Barriers to adherence to chronic obstructive pulmonary disease guidelines by primary care physicians

Abstract

Gregory D Salinas1, James C Williamson1, Ravi Kalhan2, Byron Thomashow3, Jodi L Scheckermann4, John Walsh5, Maziar Abdolrasulnia1, Jill A Foster11CE Outcomes, LLC Birmingham, AL, USA; 2Asthma-COPD Program, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; 3Division of Pulmonary, Allergy, Critical Care, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, USA; 4Boehringer-Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA; 5COPD Foundation, Miami, FL, USAPurpose: Even with the dissemination of several clinical guidelines, chronic obstructive pulmonary disease (COPD) remains underdiagnosed and mismanaged by many primary care physicians (PCPs). The objective of this study was to elucidate barriers to consistent implementation of COPD guidelines.Patients and methods: A cross-sectional study implemented in July 2008 was designed to assess attitudes and barriers to COPD guideline usage.Results: Five hundred US PCPs (309 family medicine physicians, 191 internists) were included in the analysis. Overall, 23.6% of the surveyed PCPs reported adherence to spirometry guidelines over 90% of the time; 25.8% reported adherence to guidelines related to long-acting bronchodilator (LABD) use in COPD patients. In general, physicians were only somewhat familiar with COPD guidelines, and internal medicine physicians were significantly more familiar than family physicians (P < 0.05). In a multivariate model controlling for demographics and barriers to guideline adherence, we found significant associations with two tested guideline components. Adherence to spirometry guidelines was associated with agreement with guidelines, confidence in interpreting data, ambivalence to outcome expectancy, and ability to incorporate spirometry into patient flow. Adherence to LABD therapy guidelines was associated with agreement with guidelines and confidence in gauging pharmacologic response.Conclusions: Adherence to guideline recommendations of spirometry use was predicted by agreement with the recommendations, self-efficacy, perceived outcome expectancy if recommendations were adhered to, and resource availability. Adherence to recommendations of LABD use was predicted by agreement with guideline recommendations and self-efficacy. Increasing guideline familiarity alone may have limited patient outcomes, as other barriers, such as low confidence and outcome expectancy, are more likely to impact guideline adherence.Keywords: COPD, primary care, barriers, guideline adoption