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Original Research: PNEUMONIA |

Improved Clinical Outcomes With Utilization of a Community-Acquired Pneumonia Guideline* FREE TO VIEW

Nathan C. Dean, MD, FCCP; Kim A. Bateman, MD; Steven M. Donnelly, PhD; Michael P. Silver, MPH; Greg L. Snow, PhD; David Hale, PharmD, MHA
Author and Funding Information

*From the Division of Pulmonary and Critical Care Medicine (Dr. Dean), LDS Hospital, University of Utah School of Medicine; HealthInsight (Dr. Bateman, Dr. Donnelly, and Mr. Silver); and Intermountain Healthcare (Drs. Snow and Hale), Salt Lake City, UT.

Correspondence to: Nathan C. Dean, MD, FCCP, Intermountain Healthcare, 333 South Ninth East, Salt Lake City, UT 84102; e-mail Nathan.Dean@Intermountainmail.org



Chest. 2006;130(3):794-799. doi:10.1378/chest.130.3.794
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Published online

Background: We previously reported decreased mortality following implementation of a community-acquired pneumonia guideline derived from specialty society recommendations. However, patients with respiratory failure and sepsis from pneumonia were not included, adjustment for comorbidities was limited, and no guideline compliance data were available. We also questioned whether decreased mortality continued after 1997.

Methods: We utilized Utah data from the Centers for Medicare and Medicaid from 1993 to 2003 to determine if pneumonia guideline implementation was associated with 30-day all-cause mortality, length of hospital stay, and readmission rate. We adjusted outcomes by age, gender, Deyo comorbidity score, prior hospitalizations, and race. Guideline compliance was measured by initial default guideline antibiotic administration. We included patients ≥ 66 years old with primary International Classification of Diseases, Ninth Revision, Clinical Modification codes 480.0–483.9, 485.0–486.9, 487.0, 507.0 or 518.81, and 038.x with secondary code pneumonia. We excluded patients with prior hospitalization within 10 days, patients with HIV infection or transplant recipients, and patients not treated by physicians closely affiliated with study hospitals.

Results: Mean (± SD) age of 17,728 pneumonia patients admitted to the hospital was 72.3 ± 12.0 years, 55.2% were female, and 96.0% were white. Within Intermountain Healthcare hospitals, a 1-SD increase (10%) in guideline compliance (range, 61 to 100%) was associated with mortality odds ratio (OR) of 0.92 (95% confidence interval[CI], 0.87 to 0.98; p = 0.007). Mortality OR at 16 Intermountain Healthcare hospitals was 0.89 (95% CI, 0.82 to 0.97; p = 0.007) compared with 19 other Utah hospitals. This mortality difference corresponds to approximately 20 lives saved yearly. The readmission rate was also lower.

Conclusion: Improved clinical outcomes were associated with pneumonia guideline utilization.

Figures in this Article

Community-acquired pneumonia leads to 1.7 million hospital admissions in the United States and is the most common cause of death from infection.12 Mortality averages 13.6% among hospitalized patients and is even higher among the elderly.3Expert committees have published treatment guidelines47 intended to improve the care of pneumonia patients. However, the guidelines were not prospectively validated, and whether guidelines improve clinical outcomes has been debated.811 Expert guidelines are difficult to implement, and traditional continuing medical education has little effect on physician practice.1219

Lower mortality has been observed with early administration of certain antibiotics2025 and may be reduced further by prophylaxis against deep venous thrombosis.2627 An implemented pneumonia guideline containing these elements might lower mortality. Two concurrently controlled studies2829 reported decreased mortality linked with a pneumonia treatment guideline; the first study was our prior study.28 However, the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes used to define our earlier study population did not include severe cases primarily coded as respiratory failure (518.81) or sepsis (038.x) with secondary pneumonia codes. We previously used both part A (hospital inpatient) and part B (outpatient) data in order to include outpatients, but therefore could not adjust mortality risk by the Deyo comorbidity score30 or by the number of prior hospitalizations. In addition, pneumonia guideline use could only be temporally associated with lower mortality, since we had minimal utilization data.

