Effect of Guideline Education on the Attitude Toward Issues in Terms of Adult Community-Acquired Pneumonia and Emphasis of Future Training Programs: A Nationwide Survey for Chinese Physicians in 2018
The Chinese Thoracic Society (CTS) updated the Chinese clinical practice guideline for community-acquired pneumonia (CAP) in adults in 2016. Following this update, a series of guideline training programs were launched nationwide between 2016 and 2017. To evaluate the impact of these training programs and identify existing challenges in CAP management, a national electronic questionnaire survey was conducted among physicians responsible for CAP management from March to July 2018.
The training programs were led by committee members of the Infection Assembly of the CTS and local society leaders. These programs were delivered through on-site seminars and webinars, structured into eight sections and lasting four hours. The training materials were developed by the guideline writing committee, and all lecturers underwent standardization to ensure consistent delivery of content.
The survey questionnaire comprised five sections: personal and practice characteristics, diagnosis and assessment, pathogenic examination and antibiotic treatment, other treatments, and discharge and prevention. The draft questionnaire was reviewed and approved by an expert group from the Infection Assembly of the CTS. The questionnaire was distributed via the Quick Response code on the Questionnaire Star platform.
Participants were recruited from all member hospitals of the Infection Assembly of the CTS and their local alliance hospitals. Eligible physicians who had treated CAP patients were enrolled. Data were exported into Excel or SPSS files and analyzed using SPSS version 23.0. Categorical variables were described using counts and percentages, with univariate analysis performed using the Chi-square test or Fisher exact test. Multivariate logistic regression models were used to assess the efficacy of guideline training, incorporating variables such as receipt of guideline training, hospital grade, teaching status, specialty, and job title.
A total of 6,333 physicians from 32 provincial-level divisions across China participated in the survey. Approximately two-thirds of respondents worked in the developed eastern region. The age and job titles of participants were evenly distributed. Most respondents were from departments of respiratory medicine (77.5%) and emergency departments (7.6%). The majority (71.0%) worked in Grade-A Tertiary hospitals, with 9.4% in Grade-B Tertiary hospitals and 18.3% in Secondary hospitals. Nearly three-quarters (4,640/6,333) of respondents had participated in the 2016 Chinese guideline training programs for adult CAP in 2017.
The survey revealed several positive outcomes from the guideline training programs. There was widespread use of chest imaging for diagnosis, with 77.4% of participants considering chest image changes essential for CAP diagnosis. The use of chest imaging was significantly higher among those who received guideline training. The CURB-65 score (confusion, urea, respiratory rate, blood pressure, age ≥65 years) was preferred by 72.0% of physicians for assessing CAP severity, compared to the Pneumonia Severity Index (PSI; 20.3%) and CRB-65 score (7.7%). The acceptance of the CURB-65 score was independently associated with participation in guideline training.
However, the survey also identified several misunderstandings and gaps in CAP management. A significant proportion of respondents (25%-35%) ignored the evaluation of potential pathogens before initiating empirical therapy, with 35.9% underusing antibiotics covering atypical pathogens for severe CAP. Excessive use of corticosteroids in outpatient settings was observed, with nearly one-third of physicians prescribing corticosteroids for more than half of their patients. Additionally, 57.3% of participants believed that drug availability still influenced the standardized application of antibiotics in China. Over 40% of respondents administered antibiotics for more than seven days despite a good initial response, potentially leading to overtreatment. Misinterpretations of chest imaging results were also noted, with 49.3% incorrectly regarding completely absorbed pulmonary infiltrates as an indication for antibiotic discontinuation and 25.6% as a discharge criterion.
Vaccination education was another area of concern. Nearly 75% of physicians neglected patient education on influenza and pneumococcal vaccines, regardless of their department, region, or work experience. Only 27.0% of respondents routinely recommended influenza vaccines at hospital discharge, and the recommendation rate for pneumococcal vaccines was even lower at 25.4%. This aligns with findings from a European telephone survey, which reported unsatisfactory perception and immunization levels for pneumococcal and influenza vaccines among the population aged 50 years and over.
The survey underscored the importance of appropriate CAP management in improving patient outcomes and reducing bacterial resistance. It demonstrated the effectiveness of guideline training programs in enhancing physicians’ awareness and understanding of CAP management. Similar educational interventions in China have shown that training can effectively correct inappropriate practice habits among physicians. The British Thoracic Society (BTS) has also provided effective strategies for addressing CAP management challenges, such as setting objectives, promoting CAP care bundle projects, and conducting audit programs. These measures could be adapted to address the shortcomings identified in the current survey.
Despite its comprehensive scope, the survey had several limitations. The composition of the respondent population may limit the generalizability of the results, as a majority of participants were from the eastern region and departments of respiratory medicine and emergency rooms, with relatively fewer responses from general practitioners in primary care settings. The lack of data on response rates raises the possibility of non-response bias. Additionally, the questionnaire did not cover some important issues, such as the combined use of antimicrobial drugs, intravenous-to-oral switch conditions, and the management of hyperglycemia associated with corticosteroid use.
In conclusion, the national survey highlighted the positive impact of guideline training programs on Chinese physicians’ attitudes and practices regarding adult CAP management. It also identified significant gaps and misunderstandings that need to be addressed through targeted educational interventions and policy measures. Future training programs should focus on improving the evaluation of potential pathogens, optimizing antibiotic use, enhancing vaccination education, and correcting misinterpretations of diagnostic criteria. By addressing these challenges, it is possible to further improve CAP management and patient outcomes in China.
doi.org/10.1097/CM9.0000000000001117
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