Barriers to adherence to COPD guidelines among primary care providers

Respir Med. 2012 Mar;106(3):374-81. doi: 10.1016/j.rmed.2011.09.010. Epub 2011 Oct 13.


Background: Despite efforts to disseminate guidelines for managing chronic obstructive pulmonary disease (COPD), adherence to COPD guidelines remains suboptimal. Barriers to adhering to guidelines remain poorly understood.

Methods: Clinicians from two general medicine practices in New York City were surveyed to identify barriers to implementing seven recommendations from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Barriers assessed included unfamiliarity, disagreement, low perceived benefit, low self-efficacy, and time constraints. Exact conditional regression was used to identify barriers independently associated with non-adherence.

Results: The survey was completed by 154 clinicians. Adherence was lowest to referring patients with a forced expiratory volume in 1 s (FEV(1)) <80% predicted to pulmonary rehabilitation (5%); using FEV(1) to guide management (12%); and ordering pulmonary function tests (PFTs) in smokers (17%). Adherence was intermediate to prescribing inhaled corticosteroids when FEV(1) <50% predicted (41%) and long-acting bronchodilators when FEV(1) <80% predicted (54%). Adherence was highest for influenza vaccination (90%) and smoking cessation counseling (91%). In unadjusted analyses, low familiarity with the guidelines, low self-efficacy, and time constraints were significantly associated with non-adherence to ≥2 recommendations. In adjusted analyses, low self-efficacy was associated with less adherence to prescribing inhaled corticosteroids (OR: 0.28; 95% CI: 0.10, 0.74) and time constraints were associated with less adherence to ordering PFTs in smokers (OR: 0.31; 95% CI: 0.08, 0.99).

Conclusions: Poor familiarity with recommendations, low self-efficacy, and time constraints are important barriers to adherence to COPD guidelines. This information can be used to develop tailored interventions to improve guideline adherence.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Attitude of Health Personnel
  • Clinical Competence
  • Counseling / statistics & numerical data
  • Female
  • Glucocorticoids / therapeutic use
  • Guideline Adherence / statistics & numerical data*
  • Humans
  • Influenza Vaccines
  • Male
  • New York City
  • Practice Guidelines as Topic*
  • Primary Health Care / standards*
  • Primary Health Care / statistics & numerical data
  • Pulmonary Disease, Chronic Obstructive / physiopathology
  • Pulmonary Disease, Chronic Obstructive / therapy*
  • Respiratory Function Tests / statistics & numerical data
  • Self Efficacy
  • Smoking / physiopathology
  • Smoking Cessation
  • Urban Health Services / statistics & numerical data
  • Young Adult


  • Glucocorticoids
  • Influenza Vaccines