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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.

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.

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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