Changing Physician Prescribing Behavior: The Community-Acquired Pneumonia Intervention Trial

Kim C. Coley, Susan J. Skledar , Michael J. Fine, Donald M. Yealy , Patrick P. Gleason , Michael L. Ryan, Wishwa Kapoor , and Robert A. Branch


Am J Health Syst Pharm. 2000;57(16) 

In This Article


The control period was from October 1, 1995, to May 31, 1996. Immunocompetent patients with nonsevere CAP who were admitted to the University of Pittsburgh Medical Center during that period were identified by searching the institution's Medical Archival System (MARS) for patients with an International Classification of Disease (ICD-9) code of 486 (pneumonia) in the admitting diagnosis field. MARS is a large-scale archiving system that integrates patient data from various inpatient and outpatient information systems in our health system.21 Data from central transcription, laboratory, pharmacy, radiology, and other departments are combined in a comprehensive full-text-indexed relational database. Other inclusion criteria consisted of (1) age greater than 17 years, (2) a preliminary diagnosis of CAP in the history and physical, (3) admission to a non-intensive-care unit bed, and (4) availability of a medical abstract and a history and physical in the MARS for that admission. Exclusion criteria were (1) an absence of antimicrobial use during the admission, (2) transfer from a nursing home or another hospital, (3) immunosuppression (e.g., corticosteroid use, organ transplantation, HIV positivity), (4) respiratory failure or shock, and (5) a diagnosis of cystic fibrosis or postobstructive pneumonia.

The intervention period began in August 1996. A committee of representatives from pharmacy, internal medicine, emergency medicine, infectious diseases, and clinical pharmacology was formed to determine the preferred regimen for nonsevere CAP and the best method of disseminating this information. Cefuroxime with or without erythromycin was determined to be the preferred regimen on the basis of national consensus guidelines from the American Thoracic Society, local expertise, spectrum of activity, and drug cost.[2] This recommendation was approved by the pharmacy and therapeutics (P&T) committee. No formulary restriction was placed on other antimicrobials used in the treatment of CAP. The preferred regimen was disseminated via inservice meetings, grand rounds, resident conferences, hospital newsletters, and physician memorandums.

The institution's clinical pathway for CAP was revised to reflect the new recommendations. In addition, patients admitted with a diagnosis of CAP were identified and evaluated by pharmacists. If a patient with CAP was eligible for cefuroxime therapy but was receiving a different antimicrobial agent, a pharmacist notified the prescriber of the preferred regimen.

Since many patients who are admitted to the hospital with CAP are initially seen in the emergency department (ED), separate inservice meetings were conducted there. ED case managers identified patients with CAP who were eligible for cefuroxime and notified the prescribing physician or the pharmacist. An educational memorandum from the P&T committee was posted in the ED patient care areas and placed in the charts of eligible patients (Figure 1). Finally, the automated dispensing machines in the ED were programmed to display "If CAP, first line = cefuroxime" when antimicrobial agents were prescribed. This reminded the staff to consider cefuroxime as the treatment of choice in eligible patients with CAP.

Figure 1. University of Pittsburgh Medical Center "pharmagram" for empirical treatment of nonsevere community-acquired pneumonia.


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