The management of patients with pneumonia in family medicine in Slovenia 139 IzvIrnI znanstvenI članek The management of patients with pneumonia in family medicine in Slovenia Obravnava bolnikov s pljučnico v družinski medicini v Sloveniji Aljaž Brlek, Ernestina Bedek Izvleček Izhodišče: Pljučnica je ena najpogostejših okužb obravnavanih v ambulantah družinske medici- ne. V Sloveniji celotna obravnava pljučnice na primarnem nivoju še ni bila raziskana in zato po - datkov glede upoštevanja smernic še ni. Naš namen je bil opisati obravnavo bolnikov s pljučnico v ambulantah družinske medicine in analizirati značilnosti zdravnikov in njihovih ambulant, ki vplivajo na upoštevanje smernic. Metode: Raziskavo smo izvedli kot presečno raziskavo, in sicer s pomočjo klinične vinjete in vprašanj o lastnostih zdravnikov ter njihovih ambulant v obliki spletne ankete. Kontaktirali smo 892 specialistov in zdravnikov brez specializacije ter 320 specializantov. S pomočjo smernic smo oblikovali protokol ustrezne obravnave bolnikov s pljučnico, na podlagi katerega smo vrednotili ustreznost odgovorov. Zbrane podatke smo analizirali z logistično regresijo. Rezultati: Stopnja odziva je bila 475/1212 (39,2 %). V obravnavi bolnika s pljučnico je 66,7 % zdravnikov naredilo diferencialno krvno sliko, 92,6 % CRP , 54,5 % RTG PC; 62,6 % predpisalo amoksicilin in 29,7 % amoksicilin s klavulansko kislino. Ustrezno delovno diagnozo pljučnice je postavilo 93,7 % zdravnikov, ustrezno diagnostiko 13,5 %, brez napotitve h kliničnim specialis- tom 90,3 %, ustrezno zdravljenje 53,1 % in ustrezen predpis kontrole 48,8 % zdravnikov. V celoti je bolnika s pljučnico ustrezno obravnavalo 3,2 % zdravnikov. Zaznali smo negativno povezavo med ženskim spolom in ustrezno diagnostiko ter med zdravniki, starejšimi od 45 let, in ustreznim zdravljenjem oziroma naročanjem na kontrolo. Zaključek: Z raziskavo smo prikazali številne razlike v obravnavi pljučnice. Ugotovili smo, da je le majhen delež zdravnikov predstavljenega bolnika v celoti obravnaval v skladu s smernicami. Abstract Background: Pneumonia is among the most common infections treated in family practice. In Slovenia, a comprehensive management of pneumonia at the primary level has not yet been re - searched, which results in the lack of data regarding guideline adherence. Our aim was to descri- be the management of patients with pneumonia in family practices and to analyse characteristi- cs of family physicians (FPs) and their practices which influence guideline adherence. Methods: The study was conducted as a cross-sectional research with clinical vignette and qu- estions about characteristics of FPs and their practices, in the form of an online questionnaire; 892 specialists and FPs without specialty, and 320 residents were contacted. Using the guideli- nes, a proper management protocol for patients with pneumonia was designed and used for the evaluation of respondents’ answers. The collected data were analyzed using logistic regression. Results: The response rate was 475/1212 (39.2 %). When managing patients with pneumonia, 66.7 % of FPs performed a complete blood count with differential, 92.6 % CRP , 54.5 % chest X-ray, 62.6 % prescribed amoxicillin and 29.7 % amoxicillin with clavulanic acid. The correct prelimina- ry diagnosis was provided by 93.7 % of FPs, correct diagnostics by 13.5 %, no referral by 90.3 %, Department of Family Medicine, Faculty of Medicine, University of Maribor, Maribor, Slovenia Korespondenca/ Correspondence: aljaž Brlek, e: aljaz. brlek.93@gmail.com Ključne besede: družinska medicina; pljučnica; upoštevanje kliničnih smernic; na dokazih temelječa praksa; obravnava primera Key words: family practice; pneumonia; guideline adherence; evidence- based practice; case management Prispelo: 23. 3. 2019 Sprejeto: 23. 9. 2019 @publisher.id: 2939 @primary-language: sl, en @discipline-en: Microbiology and immunology, Stomatology, Neurobiology, Oncology, Human reproduction, Cardiovascular system, Metabolic and hormonal disorders, Public health (occupational medicine), Psychiatry @discipline-sl: Mikrobiologija in imunologija, s tomatologija, nevrobiologija, Onkologija, r eprodukcija človeka, srce in ožilje, Metabolne in hormonske motnje, Javno zdravstvo (varstvo pri delu), Psihiatrija @article-type-en: Editorial, Original scientific article, Review article, Short scientific article, Professional article @article-type-sl: Uvodnik, Izvirni znanstveni članek, Pregledni znanstveni članek, klinični primer, strokovni članek @running-header: The management of patients with pneumonia in family medicine in Slovenia @reference-sl: z drav vestn | marec – april 2020 | l etnik 89 @reference-en: z drav vestn | March – april 2020 | volume 89 140 z drav vestn | marec – april 2020 | l etnik 89 JavnO zdravstv O (varstv O PrI del U) proper treatment by 53.1 % and checkup by 48.8 % of FPs. 3.2 % of FPs exhibited an altogether adequate patient management. Negative association between female FPs and adequate diagno- stics, and between FPs older than 45 years and adequate treatment and checkup was noticed. Conclusion: The research indicated many differences in managing pneumonia. Only a small share of FPs completely adhered to the set guidelines. Citirajte kot/Cite as: aljaž Brlek, ernestina Bedek. the management of patients with pneumonia in family medicine in slovenia. z drav vestn. 2020;89(3–4):139–48. DOI: 10.6016/z dravvestn.2939 1 Background Clinical guidelines can be defined as systematically developed views whi‑ ch help family physicians (FPs) and patients select proper medical care in specific clinical circumstances (1,2). The guidelines’ additional purpose is to abolish unnecessary and unfoun‑ ded differences in medical practice and to improve the quality of medical care (2,3). Despite the growing num ‑ ber of guidelines, their use in clinical practice is often unpredictable, slow and complex (2). Adhering to clinical guidelines in family practice is speci‑ fic because guidelines are mostly de‑ signed for treating individual diseases and are based on evidence obtained at a secondary or tertiary level. However, an increasing amount of research is showing that regulations aimed at the disease are less useful for multimorbid patients, who require a comprehensive approach (4‑6). Several studies show that in family practices clinical guidelines are relatively poorly adhered to (7‑14). The studies also show the differences and discrepancies when dealing with pneumonia (15‑22), and differences among countries. Since studies mostly focus on certain aspects of the management (e. g. antibiotic tre‑ atment), the comprehensive manage‑ ment is rarely presented. In Slovenia, a comprehensive management of pneu‑ monia on the primary level has not yet been researched on an adequate sample of FPs in family practices, which results in a lack of data regarding guideline ad‑ herence. The aim of this study was to assess a comprehensive management of a patient with pneumonia in family practice. We also wanted to detect possible differen‑ ces in the management, to what extent does it adhere to the guidelines, and seek possible associations between the chara‑ cteristics of FPs and their practices and their decisions during patient manage‑ ment. 2 Methods and material 2.1 Study design and settings The study was designed as a cross‑ ‑sectional research with clinical vig‑ nette in the form of an online questi‑ onnaire, including family practices across Slovenia (1). For the online qu‑ estionnaire, 1KA service by Centre for Social Informatics at the Faculty of Social Sciences, University of Ljubljana, was used. Consent was obtained from the Medical Ethics Committee of the University Medical Centre Maribor (UKC‑MB‑KME‑33/17). The management of patients with pneumonia in family medicine in Slovenia 141 IzvIrnI znanstvenI članek 2.2 Data collection The first part of the online questio‑ nnaire provided data regarding the cha‑ racteristics of FPs and their practices. The second part included clinical vig‑ nette with the description of a patient case, followed by questions on how the respondent would manage the patient during the first visit The questionnaire and clinical vig‑ nette were designed based on literature and both foreign and Slovenian guideli‑ nes. Some questions were open‑ended while others provided options respon‑ dents could choose from, as well as add an additional answer. We were interested in their preliminary diagnosis, medical tests performed, referral to specialists, non‑ pharmacological treatment, phar‑ macological treatment, the duration of sick leave and the intended checkup. The questionnaire was tested beforehand on five FPs (1). 