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Efficacy of clinical guideline implementationto improve the appropriateness of chestphysiotherapy prescription among inpatientswith community-acquired pneumonia

Idris Guessous a, Jacques Cornuz a,b, Rebecca Stoianov a, Bernard Burnand c,Jean-William Fitting d, Bertrand Yersin e, Olivier Lamy a,*

a Department of Internal Medicine, University Hospital Centre, CH-1011 Lausanne, Switzerlandb Department of Community Medicine and Public Health, University Hospital Centre, CH-1011 Lausanne, Switzerlandc Institute of Social and Preventive Medicine (IUMSP), University Hospital Centre, CH-1011 Lausanne, Switzerlandd Department of Pneumology, University Hospital Centre, CH-1011 Lausanne, Switzerlande Emergency Department, University Hospital Centre, CH-1011 Lausanne, Switzerland

Received 10 January 2008; accepted 2 April 2008Available online 10 July 2008

KEYWORDSCommunity-acquiredpneumonia;Chest physiotherapy;Guideline;Implementation

Summary

Background:Although there is no strong evidence of benefit, chest physiotherapy (CP) seems

to be commonly used in simple pneumonia. CP requires equipment and frequently involves the

assistance of a respiratory therapist, engendering a significant medical workload and cost.

Aim: To measure and compare the efficacy of two modalities of chest physiotherapy (CP)guideline implementation on the appropriateness of CP prescription among patients

hospitalised for community-acquired pneumonia (CAP).

Patients and methods: We measured the CP prescription rate and duration in all consecutive CAP

inpatients admitted in a division of generalinternal medicine at an urban teaching community hos-pital during three consecutive one-year time periods: (1) before any guideline implementation;

(2) after a passive implementation by medical grand rounds and guideline diffusion through mail-

ing; (3) after adding a one-page reminder in the CAP patients medical chart highlighting our rec-

ommendations. Death and recurrent hospitalisation rates within one year after hospitalisationwere recorded to assess whether CP prescription reduction, if any, impaired patient outcomes.

Results: During the three successive phases, 127, 157, and 147 patients with similar characteris-

tics were included. Among all CAP inpatients, the CP prescription rate decreased from 68%

Abbreviations: CP, chest physiotherapy; COPD, chronic obstructive pulmonary disease; PSI, pneumonia severity index; CAP, community-acquired pneumonia.

* Corresponding author. Tel.:41 21 314 08 76; fax: 41 21 314 08 71.E-mail address: [email protected](O. Lamy).

0954-6111/$ - see front matter2008 Elsevier Ltd. All rights reserved.doi:10.1016/j.rmed.2008.04.008

a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m/ l o c a t e / r m e d

Respiratory Medicine (2008)102, 1257e1263
mailto:[email protected]://www.elsevier.com/locate/rmedhttp://www.elsevier.com/locate/rmedmailto:[email protected]


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(86/127) to 51% (80/157), and to 48% (71/147), respectively ( Pfor trend


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(3) after adding, on the day of patient admission, a one-pagereminder in the CAP patients medical chart highlighting ourrecommendations (phase III: active implementation) (Fig. 2).The CAP guideline was developed at the end of phase I so thatit would not affect the clinical management of patients in-cluded in phase I.

CP sessions in CAP varied from case to case, butgenerally consisted of positioning the patient to optimise

ventilation and perfusion, external vibration, and incentivespirometry. The total cost of CP for each phase wascalculated based on a cost estimation of $90.90 per dayof CP, which included one intensive session and one soft CPsession. In addition, in-hospital mortality and recurrenthospitalisation rates within one year after hospitalisationwere recorded to assess whether CP prescription reduction,if any, impaired patient outcomes.

Patients and data

This study was conducted from 1997 to 2001 in the Serviceof Internal Medicine at the University Hospital Centre inLausanne, Switzerland, a 900-bed teaching hospital servingas a city hospital and tertiary reference centre providingservices to an area with more than 300,000 inhabitants. Allconsecutive adult patients (age 18 years) hospitalisedwith a primary diagnosis of CAP were eligible for the study.Records of phases I and II (retrospective data) wereidentified through a sensitive review of ICD-9-CM diagnosticdischarge codes including pneumonia with or withoutidentified pathogens. Records of phase III (prospectivedata) were identified daily in the emergency room bya research study nurse and by the fellow in charge of thestudy. All adult patients hospitalised with a primary diagno-sis of CAP were eligible for the study. The inclusion criteriawere the following: age 18 years; acute onset of at least

