Physicians' Attitudes Toward Guidelines for the Treatment of Hospitalized Nursing Home–Acquired Pneumonia

ORIGINAL STUDIES

Physicians’ Attitudes Toward Guidelines for the Treatment of Hospitalized Nursing Home–Acquired Pneumonia Ali A. El-Solh, MD, MPH, Ahmad Alhajhusain, MD, Ranime G. Saliba, MD, and Paul Drinka, MD

Objectives: To assess physician awareness, attitudes, and barriers toward the 2005 American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) guidelines for the treatment of hospitalized nursing home–acquired pneumonia (NHAP). Methods: We conducted a cross-sectional survey of 522 health care providers. The survey assessed the practice setting characteristics, physicians’ attitudes, and reported awareness of the 2005 ATS/IDSA guidelines. Factor analysis was conducted to identify scales of variables, and a reliability analysis was performed to verify the reliability of the identified scales. Results: Three hundred and ten completed the survey. Most responders (88%) reported familiarity with the practice guidelines in their field, but less than half were familiar with the ATS/IDSA NHAP guidelines. Although attitude scores regarding clinical practice guidelines did not differ significantly among various disciplines (P 5 .63), there were 2 characteristics that

Clinical guidelines are defined as ‘‘systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.’’1 The Veterans Affairs Western New York Healthcare System, Buffalo, NY (A.A.E.-S., A.A.); Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine; State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY (A.A.E.-S., A.A., R.G.S.); Department of Social and Preventive Medicine; State University of New York at Buffalo School of Public Health and Health Professions, Buffalo, NY (A.A.E.-S.); Division of Internal Medicine and Geriatrics, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI (P.D.). The authors have no conflicts of interest to report. Address correspondence to Ali A. El-Solh, MD, MPH, Medical Research, Bldg. 20 (151) VISN02, VA Western New York Healthcare System, 3495 Bailey Avenue, Buffalo, NY 14215–1199. E-mail: [email protected]

Published by Elsevier Inc. on behalf of the American Medical Directors Association DOI:10.1016/j.jamda.2010.02.021 270 El-Solh et al

correlated with positive attitudes toward the 2005 ATS/IDSA guidelines in a multivariate analysis: being a pulmonary specialist (P # .001) and time spent on CME activity per month (P 5 .03). The main barriers to the 2005 ATS/IDSA guidelines implementation were lack of awareness, concerns about practicality of using the recommended regimens, increased cost, lack of documented improved outcomes, and potential conflict with other guidelines. Conclusion: The study indicates low levels of awareness with the 2005 ATS/IDSA guidelines for treatment of hospitalized NHAP. Targeted intervention efforts including outcome assessment and cost-effective analysis may be necessary to improve adherence with the proposed guidelines. (J Am Med Dir Assoc 2011; 12: 270–276) Keywords: Nursing home pneumonia; guidelines; attitude; compliance

They are considered a good source of advice guiding decision making, a convenient education tool, and a mean to standardize medical care.2–4 However, studies that examined practitioners’ compliance found significant deviation from published guidelines.5–7 Consequently, there is increasing emphasis on overcoming barriers to the dissemination and implementation of guidelines.8 Such barriers may include accessibility of guidelines, physician attitudes toward guidelines, physician incentives to adhere to guidelines, and perceived effect of guidelines on patient outcomes.9,10 In 2005, the American Thoracic Society (ATS) and the Infectious Disease Society of America (IDSA) published a joint statement delineating the approach to treatment of health care–associated pneumonia including pneumonias acquired in nursing homes.11 The recommendations advocate broad-spectrum antimicrobial coverage to include multidrugresistant organisms. Nursing home–acquired pneumonia JAMDA – May 2011