2.3 Participants The aim was to include all FPs wor‑ king in family practices (family medicine specialists, general medicine specialists, family practice residents, and physici‑ ans without specialty). To that end, FPs (except residents) included in the List of active physicians in general medical pra- ctices, child and school dispensaries from February 28, 2017 and published on April 12, 2017 on the Health Insurance Institute of Slovenia’s web page were contacted. From it, only FPs who work in the abo‑ ve‑mentioned specialised practices were considered. Then individual FPs’ freely accessible online contact information was found. Firstly, they were contacted via telephone and after they agreed to participate, they were sent an e‑mail with the link to the questionnaire. One week later, they received a reminder. On the other hand, some residents were conta‑ cted at random by calling the specialists’ practices, and others via Young doctors’ and The Medical Chamber of Slovenia’s e‑mail databases. Residents received two e‑mails inviting them to cooperation via each of the lists. There were 892 specialists and FPs without specialty contacted; 642 di‑ rectly agreed to participate, 104 did not respond or replied that they have yet to decide, 15 were absent due to maternity leave, longer sick leave or retired, and 131 declined to cooperate. All residents who were contacted directly (12 residents) accepted the invitation for cooperation. All others agreed to cooperate after they had received an e‑mail through Young doctors or The Medical Chamber of Slovenia’s databases. 2.4 Proper patient management protocol The characteristics of FPs as inde‑ pendent variables were: gender, age, specialty, days of professional training in the past year, population of the pla‑ ce where the FP’s practice is located, pe‑ riod of employment in family practice, work status, number of registered pati‑ ents, number of patients treated per day, number of home visits per week, num‑ ber of phone consultations per day, we‑ ekly working hours, the necessity for a checkup, teaching at the faculty and re‑ search work. For statistical analysis, the characteristics were put into logical gro‑ ups. Specialty, period of employment in family medicine and work status were in collinearity with age and were excluded from the model. Information from clinical vignette re‑ presented dependable variables, which served as a basis for proper management protocol development. 142 z drav vestn | marec – april 2020 | l etnik 89 JavnO zdravstv O (varstv O PrI del U) A proper management of an outpati‑ ent case of pneumonia without risk fa‑ ctors should include the following: 1. Correct preliminary diagnosis: pneu‑ monia. 2. Adequate diagnostics: CRP and/or chest X‑ray or no medical tests what‑ soever. Other tests excluded proper diagnostics (23). 3. No referral to clinical specialists (23). 4. Adequate treatment: an antibiotic therapy with penicillin V or amoxi‑ cillin in the duration of 7–10 days was considered a proper pharmaco‑ logical treatment. Prescribing diffe‑ rent antibiotics was not consistent with adequate treatment, while other medications prescribed and non‑p‑ harmacological advices had no effect on the adequacy of patient manage‑ ment (23). 5. Timely checkup (2–3 days) (23). 6. Respondents who have selected CRP and chest X‑ray were directed to the next page containing the findings im‑ plicating pneumonia. Adequacy of a preliminary diagno‑ sis, referral to a clinical specialist and comprehensive management were not compared to the characteristics of FPs, because inadequate preliminary diagno‑ sis, referral to a clinical specialist and adequate comprehensive management were rare and amounted to less than 10 %. 2.5 Statistical analysis Results were analysed using multiva‑ riable logistic regression and presented with odds ratio (OR) with a confidence interval (CI) of 95 %. For the purpose of a regression analysis, characteristics of FPs were arranged into groups. Cramer’s V coefficient was used to evaluate the strength of collinearity between the nominal independent characteristics. Coefficient strength above 0.5 was consi‑ dered as the threshold for collinearity. Statistical analysis was performed using IBM SPSS Statistics software for Windows, version 22.0 (IBM Corp., Armonk, N.Y., USA). To account mul‑ tiple testing bias, p < 0.001 was conside‑ red statistically significant. 3 Results 3.1 Characteristics of FPs A total of 475 FPs filled out the questi‑ onnaire. The response rate for specialists and FPs without specialty was 423/892 (47 .4 %) and for residents 52/320 (16.3 %), in total 475/1212 (39.2 %). The analysis did not show statistically relevant di‑ fferences regarding age (p = 0.152), gen‑ der (p = 0.994), regional distribution (p = 0,286) and status (p = 0.091) betwe‑ en the population of all active FPs in fa‑ mily practices and the subgroup of FPs in this study. The average age of participants was 45.5 years (SD 11.1; with a range betwe‑ en 26 and 74 years), and 120 (25.3 %) of them were male. Regarding specialty, there were 267 (56.2 %) family medicine specialists, 134 (28.2 %) general medicine specialists, 52 (10.9 %) family medicine residents and 22 (4.6 %) physicians without specialty. A total of 336 (70.7 %) worked in a public institution, 113 (23.8 %) were concessio‑ naires and 26 (5.5 %) were employed by a concessionaire. Regarding population, results show that 89 (18.7 %) FPs worked in a pla‑ ce with population under 5,000; 98 (20.6 %) with 5,000–9,999; 189 (39.8 %) with 10,000–49,999 and 99 (20.8 %) in a place with ≥ 50,000 inhabitants. An ave‑ rage number of patients in the practice was 1,862.9 (SD 545.9; range 0–3400). In The management of patients with pneumonia in family medicine in Slovenia 143 IzvIrnI znanstvenI članek regard to total amount of work (in pra‑ ctice plus overtime), 47.6 % of FPs wor‑ ked over 42 hours weekly. On average, they treated 49.7 patients daily (SD 12.8; range 2–100), while 122 (25.7 %) FPs tre‑ ated ≥ 60 patients daily. In the last year, 177 (37.3 %) FPs had 1–5 days of professional training, 239 (50.3 %) 6–10 and 59 (12.4) more than 10 days. 3.2 Patient management Correct preliminary diagnosis (pne‑ umonia) was provided by 445 (93.7 %) FPs. The stipulated diagnostics, referrals and non‑pharmacological treatment are shown in Table 1 . Results showed that the more populated the place where an FP works, the higher the number of prescri‑ bed X‑rays. In the group with a popula‑ tion under 5,000, 43.8 % of FPs ordered it, in the group with a population betwe‑ en 5,000–10,000 49.0 %, in the group between 10,000–50,000 59,8 % and in the group with a population ≥ 50,000 59.6 %. Sixty‑four (13.5 %) of FPs per‑ formed correct diagnostic tests. Female gender (OR = 0.36; 95 % CI = 0.20–0.66; p < 0.001) was negatively associated with adequate diagnostic procedure (2). Characteristics of FPs as independent variables thus explained 20.1 % of vari‑ ance regarding adequate diagnostic pro‑ cedure. One medication was prescribed by 90 (18.9 %) FPs, 306 (64.4 %) prescribed two, 70 (14.7 %) three, 5 (1.1 %) four, and 4 (0.8 %) no medications. Most often prescribed were amoxicillin and parace‑ tamol (Table 2 ). 466 (98.1 %) FPs prescri‑ bed one of the antibiotics. Out of all FPs who prescribed antibi‑ otic treatment (466), 22 (4.7 %) instru‑ cted the patient to take it for less than 7 days (including both FPs who prescri‑ Table 1: Stipulated diagnostics, referrals and non-pharmacological treatment of a patient with pneumonia by 475 FPs who work in family practices in Slovenia (2017–2018). Diagnostic tests Referral to a clinical specialist Non-pharmacological treatment No tests (28; 5.9%) No referral (429; 90.3%) No advice (23; 4.8%) CRP (440; 92.6%) Internist/pulmonologist (44; 9.3%) Hydration (404; 85.1%) Complete blood count with differential (317; 66.7%) Infectious disease specialist (3; 0.6%) Rest (397; 83.6%) Chest X-ray (259; 54.5%) Quit smoking (57; 12%) Complete blood count (94; 19.8%) Respirational physiotherapy (34; 7.2%) Erythrocyte sedimentation (ESR) (36; 7.6%) Adjusted nutrition (28; 5.9%) Other (6; 1.3%) Inhalations of water vapour or physiological solution (16; 3.4%) Epidemiological instructions (12; 2.5%) Monitoring of vital signs (8; 1.7%) Non-pharmacological lowering of body temperature (5; 1.1%) Other (4; 0.8%) 144 z drav vestn | marec – april 2020 | l etnik 89 JavnO zdravstv O (varstv O PrI del U) bed azithromycin for the duration of 3–5 days), 420 (90.1 %) prescribed it for 7–10 days, 21 (4.5 %) for more than 10 days, and 3 (0.6 %) gave other instructions. Adequate (pharmacological and non‑ ‑pharmacological) treatment of pne‑ umonia was prescribed by 252 (53.1 %) FPs. FPs older than 45 years (OR = 0.31; 95 % CI = 0.20–0.48; p < 0.001) were less likely to perform an adequate tre‑ atment (3) 15.7 % of FPs younger than 45 years and 43.5 % of FPs older than 45 years prescribed amoxicillin with cla‑ vulanic acid. Characteristics of FPs as independent variables thus explained 19.8 % of variance in adequate treatment. The majority of FPs would have prescribed 7–10 days of sick leave and a checkup after 2–3 days ( Table 3 ). 