In this study, we wanted to overcome earlier limitations and also to study whether lower mortality compared with other Utah hospitals persisted beyond the first years of guideline use. We now compare mortality between Intermountain Healthcare hospitals with different levels of guideline utilization as measured by initial antibiotic administration. In addition, guideline logic has evolved since the earlier study: oral doxycycline has replaced azithromycin for non-ICU patients, enoxaparin has replaced unfractionated heparin prophylaxis, early ambulation is emphasized, and the CURB-65 rule (confusion, elevated blood urea nitrogen, elevated respiratory rate, low systolic or diastolic BP, and age > 65 years)31 is now used for admission-decision support. These and other changes in guideline logic made a new outcome study necessary.

A pneumonia guideline was introduced in Intermountain Healthcare hospitals and outpatient facilities between January 1995 and January 1998. We have reviewed the methods of guideline development and implementation.11 Briefly, clinicians developed the guideline in conjunction with administrative and data support personnel by combining local practices with American Thoracic Society and Infectious Disease Society of America recommendations for treating community-acquired pneumonia. Guideline implementation included formal presentations, academic detailing, standardized outpatient and inpatient order sheets,28 frequent reminders via several methods, and reporting of outcome data to providers. A committee that meets bimonthly keeps the pneumonia guideline logic simple, updated, and implemented. Key logic elements included currently are listed in Table 1 .

Intermountain Healthcare is a not-for-profit integrated health-care system that includes 16 general adult hospitals and > 90 outpatient clinics within the state of Utah. Facilities range from major adult tertiary care teaching/research hospitals to small hospital and clinics that are the only source of health care for their rural communities. The 100,000 annual inpatient admissions of Intermountain Healthcare represent almost one half of Utah hospital admissions. Intermountain Healthcare has an employed physician group and several non-Medicare health maintenance organization insurance plans, but many nonemployed physicians and non-health maintenance organization patients also utilize its facilities. Financial and administrative incentives encourage employed physicians to use the pneumonia guideline for yearly quality care projects. Approximately two thirds of pneumonia patients treated at Intermountain Healthcare hospitals are > 65 years of age. Other Utah hospitals included in this study are the University of Utah Health Sciences Center, six small community-owned facilities, six hospitals owned by MountainStar Healthcare, four hospitals owned by Iasis Healthcare, and two hospitals operated by LifePoint Hospitals.

Patient Inclusions and Exclusions

We used Medicare part A data, including only claims from Utah Hospitals from 1993 to 2003 for Utah resident Medicare beneficiaries aged ≥ 66 years with primary ICD-9-CM codes 480.0–483.9, 485.0–486.9, 487.0, or 507.0. We also included patients with respiratory failure (518.81) and sepsis (038.x) with a secondary pneumonia code. We excluded patients with prior hospitalization within 10 days, length of stay < 1 day, those who left the hospital against medical advice, secondary diagnosis of HIV infection (ICD-9 code 42), or organ transplantation (ICD-9 codes V42–49). Only the first hospitalization was included for patients with more than one pneumonia hospital admission in a calendar year or with two pneumonia hospital admissions within 60 days in consecutive years. Institutional review board approval was not required for this study since Healthinsight is a quality improvement organization utilizing Medicare data.

During the implementation years (1995 to 1998), each Intermountain Healthcare hospital was classified as preimplementation or postimplementation based on whether it had implemented the guideline before February of that year. Physicians who regularly admit patients to Intermountain Healthcare hospitals are more likely to follow the guideline than physicians who only occasionally admit patients. We target these closely affiliated physicians for most of our pneumonia implementation efforts.11,32 Physicians equally active in patient care at other hospitals comprise the comparison group. We therefore included only pneumonia hospital admissions by physicians with at least 10 Medicare hospital admissions per year, and at least 75% of admissions to their assigned hospital.

Guideline compliance was measured from Intermountain Healthcare pharmacy billing records, identifying the first antibiotic(s) administered to pneumonia patients defined by ICD-9-CM coding. We defined compliance as the fraction of pneumonia patients at each hospital who received the specific, default antibiotic recommendation contained in our guideline (Table 1). Antibiotic data from other Utah hospitals were not available, since pharmacy information is absent from the Medicare database. Use of heparin or enoxaparin prophylaxis in pneumonia patients was also determined from Intermountain Healthcare pharmacy billing records.

