKGROUND
  Clinical care components for people with COPD are recommended in guidelines if high-level evidence exists. However, there are gaps in their implementation, and factors which act as barriers or facilitators to their uptake are not well described. The aim of this pilot study was to explore implementation of key high-evidence COPD guideline recommendations in patients admitted to hospital with a disease exacerbation, to inform the development of a larger observational study.
  
  
  METHODS
  This study recruited consecutive COPD patients admitted to a tertiary hospital. Patient demographic, disease and admission characteristics were recorded. Information about implementation of target guideline recommendations (smoking cessation, pulmonary rehabilitation referral, influenza vaccination, medication use and long-term oxygen use if hypoxaemic) was gained from medical records and patient interviews. Interviews with hospital-based doctors examined their perspectives on recommendation implementation.
  
  
  RESULTS
  Fifteen patients (aged 76(9) years, FEV1%pred 58(15), mean(SD)) and nine doctors participated. Referral to pulmonary rehabilitation (5/15 patients) was underutilised by comparison with other high-evidence recommendations. Low awareness of pulmonary rehabilitation was a key barrier for patients and doctors. Other barriers for patients were access difficulties, low perceived health benefits, and co-morbidities. Doctors reported they tended to refer patients with severe disease and frequent hospital attendance, a finding supported by the quantitative data.
  
  
  CONCLUSIONS
  This study provides justification for a larger observational study to test the hypothesis that pulmonary rehabilitation referral is low in suitable COPD patients, and closer investigation of the reasons for this evidence-practice gap.
authors.affiliation: International Centre for Allied Health Evidence, Division of Health Sciences, University of South Australia, Adelaide, Australia. kylie.johnston@unisa.edu.au
authors.forename: Kylie
authors.initials: K
authors.lastname: Johnston
authors.forename: Karen
authors.initials: K
authors.lastname: Grimmer-Somers
authors.forename: Mary
authors.initials: M
authors.lastname: Young
authors.forename: Ral
authors.initials: R
authors.lastname: Antic
authors.forename: Peter
authors.initials: P
authors.lastname: Frith
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D058005:General Practitioners / Q000523:psychology / Q000706:statistics & numerical data; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007252:Influenza Vaccines / Q000008:administration & dosage; D007407:Interviews as Topic; D008297:Male; D008499:Medical Records / Q000706:statistics & numerical data; D010349:Patient Compliance / Q000523:psychology / Q000706:statistics & numerical data; D010865:Pilot Projects; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000534:rehabilitation / Q000628:therapy*; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012129:Respiratory Function Tests / Q000706:statistics & numerical data; D012138:Respiratory Therapy / Q000706:statistics & numerical data; D016540:Smoking Cessation / Q000706:statistics & numerical data; D014611:Vaccination / Q000706:statistics & numerical data
chemical_list: D007252:Influenza Vaccines