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Reasons for Pediatrician Nonadherence to Asthma Guidelines
Michael D. Cabana, MD, MPH;
Cynthia S. Rand, PhD;
Oren J. Becher, MD;
Haya R. Rubin, MD, PhD
Arch Pediatr Adolesc Med. 2001;155:1057-1062.
ABSTRACT
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Background The 1997 National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines
include recommendations on how to improve the quality of care for asthma.
Objective To identify barriers to physician adherence to the NHLBI guidelines.
Design Cross-sectional survey.
Participants A national random sample of 829 primary care pediatricians.
Main Outcome Measures Self-reported adherence to 4 components of the NHLBI guidelines (steroid
prescription, instructing peak flow meter use, screening and counseling patients
with asthma for smoking, and screening and counseling parents for smoking).
We also collected information on physician demographics, practice characteristics,
and possible barriers to adherence. We defined adherence as following a guideline
component more than 90% of the time.
Results The response rate was 55% (456/829). Most of the responding pediatricians
were aware of the guidelines (88%) and reported having access to a copy of
the guidelines (81%). Self-reported rates of adherence were between 39% and
53% for the guideline components. After controlling for demographics and other
barriers, we found that nonadherence was associated with specific barriers
for each guideline component: for corticosteroid prescription, lack of agreement
(odds ratio [OR], 6.8; 95% confidence interval [CI], 3.2-14.4); for peak flow
meter use, lack of self-efficacy (OR, 3.4; 95% CI, 1.9-6.1) and lack of outcome
expectancy (OR, 4.7; 95% CI, 2.5-8.9); and for screening and counseling of
patients and parents for smoking, lack of self-efficacy (OR, 3.8; 95% CI,
1.7-6.2 and OR, 2.8; 95% CI, 1.3-5.9, respectively).
Conclusions Although pediatricians in this sample were aware of the NHLBI guidelines,
a variety of barriers precluded their successful use. To improve NHLBI guideline
adherence, tailored interventions that address the barriers characteristic
of a given guideline component need to be implemented.
INTRODUCTION
THE 1997 National Heart, Lung, and Blood Institute (NHLBI) guidelines
for the diagnosis and management of asthma are intended to "bridge the gap
between current knowledge and practice"1(p1)
and improve the quality of care for asthma. Although physician guideline adherence
is crucial in translating evidence-based recommendations into improved outcomes,
poor adherence is well documented.2, 3, 4, 5, 6
Previous studies have noted barriers to physician adherence to the guidelines,
such as poor attitudes about and lack of familiarity or agreement with the
NHLBI guidelines.7, 8, 9, 10
Additional hypothesized barriers include economic disincentives, patient noncompliance,
and inadequate time or resources.11, 12
Focus groups suggest that physicians encounter different barriers to using
different components of asthma guidelines.13
Finkelstein et al2 surveyed 429 primary
care physicians and noted that despite widespread guideline awareness there
was still poor adherence, as demonstrated by underuse of written asthma action
plans and follow-up visits. Although lack of guideline awareness did not seem
to be a barrier to adherence, "remaining barriers may prevent their full adoption."2
The purpose of this study was to measure barriers, not including lack
of awareness, that affect knowledge, attitudes, and adherence to 4 different
components of the NHLBI asthma guidelines. By understanding which barriers
are associated with different guideline components, strategies can be identified
to improve physician guideline adoption and thus improve pediatric asthma
care.
SUBJECTS AND METHODS
SUBJECTS
We randomly selected 1000 general pediatricians from the American Medical
Association Masterfile of physicians in the United States, which includes
all allopathic and most osteopathic physicians regardless of membership with
the American Medical Association. We excluded pediatricians in training, pediatricians
who spent greater than 50% of their professional time outside of clinical
practice (ie, administration, research), and pediatric specialists.
Between March and May 1999, we sent a cover letter, an 8-page questionnaire,
and a prepaid return envelope to each subject. Nonrespondents received up
to 3 reminder surveys. Physicians who did not respond after 3 attempts were
contacted by telephone to confirm that they had received the survey. We did
not offer an honorarium for participation. The study was approved by the institutional
review board at the Johns Hopkins School of Medicine (Baltimore, Md).
SURVEY INSTRUMENT
The 1997 NHLBI asthma guidelines recommend that a patient with daily
asthma symptoms should be prescribed a daily inhaled corticosteroid and should
use a peak flow meter (PFM) to monitor daily symptoms. The guidelines also
recommend that patients with asthma should not smoke or be exposed to tobacco
smoke at home. We used the following questions to query respondents about
adherence to these 4 guideline components:
- For what percentage of patients with asthma with
daily symptoms (>8 years of age) do you instruct to monitor daily expiratory
peak flow meter readings?
- For what percentage of patients with asthma with
daily symptoms do you prescribe a daily inhaled corticosteroid?
- For what percentage of visits does someone in the
practice screen patients with asthma for smoking and counsel smoking cessation?
- For what percentage of visits does someone in the
practice screen parents of patients with asthma for smoking and counsel smoking
cessation?
After pilot-testing the survey with a convenience sample of 10 general
pediatricians, we selected the following response set for adherence that maximized
discrimination among the responses and could be adapted to previously established
definitions of adherence.14 For each of the
components, pediatricians indicated adherence with 1 of 5 possible responses:
"less than half of the time (<50%)," "just over half of the time (51%-75%),"
"most of the time (76%-90%)," "almost all of the time (91%-99%)," and "all
of the time (100%)."
Based on a review of guideline adherence15
and focus groups with pediatricians,13 we asked
about barriers to adherence to each of the 4 components: awareness of the
guideline, familiarity with the specific guideline component, agreement with
the component, confidence in the ability to perform the guideline component
(self-efficacy), belief that following the guideline component will affect
patient outcomes (outcome expectancy), and the presence of practice barriers.
We asked about specific practice barriers, such as lack of equipment or clinic
space, lack of time during a patient visit, lack of educational materials,
lack of support staff, and lack of reimbursement for services.
The questionnaire used a 5-point scale for respondents to indicate their
level of familiarity (1, not at all familiar; 5, extremely familiar), agreement
(1, strongly disagree; 5, strongly agree), and self-efficacy (1, not at all
confident; 5, extremely confident). We used a 4-point scale for outcome expectancy
(1, no effect; 4, large effect) and practice barriers (1, not at all significant;
4, extremely significant). We selected these different response sets from
previous physician surveys that examined these constructs separately in relation
to guideline adherence.14, 16, 17
Awareness was measured using a dichotomous response (yes/no). If pediatricians
were not aware of the guideline, we assumed they were not familiar with the
guideline components.
We asked about demographic data including year of completion of medical
school and residency, practice setting, academic affiliation, number of patients
with asthma, and board certification.
ANALYSIS
For each analysis of the 4 guideline components, our dependent variable
of interest was a pediatrician's self-reported adherence to the guidelines.
We considered pediatricians adherent if they reported following a guideline
component more than 90% of the time, based on previous definitions of adherence.14
We dichotomized the responses. A factor was present if pediatricians
answered 4 or 5 on a 5-point Likert-like scale or 3 or 4 on a 4-point scale.
Self-efficacy for corticosteroid prescription was present if pediatricians
indicated they were "very" or "extremely" confident in recognizing which patients
may benefit from corticosteroid use, recognizing adverse effects, and discussing
adverse effects. Since self-efficacy responses for screening for tobacco use
and counseling for smoking cessation were not well correlated (weighted 
= 0.41 for patients with asthma, 0.42 for parents), we included separate independent
variables for screening self-efficacy and counseling self-efficacy.
We used a  2 analysis to compare each of the independent
variables with self-reported adherence to the guideline component in question.
We used multivariate logistic regression (SAS 6.12; SAS Institute; Cary, NC)
to control for the presence of barriers, academic affiliation, and board certification.
We hypothesized that pediatricians who see fewer patients with asthma might
be less familiar with and less adherent to the guidelines and so we controlled
for the number of patients with asthma ( 100 patients vs <100). We also
hypothesized that pediatricians who completed training before 1990, when guidelines
were less common, might be less likely to be adherent. We did not include
sex in the final model since the univariate analysis showed no association
with adherence.
RESULTS
SAMPLE
Of 1000 pediatricians in our database, we excluded 47 pediatric subspecialists,
58 in practice less than 20 hours per week, and 2 still in training. Sixty-six
questionnaires were returned because of incorrect addresses or deceased recipients.
Of 827 eligible respondents, 455 (55%) returned the questionnaires. Owing
to incomplete questionnaires, not all totals are equal in the analysis of
each guideline component.
Demographic data of the survey recipients are presented in Table 1. Based on data from the American
Medical Association, respondents did not differ from nonrespondents in terms
of sex, median age, and practice setting. However, respondents were more likely
to be board certified in pediatrics (91% vs 82%; P<.01).
