Improving Clinician Self-Efficacy Does Not Increase Asthma Guideline Use by Primary Care Clinicians

Abstract

Objectives The association between changes in clinician self-efficacy and readiness to change and implementation of an asthma management program (Easy Breathing©) was examined. Methods A 36 month randomized, controlled trial was conducted involving 24 pediatric practices (88 clinicians). Randomized clinicians received interventions designed to enhance clinician self-efficacy and readiness to change which were measured at baseline and 3 years. Interventions consisted of an educational toolbox, seminars, teleconferences, mini-fellowships, opinion leader visits, clinician-specific feedback, and pay for performance. The primary outcome was program utilization (number of children enrolled in Easy Breathing/year); secondary outcomes included development of a written treatment plan and severity-appropriate therapy. Results At baseline, clinicians enrolled 149 ± 147 (mean ± SD) children/clinician/year; 84% of children had a written treatment plan and 77% of plans used severity-appropriate therapy. At baseline, higher self-efficacy scores were associated with greater program utilization (Relative Rate (RR) 1.34 (95% Confidence Interval 1.04, 1.72), p=0.04) but not treatment plan development (RR 0.63 (0.29, 1.35), p=.23) or anti-inflammatory use (RR 1.76 (0.92, 3.35), p=.09). Intervention clinicians participated in 17 interventions over 36 months. At study end, self-efficacy scores increased in intervention clinicians compared to control clinicians (p=0.01) and more clinicians were in an action stage of change (p=0.001) but these changes were not associated with changes in primary or secondary outcomes. Conclusions Self-efficacy scores correlated with program use at baseline and increased in the intervention arm but these increases were not associated with greater program-related activities. Self-efficacy may be necessary but not sufficient for behavior change.

Interventions to Modify Health Care Provider Adherence to Asthma Guidelines: A Systematic Review

“…75 The pre-post studies reported increases in the provision of action plans (27%-46%). [76][77][78]88 Both RCTs reported nonsignificant increases in patient education/asthma action plans (7% in 1 study; relative risk = 1.82 in the other study).…”

“…Of the 6 studies we reviewed, 73,[75][76][77][78]88 most included an educational component but also included (1) training in communication techniques with provision of a spirometer and training in use of the spirometer 76 ; (2) laminated posters of guidelines and medications with feedback on asthma action plan use and monthly calls from an intervention team to troubleshoot communication problems 88 ; (3) asthma kits (peak flow meters, spacers, educational materials) and systems-level changes (flow sheets and standing medication orders) 73 ; (4) systematic use of a patient questionnaire and an asthma management algorithm 77 ; (5) an asthma coordinator and feedback on performance as part of continuous quality improvement efforts; or (6) an educational toolbox with seminars, teleconferences, mini fellowships, opinion leader visits, clinician-specific feedback, and pay for performance. 75 The pre-post studies reported increases in the provision of action plans (27%-46%).…”

“…[76][77][78]88 Both RCTs reported nonsignificant increases in patient education/asthma action plans (7% in 1 study; relative risk = 1.82 in the other study). 73,75 SOE: low.…”

“…[72][73][74][75][76][77][78] All interventions included information, education, and at least 2 of the following: organizational change, decision support, and feedback and audit. Two of the 3 pre-post studies reported 25% to 49% increases in prescribing rates.…”

Use of Asthma APGAR Tools in Primary Care Practices: A Cluster-Randomized Controlled Trial

“…Perhaps combining our work with that of Cloutier et al, 62 who were able to improve pediatricians' readiness to change, would reduce this barrier.…”