Barriers to adherence to asthma management guidelines among inner-city primary care providers Juan P. Wisnivesky, MD, MPH*†; Jessica Lorenzo, MPH*; Richard Lyn-Cook, MD, MPH‡; Thomas Newman, MD§; Adam Aponte, MD; Elizabeth Kiefer, MD¶; and Ethan A. Halm, MD, MPH*# Background: Health care provider adherence to national asthma guidelines is critical in translating evidence-based recom- mendations into improved outcomes. Unfortunately, provider adherence to the National Heart, Lung, and Blood Institute (NHLBI) guidelines remains low. Objective: To identify barriers to guideline adherence among primary care professionals providing care to inner-city, minority patients with asthma. Methods: We surveyed 202 providers from 4 major general medicine practices in East Harlem in New York, New York. The study outcome was self-reported adherence to 5 NHLBI guideline components: inhaled corticosteroid (ICS) use, peak flow (PF) monitoring, action plan use, allergy testing, and influenza vaccination. Potential barriers included lack of agreement with guideline, lack of self-efficacy, lack of outcome expectancy, and external barriers. Results: Most providers reported adhering to the NHLBI guidelines for ICS use (62%) and for influenza vaccinations (73%). Self-reported adherence was 34% for PF monitoring, 9% for asthma action plan use, and 10% for allergy testing. Multivariate analyses showed that self-efficacy was associated with increased adherence to ICS use (odds ratio [OR], 2.8; P = .03), PF monitoring (OR, 2.3; P = .05), action plan use (OR, 4.9; P = .03), and influenza vaccinations (OR, 3.5; P = .05). Conversely, greater expected patient adherence was associated with increased adherence to PF monitoring (OR, 3.3; P = .03) and influenza vaccination (OR, 3.5; P = .01). Familiarity with specific guideline components and higher level of training were also predictors of adherence. Conclusions: Lack of outcome expectancy and poor provider self-efficacy prevent providers from adhering to national asthma guidelines. Efforts to improve provider adherence should address these specific barriers. Ann Allergy Asthma Immunol. 2008;101:264–270. INTRODUCTION Asthma is a common disease with an overall prevalence in the general population of 6% to 7%. 1,2 Minority, inner-city residents have disproportionately high rates of asthma inci- dence and increased morbidity and mortality. 1–4 This problem is especially serious in East Harlem, a community with asthma hospitalization and mortality rates that are several times higher than the national average. 5 Proposed explana- tions for the urban asthma problem include patient-provider communication barriers, suboptimal self-management, ac- cess-to-care barriers, poor quality of care, higher exposure to allergens, and air pollution. 6 –12 In an attempt to standardize and disseminate best practices for asthma management, the National Heart, Lung, and Blood Institute (NHLBI) guidelines for the diagnosis and treatment of asthma were developed. 13 They include a comprehensive evidence-based review of the different treatments and man- agement strategies and are currently recognized as the stan- dard of care in the United States. Implementation of the NHLBI guidelines should help in reducing practice variabil- ity and improving quality of care. Health care provider adherence to the NHLBI guidelines is a critical first step in translating these recommendations into improved outcomes. Despite more than a decade of dissem- ination efforts, several studies have documented poor adher- ence to these guidelines. 14 –18 Although previous studies have focused on potential barriers for pediatrician adherence to asthma guidelines, 19 –21 information is limited regarding the factors that influence the adoption of the guidelines among Affiliations: * Division of General Internal Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, New York; † Divi- sion of Pulmonary, Critical Care and Sleep Medicine, Department of Med- icine, Mount Sinai School of Medicine, New York, New York; ‡ Depart- ments of Medicine and Pediatrics, Methodist Willowbrook Hospital, Houston, Texas; § Division of Pulmonary Medicine, Metropolitan Hospital, New York, New York;  Department of Medicine, North General Hospital, New York, New York; ¶ Division of General Internal Medicine, College of Physician and Surgeons, Columbia University, New York, New York; # De- partment of Health Policy, Mount Sinai School of Medicine, New York, New York. Disclosures: Authors have nothing to disclose. Funding Sources: This study was funded by the Agency for Healthcare Research and Quality (K08 HS013312, Dr Wisnivesky) and the National Institute on Aging (RO1 HS09973). Dr Lyn-Cook was supported by the Empire Clinical Research Investigators Program, New York State Depart- ment of Health. Received for publication March 20, 2008; Received in revised form April 29, 2008; Accepted for publication May 19, 2008. 264 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY