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

Abstract

Purpose: 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; barriers; guideline adoption; primary care.

Figure 1

Familiarity with clinical practice guidelines. Surveyed physicians indicated their familiarity with various clinical practice guidelines. The percentages of physicians who rated themselves as “very familiar” (rated 8–10 on a 10-point scale) are shown. Internal medicine physicians are more familiar with GOLD, ATS/ERS, and ACP COPD guidelines than family medicine physicians. However, familiarity with the COPD guidelines is much less than familiarity with the JNC 7 hypertension guidelines. Note: *Significance between familiarity of specialties (P < 0.05). Abbreviations: ACP, American College of Physicians; ATS, American Thoracic Society; COPD, chronic obstructive pulmonary disease; ERS, European Respiratory Society; GOLD, Global Initiative for Chronic Obstructive Lung Disease; JNC 7, Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Figure 2

Primary care physician assessment of self-efficacy and outcome expectancy of spirometry and long-acting bronchodilator use. Surveyed physicians indicated their levels of self-efficacy (A) represented by self-assessment of their own abilities, and outcome expectancy of spirometry (B) and long-acting bronchodilator use (C) defined by views on expected helpfulness. Values show percentages of the physicians who rated themselves as “very confident” or that spirometry/long-acting bronchodilators were “very helpful” in the given areas. Note: *Statistical significance between family physicians and internists (P < 0.05). Abbreviations: COPD, chronic obstructive pulmonary disease; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity.