Implementing a hospital guideline on pneumonia: a semi-quantitative review

Background and objective: To quantify the impact of different guideline implementation interventions to improve treatment of community-acquired pneumonia (CAP) in a hospital setting. Methods: Pubmed, the Cochrane Library, the Cochrane Effective Practice and Organization of Care specialized register, EMBASE and CINAHL. Study selection: Hospital-based trials studying the effect of guidelines on compliance with care processes, clinical and/or economic outcomes in the treatment of CAP together with a description of their implementation interventions. Data extraction: Two independent reviewers extracted and categorized utilized implementation interventions, assessed intensity of use and calculated changes for process of care variables, clinical and economical outcomes. Correlations between interventions and improvement of outcomes were assessed by means of Spearman's rho-test and Mann-Whitney U-test. Results. In 27 included studies, educational meetings (21/27) and distribution of written material (14/27) were the two most used interventions. Most individual studies show positive overall results, but taken together, no significant relation between number or type of implementation interventions and improvement of outcomes could be detected. Only audit and feedback showed a significant negative influence on the improvement rate of length of stay (p = 0.003; n = 20). Conclusion: Other hospital-specific factors are likely to have a higher impact on the rate of improvement than the implementation interventions alone. Describing which interventions are most successful is unlikely to be correct without taking these hospital-specific factors into account. Future research should focus on how to identify and define these factors and how to adapt the intervention to hospital-specific factors.