This study formed part of an evaluation of all patients admitted to a tertiary hospital with a primary diagnosis of COPD exacerbation during a 2 month period. For all recruited patients, telephone contact was made with their hospital-based medical practitioner (general medicine medical registrars or interns) during admission, inviting them to join the study. One month after each patient had been discharged from hospital, contact was made with the patients’ GPs, inviting them to also participate in the study. In this way, a homogeneous purposive sample of medical practitioners actively involved in the care of COPD patients, from both tertiary and primary care settings, was obtained. Informed consent to participate in the study was gained from all medical practitioners involved.

Short semi-structured interviews were conducted with medical practitioners regarding their perspectives on implementation of target COPD recommendations, and barriers and facilitators to this process. Interviews were conducted face-to- face in a private setting and audiotaped. A single researcher (post-doctoral research fellow with qualitative research experience and clinical practice in COPD management) conducted all interviews. The interview guide asked questions about (1) medical practitioners’ experiences of implementing each guideline recommendation (ie, smoking cessation, influenza vaccination, pulmonary rehabilitation, guideline-based medications, long-term oxygen therapy for hypoxemia, plan and advice for future exacerbations); (2) barriers to, and enablers of, implementation of each guideline recommendation ( further detail supplied in Appendix). These recommendations were selected as they were supported by high levels of evidence in local³ and international² guidelines.

Audio recordings of interviews with participants were transcribed verbatim, and the transcripts were content analysed¹⁷,¹⁸ to identify and classify categories within the data in relation to the research questions. Content analysis has been described as a method of “subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns.”¹⁸ In this study, the systematic classification process specifically involved:

1. Identifying excerpts which related to the research questions.
2. Organization of groups of excerpts into categories.
3. Comparing excerpts and categories with existing analyses of barriers and enablers to evidence-based health care implementation. To avoid being restricted to any one behavior change theory, a consensus based model of theoretical domains for investigating evidence-based practice was used.¹⁹
4. Re-reading transcripts for further relevant data, with ongoing adjustment and final sorting into major categories (formed by groupings of minor categories).¹⁷ Study rigor was maintained by adherence to standardized

data collection protocol including use of a semi-structured interview guide developed a priori, transcription by an independent typist, and subsequent validation by the interviewer. An independent analyst experienced in qualitative research reviewed a random selection of 20% of the transcripts to identify themes from the data. Differences were contested through discussion and consensus reached.

Medical practitioners used confident language to describe their participation in implementation of guideline recommendations where a high level of role clarity existed. Smoking cessation and influenza vaccinations were discussed with patients “all the time”, “always”, “usually” or “definitely”. Smoking cessation advice was perceived by both groups of doctors to be most effective when implemented by the GP rather than the hospital-based medical practitioner.

Prescription of guideline-based medication was clearly described as “standard issue” and part of the role for both hospital-based medical practitioners and GPs. Responsibility for prescription of long-term oxygen use for hypoxemia was perceived as outside the roles of both general medicine registrars and GPs, falling to the respiratory specialist. However, the delineation was clear, as was the perceived role of the interviewed medical practitioners in the process.

In contrast, our data indicated a low degree of clarity about the role of the medical practitioners in referring COPD patients to PR. Hospital-based medical practitioners were unclear on patient eligibility for rehabilitation, and some GPs had not considered PR in the management of their COPD patients as in this excerpt:

Not much awareness. I don’t know what it is to be honest. I’ve got some people who have had this, but it was always initiated from the hospital, never initiated from me. (GP03)

Almost all GPs were actively engaged in strong persuasive communication regarding smoking cessation with their COPD patients who were current smokers, even where medical practitioners expressed concern about their ability to effect change:

I really push it hard. With my computer it tells me if they smoke or don’t smoke. I always discuss with them “What about giving up?” But the thing is they’ve got to want to give it up. There’s no good me telling them it’s bad for them. If they don’t want to do it, it won’t happen. But I try to plant the seed, yes. (GP08)

If I need more persuasive arguments, I will say “Are you going to wait til you’ve had your first stroke?” and that sometimes rings a bell, and I will talk to them about switching on their brain to quit. (GP05)

Medical practitioners used a number of different approaches and arguments to tailor smoking cessation discussions to the perceived needs and motivations of their patients and in some cases took care not to condemn or blame the patient. The extent of efforts to communicate regarding this recommendation was underpinned by high clinician belief in the health benefits of smoking cessation for their patients. Similarly, medical practitioners described they frequently checked the vaccination status of COPD patients, and expressed a high level of belief in the health benefits of influenza vaccination for this group.

