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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.
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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