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


Pneumonia is the sixth leading cause of death in the United States and the number one cause of death from infectious diseases. 1 It has been estimated that 2 million to 4 million cases of community-acquired pneumonia (CAP) occur annually and that up to 20% of these patients require hospitalization.[1] Initial antimicrobial therapy is largely empirical, since the list of potential pathogens in CAP is long and the cause is frequently unknown. In 1993, the American Thoracic Society published guidelines on the initial management of adults with CAP.[2] Despite the availability of guidelines, initial antimicrobial drug selection varies widely among institutions.[3] Although this variation may not negatively influence medical outcomes, it does result in large differences in the cost of antimicrobial therapy.

Intravenous antimicrobials account for a significant proportion of a hospital's total drug expenditures, and many institutions struggle with the issues of excessive and inappropriate use of antimicrobials. As a result, this drug class is a frequent target of costcontainment initiatives.[3,4,5,6,7,8,9,10,11] Considerable research has been directed at evaluating various strategies for changing prescribing behavior.[12,13,14,15,16,17,18,19,20] Although programs utilizing techniques such as automatic stop orders and therapeutic interchanges can be effective, they do little to improve the knowledge base of physicians prescribing these agents.

Data from the Pneumonia Patient Outcomes Research Team (PORT) study suggested that physicians at our tertiary academic medical center used a larger number of antimicrobial agents and more expensive agents than physicians at the other three study sites.[3,a] There were no differences in patients' baseline characteristics, such as age and severity of illness, among these study institutions, and patient outcomes, including mortality and readmission rates, were similar. In view of these findings, we implemented a program for changing antimicrobial prescribing for hospitalized patients with nonsevere CAP through a combination of interventions. A secondary objective was to reduce antimicrobial costs without compromising medical outcomes.