Determinants of Physician Familiarity with and Use of National and Local Pneumonia Practice Guidelines

Halm EA, Switzer GE, Goldman J, Chang CH, Mittman BS, Walsh MB, Fine MJ. Determinants of Physician Familiarity with and Use of National and Local Pneumonia Practice Guidelines. Paper presented at: Association for Health Services Research Annual Meeting; 1999 Jun 1; Chicago, IL.

Research Objective: Although national practice guidelines for community-acquired pneumonia (CAP) have been widelypublished by the American Thoracic Society (ATS) and many local CAP guidelines have been developed by individualhospitals, the impact of such guidelines is not known. We sought to assess: 1) physicians (MD) familiarity with and use ofATS guidelines and locally-developed hospital guidelines for CAP, and 2) hospital and MD characteristics associated withknowledge and use of CAP guidelines.Study Design: As part of a randomized trial of guideline dissemination, we administered a written, pre-intervention survey toassess MD familiarity with and use of ATS and local hospital guidelines to determine the influence they have on managementof patients with CAP. We also assessed general attitudes about guidelines using a previously validated instrument.Questionnaires were sent to 641 internal medicine (IM), family medicine, general practice, pulmonary medicine and infectiousdiseases attending MDs who treat patients with CAP in 7 hospitals in Pittsburgh, PA hospitals (1 university, 3 communityteaching, and 3 community non-teaching).Principal Findings: We received 352 completed surveys (55% response rate): 86/128 at Univ. of Pittsburgh Medical Center(UPMC) Montefiore, 49/84 at Jefferson, 19/34 at UPMC Braddock, 55/99 at UPMC Passavant, 78/147 at UPMC Shadyside,45/102 at St. Francis, and 20/47 at UPMC McKeesport. Overall, 79% of MDs were generalists (general IM, family, generalpractice) and 21% IM subspecialists (pulmonary/infectious diseases). Most MDs were white (78%) and spent the majority oftheir time providing direct patient care (median, 46 hours/wk). Specialists cared for more CAP inpatients/yr (mean, 32 v. 18;p < .0001) and did more inpatient care (mean, 27 v. 12 hrs/wk; p < .0001) then generalists. The vast majority of MDs had favorable general attitudes about practice guidelines. Respondents felt that guidelines, in general,were: good educational tools (86%), convenient sources of advice (84%), and intended to improve quality of care (83%).Overall, 78% of MDs reported at least having seen the national ATS pneumonia guideline. However, only 20% of MDs reportedusing them in patient care. Most MDs (52%) reported that the ATS guidelines influenced treatment either not at all or onlyslightly. Familiarity and use of ATS guidelines varied significantly by hospital (familiarity, 58% to 89%; and use, 28% to 8%;p < .01 for both). There was a trend towards differences in the influence of ATS guideline by hospital (42% to 82% p < .08). Use ofATS guidelines appeared highest in the university hospital (28%), intermediate in community-teaching sites (16% to 26%), andlowest in non-teaching ones (8% to 20%). There were no differences in use or influence of ATS guidelines between generalistsand specialists. Physicians were more likely to be influenced by ATS guidelines if they spent more time teaching (r = .16,p < .01), more time reading medical journals (r = .14, p < .05) or more time in administration (r = .12, p < .05). Six of the 7 study hospitals had locally developed CAP guidelines. However, nearly half of MDs (48%) were uncertain whethertheir own hospital had guidelines for CAP. Among the 290 MDs from the 6 hospitals with a documented CAP guideline, 41%reported that no local guideline existed. Among the 48 MDs from the single hospital with no local guideline, 14% reported thatone existed. Only 38% of MDs from hospitals with a local guideline said the guideline was moderately or very influential in theirmanagement of CAP. While generalists and specialists had similar knowledge of local CAP guidelines, generalists were morelikely to be frequent users of their hospital's guidelines (34% vs. 8%; p < .01).Conclusions: Although specific guidelines for the management of CAP exist on a national and local level, a sizeableproportion of MDs are unaware of their existence. Even when MDs were familiar with specific guidelines or were favorablypredisposed towards them, they appeared to have limited influence on actual patient care. Physicians engaged in moreacademic activities (teaching, reading) or practicing at more academically-oriented hospitals were more knowledgeable aboutand influenced by national guidelines.Implications for Policy, Delivery or Practice: Inadequate knowledge about practice guidelines only partly explains theirlimited impact on changing MD behavior. More effective and intensive strategies for disseminating and implementing practiceguidelines at both the national and local level are needed