Effect of Increasing the Intensity of Implementing Pneumonia Guidelines
A Randomized, Controlled Trial
- Donald M. Yealy, MD;
- Thomas E. Auble, PhD;
- Roslyn A. Stone, PhD;
- Judith R. Lave, PhD;
- Thomas P. Meehan, MD, MPH;
- Louis G. Graff, MD;
- Jonathan M. Fine, MD;
- D. Scott Obrosky, MS;
- Maria K. Mor, PhD;
- Jeff Whittle, MD, MPH; and
- Michael J. Fine, MD, MSc*
- 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.
Abstract
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.
Article and Author Information
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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).
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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).
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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.
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Current Author Addresses: Drs. Yealy and Auble: Department of Emergency Medicine, University of Pittsburgh, 230 McKee Place, Suite 500, Pittsburgh, PA 15213.
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Dr. Stone: Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, 130 DeSoto Street, Suite 304, Pittsburgh, PA 15261.
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Dr. Lave: Department of Health Services Administration, Graduate School of Public Health, University of Pittsburgh, Room A649, Pittsburgh, PA 15261.
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Dr. Meehan: Qualidigm, 100 Roscommon Drive, Middletown, CT 06457.
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Dr. Graff: Department of Emergency Medicine, New Britain General Hospital, 100 Grand Street, New Britain, CT 06050.
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Dr. J.M. Fine: Norwalk Hospital, Maple Street, Norwalk, CT 06856.
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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.
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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.
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Dr. Whittle: Clement J. Zablocki Veterans Administration Medical Center (00/PC), 5000 W. National Avenue, Milwaukee, WI 53295.
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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.
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