Original Articles: Asthma, Lower Airway Diseases
Barriers to adherence to asthma management guidelines among inner-city primary care providers

https://doi.org/10.1016/S1081-1206(10)60491-7Get rights and content

Background

Health care provider adherence to national asthma guidelines is critical in translating evidence-based recommendations into improved outcomes. Unfortunately, provider adherence to the National Heart, Lung, and Blood Institute (NHLBI) guidelines remains low.

Objective

To identify barriers to guideline adherence among primary care professionals providing care to inner-city, minority patients with asthma.

Methods

We surveyed 202 providers from 4 major general medicine practices in East Harlem in New York, New York. The study outcome was self-reported adherence to 5 NHLBI guideline components: inhaled corticosteroid (ICS) use, peak flow (PF) monitoring, action plan use, allergy testing, and influenza vaccination. Potential barriers included lack of agreement with guideline, lack of self-efficacy, lack of outcome expectancy, and external barriers.

Results

Most providers reported adhering to the NHLBI guidelines for ICS use (62%) and for influenza vaccinations (73%). Self-reported adherence was 34% for PF monitoring, 9% for asthma action plan use, and 10% for allergy testing. Multivariate analyses showed that self-efficacy was associated with increased adherence to ICS use (odds ratio [OR], 2.8; P = .03), PF monitoring (OR, 2.3; P = .05), action plan use (OR, 4.9; P = .03), and influenza vaccinations (OR, 3.5; P = .05). Conversely, greater expected patient adherence was associated with increased adherence to PF monitoring (OR, 3.3; P = .03) and influenza vaccination (OR, 3.5; P = .01). Familiarity with specific guideline components and higher level of training were also predictors of adherence.

Conclusions

Lack of outcome expectancy and poor provider self-efficacy prevent providers from adhering to national asthma guidelines. Efforts to improve provider adherence should address these specific barriers.

Section snippets

INTRODUCTION

Asthma is a common disease with an overall prevalence in the general population of 6% to 7%.1, 2 Minority, inner-city residents have disproportionately high rates of asthma incidence and increased morbidity and mortality.1, 2, 3, 4 This problem is especially serious in East Harlem, a community with asthma hospitalization and mortality rates that are several times higher than the national average.5 Proposed explanations for the urban asthma problem include patient-provider communication

Study Population

Our study population was health care providers who practiced at 3 large hospital-based general medicine clinics and 1 large community-based practice in East Harlem in New York, New York. Eligible providers were those engaged in direct patient care at 1 of these clinics whose usual patient population included adult asthmatic patients. Pediatricians, pulmonary specialists, and allergy specialists were excluded. Primary care providers were identified from the clinic rosters. Physicians in training

RESULTS

Of the 296 primary care providers offered participation in the study, 223 (75%) completed the survey. Twenty-one surveys (9%) were excluded because more than 50% of the responses were missing, leaving 202 surveys available for analysis. Table 1 gives the baseline sociodemographic characteristics of the participating providers. Consistent with other hospital-based primary care clinics, most providers (79%) in the study were residents receiving training. Despite the fact that Hispanics are more

DISCUSSION

Asthma is a common chronic medical condition that causes considerable morbidity and mortality among minority inner-city populations.5, 7, 25, 26, 27, 28, 29 Although the origin of this problem is likely multifactorial, suboptimal quality of care is an important factor that contributes to poor outcomes among urban asthmatic patients. This study evaluated potential barriers to clinician adherence to the NHLBI guidelines, one of the most widely accepted references for evidence-based asthma care

ACKNOWLEDGMENTS

We thank Nicky O’Connor, Amy Carney, Jessica Segni, and Julian Baez, from the Mount Sinai School of Medicine, whose help was invaluable to this study, as well as all the providers who completed the survey.

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    Disclosures: Authors have nothing to disclose.

    Funding Sources: This study was funded by the Agency for Healthcare Research and Quality (K08 HS013312, Dr Wisnivesky) and the National Institute on Aging (RO1 HS09973). Dr Lyn-Cook was supported by the Empire Clinical Research Investigators Program, New York State Department of Health.

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