Inner city docs not following asthma guidelines

NEW YORK (Reuters Health) - Many inner-city primary care physicians "at the epicenter" of the current asthma epidemic do not adhere to national asthma practice guidelines published more than a decade ago, according to results of a survey.

"Rates of provider adherence to most components of National Institutes of Health (NIH) guidelines remain suboptimal," Dr. Juan P. Wisnivesky from Mount Sinai School of Medicine, New York, told Reuters Health. "Inadequate treatment may contribute to (the high rate of complications) observed amongst inner-city asthmatics."

Two key barriers to asthma guideline adherence emerged in the survey of 202 primary care providers from four major general medicine practices in and around New York City.

"Lack of outcome expectancy (i.e. that the recommendation will improve patients outcomes) or self-efficacy (the provider's ability to successfully implement the recommendation) were the most important predictors of lack of provider adherence to NIH guideline recommendations," Wisnivesky said.

Providers may lack confidence "in their ability to address concerns about (steroid inhaler) use, appropriately demonstrate the use of...inhalers, implement (lung function) monitoring, or develop and discuss with patients an asthma action plan," Wisnivesky and colleagues suggest in their report in the Annals of Allergy, Asthma and Immunology.

In the survey, providers were asked to report their adherence to five National Heart, Lung and Blood Institute (NHLBI) guideline components: steroid inhaler use, lung function monitoring, action plan use, allergy testing, and influenza vaccination.

Self-reported familiarity with specific components was only 56 percent for steroid inhaler use and 57 percent for influenza vaccination and "even worse" for recommendations about lung function monitoring (44 percent), asthma action plan use (32 percent) and allergy testing referrals (19 percent), the researchers report.

Further analyses showed that lack of confidence in the ability to implement a guideline and lower level of training were strongly associated with non-adherence to steroid inhaler use among patients with persistent asthma and with not having an asthma action plan or recommending influenza vaccination.

These results, the researchers say, suggest that interventions to improve primary care provider adherence to NHLBI guidelines need to focus not only on increasing knowledge and skills but also on increasing clinicians' belief in their ability to effectively implement the guidelines.

SOURCE: Annals of Allergy, Asthma, and Immunology, September 2008.