Effect of Increasing the Intensity of Implementing Pneumonia Guidelines

A Randomized, Controlled Trial

20 December 2005 | Volume 143 Issue 12 | Pages 881-894

Background: Despite the development of evidence-based pneumonia guidelines, limited data exist on the most effective means to implement guideline recommendations into clinical practice.

Objective: To compare the effectiveness and safety of 3 guideline implementation strategies.

Design: Cluster-randomized, controlled trial.

Setting: 32 emergency departments in Pennsylvania and Connecticut.

Patients: 3219 patients with a clinical and radiographic diagnosis of pneumonia.

Interventions: The authors implemented a project-developed guideline for the initial site of treatment based on the Pneumonia Severity Index and performance of evidence-based processes of care at the emergency department level. Guideline implementation strategies were defined as low (n = 8), moderate (n = 12), and high intensity (n = 12).

Measurements: Effectiveness outcomes were the rate at which low-risk patients were treated on an outpatient basis and the performance of recommended processes of care. Safety outcomes included death, subsequent hospitalization for outpatients, and medical complications for inpatients.

Results: More low-risk patients (n = 1901) were treated as outpatients in the moderate-intensity and high-intensity groups than in the low-intensity group (high-intensity group, 61.9%; moderate-intensity group, 61.0%; low-intensity group, 37.5%; P = 0.004). More outpatients (n = 1125) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 60.9%; moderate-intensity group, 28.3%; low-intensity group, 25.3%; P < 0.001); more inpatients (n = 2076) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 44.3%; moderate-intensity group, 30.1%; low-intensity group, 23.0%; P < 0.001). No statistically significant differences in safety outcomes were observed across interventions.

Limitations: Twenty percent of eligible patients were not enrolled, and data on effectiveness outcomes were not collected before the trial.

Conclusions: Both moderate-intensity and high-intensity guideline implementation strategies safely increased the proportion of low-risk patients with pneumonia who were treated as outpatients. The high-intensity strategy was most effective for increasing the performance of the recommended processes of care for outpatients and inpatients.

*For the names of individuals who served as project coordinators, local study investigators, research staff, and study research nurses, see the Appendix.

Editors' Notes Context The effects of intensified efforts to translate guidelines into practice are poorly understood. Content Thirty-two emergency departments were randomly assigned to low-intensity, moderate-intensity, and high-intensity strategies for implementing guidelines for community-acquired pneumonia. More low-risk patients were appropriately treated as outpatients in moderate-intensity and high-intensity implementation sites. Adherence to recommended processes of care was better with the high-intensity intervention. Mortality rates, hospitalization after initial outpatient treatment, and inpatient medical complications were similar irrespective of guideline implementation strategy. Implications The most intense guideline implementation strategy resulted in the highest adherence to recommended processes of care. —The Editors

 

Author and Article Information

From University of Pittsburgh and the Veterans Affairs Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania; Qualidigm, Middletown, Connecticut; Yale University School of Medicine, New Haven, Connecticut; New Britain General Hospital, New Britain, Connecticut; Norwalk Hospital, Norwalk, Connecticut; University of Connecticut, Storrs, Connecticut; and Clement J. Zablocki Veterans Administration Medical Center and Medical College of Wisconsin, Milwaukee, Wisconsin.

Grant Support: By the Agency for Healthcare Research and Quality (grant number R01 HS10049). Dr. M.J. Fine received support from the National Institute of Allergy and Infectious Diseases (grant number K24 AI001769).

Potential Financial Conflicts of Interest: Consultancies: M.J. Fine (University of Pennsylvania, GeneSoft Pharmaceuticals Inc.); Honoraria: M.J. Fine (Zynx Health Corporation, STA Healthcare Communications Inc., University of Alberta, Maine Medical Center); Expert testimony: M.J. Fine (Stephen Lynn Klein, Kellogg & Siegelman, Swanson, Martin, & Bell, William J. Burke, Chad McGowan, Chernett, Wasserman, Yarger, Pasternak, LLC); Grants received: M.J. Fine (Pfizer Inc.); Royalties: M.J. Fine (Up-to-Date).

Requests for Single Reprints: Michael J. Fine, MD, MSc, Veterans Administration Pittsburgh Healthcare System (151-C-U), Center for Health Equity Research and Promotion, University Drive C, Building 28, 1A102, Pittsburgh, PA 15240; e-mail, Michael.Fine{at}va.gov.

Current Author Addresses: Drs. Yealy and Auble: Department of Emergency Medicine, University of Pittsburgh, 230 McKee Place, Suite 500, Pittsburgh, PA 15213.

Dr. Stone: Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, 130 DeSoto Street, Suite 304, Pittsburgh, PA 15261.

Dr. Lave: Department of Health Services Administration, Graduate School of Public Health, University of Pittsburgh, Room A649, Pittsburgh, PA 15261.

Dr. Meehan: Qualidigm, 100 Roscommon Drive, Middletown, CT 06457.

Dr. Graff: Department of Emergency Medicine, New Britain General Hospital, 100 Grand Street, New Britain, CT 06050.

Dr. J.M. Fine: Norwalk Hospital, Maple Street, Norwalk, CT 06856.

Mr. Obrosky: Veterans Administration Pittsburgh Healthcare System (151-C-U), Center for Health Equity Research and Promotion, University Drive C, Suite 1A126, Pittsburgh, PA 15240.

Dr. Mor: Veterans Administration Pittsburgh Healthcare System (151-C-U), Center for Health Equity Research and Promotion, University Drive C, Suite 1A110, Pittsburgh, PA 15240.

Dr. Whittle: Clement J. Zablocki Veterans Administration Medical Center (00/PC), 5000 W. National Avenue, Milwaukee, WI 53295.

Dr. M.J. Fine: Veterans Administration Pittsburgh Healthcare System (151-C-U), Center for Health Equity Research and Promotion, University Drive C, Building 28, Suite 1A102, Pittsburgh, PA 15240.