(NHAP) was included on the basis of bacteriology data from intubated residents and reports demonstrating increased mortality in patients with serious drug-resistant pathogens who did not receive adequate initial antibiotic coverage. There was, however, no strong evidence to indicate that such broad coverage actually improved outcomes in NHAP. Subsequent publications favored limiting broad coverage to higher risk subgroups of NHAP.12,13 A recent study assessing the antimicrobial prescription patterns for hospitalized patients with NHAP found poor compliance with the 2005 ATS/IDSA published guidelines.14 Antibiotic choice was influenced by patients’ age, severity of illness, and providers’ academic affiliation. Other studies involving cancer-screening guidelines found that adherence was related to agreement with guidelines, level of continuing medical education, and perceived probability of the disease.15 Characteristics associated with disagreement with recommended guidelines include older age, male sex, and not having completed a postgraduate residency program. Hence, understanding physician characteristics that are associated with adherence to guidelines can help overcome barriers to compliance and create better educational programs for physicians. To our knowledge, we are not aware of any investigation performed with the intention of understanding physicians’ attitudes and practice patterns toward antibiotic regimens for the treatment of hospitalized NHAP. Therefore, the objectives of this study were the following: (1) to assess physicians’ attitudes toward practice guidelines in general and toward a specific guideline—the 2005 ATS/IDSA Guidelines for the treatment of NHAP, (2) to correlate these attitudes with physicians and practice characteristics, and (3) to identify potential barriers to implementation. METHODS Sample After obtaining approval from the Institutional Review Board, we conducted a cross-sectional survey of health care providers from the following specialties: geriatric medicine, general internal medicine, family medicine, and pulmonary medicine. Information on the providers was obtained from the 2007 Health Care Database. The questionnaire was sent via electronic mail between November 2008 and February 2009. A second electronic mail was sent for nonresponders 2 weeks after the first e-mail. Physicians who had no hospital privileges or were not involved in treating or being consulted on nursing home patients were excluded. Questionnaire Content Attributes of physicians’ attitudes toward guidelines were derived from an in-house quality improvement project that was received from all physicians affiliated with 3 hospitals (n 5 128). The 10-page standardized questionnaire consisted of 37 questions and was divided into 2 sections. The first section assessed demographic as well as professional characteristics of the providers such as age, gender, year of graduation, years in practice, practice location (rural, suburban, or urban), medical specialty, time spent weekly on continuing ORIGINAL STUDIES

medical education (CME), hospital size, and affiliation with an academic center. The second section was modeled after tools originally developed by Cabana and coworkers16,17 and included 28 statements about practice guidelines in general and examined the familiarity, attitudes, and barriers toward use of the ATS/IDSA Guidelines for the treatment of hospitalized pneumonia apart from whether a local guideline is being used. Answers were coded using a 5-point Likert scale18 (0–4) ranging from ‘‘strongly disagree’’ (scoring 0 point) to ‘‘strongly agree’’ (scoring 4 points) and from ‘‘I see no problem at all’’ (scoring 0 point) to ‘‘I see a very big problem’’ (scoring 4 points). Negative items were reverse scored so that the higher the score, the more positive the attitudes. A total score was obtained by adding the points from each of the individual items. Factor Analysis To reduce the number of dependent variables and improve the interpretation of the data, an explanatory factor analysis was performed to understand the underlying dimensions of the 28 items that assessed guideline attitudes. Factor analysis is based on the premise that questions sharing similar dimensions are highly correlated and items that measure dissimilar dimensions are poorly correlated.19 A Varimax (oblique) rotation was subsequently conducted on the retained factors to help with interpretation. Items with loadings greater than 0.4 were assigned to a factor. Otherwise, they were eliminated from the analysis. Accordingly, a 2-factor solution seemed most meaningful in describing the dimensionality of attitudes toward guidelines. Factor 1 comprised 10 items that addressed attitudes toward guidelines in general with a possible range of scores from 0 to 40. Factor 2 contained 8 items, which were directed toward 2005 ATS/IDSA Guidelines and ranged in score from 0 to 32 (Table 1). Cronbach’s reliability coefficient was computed for each factor to measure internal consistency. The final scale accounted for 53.6% of the total variance and the Cronbach’s alphas of the factor were 0.84 and 0.79, respectively. An independent analyst commented on the content and format of each survey question. After these changes were made, a final survey was then e-mailed to all participating physicians. Statistical Analysis The survey data were analyzed using SPSS statistical software (SPSS version 10, 2000; SPSS, Chicago, IL). Bivariate analyses, including c2 and t-tests, were conducted to assess the relationships between the physician demographic and practice characteristics, physician knowledge, and physician adherence to the guidelines. Modes were imputed for incidental missing observations. Analysis of variance (ANOVA) was used to determine whether there were significant differences in mean attitude scores for practice guidelines in general and for the 2005 ATS/ IDSA Guidelines among practitioners with different demographic characteristics. To account for the difference in number of items in Factors 1 and 2, the mean scores were displayed also as a percentage. Demographic and El-Solh et al 271

