title: Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial.
abstract: 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.
  
  
  METHODS
  Cluster-randomized, controlled trial.
  
  
  METHODS
  32 emergency departments in Pennsylvania and Connecticut.
  
  
  METHODS
  3219 patients with a clinical and radiographic diagnosis of pneumonia.
  
  
  METHODS
  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).
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: University of Pittsburgh and the Veterans Affairs Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania 15240, USA.
authors.forename: Donald M
authors.initials: DM
authors.lastname: Yealy
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Auble
authors.forename: Roslyn A
authors.initials: RA
authors.lastname: Stone
authors.forename: Judith R
authors.initials: JR
authors.lastname: Lave
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Meehan
authors.forename: Louis G
authors.initials: LG
authors.lastname: Graff
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Fine
authors.forename: D Scott
authors.initials: DS
authors.lastname: Obrosky
authors.forename: Maria K
authors.initials: MK
authors.lastname: Mor
authors.forename: Jeff
authors.initials: J
authors.lastname: Whittle
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Fine
mesh_terms: D000368:Aged; D017714:Community-Acquired Infections / Q000188:drug therapy; D003237:Connecticut; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D010414:Pennsylvania; D011014:Pneumonia / Q000188:drug therapy*; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care