Key Point

A guideline implementation strategy of moderate to high intensity can elevate the quality of pneumonia care without compromising patient safety.

PITTSBURGH—With current pneumonia guidelines, the more concentrated the treatment implementation strategy the better, a large, multicenter study has confirmed.¹ "We showed that with a fairly intensive implementation effort, we can improve the quality of pneumonia care without adversely affecting patient outcomes," Michael J. Fine, MD, Professor of Medicine at the University of Pittsburgh and Director of the VA Center for Health Equity Research and Promotion, told Pulmonary Reviews. The two main improvements seen were a greater likelihood that pneumonia patients who were at low risk of death would receive less costly outpatient care and that emergency department medical providers would follow guideline-recommended care.

LOOKING AT THREE DIFFERENT STRATEGIES OF GUIDELINES IMPLENTATION

Three strategies for pneumonia guideline implementation—low-, moderate-, and high-intensity—were assessed among 3,219 patients diagnosed with pneumonia at 32 emergency departments. For the one-year study, the authors developed an evidence-based pneumonia guideline that included recommendations for initial site of treatment based on the pneumonia severity index (PSI) and outlined the appropriate diagnostic and therapeutic processes of care for outpatients and inpatients.

Eight emergency departments were randomized to the low-intensity strategy, which included the distribution of hospital-specific performance data, from a national pneumonia quality improvement program, to emergency department and quality improvement directors. Also, the emergency department directors were asked to develop a quality improvement plan incorporating the authors’ pneumonia guideline; this measure was voluntary, however.

The moderate-intensity strategy included the low-intensity strategies; in addition, medical providers at the 12 emergency departments in the moderate-intensity arm received on-site education about the pneumonia guideline, particularly the use of the PSI, before patient enrollment in the study.

"The 12 emergency departments in the high-intensity group received all low-intensity and moderate-intensity strategies, real-time reminders, medical provider audits and feedback, and continuous quality improvement activities that were implemented throughout the study period," related the authors. The reminders, they noted, consisted of a page of instructions on how to use the PSI to guide the initial site of treatment, as well as recommendations for the initial processes of care.

Effectiveness outcomes were the rate at which the low-risk group received outpatient treatment and the performance of recommended processes of care.

HIGH INTENSITY STRATEGY IMPROVES QUALITY OF CARE

The rates of outpatient care among low-risk individuals were 37.5%, 61%, and 61.9%, respectively, in the low-, moderate-, and high-intensity groups. The differences in these rates were significant between the low-intensity arm and the other two study arms but not between the moderate- and high-intensity arms.

Both outpatients and inpatients in the high-intensity arm were far more likely than those in the moderate- and low-intensity arms to receive the initial processes of care recommended in the authors’ pneumonia guideline. The rates of receiving all four initial processes of care for the outpatients in the low-, medium-, and high-intensity arms were 60.9%, 28.3%, and 25.3%, respectively; the rates were 44.3%, 30.1%, and 23%, respectively, among inpatients. No differences were observed among any of the study arms in 30-day mortality, the median number of days required to return to work and usual activities, or patient satisfaction with care.

The study findings support the use of more intense pneumonia guideline implementation strategies on a broader scale, concluded Dr. Fine. "Our study may apply to acute conditions other than pneumonia frequently treated in the emergency department," he noted.

—Timothy Begany

Reference
1. Yealy DM, Auble TE, Stone RA, et al. Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial. Ann Intern Med. 2005;143:881-894.

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