Clinical practice guidelines vs actual clinical practice - The asthma paradigm

In recent years, a multitude of practice guidelines, statements, position p apers, and "best practices" have been promulgated for a number of disease e ntities by a variety of medical societies and managed care organizations, I n the case of asthma, for example, the National Heart, Lung, and Blood Inst itute of the National Institutes of Health (NIH) initially published guidel ines for the diagnosis and management of asthma in 1991; these recommendati ons were updated in 1997. However, health-care providers have not widely an d consistently adhered to these guidelines. Several recent publications sug gest that this underutilization of the NIM 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-affliated physician s. Moreover, both primary-care physicians and "asthma specialists" share de ficits in their knowledge base. To compound the problem, patients with asth ma also demonstrate poor adherence to the guidelines. This poor adherence i s evident irrespective of the patient's socioeconomic status. These types o f data clearly indicate a need for further educational programs directed to both physicians and patients. However, as with the development and promulg ation of any practice guideline, physicians need to be convinced that there exists compelling evidence from well-controlled clinical trials, for examp le, or from evidence-based medicine, to substantiate implementation of thes e guidelines.