title: Barriers to adherence to asthma management guidelines among inner-city primary care providers.
abstract: 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.
authors.affiliation: Division of General Internal Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA. juan.wisnivesky@mssm.edu
authors.forename: Juan P
authors.initials: JP
authors.lastname: Wisnivesky
authors.forename: Jessica
authors.initials: J
authors.lastname: Lorenzo
authors.forename: Richard
authors.initials: R
authors.lastname: Lyn-Cook
authors.forename: Thomas
authors.initials: T
authors.lastname: Newman
authors.forename: Adam
authors.initials: A
authors.lastname: Aponte
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Kiefer
authors.forename: Ethan A
authors.initials: EA
authors.lastname: Halm
mesh_terms: D001249:Asthma / Q000628:therapy*; D001291:Attitude of Health Personnel; D019468:Disease Management; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D019538:Health Care Surveys; D006282:Health Personnel; D006801:Humans; D008913:Minority Groups; D015999:Multivariate Analysis; D009519:New York City; D016017:Odds Ratio; D010349:Patient Compliance; D017410:Practice Guidelines as Topic; D011320:Primary Health Care; D019037:Urban Health Services