Statistical Analysis

Logistic regression was used to determine if guideline utilization and level of compliance are associated with the outcomes of 30-day mortality, 30-day all-cause readmission rate, and length of hospital stay. We adjusted 30-day all-cause mortality by age, gender, Deyo comorbidity score, number of hospitalizations within prior year, admission year, and race. We also included in the models categorical variables identifying Intermountain Healthcare hospitals, postimplementation hospital admissions, and an Intermountain Healthcare postimplementation interaction term. Odds ratios (ORs) reported for mortality do not include the preimplementation/postimplementation main effect or the Intermountain Healthcare implementation interaction term, since neither was significant. Because the Deyo comorbidity score requires 1 prior year of hospitalization data, we used 1993 data for this calculation and did not include 1993 pneumonia hospital admissions in outcome analyses. We defined prolonged length of stay as > 7.0 days, the 75th percentile of the length of stay distribution.31 Patients who died during hospitalization were excluded from the length of stay analysis. Patients who died within 30 days of hospital admission were excluded from the model with 30-day readmission as the outcome. The level of statistical significance was defined as ≤ 0.05.

The Utah Medicare fee-for-service population ≥ 65 years of age averaged 185,310 beneficiaries during the study years, ranging from 133,130 in 1994 to 223,846 in 2003. Altogether, the 10 years comprise 1,853,097 patient-years and 32,888 pneumonia hospital admissions. The hospital admission rate was therefore 17.7 per 1,000 patient years, ranging from 17.0 in 1998 to 22.4 in 1995. After the exclusions enumerated in Table 2 , 17,728 pneumonia admissions remained for analysis. Mean (± SD) age of the study population was 72.3 ± 12.0 years, 55.2% were female, and 96.0% were white.

Mortality

Guideline compliance for default antibiotic administration ranged from 0.61 to 1.0 at different Intermountain Healthcare hospitals. Figure 1 illustrates adjusted OR for mortality after 1997 (when the guideline was implemented system-wide) by fraction of antibiotic compliance. The reference for individual Intermountain Healthcare hospitals in Figure 1 is other Utah hospitals as a group. We adjusted mortality by age, gender, ethnicity, admission year, Deyo comorbidity score, and number of admissions in the prior year. Weighted by the number of hospital admissions, Spearman r was − 0.53 (p = 0.034). In a logistic regression model restricted to Intermountain Healthcare hospital admissions after guideline implementation, a 1-SD increase in compliance (approximately 10%) was associated with an OR of 0.92 (95% confidence interval [CI], 0.87 to 0.98; p = 0.007). There was no significant correlation between OR for mortality and use of heparin or enoxaparin prophylaxis against deep venous thrombosis: Spearman r = − 0.24 (p = 0.38).

Crude mortality at other Utah hospitals from 1994 to 2003 was 15.8% (range, 13.6 to 18.0%) vs 14.5% (range, 12.3 to 16.6% at Intermountain Healthcare hospitals). Mortality per 1,000 patient-years varied between years but overall did not change over the study period. Adjusted OR at Intermountain Healthcare hospitals during the study period was 0.89 (95% CI, 0.82 to 0.97; p = 0.007) compared with other Utah hospitals. The difference in mortality between preimplementation and postimplementation periods in Intermountain Healthcare hospitals was not significantly different from the change in other hospitals (OR, 0.94; p = 0.57). Examining just the Intermountain Healthcare hospitals before vs after implementation, OR was 0.92 (p = 0.274; 95% CI, 0.78 to 1.07). Dating the preimplementation/postimplementation comparison as January 1, 1997, among other Utah hospitals, the OR was 0.975 (p = 0.694).