In contrast, medical practitioners reported a spectrum of experience and attitudes regarding giving patient advice on use of medication for self-management of exacerbations. Decisions about whether or not to recommend an action plan took into consideration patients’ perceived decision-making ability and symptom recognition. While a few instances of persuasive communication with patients regarding participation in PR were identified, in most cases interview data reflected low awareness and support for PR, for example:

I think it is something that is not out there openly that we forget to be able to refer, so I think if it was more publicized and we had more awareness of these things being around we would probably refer more people. (HD3)

The ease of implementation of COPD care recommendations by medical practitioners was associated with the complexity of behavior change required (Figure 1). For example, annual influenza vaccinations, or institution of long-term oxygen in hypoxemic patients were described as simple, well-established processes:

That one is quite well established. So we’ll ring up the thoracic consultant to approve it and we’ll ring up the oxygen nurse. So that line is very established. (HD1)

However, care recommendations which required a high degree of behavior change, such as attendance at PR, were recognized as more difficult for patients to adopt. While some medical practitioners appreciated the health benefits achievable through PR, many were aware of the time, travel and effort required for patients to attend a PR program, and in many instances the costs were judged to outweigh the perceived benefits.

Well they’ve got to be motivated. And they’ve got to have the intellectual ability and the organizational skills to get there. And the time available to attend … They have to be physically able to get there. They have to be able to have transport. (GP11)

Similarly, provision of a plan and advice for management of future exacerbations required complex self-management behaviors from the patients, including cognitive skills, symptom recognition, decision making, anxiety regulation, and changes to lifestyle. Here medical practitioners appeared concerned that patients did not often have these health literacy and translational skills or self-confidence to enact agreed self-treatment actions, but medical practitioners lacked means or time to teach the skills required for self-management.

Well-implemented COPD care recommendations were facilitated by high levels of community, organizational, clinician and patient support. For example, medical practitioners described implementation of influenza vaccinations as supported by a visible public health campaign and high community awareness. Within their organizations implementation was facilitated by computerized decision support systems and nurse-run clinics to administer the vaccine. Similarly, guideline-based medication in COPD patients was supported organizationally by continuing education and seminars, and implementation by ward-based pharmacists and general practice nurses. Implementation of smoking cessation in COPD patients, already supported by public health campaigns and legislative change, had moderate support available through a telephone counselling service.

However, low levels of clinician awareness of PR reflected less support at all levels for implementation of this therapy in COPD patients. Structurally, medical practitioners mentioned the difficult or unclear referral process, and long waiting periods, which presented barriers to implementation. Medical practitioners raised broader issues of ongoing chronic disease management in patients with COPD in relation to the use of action plans. The lack of service after hospital discharge for patients with COPD who are anxious and require reassurance and advice regarding exacerbation was indicated by one hospital doctor. A number of GPs described COPD patients who frequently called the GP for reassurance and advice regarding symptom interpretation and the need to commence additional medication.

Information was sought regarding (1) medical practitioners’ experiences of implementing each guideline recommendation (ie, smoking cessation, influenza vaccination, pulmonary rehabilitation, guideline-based medications, long-term oxygen therapy for hypoxemia, plan and advice for future exacerbations); (2) barriers to, and enablers of, implementation of each guideline recommendation.

Starter questions as below were used to seek this information. Follow-up questions depended on individual participant responses, and prompts were used to gather more detailed information about barriers and facilitators to the implementation of recommendations in relation to each intervention strategy.

For COPD patients who are current smokers, would you in general initiate smoking cessation therapy if this hasn’t been done? What would this involve?

What are the barriers to you using these sorts of strategies?

Are there things that facilitate you implementing smoking cessation therapy?

Pulmonary rehabilitation (PR) may benefit a subgroup of patients with COPD.

Have you been involved with recommending pulmonary rehabilitation for any patients with COPD?

In general what would indicate you to refer a patient for PR?

What do you see as the barriers with getting suitable COPD patients you see into pulmonary rehab?

What strategies or structures are in place to help you get suitable COPD patients to PR?

Hospital-based medical practitioners: Would you generally check with COPD inpatients about whether they have had an influenza vaccination? Would you take any action if they hadn’t had one?

General practitioners: Are you involved with providing influenza vaccinations to COPD patients?

Both: What factors help the implementation of influenza vaccinations in COPD patients?

If a patient needs home oxygen, how does this treatment get implemented? What strategies are in place to facilitate assessment and implementation of oxygen for chronically hypoxemic patients? Are there barriers to this process?

Clearly medication is an important part of management for patients with COPD; what do you generally prescribe? Are there things that influence you in making decisions about prescription for COPD patients?

Are there ways you find useful to help patients get access to and effectively take the prescribed medication (prompts: use of devices, checking of adherence and device use)?

Are there factors that make it difficult for patients to get access to and effectively take the required medication?

Do you discuss with COPD patients how to recognize and what to do in the event of a future exacerbation? What advice do you give? Do you write this down or make use of other resources to communicate this to the patient? Why does/doesn’t this get implemented?