one clinical finding suggestive of pneumonia, includingcough, dyspnoea, pleuritic chest pain, sputum production,fever or altered mental status; and the presence ofa newly-acquired radiographic pulmonary infiltrateconfirmed by a radiologist. Patients with immunodeficiencyvirus infection, neutropenia related to chemotherapy,organ transplant, cystic fibrosis or congestive heart failurewere excluded, as were patients who were transferred tothe ICU, admitted from a nursing home, hospitalised withinthe 10 previous days or discharged home during the first24 h of hospitalisation. For patients hospitalised with CAPon more than one occasion during the study period, onlythe initial episode was evaluated.

Data on demographic characteristics, comorbid illnesses,physical examination findings, initial investigations, anti-biotherapy, ancillary treatments, follow-up and outcome

were collected by chart review. Severity of community-acquired pneumonia was assessed by the pneumoniaseverity index (PSI) proposed by Fine et al.20 The PSI isbased on derivation and validation cohorts of more than50,000 patients with CAP. Briefly, the PSI stratifies patientsinto 5 mortality risk classes, and its ability to predict mortal-ity has been confirmed in multiple subsequent studies. Onthe basis of associated mortality rates, it has been suggested

that risk class I and II patients should be treated asoutpatients, risk class III patients should be treated in anobservation unit or with a short hospitalisation, and risk classIV and V patients should be treated as inpatients. A diagnosisof COPD was retained on the basis of ICD-9-CM diagnosticdischarge codes. Medical records of all included patientswere manually and electronically reviewed using hospitaldatabases to assess the number, date and cause ofre-admissions.

Statistical analysis

Descriptive and comparative statistical tests (paired andnon-pairedt-test, Chi square test or exact Fisher test), andP for linear trend to examine trends across phases wereapplied using Stata (V 9.1, Stata Corporation, CollegeStation, TX, USA). Pvalues


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inpatients without COPD from 58% (59/96), to 46% (56/121),and to 36% (36/100) (P for trend


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Discussion

Our study demonstrated that both passive and activeimplementations of the guideline appeared to improvethe appropriateness of CP prescription among inpatientswith CAP. Improvement was more pronounced during theactive implementation phase with a greater impact onchest physiotherapy duration. Moreover, the reduction inCP prescription and duration seemed disconnected withworse medical outcomes. The total cost of CP was reducedby nearly 50% after the active implementation.

In recent years, strategies aimed at reducing the medicalworkload and cost of patients hospitalised for CAP have beenproposed.Sincea lengthof stay reduction hasbeen generallyunassociated with an increase in adverse outcomes,21 effortshave focused on interventions inclined to reduce the length

of stay for patients with CAP. Therefore, processes includingtriage decisions, risk stratification for outpatient care andearly transition from intravenous to oral antibiotics havebeen evaluated.19,22e24 in addition to the length of hospitalstay, CAP inpatient management includes practices notsupported by evidence of effectiveness.

Indications regarding CP prescription are clearly lackingin CAP guidelines and review.25e27 The British Thoracic

Society Guideline and European Study on Community Ac-quired Pneumonia (ESOCPA) committee are among thefew that assessed recommendations regarding CP.28,29 CP

in acute pneumonia obtained a grade III recommendation(i.e., one or more retrospective clinical studies thataddress but do not rigorously answer the question) in theBritish Thoracic Society Guideline, and the ESOCAP commit-tee stressed that the body of data regarding CP is small butthat CP seemed justified for patients with chronic airwaydisease.

Despite the lack of evidence, CP seems to be overused.In 1996, Alexander et al. demonstrated that more than 50%of CP prescriptions were inappropriate.15 This high level ofinappropriateness was previously observed.17,30,31 Morerecently, we reported that 59% of inpatients with CAPreceived CP although they had no accepted indications.18

Not only has CP been overprescribed, CP prescriptionduration appeared to be too long, with duration quitesimilar to the length of hospital stay.18 One explanationmight be that physicians do not regularly reassess therationale for pursuing CP.