Readmission

All-cause 30-day readmission rate was 11.7% at other Utah hospitals, ranging from 9.6 to 13.2% over the study period. The readmission rate at Intermountain Healthcare hospitals was 10.2% (range, 8.5 to 11.7%). In a logistic regression model, the OR for readmission within 30 days of discharge for the Intermountain Healthcare hospitals was 0.86 (95% CI, 0.78 to 0.96; p = 0.006) compared with other hospitals. Among Intermountain Healthcare hospitals, there was no significant correlation between readmission and level of compliance with guideline antibiotic administration (Spearman r = 0.07, p = 0.787) or deep venous thrombosis prophylaxis (Spearman r = − 0.054, p = 0.842).

Length of Stay

Unadjusted pneumonia length of stay at Intermountain Healthcare hospitals was similar to other Utah hospitals (Table 3 ). Length of stay > 7 days (see “Materials and Methods”) was more common at Intermountain Healthcare hospitals, although the difference narrowed after guideline implementation. In a logistic regression model, the OR for length of stay > 7 days at Intermountain Healthcare hospitals was 1.22 (95% CI, 1.13 to 1.31; p < 0.001) compared with other hospitals. Length of stay > 7 days decreased significantly between preimplementation and postimplementation periods at Intermountain Healthcare hospitals (OR, 0.88; 95% CI, 1.13 to 1.31; p = 0.004).

The Intermountain Healthcare pneumonia guideline was associated with decreased all-cause 30-day mortality in this 10-year analysis. Lower mortality was linked with administration of specific guideline-recommended antibiotics, a marker for use of other guideline elements in our view. Intermountain Healthcare hospitals demonstrate lower mortality compared with other Utah hospitals. These results confirm our earlier study28 while using better adjustment for comorbidities, a longer period of study, and including more severely ill patients. Comparison between Intermountain Healthcare and other Utah hospitals may underestimate the benefit of our guideline, since other hospitals also have worked to improve pneumonia care, and some physicians work at both Intermountain Healthcare and other hospitals. The observed mortality difference corresponds to approximately 20 Utah lives saved yearly.

Length of stay > 7 days was slightly more common at Intermountain Healthcare hospitals. While our guideline contains logic for IV to oral antibiotic switch, it does not emphasize early discharge. Longer length of stay at Intermountain Healthcare hospitals might reflect lack of focus on this outcome. Given the correlation reported between shorter length of stay and adverse outcomes in Connecticut,33 it is also possible that longer length of stay at Intermountain Healthcare hospitals is linked with better outcomes. However, length of stay > 7 days was less common after guideline implementation; at the same time, Intermountain Healthcare hospital mortality and readmission rate were lower than other hospitals.

Capelastegui et al29 reported a larger decrease in mortality at the Galdakao hospital in Spain than we observed. Antibiotic treatment duration decreased while use of guideline-recommended antibiotics increased (both p < 0.001). Survival at 30 days was higher (OR, 2.14; 95% CI, 1.23 to 3.72), and length of stay was reduced by 1.8 days. No significant changes in these parameters were noted concurrently in four control hospitals. Among differences in our study are that health-care systems differ between Spain and the United States, that we implemented the guideline at 16 hospitals instead of 1 hospital, and that our observation period was longer.

Marrie et al34 reported a lower rate of admission and shorter length of hospital stay but no difference in mortality at 19 hospitals randomized between pathway and “conventional management.” More than 1,700 consecutive emergency department patients were enrolled in 6 months. In addition to admission-decision support, the pathway featured levofloxacin monotherapy and objective criteria for switch from IV to oral antibiotics and discharge. Compared to the study by Capelastegui et al29 and our study, fewer patients over a shorter period of time were studied by Marrie et al.34 Guideline logic and the Canadian Health System where the study by Marrie et al34 was conducted also differ.

