The Realities of Guidelines: Does the Outcome Match the Effort?
ABSTRACT & COMMENTARY
Synopsis: In an analysis of asthma prescribing patterns, a surprising trend toward increased ratios of bronchodilators to inhaled corticosteroids was noted from 1991 to 1993, despite the introduction in 1991 of national asthma care guidelines that emphasized the use of inhaled corticosteroids to reduce airway inflammation.
Source: Lang DM, et al. Arch Intern Med 1997;157:1193-1200.
Clinical practice guidelines are a reality of the daily practice of medicine. These ever-proliferating documents are designed to provide the practitioner with a synthesis of best diagnostic and therapeutic evidence upon which to base management decisions. However, there are often gaps in implementation, and actual practice often falls short of the approach offered by the guideline. The reasons for this discrepancy are often multifactorial and include both patient and practitioner resistance, as well as misaligned financial incentives. Among the most significant efforts in this area were the National Heart, Lung, and Blood Institutes guideline for the management of asthma, initially produced in 1991 and redone this year.1 The major focus of this care pathway was the use of inhaled corticosteroids to suppress airway inflammation. This intervention has been demonstrated to both improve quality of life and reduce fatal asthmatic episodes.2,3
Lang et al examined the actual application of the guideline in Philadelphia, using a cross-sectional study design. Bronchodilator and inhaled steroid prescriptions were determined in 45 zip codes and compared by univariate and multivariate analysis for epidemiologic and demographic features, which were related to prescription patterns. The ratio of bronchodilator to inhaled steroid prescriptions was used as a surrogate marker for guideline compliance. Despite the publication and dissemination of the guideline, the ratio of bronchodilator to steroid prescriptions actually increased over the time of study, from a monthly average of 6.6 to 8.6. This observation was based primarily on the decline in overall inhaled steroid prescriptions. The demographic features most strongly associated with this trend were lower proportions of residents who were high school graduates, fewer asthma care providers, and greater portions of residents who were African American, Hispanic, or below the poverty line. These factors correlated with the most rapidly increasing bronchodilator use.
COMMENT BY ALAN M. FEIN, MD
This study provides significant insight into the management of asthma and to the issue of guideline compliance in general. It is clear that despite the widespread attempt to disseminate national asthma guidelines, compliance that should have peaked at six months was lagging. The factors associated with failure to prescribe inhaled corticosteroids were related both to patient and caregiver issues. Lower rates of high school education and poverty were independently associated with reduced inhaled steroid prescription rates. This probably reflects both a lack of "belief" that a medicine that is inhaled has the same efficacy as one that is ingested and the higher level of training required to ensure proper inhaler technique. The reduced availability of both primary and specialist care for asthma in the areas with the lowest use of inhaled steroids also emphasizes the importance of physicians to patient education, and particularly in asthma self-management. Since there is no asthma risk adjustment of the data, it is possible that the lower rates of inhaled steroid use reflected a higher oral use of corticosteroids or other anti-inflammatory agents since asthma fatality has been associated with lower socioeconomic status. These data also highlight the difficulty of disseminating and implementing guidelines. Physicians and patients must buy into the premises of the guideline and alter behaviors that may not be entirely rationally grounded. In addition, the focus in areas of poverty on episodic rather than preventive care may reduce incentives for physicians to keep patients from hospitalization. As has been stated in the past, "It is not only necessary to produce soap, you must get people to wash."
References
1. Guidelines for the diagnosis and management of asthma. Washington, DC: U.S. Department of Health and Human Services; 1991. Publication 91-3042.
2. Juniper EF, et al. Effect of long-term treatment with an inhaled corticosteroid (budesonide) on airway hyperresponsiveness and clinical asthma in nonsteroid-dependent asthmatics. Am Rev Respir Dis 1990;142:832-836.
3. Haahtela T, et al. Comparison of a b-agonist, terbutaline, with an inhaled corticosteroid, budesonide, in newly detected asthma. N Engl J Med 1991;325: 388-392.
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