Table 1. Survey Items Measuring Attitudes toward Practice Guidelines in General and the 2005 American Thoracic Society/ Infectious Diseases Society of America Guidelines Attitudes toward general practice guidelines - There are so many guidelines available that it is nearly impossible to keep up - I do not have the time to stay informed about available guidelines - Guidelines are too prescriptive - Generally, practice guidelines are cumbersome and inconvenient - Guidelines are difficult to apply and adapt to my specific practice - The costs of practice guidelines outweigh the benefits - Guidelines interfere with my professional autonomy - Generally, I would prefer to continue my routines and habits rather than to change based on practice guidelines - Guidelines improve patient outcomes - Guidelines help to standardize care and ensure that patients are treated in a consistent way Attitudes toward 2005 American Thoracic Society/ Infectious Diseases Society of America guidelines - I am not familiar with the guidelines’ recommendations - I have little confidence that the authors of the guidelines are well qualified and knowledgeable about nursing home–acquired pneumonia - The guidelines are based on questionable scientific evidence - There is inconclusive evidence that the guidelines will improve outcome - It is not practical to follow the guidelines’ recommendations - There are other guidelines that conflict with this one - The guidelines’ recommendations are costly to implement - The guidelines are user friendly

professional variables were then entered into 2 separate linear regression models to examine the independent effects of each variable on attitude scores for the general practice guideline and for the 2005 ATS/IDSA Guidelines. A multicollinearity test was performed using the variance inflation factor to assess the degree of correlation between independent variables. All tests were 2-tailed, and an alpha of P less than or equal to .05 was considered statistically significant. RESULTS

Table 2. Physicians’ Characteristics and Attitudes toward Practice Guidelines (n 5 310) Characteristics

n (%)

Gender Male Female Age, y \30 30–39 40–49 50–59 .60 Years in practice \3 3–10 11–20 21–30 .30 Specialty Geriatric Internal medicine Family medicine Pulmonary Board Certified Yes No Hours spent on continuing medical education/ month \1 1–5 .5 Location of practice Rural Suburban Urban Hospital affiliation with an academic center Yes No Hospital size (beds) 100–199 200–399 400–599 .600

189 (61.0) 121 (39.0) 18 (5.8) 127 (41.0) 80 (25.8) 64 (20.6) 21 (6.7) 59 (19.0) 111 (35.8) 67 (21.6) 57 (18.4) 16 (5.2) 63 (20.3) 82 (26.5) 93 (30.0) 72 (23.2) 283 (91.3) 27 (8.7) 17 (1.6) 164 (52.9) 129 (41.6) 25 (8.1) 122 (39.6) 163 (52.6) 108 (34.8) 202 (65.2) 34 (11.0) 118 (38.1) 109 (35.2) 49 (15.8)

cians, and family medicine practitioners (26.5%, 20.3%, and 30% respectively). The working affiliation of the respondents showed that most physicians were practicing in an urban, nonacademic hospital. Seventy-four percent of participating physicians rarely or never obtained specialty consultation for inpatient treatment of NHAP.

