Effect of increasing the intensity of implementing pneumonia guidelines : A randomized, controlled trial

• Published in: Annals of internal medicine Vol. 143; no. 12; pp. 881 - 894
• Main Authors: YEALY, Donald M, AUBLE, Thomas E, FINE, Michael J, STONE, Roslyn A, LAVE, Judith R, MEEHAN, Thomas P, GRAFF, Louis G, FINE, Jonathan M, OBROSKY, D. Scott, MOR, Maria K, WHITTLE, Jeff
• Format: Journal Article
• Language: English
• Published: Philadelphia, PA American College of Physicians 20.12.2005
• Subjects: Aged; Antibiotics; Bacterial diseases; Bacterial diseases of the respiratory system; Biological and medical sciences; Clinical trials; Community-Acquired Infections - drug therapy; Connecticut; Effectiveness; Emergency Service, Hospital - standards; Female; Guideline Adherence; Hospitals; Human bacterial diseases; Humans; Infectious diseases; Male; Medical research; Medical sciences; Medical treatment; Pennsylvania; Pneumonia; Pneumonia - drug therapy; Practice Guidelines as Topic; Quality Assurance, Health Care; Studies; Connecticut; Pennsylvania; Human; Lung disease; Pneumonia; Medical practice; Respiratory disease; Intensity; Evidence-based medicine; Recommendation; Medicine; Randomization; Clinical management; Randomised controlled trial; Clinical trial; Public health
• ISSN: 0003-4819; 1539-3704
• DOI: 10.7326/0003-4819-143-12-200512200-00006

Despite the development of evidence-based pneumonia guidelines, limited data exist on the most effective means to implement guideline recommendations into clinical practice. To compare the effectiveness and safety of 3 guideline implementation strategies. Cluster-randomized, controlled trial. 32 emergency departments in Pennsylvania and Connecticut. 3219 patients with a clinical and radiographic diagnosis of pneumonia. 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). 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. 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. Twenty percent of eligible patients were not enrolled, and data on effectiveness outcomes were not collected before the trial. 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.