Yealy et al35 reported a lower admission rate with a high-intensity guideline implementation strategy compared with low-intensity strategy in 32 emergency departments randomized between three different strategies of implementation. The lack of clinical outcome differences the study by Yealy et al35 could be due to the wide range of antibiotics allowed, and perhaps to the absence of a nonguideline control group. The prospective design used by Marrie et al34and Yealy et al35 is stronger methodologically than our study but is limited by the requirement for individual informed consent. This results in nonrandom exclusion of pneumonia patients that could produce different results than inclusion of the entire pneumonia population in our study and that of Capelastegui et al.29

We believe guideline impact should be studied by comparing pneumonia outcomes between treatment sites with or without implemented guidelines. Comparing outcomes in individual patients treated according to, or outside guideline recommendations is limited by selection bias. Studies by Hauck et al,36Mortensen et al,37and Menendez et al38 reported lower mortality in patients treated by guideline logic than in nonguideline-treated patients. Patients were stratified by severity of illness; mortality was lower in all but the most severe cases. However, patients were not randomized between guideline and nonguideline treatment. Therefore, patients selected by physicians to be treated differently than guideline recommendations might have differed in clinical characteristics and mortality risk not adequately adjusted by severity stratification.

We cannot exclude the possibility that Intermountain Healthcare hospitals demonstrate lower pneumonia mortality for reasons separate from the guideline. Guideline compliance association with lower mortality might not be causally linked. However, the definition of compliance used was very specific to our pneumonia guideline, as other antibiotics recommended by international guidelines were defined as noncompliant. If we had assumed that mortality was the same between Intermountain Healthcare and other Utah Hospitals prior to guideline implementation, the OR for mortality following implementation would have been 0.88 (95% CI, 0.81 to 0.96; p < 0.005). However, we elected to analyze the data conservatively by not making this assumption.

Significant limitations to these data and conclusions are present, mostly attributable to the paucity of clinical data within the Medicare part A database. Pneumonia severity index or CURB-65 scores would enable better severity adjustment, but data necessary for calculating these scores are not available in the Medicare database. Data on process of pneumonia care are likewise unavailable, so that only Intermountain Healthcare hospitals have guideline antibiotic administration as a marker for guideline use. Data on timing of the first antibiotic dose did not become available until 2004, while our study period ended in 2003.

We have validated the Intermountain Healthcare pneumonia guideline and in turn the specialty society recommendations from which it was derived. This study only included patients ≥ 66 years old, but the principles of care likely apply equally to younger pneumonia patients, saving additional lives. Implementing a guideline that standardizes treatment for most patients according to literature-based, current recommendations appears beneficial.

Abbreviations: CI = confidence interval; CURB-65 = confusion, elevated blood urea nitrogen, elevated respiratory rate, low systolic or diastolic BP, and age > 65 years; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; OR = odds ratio

The authors have no relevant conflicts of interest to report.

This study was funded by the Deseret Foundation and HealthInsight, Salt Lake City.

The analyses upon which this publication is based were performed under contract No. 500–02-UT01, funded by the Centers for Medicare and Medicaid Services, an agency of the US Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government. The authors assume full responsibility for the accuracy and completeness of the ideas presented.

Table Graphic Jump Location
Table 1. Key Elements of the 2005 Intermountain Healthcare Pneumonia Guideline Logic
Table Graphic Jump Location
Table 2. Patients Excluded From Analysis
Figure Jump LinkFigure 1. Compliance with guideline-recommended antibiotics at Intermountain Healthcare hospitals is plotted against adjusted OR for 30-day all-cause mortality. Circle area reflects the number of admissions per hospital. The odds of mortality are 0.92 (p = 0.007) for each 10% increase in compliance.Grahic Jump Location
Table Graphic Jump Location
Table 3. Length of Stay Before and After Guideline Implementation

We thank the nurses, respiratory therapists, pharmacists, administrators, and physicians of Intermountain Healthcare for collaborating to improve pneumonia care.

Niederman, MS, McCombs, JS, Unger, AN, et al (1998) The cost of treating community-acquired pneumonia.Clin Ther20,820-837. [CrossRef] [PubMed]
 
Medicare and Medicaid statistical supplement, 1995. Health Care Financ Rev. 1995;;16 (September).
 
