Clinical practice guidelines vs actual clinical practice : the asthma paradigm

In recent years, a multitude of practice guidelines, statements, position papers, and "best practices" have been promulgated for a number of disease entities by a variety of medical societies and managed care organizations. In the case of asthma, for example, the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) initially published guidelines for the diagnosis and management of asthma in 1991; these recommendations were updated in 1997. However, health-care providers have not widely and consistently adhered to these guidelines. Several recent publications suggest that this underutilization of the NIH asthma guidelines may in part be related to a lack of understanding. This lack of understanding appears to span the spectrum of physicians in private practice, physicians working in health maintenance organizations, as well as university-affiliated physicians. Moreover, both primary-care physicians and "asthma specialists" share deficits in their knowledge base. To compound the problem, patients with asthma also demonstrate poor adherence to the guidelines. This poor adherence is evident irrespective of the patient's socioeconomic status. These types of data clearly indicate a need for further educational programs directed to both physicians and patients. However, as with the development and promulgation of any practice guideline, physicians need to be convinced that there exists compelling evidence from well-controlled clinical trials, for example, or from evidence-based medicine, to substantiate implementation of these guidelines.