Antibiotic use, hospital admissions, and mortality before and after implementing guidelines for nursing home-acquired pneumonia

OBJECTIVES: To compare two strategies for implementing guidelines for nursi ng home-acquired pneumonia (NHAP) and to measure outcomes associated with t reatment in accordance with the guidelines. DESIGN: Randomized controlled trial. SETTING: Ten skilled nursing facilities (SNFs) from a single metropolitan a rea. PARTICIPANTS: Patients with an episode of pneumonia acquired more than 3 da ys after admission to SNF (N = 350): 226 preintervention episodes of pneumo nia and 116 postintervention episodes. INTERVENTIONS: Multi-faceted education intervention including small-group c onsensus process limited to physicians and a similar intervention that incl uded physicians and nurses within randomly selected SNFs. MEASUREMENTS: Antibiotic use at diagnosis compared with the guidelines, hos pital admission, severity of pneumonia, and 30-day mortality. RESULTS: Data were complete for 344 episodes of NHAP. For the preinterventi on group (n = 226), 62.2% (79/127) of the episodes were treated with parent eral antibiotics (PA) when PA were recommended by the guidelines and 57.6% (57/99) of episodes were treated with oral antibiotics OA) when OA were ind icated by the guidelines. Postintervention, treatment with PA and OA accord ing to the guidelines was not significantly different between the two group s of randomized SNFs. A multivariate analysis comparing PA use pre- and pos tintervention for all SNFs, adjusted for variation in the frequency and sev erity of pneumonia, found significantly more of the postintervention episod es were treated with PA in accordance with the guidelines (P < .02). A prei ntervention significant difference in 30-day mortality observed between epi sodes with indications for PA (37.8% (48/127)) and episodes with indication s for OA (6.1% (6/99)) (P < .001) was not present postintervention (11.5 % (6/52); (23.8 % (15/64); P = .06). There was no significant difference in 3 0-day mortality preintervention and postintervention for episodes with guid eline indications for OA (P = .35) or for PA (P = .05) (P = .16 for multiva riate analysis). The difference in PA use was not associated with significa nt differences in hospital admissions for episodes on NHAP. CONCLUSION: The increase in the use of PA provides evidence that care withi n SNFs can be significantly changed using standard quality improvement tech niques. Use of the guidelines did not significantly affect mortality. The a ddition of a practical severity of NHAP model or a change in reimbursement structure may enhance the guidelines' impact on hospitalization for NHAP. T he financial benefits available with use of the guidelines will be limited unless the guidelines contribute to a reduction in rates of hospitalization .