Fine, MJ, Smith, MA, Carson, CA, et al Prognosis and outcomes of patients with community-acquired pneumonia.JAMA1995;274,134-141
 
American Thoracic Society.. Guidelines for the initial management of adults with community acquired pneumonia: diagnosis, assessment of severity, antimicrobial therapy, and prevention.Am J Respir Crit Care Med2001;163,1730-1754. [PubMed]
 
Mandell, LA, Bartlett, JG, Dowell, SF, et al Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Infectious Disease Society of America.Clin Infect Dis2003;37,1405-1433. [CrossRef] [PubMed]
 
Mandell, LA, Marrie, TJ, Grossman, RF, and the Canadian CAP working group.. et al Canadian guidelines for the initial management of community-acquired pneumonia.Clin Infect Dis2000;31,383-421. [CrossRef] [PubMed]
 
British Thoracic Society guidelines for management of community-acquired pneumonia in adults.Thorax2001;56(suppl IV),iv1-iv64
 
Fein, AM, Niederman, MS Guidelines for the initial management of community-acquired pneumonia: savory recipe or cookbook for disaster?Am J Respir Crit Care Med1995;152,1149-1153. [PubMed]
 
Weingarten, S Practice guidelines and prediction rules should be subject to careful clinical testing.JAMA1997;277,1977-1978. [CrossRef] [PubMed]
 
Nathwani, D, Rubenstein, E, Barlow, G, et al Do guidelines for community-acquired pneumonia improve the cost-effectiveness of hospital care?Clin Infect Dis2001;32,728-741. [CrossRef] [PubMed]
 
Dean, NC, Bateman, KA Local guidelines for community-acquired pneumonia: development, implementation, and outcome studies.Infect Dis Clin North Am2004;18,975-991. [CrossRef] [PubMed]
 
Davis, DA, Thomson, MA, Oxman, AD, et al Evidence for the effectiveness of CME: a review of 50 randomized controlled trials.JAMA1992;268,111-1117
 
Lomas, J, Anderson, GM, Domnick-Pierre, KD, et al Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians.N Engl J Med1989;321,1306-1311. [CrossRef] [PubMed]
 
Gleicher, N Cesarean section rates in the United States: the short-term failure of the national consensus development conference in 1980.JAMA1984;252,3273-3276. [CrossRef] [PubMed]
 
Greco, PJ, Eisenberg, JM Changing physician’s practices.N Engl J Med1993;329,1271-1273. [CrossRef] [PubMed]
 
Mittman, BS, Tonesk, X, Jacobson, PD Implementing clinical practice guidelines.Qual Rev Bull1992;18,413-422
 
Tunis, SR, Hayward, RSA, Wilson, MC, et al Internists’ attitudes about clinical practice guidelines.Ann Intern Med1994;120,956-963. [PubMed]
 
Hadlock, C, Niederman, MS, Stelmach, WJ Clinical pathways in an acute care setting: community acquired pneumonia.Infect Dis Clin Pract1996;5(4 suppl),S166-S173
 
Halm, EA, Horowitz, C, Silver, A, et al Limited impact of a multicenter intervention to improve the quality and efficiency of pneumonia care.Chest2004;126,100-107. [CrossRef] [PubMed]
 
Gleason, PP, Meehan, TP, Fine, JM, et al Associations between initial antimicrobial therapy and medical outcomes for hospitalized elderly patients with pneumonia.Arch Intern Med1999;159,2562-2572. [CrossRef] [PubMed]
 
Houck, PM, MacLehose, RF, Niederman, MS, et al Empiric antibiotic therapy and mortality among Medicare pneumonia patients in 10 western states.Chest2001;119,1427-1426. [CrossRef] [PubMed]
 
Waterer, GW, Somes, GW, Wunderink, RG Monotherapy may be suboptimal for severe bacteremic pneumococcal pneumonia.Arch Intern Med2001;161,1837-1842. [CrossRef] [PubMed]
 
Brown, RB, Iannini, P, Gross, P, et al Impact of initial antibiotic choice on clinical outcomes in community-acquired pneumonia: analysis of a hospital claims-made database.Chest2003;123,1503-1511. [CrossRef] [PubMed]
 
Meehan, TP, Fine, MJ, Krumholz, HM, et al Quality of care, process, and outcomes in elderly patients with pneumonia.JAMA1997;278,2080-2084. [CrossRef] [PubMed]
 