CP requires equipment and frequently involves theassistance of at least one respiratory therapist, engender-ing a significant medical workload and cost. When includingthe personnel and equipment costs, the annual cost of CPdelivered in a medical centre has been estimated to bemore than $1 million.15

Strategies to reduce the inappropriate utilisation of CPhave been evaluated through randomised and prospectiveobservational studies. One of them showed that the number

of inappropriate CP prescriptions could be significantlyreduced without impairing the patients outcome. It wasalso estimated that the reductionwould be associated withannual cost savings of $319,000.15 More recently, three ad-ditional studies have investigated different strategies toimprove respiratory care utilisation.16,32,33 All comparedthe impact of respiratory therapist-initiated treatment tophysician-directed orders on CP prescription rate. Thesethree studies suggested that the instances of inappropriaterespiratory care significantly decrease with respiratorytherapist-initiated treatment.

Our study has some limitations. First, we have notclearly defined the three CAP indications, i.e., a severe

Figure 4 Duration of chest physiotherapy by phases. Phase I (nZ 127), phase II (nZ 157) and phase III (nZ 147). P for

trend


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COPD, neuromuscular pathology, or important bron-chial secretions, which might limit the generalisation ofour findings. Second, the before and after study designmight have introduced bias in the following manner.Differences in confounding factors between the threegroups might partially explain differences in outcome forreasons unrelated to the CAP guidelines. For example, the

lower proportion of hypoxemic patients at admission couldhave resulted in a decrease in CP prescriptions in groupswith less hypoxemic patients. Third, because the physicianswho worked in our institution during phases II and III mighthave been informed of the study aims, they might havechanged their practice independently of the guidelineimplementation (Hawthorne effect). Finally, our guidelinereported weak evidence for prescribing CP in CAP. Althoughguidelines are generally understood as a compression ofstrong indications aimed to correct the inappropriateunderuse of an intervention, we stress that the clinicalutility of guidelines should not be limited to this aim.Indeed, the inappropriate overuse of medical interventions

has also stimulated the development of recommendations,and guidelines with a limited amount or lack of evidence,appeared to also helpdoctors in making the right decisions,i.e., not to prescribe.34e39 Although we cannot report theexact mechanism by which providers did eventually decidenot to prescribe CP and acknowledge that further workshould be done to assess the impact of the level of evidence(i.e., weak) on provider decision, we demonstrated theinitial step, that is the reduction of unnecessary CPprescription after guideline implementation. We do thinkthat our findings might add new elements to the experi-ences assessed from previous studies. First, the methodwe used to implement our guideline e a one-page reminderin CAP patients medical charts e might be easier to

reproduce (external validity) and less expensive thanstrategies previously proposed. For example, Alexanderet al. chose to put a physician fellow in charge of explainingby phoneto each physician whether CP is indicated for theirpatients.15 This strategy seems hardly reproducible, as itrequires an additional physician, and probably inefficientbecause of its potential cost. Second, previous studieschose a respiratory therapist-initiated treatment approach(i.e., respiratory therapists were first specifically trained touse algorithms and then ordered or not CP to inpa-tients).16,32,33 Although these studies showed significantreduction in respiratory care services, their conclusionsmight be difficult to generalise in other settings with

limited training resources and respiratory therapists. Askingrespiratory therapists to evaluate each inpatient anddecide whether they should receive CP could furtherincrease their workload and limit their availability for otherpatients who may require urgent respiratory care. By usingmedical rounds or a one-page reminder in a patients med-ical chart, our strategy was a physician-based approach

that might not only be more reproducible but also betterfulfil the final aims of guideline implementation, whichare to change and improve physicians clinical practice.Finally, our study highlighted the need to further evaluatewhether CP is actually useful for inpatients with CAP. Thebeforeeafter study is the most commonly encountered de-sign in quality improvement research;40 however, to obtainvalid assessment of the efficacy of CP in CAP, more robustdesigns (e.g., randomised controlled trials) are needed.

In summary, although it does not use a randomiseddesign, this study indicates that guidelines for the use ofCP in patients with CAP might enable more appropriate andcost-saving care by restricting its use and limiting it for

absolutely necessary occasions. The external validity of thissimple intervention should be evaluated in other settingsand eventually at different levels of CAP medical care.

Conflict of interest statement

The authors hereby declare that they have no financial orpersonal interests.

Acknowledgements

The Department of Internal Medicine, University Hospital

Centre in Lausanne funded the study.

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Table 2 Rate and cause of recurrent hospitalisationa

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after hospitalisation

Phase I: baseline

(nZ 127)

Phase II: passive

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Phase III: passive active

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Pvalue

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