Barriers to delivering asthma care: a qualitative study of general practitioners

Dianne P Goeman, Jo A Douglass, Chris D Hogan, Rosalie A Aroni, Michael J Abramson, Susan M Sawyer, Kay Stewart and Lena A Sanci
Med J Aust 2005; 183 (9): 457-460. || doi: 10.5694/j.1326-5377.2005.tb07122.x
Published online: 7 November 2005


Objectives: To ascertain what general practitioners’ priorities are for achieving optimal outcomes in people with asthma, and the barriers they face in delivering this care.

Design: A qualitative study using the Nominal Group Technique (a highly structured meeting to gain information from experts about a particular issue) was conducted between August 2002 and September 2003. GPs in six discussion groups were asked “What do you think is needed to achieve best outcomes for asthma care?” To augment analysis of the discussion, sessions were taped and transcribed.

Participants: Forty-nine GPs were recruited: 34 from metropolitan and 15 from rural areas.

Results: All groups nominated asthma education for patients and continuing professional education for GPs as major priorities, but they also described educational and structural barriers to achieving these priorities. Other priorities were: medication adherence, facilitating regular patient review, negotiated treatment/management plans, making the correct diagnosis, increased remuneration and consultation time, and safer asthma medications and access to these. Health promotion initiatives and increased public awareness were also priorities. Spirometry was a significant cause of uncertainty. Overall, written asthma action plans were not considered a high priority.

Conclusions: Remarkable consistency was found between GPs’ priorities for delivering best asthma care. Our study identified barriers to asthma guideline adherence, including accessible, relevant education for GPs, and structural, time and cost barriers GPs must overcome in providing asthma treatment and patient education.

For most people with asthma, general practitioners provide education as well as treatment.1 To lower the morbidity and mortality of asthma, treatment guidelines have been developed that focus on achieving best outcomes by self-management.2,3 However, the provision of asthma action plans, a key indicator of adherence to guidelines, is progressively falling, and community studies reveal that less than 60% of guideline standards are achieved.4,5

In recent studies of patients’ priorities for asthma care, one of the recurrent themes was the importance of the doctor–patient relationship.6,7 Improving the implementation of asthma guidelines requires not only insights into the perspectives of those living with asthma,6,7 but also an understanding of what GPs’ priorities are for achieving optimal outcomes in people with asthma, and the barriers they face in delivering this care. We therefore conducted a qualitative study asking GPs “What do you think is needed to achieve best outcomes in people with asthma?


Forty-nine GPs participated in one of six Nominal Group Technique sessions. Thirty-four GPs from a city or suburban area attended one of five group sessions, and 15 regionally based GPs attended one group session.

Priorities for asthma care

There was a high level of consistency between the top priorities of each group, as shown in the Box.

Continuing medical education

Continuing medical education was a high priority for all groups studied. Issues referred to were: education in the use of new agents, the use of spacers versus nebulisers, managing severe asthma, detecting early asthma, stages of treatment, complications of treatment, diagnosis of asthma, and the use of spirometry. Conversely, lack of time and access were identified as a limitation to continuing medical education by both rural and metropolitan groups.

Drug side effects were a particular concern.

Consistency of the education and information provided to patients by health professionals of all disciplines was recognised as crucial to achieving good outcomes. One group strongly supported education for doctors on how to effectively educate patients.

Another group discussed the challenges of managing patients who knew more about managing asthma than their doctor.


Our study confirms the presence of a gap between current asthma guidelines and Australian GPs’ priorities for optimal asthma care. The top priorities identified by GPs in our study included patient education, continuing professional education, medication adherence, promoting regular review, developing an asthma management treatment plan, and correct diagnosis and management.

Some of these priorities are included within asthma guidelines, but are not given the same prominence as the GPs gave them. For example, patient education is the final step of the 6-step Asthma Management Plan, and patient adherence is a small part of this step, yet was a top priority for the GPs in our groups. Our findings suggest that to deliver asthma care according to GPs’ priorities, broader issues need to be addressed, such as facilitating relationships with patients, making an accurate diagnosis, establishing a patient recall system, and finding the time required to provide asthma education. The GPs commented that the 3+ Visit Plan dealt with some of these issues, in particular promoting spirometry to clarify diagnosis, but did not necessarily facilitate other issues, such as the time required, adequate remuneration, and patient recalls.