Physicians’ Characteristics The survey was sent to 522 physicians. A total of 291 physicians returned the survey (55.7%) after the first e-mail and 59 physicians after the second e-mail (11.3%). There were no significant differences in demographics between respondents to the first and second mailings. A total of 350 physicians completed the survey. Forty physicians were excluded either because they did not treat NHAP or had no hospital privileges. Demographic information on survey respondents is summarized in Table 2. About 60% of the participants were male, 46.9% were younger than 40 years and 54.9% of them had been in practice for less than 10 years. Pulmonary physicians accounted for 23.2% of all participants. The rest were internists, geriatri272 El-Solh et al

Attitude Regarding Clinical Practice in General Most respondents reported familiarity with the practice guidelines in their field. Only 12% stated that they were not. The mean score for the scale measuring general attitudes regarding clinical practice guidelines was 29.8  4.1 (range 10–38) (75%). Although attitude scores among various disciplines did not differ significantly from each other (P 5 .63), practitioners in the younger age groups (\ 50 years old) and who had been practicing for less than 20 years were more likely to have positive attitudes than those in the older age groups (. 50 years old) or who had been in practice for more than 20 years (P \ .001). These 2 variables however JAMDA – May 2011

Table 3.

Analysis of Physicians’ Attitudes toward Practice Guidelines: Univariate Analysis

Univariate Analysis

General Guidelines

Characteristics

Mean Score

Gender Male Female Age, y \30 30–39 40–49 50–59 .60 Years in practice \3 3–10 11–20 21–30 .30 Specialty Geriatric Internal medicine Family medicine Pulmonary Board Certified Yes No Hours spent on continuing medical education /month \1 1–5 .5 Location of practice Rural Suburban Urban Hospital affiliation with an academic center Yes No Hospital size (beds) 100–199 200–399 400–599 .600 Specialty consultation Rarely or never Frequent or always

2005 ATS/IDSA Guidelines P Value

Mean Score

.48 31.6 32.4

P Value .64

16.1 16.5 .18

\.001 32.4 30.1 29.5 27.4 25.8

12.4 12.8 11.7 11.4 10.5 .007

30.2 31.5 30.1 27.8 24.7

.25 11.8 12.1 12.8 11.7 10.7

.54 28.7 30.2 29.9 29.5

\.001 10.6 11.9 9.5 18.4

.76 29.7 29.5

.97 13.8 13.7

.15 28.6 28.9 29.5

.005 12.6 13.4 13.8

.32 28.6 29.9 29.4

.21 13.8 14.6 13.7

.09 31.5 28.7

.02 14.3 12.8

.04 27.4 29.1 31.5 30.3

.43 11.2 12.2 12.7 12.5

.24 28.7 29.1

.47 12.1 12.6

ATS/IDSA, American Thoracic Society/ Infectious Diseases Society of America.

were highly correlated (r 5 0.71). Attitude scores were also significantly higher in those practicing in larger hospitals (more than 400 beds) (P 5 .04) but board certification, affiliation with academic health center, or practice location was not correlated with attitudes. In the multivariate regression analyses, only age and hospital size were found to be independently associated with positive attitude (Tables 3 and 4). Attitude Regarding 2005 ATS/IDSA Guideline The mean score for the scale measuring attitudes regarding 2005 ATS/IDSA Guidelines for the treatment of hospitalized NHAP was 12.7  3.2 (range 6–29) (40%). There were 3 characteristics that correlated with positive attitudes toward the guideline: (1) being a pulmonary specialist (P # .001), (2) working in a university-affiliated hospital (P 5 .02), ORIGINAL STUDIES

