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Published on: August 24, 2019
Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial
Donald M Yealy1, Thomas E Auble, Roslyn A Stone
1University of Pittsburgh and the Veterans Affairs Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania 15240, USA.
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.
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