Reasons for pediatrician nonadherence to asthma guidelines

Background: The 1997 National Heart, Lung, and Blood Institute (NHLBI) asth ma guidelines include recommendations on how to improve the quality of care for asthma. Objective: To identify barriers to physician adherence to the NHLBI guideli nes. 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, screeni ng and counseling patients with asthma for smoking, and screening and couns eling parents for smoking). We also collected information on physician demo graphics, practice characteristics, and possible barriers to adherence. We defined adherence as following a guideline component more than 90% of the t ime. Results: The response rate was 55% (456/829). Most of the responding pediat ricians 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 demographi cs and other barriers, we found that nonadherence was associated with speci fic 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 s creening and counseling of patients and parents for smoking, lack of self-e fficacy (OR, 3.8; 95% CI, 1.7-6.2 and OR, 2.8; 95% CI, 1.3-5.9, respectivel y). Conclusions: Although pediatricians in this sample were aware of the NHLBI guidelines, a variety of barriers precluded their successful use. To improv e NHLBI guideline adherence, tailored interventions that address the barrie rs characteristic of a given guideline component need to be implemented.