and (3) spending more than 1 hour on CME activity per month (P 5 .005). Age, years in practice, board certification, hospital characteristics, and type of practice had no association with the use of 2005 ATS/IDSA Guidelines. Multivariate analyses identified 2 variables, practicing as pulmonary specialist and time spent on CME activity per month, as independent factors associated with positive attitudes toward the guidelines (Tables 3 and 4). Only 140 physicians (45.2%) reported being familiar with the 2005 ATS/IDSA Guidelines: 51% were pulmonary physicians, 24% internal medicine physicians, 17% family medicine physicians, and 8% were geriatricians. Considering the ‘‘I strongly agree’’ and ‘‘I agree’’ responses of the 5-point Likert scale, the 4 most important barriers to guideline adherence besides the lack of familiarity were the practicality of El-Solh et al 273

Table 4.

Analysis of Physicians’ Attitudes toward Practice Guidelines: Multivariate Analysis

Multivariate Analysis

General Guidelines

2005 ATS/IDSA Guidelines

Variables

Regression Coefficient

P Value

Regression Coefficient

P Value

Age Specialty Hours spent on CME Hospital affiliation with academic center Hospital size

–0.76 0.06 0.19 0.54 0.61

.005 .78 .45 .13 .02

–0.14 0.59 0.47 0.23 .09

.43 \.001 .03 .07 .84

ATS/IDSA, American Thoracic Society/ Infectious Diseases Society of America; CME, continuing medical education.

using the recommended regimens (61%), the lack of documented improved outcomes for the proposed guidelines (55%), the concern about increased costs (49%), and the potential conflict with other guidelines (47%) (Table 5). DISCUSSION This is the first study, to our knowledge, to examine physicians’ attitude to the 2005 ATS/IDSA Guidelines for the treatment of hospitalized NHAP. The study demonstrated a positive attitude to guidelines in general, yet only 45% of those surveyed reported being familiar with the 2005 ATS/ IDSA Guidelines. Most practitioners judged guidelines to be a convenient source of information that can improve the quality of health care. However, several differences in attitudes based on physicians’ characteristics were observed. Younger age was significantly related to positive attitudes toward guidelines. Others have reported greater acceptance of guidelines and practice standards among younger physicians.20,21 Guidelines may be most influential when clinicians are less experienced, as long-held beliefs may be difficult to modify even with rigorously proven evidence-based guidelines. Larger hospital size was also a determinant of a positive attitude toward guidelines. Our finding supports the suggestion by Yu and colleagues22 that variation in guideline compliance and resource use across centers may not be attributable to patient-related factors but rather to organizational factors and physician beliefs. Larger hospitals may have dedicated geriatric wards or specialized elderly care that would favor adherence to guidelines. This is becoming more prevaTable 5.

lent in light of the established quality-improvement paradigm of the day, which emphasizes the importance of continuously measuring process adherence and outcomes as a prerequisite for improving patient care. In contrast to the positive attitude toward practice guidelines in general, there was a relatively less positive attitude toward the 2005 ATS/IDSA Guidelines. One of the striking differences among physicians’ attitudes is its association with their subspecialty practices. Pulmonary physicians were found to have a more positive attitude toward the 2005 ATS/IDSA Guidelines than other practitioners. This is not surprising given that the guidelines were developed and published by the American Thoracic Society and the Infectious Disease Society of America with no participation, to our knowledge, from the geriatric or internal medicine specialties. In addition, current guidelines for the management of nursing home–acquired pneumonia are conflicting and diverging opinions exist regarding the strength of the evidence for the recommendations.11,23,24 Supporting this conclusion is the vast array of antimicrobial prescription patterns in the treatment of patients with this ailment.16 Not surprisingly, exposure to more sources of medical information was associated with higher attitude scores toward the 2005 ATS/IDSA Guidelines, which may reflect a more ‘‘evidence-based medicine’’ attitude in the respondents. Perhaps the most significant barrier to physician adherence to the 2005 ATS/IDSA Guidelines identified in our study was unfamiliarity with the 2005 ATS/IDSA Guidelines’ recommendations. A review of 31 surveys on physicians’ familiarity with guideline recommendations found a median

