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The treatment of chronic obstructive pulmonary disease (COPD) has been guided for decades by robust clinical practice guidelines (CPGs), such as NICE1 and GesEPOC,2 as well as international recommendations such as GOLD,3 which provide clinicians with clear recommendations for diagnosis, risk stratification and pharmacological management. Yet, as the study by Yin and colleagues published in this issue in Thorax 4 demonstrates, the translation of these recommendations into real-world clinical practice remains strikingly incomplete. Despite widespread dissemination of CPGs and the growing availability of effective inhaled therapies, adherence to guideline-based care continues to be disappointingly low.5