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Clinical Practice Guidelines vs Actual Clinical Practice^*

The Asthma Paradigm

^* From US Medical Affairs-Respiratory, Glaxo Wellcome Inc, Research Triangle Park, NC.

Correspondence to: Courtney Crim, MD, FCCP, Glaxo Wellcome Inc., 5 Moore Drive, 17.1315B, PO Box 13398, Research Triangle Park, NC 27709-3398; e-mail: cc81095{at}glaxowellcome.com

	Abstract

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In recent years, a multitude of practice guidelines, statements, position papers, and "best practices" have been promulgated for a number of disease entities by a variety of medical societies and managed care organizations. In the case of asthma, for example, the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) initially published guidelines for the diagnosis and management of asthma in 1991; these recommendations were updated in 1997. However, health-care providers have not widely and consistently adhered to these guidelines. Several recent publications suggest that this underutilization of the NIH asthma guidelines may in part be related to a lack of understanding. This lack of understanding appears to span the spectrum of physicians in private practice, physicians working in health maintenance organizations, as well as university-affiliated physicians. Moreover, both primary-care physicians and "asthma specialists" share deficits in their knowledge base. To compound the problem, patients with asthma also demonstrate poor adherence to the guidelines. This poor adherence is evident irrespective of the patient’s socioeconomic status. These types of data clearly indicate a need for further educational programs directed to both physicians and patients. However, as with the development and promulgation of any practice guideline, physicians need to be convinced that there exists compelling evidence from well-controlled clinical trials, for example, or from evidence-based medicine, to substantiate implementation of these guidelines.

Key Words: asthma • practice guidelines

	Introduction

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The practice of medicine in the United States has undergone significant changes during the past decade. For example, in contrast to the situation in earlier years, managed care organizations have assumed a larger voice in the delivery of medical care and in formulary decisions. Along with these changes has been the promulgation by various medical societies (and even health maintenance organizations [HMOs]) of practice guidelines, statements, position papers, and "best practices." In general, the purpose of these guidelines is to provide assistance to clinicians in the diagnosis and treatment of specific medical conditions. For example, both the American Thoracic Society and the Infectious Disease Society of America have issued guidelines for the diagnosis and management of community-acquired pneumo-nia.^{1 2} Asthma is another disease state associated with significant morbidity and mortality, for which guidelines have been published.³

Asthma is a chronic inflammatory disease of the airways that affects approximately 15 to 17 million persons in the United States.^{4 5} One impetus to the publication of recent asthma guidelines by the Na-tional Heart, Lung, and Blood Institute (NHLBI) National Asthma Education and Prevention Program was the concern about data suggesting an increase in morbidity and mortality. The guidelines most recently published in the 1997 expert panel report-2 (EPR-2), expanded on the earlier recommendations⁶ and emphasized the role of inflammation in the pathogenesis of asthma. The report also presented ". . . basic recommendations for the diagnosis and management of asthma that will help clinicians and patients make appropriate decisions about asthma care."³

Although the NHLBI asthma guidelines have been in existence for nearly a decade, they have notbeen widely and consistently utilized by health-care providers.^{7 8 9 10 11 12} This lack of adherence to published guidelines appears to occur not only with patients living in poverty, but also with those who are managed in certain HMOs.^{7 8 9 10} This poor adherence to the guidelines by physicians appears in part to be related to a lack of understanding of the guidelines. For example, to a group of physicians in a university setting, Doerschug and colleagues¹¹ administered a multiple-choice test of asthma knowledge that was based on the NHLBI guidelines (EPR-2). The physicians included asthma specialists, primary-care faculty, asthma subspecialty residents, and house staff. The mean total correct score for all physicians was 60%, with the asthma specialists scoring slightly higher at 78%. However, no group scored at least 65% in the category of estimating disease severity, with most underestimating disease activity.¹¹ Moreover, in a random sample of asthma patients receiving care at their institution, the authors reported that contrary to EPR-2, less than half of the patients had undergone spirometry in the prior 2 years. In addition, one in five patients was receiving inadequate "step" therapy.¹¹ Thus, this unfamiliarity with the guidelines may partially explain its underutilization by physicians.

This "disconnect" with the guidelines on the part of physicians has had a major impact in the management of asthma patients. Legorreta and associates¹⁰ surveyed asthmatics receiving care in an independent physicians’ association-type HMO and noted that 72% of respondents with severe disease reported having a steroid inhaler, of whom only 26% used it daily. In addition, although 26% of respondents reported having a peak flowmeter, only 16% used it on a daily basis.¹⁰ Similar observations noted in the "Asthma in America" survey also confirm that asthma management in the United States is falling short of the goals of the NHLBI EPR-2.¹² Asthma in America was a survey conducted in 1998 with a national sample of 2,509 adults with asthma or parents of children with asthma, 700 health-care providers (including 512 physicians), and 1,000 adults from the general public. Glaxo Wellcome Inc. funded the survey.

