Barriers and Enablers to Objective Testing for Asthma and COPD in Primary Care: A Systematic Review Using the Theoretical Domains Framework

Abstract

Background: Although guidelines long have recommended objective pulmonary function testing to diagnose asthma and COPD, many primary care patients receive a clinical diagnosis of asthma or COPD without objective testing. This often leads to unnecessary treatment with associated incremental costs and side effects and delays actual diagnosis.

Research question: What are the barriers and enablers to lung function testing for asthma, COPD, or both in primary care?

Study design and methods: We searched the literature for qualitative and quantitative studies reporting barriers, enablers, or both to in-office or out-of-office lung function testing for diagnosing asthma, COPD, or both in primary care. Two reviewers independently screened abstracts and full texts, assessed methodologic quality using the Mixed Methods Appraisal Tool, and extracted data from included studies. Identified barriers and enablers were categorized using the Theoretical Domains Framework (TDF), applying a pre-established coding manual.

Results: We identified 7,988 unique articles, reviewed 336 full-text articles, and included 18 studies in this systematic review. Of these 18, 12 were quantitative, three were qualitative, and three used mixed methods. All 18 addressed in-office testing and 11 also addressed out-of-office testing. Barriers and enablers overlapped for asthma and COPD, and in-office and out-of-office settings. We identified more reported barriers (eg, lack of knowledge of the usefulness of spirometry) than enablers (eg, skills for performing reliable spirometry). Barriers mapped to nine (of a possible 14) TDF domains (for both in-office and out-of-office settings). Enablers mapped to three domains for in-office testing and five domains for out-of-office testing.

Interpretation: Barriers to objective testing for airway disease in primary care are complex and span many theoretical domains. Correspondingly, a successful intervention must leverage multiple behavior change techniques. A theory-based, multifaceted intervention to address underuse of diagnostic testing for asthma or COPD now should be developed and tested.

Keywords: COPD; asthma; barriers; enablers; primary care; pulmonary function testing; spirometry.