Understanding physician adherence with a pneumonia practice guideline - Effects of patient, system, and physician factors

Background: Adherence with clinical practice guidelines is highly variable. Reasons for their inconsistent performance have not been well studied. Objective: To determine the patient, system, and physician factors that may explain why physicians may not follow guidelines. Methods: We used chart review and physician surveys to measure adherence wi th an actively implemented guideline to reduce hospitalizations for patient s coming to the emergency department with community-acquired pneumonia. Log istic regression analyses were used to identify factors associated with gui deline nonadherence. Results: Overall nonadherence with the guideline was 43.6%, with 71 of 163 low-risk patients with pneumonia being hospitalized despite the recommendat ion for outpatient therapy. In univariate analyses, nonadherence to the gui deline was more likely for patients who were aged 65 years or older, were m ale, were employed, and had multilobar disease or other comorbid conditions (P<.05). Active involvement of a primary care physician in the admission d ecision also increased nonadherence (odds ratio, 4.9; 95% confidence interv al, 2.2-11.0). Physicians with more pneumonia experience were more likely n ot to follow the guideline (P<.001). In multivariate models, the odds of no nadherence were 2 to 3 times greater when patients were 65 years or older, were male, or had multilobar disease, or the primary care physician was inv olved in the triage decision (P<.05). Physicians' reasons for admission wer e the presence of active comorbidities (55%), the primary care physician's wish for hospitalization (41%), the presence of worse pneumonia than the gu ideline indicated (36%), patient preference (17%), and inadequate home supp ort (16%). Conclusions: Nonadherence to a pneumonia guideline was associated with a va riety of patient, system, and physician factors. Guideline implementation s trategies should take into account the heterogeneous forces that can influe nce physician decision making.