Barriers to Implementing the 2005 American Thoracic Society/ Infectious Diseases Society of America Guidelines

I am not familiar with the guidelines recommendations I have little confidence that the authors of the guidelines are well qualified and knowledgeable about nursing home–acquired pneumonia The guidelines are based on questionable scientific evidence There is inconclusive evidence that the guidelines will improve outcome It is not practical to follow the guidelines’ recommendations There are other guidelines that conflict with this one The guidelines’ recommendations are costly to implement The guidelines are user friendly

274 El-Solh et al

Strongly Agree/Agree n (%)

Don’t Know n (%)

Strongly Disagree/ Disagree n (%)

158 (51) 53 (17)

12 (4) 162 (52)

140 (45) 95 (31)

89 (29)

147 (47)

74 (24)

171 (55)

67 (22)

72 (23)

188 ( 61)

63 (20)

59 (19)

147 (47) 151 (49)

43 (14) 130 (42)

120 (39) 29 (9)

96 (31)

81 (26)

133 (43)

JAMDA – May 2011

unfamiliarity rate of 57%.17 In our study, more than half of the physicians surveyed acknowledged their lack of familiarity with the 2005 ATS/IDSA Guidelines for the treatment of hospitalized NHAP. Knowing that physician awareness and knowledge of the content of the guidelines are important in assessing compliance,25 it is not surprising that only 19% of the antimicrobial therapy prescribed for the treatment of hospitalized NHAP was concordant with the 2005 ATS/ IDSA Guidelines compared with 65% with the 2003 IDSA Guidelines.14 Other potential barriers for the 2005 ATS/IDSA Guidelines is the belief that the practice recommendations might not be feasible or beneficial to the nursing home population. The use of combination therapy with broad-spectrum antibiotics, as dictated by the guidelines, requires intravenous access and possibly a prolonged hospital stay. Many studies have documented that such prolonged hospitalization might be associated with decline in physical and cognitive function in these frail elderly, in addition to a higher rate of adverse events including morbidity and mortality.26–28 Lack of proven efficacy or outcome expectancy is also an important barrier to adherence to the 2005 ATS/IDSA Guidelines according to 55% of the physicians in our survey. Others reported similar rates of physicians’ lack of outcome expectancy regarding guideline adherence.17 Feedback and audit to demonstrate the positive outcomes of guideline adherence have previously been described as useful interventions to deal with low outcome expectancy of physicians.29 Unfortunately, the impact of the 2005 ATS/IDSA Guidelines on clinical outcome measures of NHAP such as time to clinical stability, length of hospital stay, and overall mortality has not been rigorously investigated. There is only one retrospective study that examined the outcomes of 334 cases of hospitalized NHAP based on the treatment they have received. Interestingly, treatment with an antibiotic regimen according to the 2005 ATS/IDSA Guidelines achieved comparable time to clinical stability and inhospital and 30-day mortality with a regimen based on the 2003 community-acquired pneumonia guideline.30 Our study had several strengths. The response rate was relatively high, which is probably attributable to the relevance of this topic among practitioners. Moreover, our questionnaire was based on a comprehensive conceptual framework, which takes into account the different categories of factors known to impact on guideline dissemination and uptake.31,32 Limitations of this study include the fact that physicians’ attitudes toward guidelines is a complex behavior influenced by many factors that cannot be easily captured through responses to a written survey. Additionally, our study results may not be generalizable to other organizations or practitioners. It is difficult to compare our findings with others, since no studies have explored the relation between physicians’ characteristics and attitudes toward NHAP guidelines. In summary, we have found that although most physicians have positive attitudes toward clinical practice guidelines, they had a less enthusiastic attitude toward the 2005 ATS/ IDSA Guidelines. Our study points to the importance of ORIGINAL STUDIES

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