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Open Access Research article

Which chronic obstructive pulmonary disease care recommendations have low implementation and why? A pilot study

Kylie Johnston1*, Karen Grimmer-Somers1, Mary Young2, Ral Antic3 and Peter Frith4

Author Affiliations

1 International Centre for Allied Health Evidence, Division of Health Sciences, University of South Australia, Adelaide, Australia

2 Transitional and Community Service, Royal Adelaide Hospital, Adelaide, Australia

3 Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, Australia

4 Respiratory, Allergy and Sleep Services, Repatriation General Hospital and Flinders University, Adelaide, Australia

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BMC Research Notes 2012, 5:652  doi:10.1186/1756-0500-5-652

Published: 23 November 2012



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.


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.


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.


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.

Implementation; Guidelines; Chronic obstructive pulmonary disease; Pulmonary rehabilitation