Despite the strength of evidence supporting their use,10 written asthma action plans to deal with severe exacerbations were not a priority for the GPs we studied, consistent with reports from the United Kingdom and the downward trends occurring in action plan ownership.4,6 There was, however, broad support for asthma management plans, as suggested by the 6-step Asthma Management Plan.2 This was distinct from specific support for a written asthma action plan.

Translating guidelines into clinical practice remains a challenge for medicine, even when evidence of treatment efficacy is compelling.11-13 A meta-analysis studying the effect of educational interventions in changing clinical practice revealed that multi-faceted interventions, which include structural reinforcers and enabling mechanisms, are more likely to change practice.14-17 Consistent with this, the GPs we studied prioritised widely targeted interventions encompassing clinicians, patients and the community. The structural changes to practice environments supported by this study included longer consultation times, the removal of barriers, such as expense, to patients’ receiving optimal medication, and facilitating medical review.

Current models of chronic illness care emphasise a “patient-centred” approach,7,18 which was recognised by the GPs in our study when discussing the challenges of dealing with “expert patients”, and they indicated a need for continuing professional education so they were better equipped to educate their patients.19,20 These results support the value of professional development focusing not only on improving physicians’ therapeutic skills, but also their skills in communication and patient education, as in the highly successful PACE (Provider Asthma Care Education) program.21

The use of practice nurses is well established in the United Kingdom, the United States and New Zealand.22 While this model is still evolving in Australia, with only 40% of practices having a nurse,23 it provides the possibility for a huge improvement in the provision of optimal asthma care, as it would overcome many of the structural barriers identified by GPs.

It has been argued that improving access to spirometry in primary care may improve accurate diagnosis and compliance with guidelines.24 However, many GPs, especially those from regional areas, thought spiro-meters too expensive, and some GPs lacked confidence in their use. Our study suggests a significant divergence between recommendations regarding spirometry and GPs’ confidence to perform and interpret the tests.

As far as we are aware, our study is the first to ascertain Australian GPs’ priorities for the delivery of optimal asthma care. The GPs were able to nominate structural barriers to implementing best care, and their priorities for optimal asthma care showed remarkable consistency. To deliver care according to asthma guidelines, the prior-ities of GPs need to be incorporated into multifaceted interventions addressing structural and systematic issues in care delivery.

Received 8 June 2005, accepted 8 September 2005

  • Dianne P Goeman1
  • Jo A Douglass2
  • Chris D Hogan3
  • Rosalie A Aroni4
  • Michael J Abramson5
  • Susan M Sawyer6
  • Kay Stewart7
  • Lena A Sanci8

  • 1 Department of Allergy, Immunology and Respiratory Medicine, and the Cooperative Research Centre for Asthma, The Alfred Hospital and Monash University, Melbourne, VIC.
  • 2 Royal Australian College of General Practitioners, South Melbourne, VIC.
  • 3 Monash Institute of Health Services Research, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC.
  • 4 Department of Epidemiology and Preventive Medicine, Monash University, Central and Eastern Clinical School, Melbourne, VIC.
  • 5 Centre for Adolescent Health, Royal Children’s Hospital and University of Melbourne, Parkville, VIC.
  • 6 Department of Pharmacy Practice, Victorian College of Pharmacy, Parkville, VIC.
  • 7 Department of General Practice, University of Melbourne, Carlton, VIC.



We would like to thank Katrina Marks from the RACGP, Michelle Wills (South City Division of General Practice), and Angela Rodaughan (South Gippsland Division of General Practice) for their help with the recruitment of general practitioners. We are grateful to all the general practitioners who participated in the Nominal Group Technique discussions. The study was funded by the Cooperative Research Centre for Asthma, University of Sydney.

Competing interests:

None identified.

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