As a further illustration of this disconnect or communication gap between physicians and patients, the Asthma in America survey found the following: (1) although 70% of physicians say they use spirometry on an ongoing basis, only 35% of asthmatics report having had pulmonary function testing in the past year; (2) 83% of doctors reported prescribing a peak flowmeter, yet only 62% of patients ever heard of the device (28% of asthmatics reported actually having a peak flowmeter, but only 9% actually used it at least once a week); and (3) 70% of physicians indicate they prepare an action plan for their asthmatics, but only 27% of patients acknowledge having a written action plan.¹²

As noted earlier, Doerschug and colleagues¹¹ noted a misunderstanding by physicians of the EPR-2 asthma guidelines. In support of these observations, the Asthma in America survey found that 11% of physicians caring for asthmatics were unaware of the guidelines. Of those familiar with the guidelines, 32% reported that they always followed them, whereas 48% said they followed the guidelines most of the time.¹² Finally, 92% of physicians surveyed agreed that anti-inflammatory drugs were essential in the management of persistent asthma. However, although 86% of physicians indicated that they would prescribe inhaled corticosteroids for moderate persistent asthma, only 19% of patients with persistent asthma reported taking inhaled steroids in the past month.¹²

In summary, recent data indicate that despite the existence of national asthma guidelines for nearly 10 years, there still remains a pressing need for educational programs directed toward physicians. The EPR-2 emphasizes that patients are partners with health-care providers in their asthma care; therefore, patient education is of paramount importance. This facet of asthma care undoubtedly will require an appropriate allocation of time on the part of the health-care professional to perform this task. Clearly, however, it is critical that if health-care providers are to be expected to perform this education, they must be convinced that there exists sufficient evidence to substantiate implementation of the guidelines. Only then will they be willing to alter their behavior and translate the guidelines into their own clinical practice.

	Footnotes

 
Abbreviations: EPR-2 = expert panel report 2; HMO = health maintenance organization; NHLBI = National Heart, Lung, and Blood Institute; NIH = National Institutes of Health

	References

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1. Niederman, MS, Bass, JB, Campbell, GD, et al (1993) Guidelines for the initial empiric therapy of community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. Am Rev Respir Dis 148,1418-1426[ISI][Medline]
2. Bartlett, JG, Breiman, RF, Mandell, LA, et al (1998) Community-acquired pneumonia in adults: guidelines for management. Clin Infect Dis 26,811-838[ISI][Medline]
3. National Asthma Education and Prevention Program. Expert panel report 2: guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health, April 1997; Publication No. 97–4051
4. Centers for Disease Control and Prevention. Forecasted state-specific estimates of self-reported asthma prevalence-United States, 1998 MMWR Morb Mortal Wkly Rep 1998; 47:1022–1025
5. Adams PF, Hendershot GE, Marano MA. Current estimates from the National Health Interview Survey, 1996. Vital Health Stat 10. 1999; 10:62
6. National Asthma Education and Prevention Program. Expert panel report: guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health, 1991; NIH Publication No. 92–3042
7. Gottlieb, DJ, Beiser, AS, O’Connor, GT (1995) Poverty, race, and medication use are correlates of asthma hospitalization rates. Chest 108,28-35[Abstract/Free Full Text]
8. Lang, DM, Sherman, MS, Polansky, M (1997) Guidelines and realities of asthma management. Arch Intern Med 157,1193-1200[Abstract]
9. Vollmer, WM, O’Hollaren, M, Ettinger, KM, et al (1997) Specialty differences in the management of asthma. Arch Intern Med 157,1201-1208[Abstract]
10. Legorreta, AP, Christian-Herman, J, O’Connor, RD, et al (1998) Compliance with national asthma management guidelines and specialty care. Arch Intern Med 158,457-464[Abstract/Free Full Text]
11. Doerschug, KC, Peterson, MW, Dayton, CS, et al (1999) Asthma guidelines: an assessment of physician understanding and practice. Am J Respir Crit Care Med 159,1735-1741[Abstract/Free Full Text]
12. Rickard, KA, Stempel, DA (1999) Asthma survey demonstrates that the goals of the NHLB1 have not been accomplished (abstract). J Allergy Clin Immunol 103; (1 pt 2),S171

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