Management of asthma and COPD patients: feasibility of the application of guidelines in general practice

Objective. To examine the feasibility of the application of guidelines to the management of asthma and chronic obstructive pulmonary disease (COPD) by assessing compliance with the guidelines and listing the barriers general practitioners (GPs) encountered during implementation. Insight into the feasibility of individual items in the guidelines can guide implementation strategies in the future and, if necessary, support revision of the guidelines. Design. Descriptive study of care delivered during the implementation of guidelines by means of documentation of the care provided, education, feedback on compliance and peer review. Setting. General practice. Study participants. Sixteen GPs in 14 general practices. Main outcome measures. Compliance was expressed as the percentage of patients per practice managed by the GPs according to the guidelines. For each patient (n=413) data were collected on the care delivered during the first year of the implementation. Barriers encountered were derived from the summaries of the discussions held during the monthly meetings. Results. The GPs were most compliant on the items 'PEFR measurement at every consultation' (98%),'allergy test' (78%) and 'advice to stop smoking' (82%), and less compliant on the items 'four or more consultations a year' (46%),'ordering spirometry' (33%), 'adjustment of medication' (42%), 'check on inhalation technique' (38%) and referral to a chest physician (17%) or a district nurse (5%). The main barriers were the amount of time to be invested, doubts about the necessity of regular consultations and about the indications for ordering spirometry and for referral to a chest physician or a district nurse. Conclusion. Although the feasibility was assessed in a fairly optimal situation, compliance with the guidelines was not maximal, and differed between the individual items of care. Suggestions are given for further improvements in compliance with the guidelines and for revision of the guidelines.