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Barriers pediatricians face when using asthma practice guidelines
M D Cabana1, B E Ebel, L Cooper-Patrick
1Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
Insights
Pediatricians face many barriers to using asthma guidelines, including time limits and lack of agreement. Tailoring interventions to physician experience and guideline type is key for better adherence to National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines.
Area of Science:
- Pediatric Pulmonology
- Clinical Practice Guidelines
- Healthcare Delivery
Background:
- The 1997 National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines aimed to standardize care.
- Understanding barriers to guideline implementation is crucial for improving asthma management.
- Pediatricians' perspectives on guideline adherence are essential for effective interventions.
Purpose of the Study:
- To identify and describe the barriers encountered by pediatricians in adhering to specific recommendations within the 1997 NHLBI asthma guidelines.
- To explore how recommendation type and physician experience influence perceived barriers.
Main Methods:
- Conducted 3 focus groups with 21 pediatricians and 1 nurse practitioner.
- Discussed barriers related to inhaled corticosteroids, peak flowmeter use, smoking cessation, and allergen counseling.
- Analyzed 171 comments identifying specific obstacles to guideline adherence.
Main Results:
- Identified 171 distinct barriers to guideline adherence.
- Physician experience (year of graduation) correlated with specific barriers (e.g., agreement for senior vs. confidence for junior physicians).
- Time limitations were a universal barrier; inertia of previous practice was noted by senior physicians.
Conclusions:
- Adherence barriers include lack of awareness, familiarity, agreement, and external factors (environmental, guideline, patient).
- Novel barriers identified include lack of self-efficacy, outcome expectancy, and inertia of previous practice.
- Interventions must be tailored to physician demographics and the specific type of guideline recommendation to enhance NHLBI asthma guideline adherence.
Objective:
To describe barriers to the successful use of the 1997 National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines.
Methods:
We conducted 3 focus groups to understand barriers to the use of 4 recommendations within the NHLBI guidelines (prescription of inhaled corticosteroids, recommendation of daily peak flowmeter use, smoking cessation screening and counseling, and allergen exposure counseling).
Participants:
Twenty-one pediatricians and 1 nurse practitioner, who each followed an average of 47 patients with asthma, participated. Six participants (27%) had a faculty or adjunct appointment at a medical school. Nineteen (90%) of the 21 pediatricians were board certified.
Results:
We identified 171 comments about barriers to adherence. Type of recommendation and physician year of graduation from medical school were related to which barrier was prominent. For corticosteroid prescription, senior physicians mentioned lack of agreement, whereas younger physicians described lack of confidence in dosing or recognizing contraindications. For peak flow-meter use, senior physicians emphasized lack of training. Only senior physicians described the inertia of previous practice as a barrier. All groups mentioned time limitations.
Conclusions:
Efforts to improve adherence to asthma guidelines should consider the range of barriers that pediatricians face, such as lack of awareness, familiarity, or agreement, and external barriers owing to environmental, guideline, or patient factors. In addition, this study documents barriers not previously considered, such as lack of self-efficacy, lack of outcome expectancy, and inertia of previous practice, that prevent adherence. Because type of recommendation and physician demographics are related to which barriers are prominent, interventions to improve NHLBI guideline adherence should be tailored to these factors.