Houck, PM, Bratzler, DW, Nsa, W, et al Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia.Arch Intern Med2004;164,637-644. [CrossRef] [PubMed]
 
Geerts, WH, Heit, JA, Clagett, P, et al Prevention of venous thromboembolism.Chest2001;119(suppl),132S-175S
 
Samama, MM, Cohen, AT, Darmon, JY, et al A comparison of enoxaparin with placebo for prevention of venous thromboembolism in acutely ill medical patients.N Engl J Med1999;341,793-800. [CrossRef] [PubMed]
 
Dean, NC, Silver, MP, Bateman, KA, et al Decreased mortality after implementation of a treatment guideline for community-acquired pneumonia.Am J Med2001;110,451-457. [CrossRef] [PubMed]
 
Capelastegui, A, Espana, PP, Quintana, JM, et al Improvement in process of care and outcomes after implementing a guideline for the management of community-acquired pneumonia: a controlled before and after design study.Clin Infect Dis2004;39,955-96328. [CrossRef] [PubMed]
 
Deyo, RA, Cherkin, DC, Ciol, MA Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.J Clin Epidemiol1992;45,531-536
 
Lim, WS, van der Eerden, MM, Laing, R, et al Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study.Thorax2003;58,377-382. [CrossRef] [PubMed]
 
Dean, NC, Silver, MP, Bateman, KA Frequency of specialty physician care in community acquired pneumonia.Chest2000;117,393-397. [CrossRef] [PubMed]
 
Metersky, ML, Tate, JP, Fine, MJ, et al Temporal trends in outcomes of older patients with pneumonia.Arch Intern Med2000;160,3385-3391. [CrossRef] [PubMed]
 
Marrie, TJ, Lau, CY, Wheeler, SL, et al A controlled trial of a critical pathway for treatment of community-acquired pneumonia.JAMA2000;283,749-755. [CrossRef] [PubMed]
 
Yealy, DM, Auble, TE, Stone, RA, et al Effect of increasing the intensity of implementing pneumonia guidelines.Ann Intern Med2005;143,881-894. [PubMed]
 
Hauck, LD, Adler, LM, Mulla, ZD Clinical pathway care improves outcomes among patients hospitalized for community-acquired pneumonia.Ann Epidemiol2004;14,669-675. [CrossRef] [PubMed]
 
Mortensen, EM, Restrepo, M, Anzueto, A, et al Effects of guideline-concordant therapy on mortality among patients with community-acquired pneumonia.Am J Med2004;117,726-731. [CrossRef] [PubMed]
 
Menendez, R, Torres, A, Zalacain, R, et al Guidelines for the treatment of community-acquired pneumonia: predictors of adherence and outcome.Am J Respir Crit Care Med2005;172,757-762. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. Compliance with guideline-recommended antibiotics at Intermountain Healthcare hospitals is plotted against adjusted OR for 30-day all-cause mortality. Circle area reflects the number of admissions per hospital. The odds of mortality are 0.92 (p = 0.007) for each 10% increase in compliance.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Key Elements of the 2005 Intermountain Healthcare Pneumonia Guideline Logic
Table Graphic Jump Location
Table 2. Patients Excluded From Analysis
Table Graphic Jump Location
Table 3. Length of Stay Before and After Guideline Implementation

References

Niederman, MS, McCombs, JS, Unger, AN, et al (1998) The cost of treating community-acquired pneumonia.Clin Ther20,820-837. [CrossRef] [PubMed]
 
Medicare and Medicaid statistical supplement, 1995. Health Care Financ Rev. 1995;;16 (September).
 