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Table 1. Characteristics of Survey Recipients
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GUIDELINE AWARENESS AND ACCESS
Eighty-eight percent of responding pediatricians were aware of the NHLBI
guidelines. Eighty-one percent indicated that they had access to a copy of
the guidelines; 13% were not sure. The remainder did not have access to a
copy. Of the pediatricians who were aware, 77% reported that they were at
least "adequately familiar" with the guidelines overall.
Respondents learned about the guidelines by reading a copy of the report
(70%), attending continuing medical education (46%), and hearing information
from pharmaceutical representatives (27%), other physicians (21%), or nonphysician
colleagues (1%). Three percent listed other sources, including the National
Institutes of Health, medical journals, residency training, managed care organizations,
or insurance companies. Respondents learned about guidelines from 1 source
(54%), 2 sources (25%), or 3 or more sources (21%). When multiple sources
were cited, the most common combination was reading a copy of the guidelines
and continuing medical education (66%). (Since respondents could indicate
more than one answer, the totals are greater than 100%.)
We were concerned that respondents might give socially acceptable answers
and overreport guideline familiarity. To test this possibility, we asked about
items not present in the guidelines. When queried about recommendations for
genetic testing for asthma, which are not present in the guidelines, only
5% of respondents indicated they were very or extremely familiar with such
recommendations. In addition, the guidelines suggest that PFMs are useful
for monitoring, not diagnosing asthma. Only 1% of respondents strongly agreed
that "peak flow meters can be used alone in the diagnosis of asthma." These
low percentages indirectly suggest validity in the responses and mitigate
concerns about the overreporting of familiarity.
RATES OF ADHERENCE
Table 2 presents rates of
self-reported adherence for the guideline components, stratified by sex and
year of residency completion. Pediatricians reported similar rates for the
prescription of corticosteroids (53%) and screening and counseling for smoking
cessation to parents (53%). The rate of screening and counseling for smoking
cessation to patients (43%) was somewhat lower, and instruction of daily PFM
use (39%) had the lowest rate of adherence.
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Table 2. Self-reported Adherence to 4 Guideline Components*
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BARRIERS TO ADHERENCE
Table 3 presents the prevalence
of each barrier for each guideline component. The prevalence of lack of familiarity
with each recommendation ranged from 25% to 34%. Since becoming familiar with
a recommendation represents a more active process than passive awareness,
lack of familiarity for all of the guideline components was more prevalent
than lack of overall guideline awareness (12%).
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Table 3. Percentage of Respondents Indicating Barriers to Adherence*
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In terms of external or practice-related barriers, approximately half
of pediatricians reported lack of time for guideline components that involved
intensive counseling and education, such as screening and counseling for smoking
cessation to parents (50%) and patients (50%). Physicians reported lack of
time less frequently for corticosteroid prescription (12%), which may require
less counseling.
Different barriers were more prominent for different guideline components.
For example, lack of agreement was more common for corticosteroid prescription,
while lack of outcome expectancy was more common for the other guideline components.
ASSOCIATION OF BARRIERS WITH ADHERENCE
For each of the 4 guideline components, we examined the association
between each barrier and pediatrician adherence. The unadjusted odds ratios
(ORs) for all barriers were significantly greater than 1, which suggests that
the presence of any of these factors increases the likelihood of nonadherence.
We hypothesized that some barriers might be more prominent for each
guideline component. In addition, although a barrier might be prevalent, it
might not necessarily be associated with physician nonadherence after controlling
for the presence of other barriers. Table
4 presents the results of multivariate logistic regression analysis,
which was used to control for the presence of other barriers and demographic
characteristics. Only lack of familiarity (OR, 1.64-2.51) and the presence
of external barriers (OR, 1.65-1.90) are significantly associated with nonadherence
to all 4 guideline components.
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Table 4. Logistic Regression Model of Pediatrician Nonadherence to
4 Guideline Components*
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Each guideline component has a unique set of barriers associated with
nonadherence. For example, nonadherence to corticosteroid prescription is
associated with lack of agreement (OR, 6.79; 95% confidence interval [CI],
3.20-14.4) and academic affiliation (OR, 0.52; 95% CI, 0.33-0.82). Nonadherence
to recommendations for PFM use is associated with lack of self-efficacy (OR,
3.36; 95% CI, 1.85-6.10) and lack of outcome expectancy (OR, 4.67; 95% CI,
2.46-8.86).
Factors associated with nonadherence to smoking screening and counseling
to patients and parents include lack of self-efficacy to inquire about smoking
status (OR, 2.81; 95%CI, 1.34-5.89 and OR, 3.81; 95% CI, 1.70-6.19, respectively).
For smoking screening and cessation counseling to patients, academic affiliation
seems to be associated with increased adherence (OR, 1.63; 95% CI, 1.04-2.51).
COMMENT
We systematically examined barriers to pediatrician knowledge, attitudes,
and self-reported adherence to the 1997 NHLBI asthma guidelines and found
that each guideline component is associated with specific barriers to adherence.
These findings have implications for selecting methods to improve adherence
and quality of care for asthma. Self-reported adherence rates (defined as
following recommendations for more than 90% of cases) range between only 38%
and 53% for the 4 guideline components we queried.
Similar to Finkelstein et al,2 we found
that most pediatricians are aware of the guidelines and have access to a copy
of them. However, multiple factors are associated with poor guideline adherence.
In addition, although a barrier may be prevalent (ie, lack of outcome expectancy
for smoking cessation screening and counseling), it may not necessarily be
associated with nonadherence after controlling for other barriers.
Although lack of awareness has been cited as a common barrier to adherence,4, 18, 19 in our study, pediatrician
awareness of the NHLBI guidelines (84% aware) was high compared with other
guidelines. A previous study documenting awareness to 4 practice guidelines
found rates ranging from 12% to 66%.7
For all components of the guidelines, lack of time, lack of educational
materials, lack of support staff, and lack of reimbursement were similar reasons
for nonadherence. Pediatricians might perceive these factors as related since
educational materials and support staff are factors that might mitigate the
barrier of lack of time, while proper reimbursement might compensate for the
extended time needed to counsel or educate a patient.
LIMITATIONS
There are several limitations to this study. Our survey response rate
was only 55% and respondents were more likely to be board-certified in pediatrics.
Both factors may affect the generalizability of our results to practicing
pediatricians.
Adherence was based on self-report, which might not reflect actual adherence.
Studies of physician practice suggest that physician self-report can overestimate
or underestimate actual practice when compared with chart audits or patient
surveys.20, 21, 22
However, our purpose was to investigate if different recommendations are associated
with a different profile of barriers. The analysis assumes that self-report
bias will affect measures of barriers to adherence as well as guideline adherence,
thus preserving the profile of barriers for each guideline component.
It is also encouraging that few respondents reported familiarity with
the spurious guideline components that we included to test the validity of
self-report. Results from other studies suggest that physician self-report
is not wildly misleading. For example, Diette et al23
surveyed 318 parents of children with asthma and found that 55% of patients
with daily asthma symptoms used a daily controller medication compared with
54% in our study. Warman et al5 surveyed 220
parents of children with asthma and found that only 30% of children with persistent
asthma had PFMs. In our sample, self-reported adherence rate for instruction
of PFM use was similar at 38%. Finally, the presence of a barrier to adherence
is based on the respondents' perception of the barrier, which may not accurately
reflect how problematic a barrier is. Whether the problem is actual or perceived
may also affect the type of intervention required.
IMPLICATIONS
These results have implications for selecting interventions to improve
practice. Interventions should be tailored to the guideline component being
addressed. For example, the factors associated with adherence to steroid prescription
and PFM use are different and interventions for each recommendation, although
from the same guideline, may take different forms.
Since lack of agreement is associated with steroid prescription, interventions
might theoretically include physician participation in guideline development24, 25, 26 or guideline endorsement
by local opinion leaders or specialty societies.27, 28, 29
In several studies, physicians indicated greater confidence in guidelines
developed by their own specialty organization.30, 31, 32, 33
Increased awareness of the endorsement of the NHLBI guidelines by pediatric
professional organizations might improve pediatrician guideline agreement.
Although the American Academy of Pediatrics was represented during the guideline
development and publicly endorsed the guidelines,34
pediatricians may not be aware of these events.
Since low self-efficacy was associated with nonadherence to instructing
PFM use, interventions might include practical workshops rather than traditional
continuing medical education lectures.35 Interactive
seminars have demonstrated improved physician communication and management
of asthma36 and use of metered-dose inhalers
and spacers.37 Feedback and audit to demonstrate
that PFMs actually affect outcomes of asthma treatment may improve an individual's
outcome expectancy. Interventions might also directly target sources of poor
physician outcome expectancy, such as poor patient asthma self-management
or compliance in general.38, 39, 40
In general, multipronged interventions are more successful than single
interventions in changing practice.41 This
study reinforces the need for multiple interventions for overall adherence
and tailored interventions to address characteristic barriers of each guideline
component.
