CRD summary

The authors concluded that interventions which encourage adherence to community-acquired pneumonia guidelines are safe and are associated with improvements in patient and process outcomes. The limited search, inadequate reporting of review methods and quality assessment of the included studies, and the paucity of good quality evidence, make the reliability of such a strong conclusion uncertain.

Authors' objectives

To evaluate the effects of guidelines for the treatment of community-acquired pneumonia (CAP) and to identify barriers to the adoption and use of CAP guidelines; this abstract concentrates on the effect of the intervention.

Searching

MEDLINE was searched from inception to July 2004 for English language reports; the search terms were reported. In addition, the reference lists of the retrieved studies were screened and experts in the field were contacted.

Study selection

Assessment of study quality

The authors did not state that they assessed validity.

Data extraction

The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction.

For each study, data on LOS or BDPM and mortality were extracted for each treatment group, together with the levels of statistical significance of the difference between treatment groups. The rates of hospital admissions, guideline-recommended antibiotic use and adherence were also extracted.

Methods of synthesis

Results of the review

Six studies (n=31,618) were included: 2 cluster RCTs (n=2,351), 2 before-and-after studies with concurrent controls (n=28,840) and 2 time series (n=427).

One cluster RCT, 1 before-and-after study and 1 time series reported statistically significant reductions in LOS or BDPM, and 1 before-and-after study reported statistically significant reductions in mortality when patients received CAP treatment according to the guidelines; other studies reported no significant difference in LOS or BDPM (3 studies) or mortality (4 studies) between patient groups.

All 6 studies reported significant improvements in at least one process measure in patients receiving CAP treatment according to the guidelines. Improvements were found in the hospital admission rates for low-risk patients (1 study), the time till administration of first antibiotic (2 studies), the use of guideline-recommended antibiotics (1 study), and the use of appropriate monotherapy and a shorter duration of intravenous therapy (1 study).

Authors' conclusions

Interventions that encourage adherence to CAP guidelines are safe and are associated with improvements in patient and process outcomes.

CRD commentary

The review addressed a clear question that was defined in terms of the participants, intervention, outcomes and study design; the inclusion criteria for outcomes and study design were broad. Although experts in the field were contacted (so unpublished studies may have been identified), only one database was searched and only English language studies were included, therefore publication and language bias might have resulted in the omission of relevant studies. Study validity was not assessed and few study details were provided. The methods used to select the studies and extract the data were not described, so it is not known whether any efforts were made to reduce reviewer error and bias.

In view of the diversity of the studies, a narrative synthesis was appropriate. However, the results were not discussed with respect to study design or any other indicator of study quality, and reporting tended to focus on positive results. Only results data for LOS or BDPM and mortality were reported consistently for each study in the tables, and so it was not possible to confirm the reporting for other outcomes. In addition, potential causes of differences among the studies were not discussed. The limited search, the lack of an assessment of the quality of the included studies, and the lack of reporting of review methods and of some results, make it difficult to confirm the reliability of the authors' conclusion. A more cautious conclusion might have been appropriate in view of the inconsistent results from a small number of studies of variable design.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated that future studies which evaluate CAP guidelines should be well designed, examine multiple strategies to overcome barriers to the adoption of guidelines, and convince care providers that adherence to guidelines can improve patient outcomes.

Funding

Institute of Health Economics, Edmonton, AB, Canada.

Bibliographic details

Simpson S H, Marrie T J, Majumdar S R. Do guidelines guide pneumonia practice: a systematic review of interventions and barriers to best practice in the management of community-acquired pneumonia. Respiratory Care Clinics of North America 2005; 11(1): 1-13. [PubMed: 15763217]

Indexing Status

Subject indexing assigned by NLM

MeSH

Alberta; Anti-Bacterial Agents; Community-Acquired Infections /drug therapy /microbiology /mortality; Drug Therapy, Combination /therapeutic use; Female; Guideline Adherence; Humans; Male; Outcome Assessment (Health Care); Physician's Practice Patterns; Pneumonia, Bacterial /drug therapy /microbiology /mortality; Practice Guidelines as Topic; Prognosis; Randomized Controlled Trials as Topic; Risk Assessment; Severity of Illness Index; Survival Analysis; Treatment Outcome

AccessionNumber

12005003719

Database entry date

29/02/2008

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.