title: Effect of local standards on the implementation of national guidelines for asthma: primary care agreement with national asthma guidelines.
abstract: OBJECTIVE
  To assess the level of modification by local primary care doctors of key aspects of the National Asthma Education Program (NAEP) Guidelines for the Diagnosis and Management of Asthma.
  
  
  METHODS
  A random sample of primary care physicians participating in local asthma guideline development.
  
  
  METHODS
  Two hospital systems, one based in an urban environment, and a second in a community and rural environment.
  
  
  METHODS
  Primary care physicians.
  
  
  METHODS
  Design of consensus-based local asthma guidelines using a modified Delphi approach.
  
  
  RESULTS
  A total of 42 physicians participated in the local guideline development. With few exceptions, the primary care physicians modified in major ways the NAEP Guidelines regarding the role of pulmonary function testing and spirometry. Specifically, the local guidelines did not require peak flow and spirometry measurements as the basis for initiating inhaled steroids as did the national guidelines. All 42 physicians emphasized a clinical diagnosis versus one based on a pulmonary function. Peak flow monitoring was recommended by 35 (83%) of physicians in selected patients only, in contrast to the national guidelines, which emphasized monitoring for all patients routinely and during exacerbations. There was strong agreement with the national guidelines on the role and importance of patient education, and on the indications for the use of inhaled steroids.
  
  
  CONCLUSIONS
  Disagreement by primary care doctors with parts of the NAEP guideline is a potential cause for poor compliance and lack of influence on patient care. Recognizing the need to modify or customize guidelines through field testing with local primary care physicians will improve acceptance of national guidelines.
authors.affiliation: Department of Medicine, New England Medical Center, Boston, Mass 02111, USA.
authors.forename: H A
authors.initials: HA
authors.lastname: Picken
authors.forename: S
authors.initials: S
authors.lastname: Greenfield
authors.forename: D
authors.initials: D
authors.lastname: Teres
authors.forename: P S
authors.initials: PS
authors.lastname: Hirway
authors.forename: J N
authors.initials: JN
authors.lastname: Landis
mesh_terms: D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage; D001249:Asthma / Q000175:diagnosis* / Q000188:drug therapy*; D003625:Data Collection; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008404:Massachusetts; D017410:Practice Guidelines as Topic / Q000592:standards*; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care / Q000592:standards*; D012017:Referral and Consultation / Q000592:standards; D012129:Respiratory Function Tests; D012424:Rural Population; D014505:Urban Population
chemical_list: D000305:Adrenal Cortex Hormones