In conclusion, although pediatricians in this sample seem to be well
aware of the NHLBI asthma guidelines, there are many barriers to their use.
Interventions to improve the rate of prescription of daily inhaled corticosteroids
should attempt to foster pediatrician agreement. Efforts to improve the rate
of PFM instruction to patients who have daily asthma should focus on teaching
pediatricians how to use PFMs to guide asthma therapy and should show pediatricians
how outcomes are affected by their patient's use of PFMs. Finally, interventions
to increase the use of smoking cessation counseling should attempt to improve
pediatrician confidence to inquire about tobacco use among patients and parents.
AUTHOR INFORMATION
What This Study Adds
The NHLBI guidelines offer recommendations to improve the care of asthma.
Previous studies have shown that despite pediatrician awareness of the NHLBI
asthma guidelines, there are additional barriers, such as lack of agreement,
poor self-efficacy, or practice-related barriers, that prevent pediatrician
adherence to these guidelines. This study documents that different components
of the guidelines are associated with specific barriers to adherence. To improve
pediatrician adherence to the NHLBI guidelines and asthma care, interventions
should be tailored to these barriers.
Accepted for publication May 10, 2001.
This research was supported in part by the Robert Wood Johnson Foundation,
Princeton, NJ.
Presented in part at the Society for Pediatric Research Meeting, Boston,
Mass, May 14, 2000.
We would like to thank Suchitra Chandrasekaran and Yezhisai Thirumavalavan
for their help in organizing this study.
From the Departments of Pediatrics (Drs Cabana and Becher), Medicine
(Drs Rubin and Rand), and Psychiatry (Dr Rand), and the Robert Wood Johnson
Clinical Scholars Program (Drs Cabana and Rubin), Johns Hopkins School of
Medicine; and the Department of Health Policy and Management, Johns Hopkins
School of Hygiene and Public Health (Dr Rubin), Baltimore, Md. Dr Cabana is
currently affiliated with the Child Health Evaluation and Research Unit at
the Division of General Pediatrics, University of Michigan Health System,
Ann Arbor.
Corresponding author: Michael D. Cabana, MD, MPH, Division of General
Pediatrics, University of Michigan School of Medicine, Room 6D09, North Ingalls
Bldg, Box 0456, 300 N Ingalls St, Ann Arbor, MI 48109-0456 (e-mail: mcabana{at}med.umich.edu).
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Yawn et al.
Pediatrics 2006;118:322-329.
ABSTRACT
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A randomized clinical trial of clinician feedback to improve quality of care for inner-city children with asthma.
Kattan et al.
Pediatrics 2006;117:e1095-e1103.
ABSTRACT
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What Providers from General Emergency Departments Say about Implementing a Pediatric Asthma Pathway
Butterfoss et al.
CLIN PEDIATR 2006;45:325-333.
ABSTRACT
Change in approach and delivery of medical care in children with asthma: results from a multicenter emergency department educational asthma management program.
Boychuk et al.
Pediatrics 2006;117:S145-S151.
ABSTRACT
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The effect of inhaled budesonide on adrenal and growth suppression in asthmatic children
Priftis et al.
Eur Respir J 2006;27:316-320.
ABSTRACT
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Improved Asthma Care After Enrollment in the State Children's Health Insurance Program in New York
Szilagyi et al.
Pediatrics 2006;117:486-496.
ABSTRACT
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Fast Facts: Asthma
Brown
Chest 2005;128:4053-4053.
ABSTRACT
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Barriers to physician adherence to a subfertility guideline
Haagen et al.
Hum Reprod 2005;20:3301-3306.
ABSTRACT
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EHRs can help drive implementation of evidence-based guidelines
Lehmann et al.
AAP News 2004;25:189-189.
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Limits of the HEDIS Criteria in Determining Asthma Severity for Children
Cabana et al.
Pediatrics 2004;114:1049-1055.
ABSTRACT
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Thinking Outside the Inhaler: Potential Barriers to Controlled Asthma in Children
Potts and Reagan
Journal of Pharmacy Practice 2004;17:211-220.
ABSTRACT
A Survey of Medicaid Recipients With Asthma: Perceptions of Self- |
