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Michael D. Cabana, MD, MPH; Beth E. Ebel, MD; Lisa Cooper-Patrick, MD, MPH; Neil R. Powe, MD, MPH, MBA; Haya R. Rubin, MD, PhD; Cynthia S. Rand, PhD

Arch Pediatr Adolesc Med. 2000;154:685-693.

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 flowmeter 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.

From the Departments of Pediatrics (Drs Cabana and Ebel), Medicine (Drs Cooper-Patrick, Powe, Rubin, and Rand), and Psychiatry (Dr Rand) and the Robert Wood Johnson Clinical Scholars Program (Drs Cabana, Powe, and Rubin), Johns Hopkins School of Medicine, and the Departments of Health Policy and Management (Drs Cooper-Patrick, Powe, and Rubin) and Epidemiology (Dr Powe), Johns Hopkins School of Hygiene and Public Health, Baltimore, Md. Dr Cabana is now with the Division of General Pediatrics, Department of Pediatrics and Communicable Diseases, University of Michigan Medical System, Ann Arbor, and Dr Ebel is now with the Robert Wood Johnson Clinical Scholars Program at the University of Washington, Seattle.

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