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

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          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.


          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.


          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.

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          Most cited references 4

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          Physician adherence to preventive cardiology guidelines for women.

          Despite the publication of the American Heart Association/American College of Cardiology (AHA/ACC) "Guide to Preventive Cardiology for Women" primary care screening and treatment of women at risk for coronary heart disease risk is not optimal. The purpose of this article is to apply a framework of physician behavior to describe specific challenges in implementing clinical practice guidelines for women's cardiovascular health in the primary care setting. Specifically, we illustrate 1) underlying barriers to adherence, 2) attempts and interventions to overcome these barriers, and 3) future areas of research to improve physician adherence to guidelines for the prevention and treatment of heart disease in women.
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            A cluster randomised controlled trial of nurse and GP partnership for care of Chronic Obstructive Pulmonary Disease

            Background Chronic obstructive pulmonary disease (COPD) is a significant health problem worldwide. This randomised controlled trial aims at testing a new approach that involves a registered nurse working in partnership with patients, general practitioners (GPs) and other health professionals to provide care to patients according to the evidence-based clinical practice guidelines. The aim is to determine the impact of this partnership on the quality of care and patient outcomes. Methods A cluster randomised control trial design was chosen for this study. Randomisation occurred at practice level. GPs practising in South Western Sydney, Australia and their COPD patients were recruited for the study. The intervention was implemented by nurses specifically recruited and trained for this study. Nurses, working in partnership with GPs, developed care plans for patients based on the Australian COPDX guidelines. The aim was to optimise patient management, improve function, prevent deterioration and enhance patient knowledge and skills. Control group patients received 'usual' care from their GPs. Data collection includes patient demographic profiles and their co-morbidities. Spirometry is being performed to assess patients' COPD status and CO analyser to validate their smoking status. Patients' quality of life and overall health status are being measured by St George's Respiratory Questionnaire and SF-12 respectively. Other patient measures being recorded include health service use, immunisation status, and knowledge of COPD. Qualitative methods will be used to explore participants' satisfaction with the intervention and their opinion about the value of the partnership. Analysis Analysis will be by intention to treat. Intra-cluster (practice) correlation coefficients will be determined and published for all primary outcome variables to assist future research. The effect of the intervention on outcomes measured on a continuous scale will be estimated and tested using mixed model analysis of variance in which time and treatment group will be fixed effects and GP practice and subject nested within practice will be random effects. The effect of the intervention on the dichotomous variables (such as smoking status, patient knowledge) will be analysed using generalised estimating equations with a logistic link and a model structure that is analogous to that described above. Trial registration ACTRN012606000304538
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              Controversies in the use of spirometry for early recognition and diagnosis of chronic obstructive pulmonary disease in cigarette smokers.

               R Crapo,  P Enright (2000)
              Office spirometry used to detect COPD in smokers ages 44 and above with respiratory symptoms probably meets the criteria for a population-based screening test and for clinical case finding: If not detected early, COPD causes substantial morbidity or mortality, and smoking cessation is more effective when COPD is recognized before exertional dyspnea develops. Office spirometry is a feasible testing strategy and may be used to encourage smoking cessation efforts that change behavior in at least some patients. Office spirometry is relatively simple and affordable, is safe, and includes an action plan with minimal adverse effects. On the other hand, the false-positive and false-negative rates of office spirometry in the primary care setting may be higher than diagnostic spirometry performed during epidemiologic studies or in diagnostic pulmonary function laboratories, and the incremental benefit of office spirometry on smoking cessation rates is poorly established (when added to referral to an AHCPR-based smoking cessation program).

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                28 February 2011
                : 6
                : 171-179
                [1 ]CE Outcomes, LLC Birmingham, AL, USA;
                [2 ]Asthma-COPD Program, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA;
                [3 ]Division of Pulmonary, Allergy, Critical Care, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, USA;
                [4 ]Boehringer-Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA;
                [5 ]COPD Foundation, Miami, FL, USA
                Author notes
                Correspondence: Gregory D Salinas, CE Outcomes, LLC; 107 Frankfurt Circle, Birmingham, AL 35226, USA, Tel +1 205 259 1500, Email greg.salinas@
                © 2011 Salinas et al, publisher and licensee Dove Medical Press Ltd.

                This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.

                Original Research

                Respiratory medicine

                guideline adoption, primary care, copd, barriers


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