Improvement of process-of-care and outcomes after implementing a guideline for the management of community-acquired pneumonia:: A controlled before-and-after design study

Background. Studies investigating the impact of guideline implementation for inpatient management of community- acquired pneumonia ( CAP) usually have methodological limitations. We present a controlled study that compared interventions before and after the implementation of a practice guideline. Methods. Clinical and demographic characteristics, as well as process- of- care and outcome indicators, were recorded for all patients with CAP who were admitted to Galdakao Hospital ( Galdakao, Spain) in the 19- month period after the implementation, on 1 March 2000, of a guideline for the treatment of CAP. These data were also recorded for all patients with CAP who were admitted to this hospital during the year before the guideline was implemented, as well as for randomly selected inpatients with CAP at 4 other hospitals during both periods ( i. e., before and after guideline implementation) who were chosen as an external comparison group. Multivariate linear and logistic regression models were employed for adjustment. Results. Guideline implementation resulted in shorter durations of antibiotic treatment (P < .001) and intra- venous treatment (P < .001), better coverage of atypical pathogens (P < .001), and improved appropriateness of antibiotic treatment (P< .001), compared with the period before the guideline was implemented. The adjusted analyses revealed decreases in 30- day mortality ( odds ratio [ OR], 2.14; 95% confidence interval [ CI], 1.23 - 3.72) and in- hospital mortality ( OR, 2.46; 95% CI, 1.37 - 4.41) and a 1.8- day reduction in the duration of hospital stay. In the control hospitals, there were small but statistically insignificant changes in these indicators for admitted patients. Conclusions. This study, which was performed with an adequate, controlled before- and- after intervention design, demonstrated significant improvements in both process- of- care and outcome indicators after implementation of a guideline for treating CAP.