Implementation of an evidence-based guideline to reduce duration of intravenous antibiotic therapy and length of stay for patients hospitalized with community-acquired pneumonia: a randomized controlled trial.
OBJECTIVE
Patients with pneumonia often remain hospitalized after they are stable clinically, and the duration of intravenous antibiotic therapy is a rate-limiting step for discharge. The purpose of this study was to determine whether implementation of an evidence-based guideline would reduce the duration of intravenous antibiotic therapy and length of stay for patients hospitalized with pneumonia.


METHODS
In a seven-site, cluster randomized clinical trial, we enrolled 325 control and 283 intervention patients who were admitted by one of 116 physician groups. Within site, physician groups were assigned randomly to receive a practice guideline alone (control arm) or a practice guideline that was implemented using a multifaceted strategy (intervention arm). The effectiveness of guideline implementation was measured by the duration of intravenous antibiotic therapy and length of stay; differences in the rates of discontinuation and hospital discharge were assessed with proportional hazards models. Medical outcomes were assessed at 30 days.


RESULTS
Intravenous antibiotic therapy was discontinued somewhat more quickly in the intervention group (hazard ratio [HR] =1.23; 95% confidence interval [CI]: 1.00 to 1.52; P = 0.06) than in the control group. Intervention patients were discharged more quickly, but the difference was not statistically significant (HR = 1.16; 95% CI: 0.97 to 1.38; P = 0.11). Fewer intervention (55% [157/283]) than control (63% [206/325]) patients had medical complications during the index hospitalization (P = 0.04), with no differences in other medical outcomes, including mortality, rehospitalization, and return to usual activities, between treatment arms.


CONCLUSIONS
The multifaceted guideline implementation strategy resulted in a slight reduction in the duration of intravenous antibiotic therapy and a nonsignificant reduction in length of stay, without affecting patient outcomes.
Fine
Michael J
MJ
Division of General Medicine, Department of Medicine, Graduate School of Public Health, University of Pittsburgh, and VA Center for Health Equality Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA. finemj@msx.upmc.edu
Stone
Roslyn A
RA
Lave
Judith R
JR
Hough
Linda J
LJ
Obrosky
D Scott
DS
Mor
Maria K
MK
Kapoor
Wishwa N
WN
D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D017714:Community-Acquired Infections / Q000188:drug therapy; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D007275:Injections, Intravenous; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D017060:Patient Satisfaction; D011014:Pneumonia / Q000188:drug therapy*; D016016:Proportional Hazards Models; D013997:Time Factors
D000900:Anti-Bacterial Agents