Fine, MJ, Smith, MA, Carson, CA, et al Prognosis and outcomes of patients with community-acquired pneumonia.JAMA1995;274,134-141
 
American Thoracic Society.. Guidelines for the initial management of adults with community acquired pneumonia: diagnosis, assessment of severity, antimicrobial therapy, and prevention.Am J Respir Crit Care Med2001;163,1730-1754. [PubMed]
 
Mandell, LA, Bartlett, JG, Dowell, SF, et al Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Infectious Disease Society of America.Clin Infect Dis2003;37,1405-1433. [CrossRef] [PubMed]
 
Mandell, LA, Marrie, TJ, Grossman, RF, and the Canadian CAP working group.. et al Canadian guidelines for the initial management of community-acquired pneumonia.Clin Infect Dis2000;31,383-421. [CrossRef] [PubMed]
 
British Thoracic Society guidelines for management of community-acquired pneumonia in adults.Thorax2001;56(suppl IV),iv1-iv64
 
Fein, AM, Niederman, MS Guidelines for the initial management of community-acquired pneumonia: savory recipe or cookbook for disaster?Am J Respir Crit Care Med1995;152,1149-1153. [PubMed]
 
Weingarten, S Practice guidelines and prediction rules should be subject to careful clinical testing.JAMA1997;277,1977-1978. [CrossRef] [PubMed]
 
Nathwani, D, Rubenstein, E, Barlow, G, et al Do guidelines for community-acquired pneumonia improve the cost-effectiveness of hospital care?Clin Infect Dis2001;32,728-741. [CrossRef] [PubMed]
 
Dean, NC, Bateman, KA Local guidelines for community-acquired pneumonia: development, implementation, and outcome studies.Infect Dis Clin North Am2004;18,975-991. [CrossRef] [PubMed]
 
Davis, DA, Thomson, MA, Oxman, AD, et al Evidence for the effectiveness of CME: a review of 50 randomized controlled trials.JAMA1992;268,111-1117
 
Lomas, J, Anderson, GM, Domnick-Pierre, KD, et al Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians.N Engl J Med1989;321,1306-1311. [CrossRef] [PubMed]
 
Gleicher, N Cesarean section rates in the United States: the short-term failure of the national consensus development conference in 1980.JAMA1984;252,3273-3276. [CrossRef] [PubMed]
 
Greco, PJ, Eisenberg, JM Changing physician’s practices.N Engl J Med1993;329,1271-1273. [CrossRef] [PubMed]
 
Mittman, BS, Tonesk, X, Jacobson, PD Implementing clinical practice guidelines.Qual Rev Bull1992;18,413-422
 
Tunis, SR, Hayward, RSA, Wilson, MC, et al Internists’ attitudes about clinical practice guidelines.Ann Intern Med1994;120,956-963. [PubMed]
 
Hadlock, C, Niederman, MS, Stelmach, WJ Clinical pathways in an acute care setting: community acquired pneumonia.Infect Dis Clin Pract1996;5(4 suppl),S166-S173
 
Halm, EA, Horowitz, C, Silver, A, et al Limited impact of a multicenter intervention to improve the quality and efficiency of pneumonia care.Chest2004;126,100-107. [CrossRef] [PubMed]
 
Gleason, PP, Meehan, TP, Fine, JM, et al Associations between initial antimicrobial therapy and medical outcomes for hospitalized elderly patients with pneumonia.Arch Intern Med1999;159,2562-2572. [CrossRef] [PubMed]
 
Houck, PM, MacLehose, RF, Niederman, MS, et al Empiric antibiotic therapy and mortality among Medicare pneumonia patients in 10 western states.Chest2001;119,1427-1426. [CrossRef] [PubMed]
 
Waterer, GW, Somes, GW, Wunderink, RG Monotherapy may be suboptimal for severe bacteremic pneumococcal pneumonia.Arch Intern Med2001;161,1837-1842. [CrossRef] [PubMed]
 
Brown, RB, Iannini, P, Gross, P, et al Impact of initial antibiotic choice on clinical outcomes in community-acquired pneumonia: analysis of a hospital claims-made database.Chest2003;123,1503-1511. [CrossRef] [PubMed]
 
Meehan, TP, Fine, MJ, Krumholz, HM, et al Quality of care, process, and outcomes in elderly patients with pneumonia.JAMA1997;278,2080-2084. [CrossRef] [PubMed]
 
Houck, PM, Bratzler, DW, Nsa, W, et al Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia.Arch Intern Med2004;164,637-644. [CrossRef] [PubMed]
 
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