This study examined PCP attitudes and perceptions to the adherence to GOLD COPD practice guidelines. One main finding was that only 1 of 4 PCPs adhered to either guideline recommendation on spirometry and LABD use more than 90% of the time. 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. Survey respondents demonstrated greater awareness of COPD practice guidelines disseminated by GOLD than to those released by the ATS/ERS. Internal medicine physicians indicated more familiarity with COPD guidelines than family physicians, possibly in part because internal medicine physicians may care for more patients with COPD than family practitioners. Internists were most familiar with the ACP guidelines.
Less than one-third (31.6%) of PCPs cited high familiarity with the GOLD guidelines. This finding rests in stark contrast with the more than three-quarters (76.4%) of respondents who indicated high familiarity with JNC 7 hypertension guidelines. Although the greater degree of familiarity with hypertension guidelines may in part be attributed to the higher prevalence of hypertension than of COPD, the disparity between guideline awareness for these two common disease processes suggests that there may be room for improvement in the dissemination of COPD guidelines.
However, increased awareness and dissemination of guidelines alone may not necessarily translate into greater incorporation of such guidelines into practice. A study by Christian et al examining quality of cardiovascular disease preventive care found that self-reported incorporation of relevant guidelines was lower than awareness levels.15
In their original paper on pediatric asthma guidelines, Cabana et al found that some element of their model applied to nonadherence to every guideline component they tested,11
including familiarity. In our model, familiarity with any guideline did not impact adherence to guideline statements. There was also discordance between self-reported confidence in pulmonary function test selection and the importance given to spirometry. More than two-thirds (69%) of PCPs indicated that they were extremely confident in choosing the appropriate pulmonary function test to determine whether COPD is present, and a majority (62.6%) cited high confidence in ability to interpret spirometry results. Furthermore, although 60% of PCPs indicated that spirometry testing would be extremely helpful in guiding therapeutic management in a patient with newly suspected COPD, less than one-third (29.6%) strongly agreed that a suspected diagnosis of COPD should be confirmed by spirometry. Only about half (52.3%) of PCPs indicated that spirometry would be extremely helpful in improving health outcomes in a patient with newly suspected COPD.
It should be noted that not all COPD practice guidelines unequivocally support spirometry. The ATS/ERS guidelines support the use of spirometry in primary care practice, whereas the ACP guidelines state that there is insufficient evidence for the use of spirometry for screening.16
One trial has examined the use of a combined nurse and physician intervention to increase and improve spirometry performance but found no difference in outcomes of care between treatment and usual care groups.18
The correct diagnosis of COPD remained very low (8% in both groups). Another trial is currently underway to examine a combined physician–nurse intervention.19
Our study also examined physician perspectives regarding therapy for COPD. Nearly two-thirds of PCPs indicated high confidence in recommending an optimal therapeutic regimen and gauging response to pharmacotherapy in a patient with established COPD and mild exertional dyspnea. Nonetheless, substantially less than half (39.7%) of PCPs strongly agreed with the addition of an LABD to the treatment regimen of a patient with stage 2–3 COPD experiencing dyspnea despite use of a short-acting bronchodilator. This discrepancy between self-reported practice recommendation and outcome expectancy is somewhat surprising since more than two-thirds of respondents indicated that the use of an LABD in such a patient would be extremely helpful in reducing exertional dyspnea, increasing overall activity level, and improving quality of life. Perhaps our findings on physician attitudes toward LABDs are tempered by studies contemporary to ours that reported potential adverse effects from LABD use.20
Clinicians may place more weight on mortality reduction as an indication for therapy, hence the low rate of strong agreement with use of an LABD for COPD.
Limitations of the study
In light of our findings, the model that we used to identify potential barriers to guideline adherence may have, in retrospect, omitted some important components. The finding of integration of office-based spirometry into patient flow as a significant barrier suggests that we may not have included certain factors to understand why spirometry is perceived to have low utility. Due to space constraints within the instrument, our LABD model was less comprehensive than the spirometry model and may have left out relevant barriers and other determinants of adherence (such as cost–benefit and contradictory evidence-based information).
Adherence was measured only by physician self-reporting and not corroborated by chart audits or other external checks. Physicians have been shown to have a limited ability to accurately self-assess;23
thus, the accuracy of our self-efficacy and adherence data may be limited. This study was conducted among mainly community-based PCPs who quickly responded to an invitation to participate. Although the sample differed somewhat from the overall population of PCPs within the AMA Physician Masterfile in terms of gender, it was statistically similar on all other parameters measured. With similar demographics and the use of 500 as a representative sample, there is no reason to believe that the perceptions of respondents are significantly different from those of the overall PCP population. Furthermore, the study findings are aligned with previously reported findings that self-efficacy, outcome expectancies, and external barriers may be more influential determinants of guideline adherence than simple guideline familiarity. Given the aforementioned limitations, this is the first study to our knowledge to use a framework such as Cabana et al’s in examining barriers to COPD guideline adoption.
Findings from this study offer some useful guidance in improving adherence to COPD guidelines. COPD guidelines appear to be less well known than guidelines for other prevalent diseases. Although guideline familiarity was not a predictor of adherence in the model, it may nevertheless be an early prerequisite. Efforts to increase the legitimacy and utility of this guideline for PCPs may be important. To improve guideline adoption, attitudes that can facilitate or impede guideline adoption must also be targeted. Agreement with guideline recommendations was a significant predictor of adherence. However, 1 in 5 PCPs reported ambivalence or disagreement with recommendations, and many were unconvinced that implementing recommendations would be beneficial. Information about specific recommendations must therefore simultaneously demonstrate the basis for the recommendation and its utility in the primary care setting.
Inadequate confidence in interpreting spirometry data may limit the utility of testing, and in this study was an independent predictor of nonadherence. Low confidence levels were rare, but more than 1 in 3 PCPs had only moderate confidence in their spirometry interpretation skills. This may reflect a synthesis, rather than a knowledge gap, and may point to difficulty in understanding how spirometry data relate to other clinical findings and improve diagnostic accuracy. To an extent, guidelines may be able to elaborate on the application of spirometry results in practice, but additional opportunities that allow PCPs to practice and refine spirometry interpretation skills may also be needed.
This study drew attention to the importance of measuring therapeutic response. Physicians who have difficulty gauging how patients have responded to therapy were somewhat less likely to adhere to recommendations on LABD use. LABDs may produce subtle, but meaningful, improvements during activity and may reduce exacerbation risk. PCPs may need more information regarding how LABDs improve respiratory health as well as tools that allow them to gauge improvement.