232 (48.8 %) FPs ordered an adequate chec‑ kup. FPs older than 45 years (OR = 0.48; 95 % CI = 0.31–0.75; p < 0.001) were less likely to perform an adequate chec‑ kup (4) Characteristics of FPs as inde‑ pendent variables thus explain 14.8 % of variance in adequate checkup order. An altogether adequate management of a patient with pneumonia was carried out by 15 (3.2 %) FPs. 4 Discussion Our study showed that only a mino‑ rity of FPs completely adhered to the guidelines. Numerous differences were noticed. It was estimated that in the majo‑ rity of cases this would have no negative consequences for the patient, but it wou‑ ld result in a non‑optimal management in terms of excessive tests and referrals, Table 2: Medications that were prescribed by 475 FPs working in family practices in Slovenia for the treatment of patients with pneumonia (2017–2018). A group of prescribed medications (number and % of FPs) Generic name (number and % of FPs) Antibiotic (466; 98.1 %) Amoxicillin (297; 62.6 %) Amoxicillin with clavulanic acid (141; 29.7 %) Penicillin (10; 2.1 %) Ampicillin (10; 2.1 %) Clarithromycin (3; 0.6 %) Moxifloxacin (3; 0.6 %) Azithromycin (2; 0.4 %) Anti-pyretic /analgesic (368; 77.5 %) Paracetamol (349; 73.5 %) Unidentified anti-pyretic (13; 2.7 %) Naproxen (3; 0.6 %) Ibuprofen (2; 0.4 %) Metamizole (1; 0.2 %) Expectorant /cough syrup/mucolytic (72; 15.2 %) Acetylcysteine, bromhexine, ambroxol Bronchodilator (16; 3.4 %) Salbutamol, fenoterol and ipatropium bromide Antitussive (6; 1.3 %) Butamirate or undefined Other (2; 0.4 %) The management of patients with pneumonia in family medicine in Slovenia 145 IzvIrnI znanstvenI članek improper prescription of antibiotics and non‑ pharmacological treatment, durati‑ on of sick leave and checkups. Ordering a complete blood count with or without differential was the main deviation from the guidelines. We have noticed a nega‑ tive association between female FPs and adequate diagnostics, and more impor‑ tantly, between FPs older than 45 years and adequate treatment and adequate checkup. The Slovenian guidelines for the management of outpatient pneumonia without risk factors in patients younger than 65 years state CRP and/or chest X‑ray as diagnostic tools. The same is ad‑ vised by the European and British guide‑ lines (23‑25). These tests are not strictly necessary if the FP is certain – based on clinical status – that the patient suffers from pneumonia (23‑26). The European guidelines advise performing CRP and only in ambiguous cases an additional chest X‑ray (24). This corresponds to our data. CRP was the test used most of‑ ten (92.6 %), which could indicate its good availability in family practices and the ambition of FPs to distinguish between acute bronchi‑ tis and pneumonia. This matches data from Denmark and differs from Spanish data where X‑ray is used most often (15). Frequently, FPs ordered a complete blo‑ od count or complete blood count with differential, which is not recommen‑ ded by guidelines unless the patient is older than 65 or has additional risk factors (23,25). That was the main rea‑ son why diagnostic tests were rarely in accordance with the guidelines. Other studies showed that FPs in European countries ordered chest X‑ray more frequently than in our study (16,17). The association between the population size in the place where FPs work and between the number of ordered chest X‑rays could be explained by easier access to the procedure in bigger cities, but this has not yet been studied (15‑17). The literature provides a few general guidelines regarding proper non‑ phar‑ macological treatment of pneumonia (rest, increased liquid intake, omission of smoking, monitoring one’s wellbeing, measuring vital signs), but not enough to establish proper and improper com‑ binations (23,25). FPs rarely prescribed monitoring of vital signs (1.7 %), which is specifically mentioned in the guide‑ lines (23,25). Studies investigating non ‑ ‑pharmacological treatment were not found, indicating the lack of literature regarding the effectiveness of such advi‑ ces. Proper antibiotic therapy depends on the regional resistance of pneumococcus to penicillin. With that in mind, mostly the Slovenian guidelines were conside‑ red; they match Great Britain’s, but differ significantly from America’s (23,25,27). FPs in our study mostly prescribed amoxicillin as a correct and amoxicil‑ lin with clavulanic acid as an incorrect antibiotic, which matches data from two French studies (16 ,18). Rarely prescri ‑ bed macrolides are in contrast with data from Italy, where FPs more often prescribe cephalosporins and macroli‑ des. It is worth mentioning that except in one study (18) data from those studies Table 3: Stipulated duration of sick leave and checkup prescribed by 475 FPs who work in family practices in Slovenia (2017–2018). Duration of sick leave Checkup after <7 days 25 (5.3 %) 2–3 days 232 (48.8 %) 7–10 days 214 (45.1 %) 4–5 days 145 (30.5 %) 11–14 days 141 (29.7 %) >5 days 96 (20.2 %) >14 days 75 (15.8 %) Other 2 (0.4 %) Other 20 (4.2 %) 146 z drav vestn | marec – april 2020 | l etnik 89 JavnO zdravstv O (varstv O PrI del U) are presented jointly for both high‑ and low‑risk patients (16,17). Most FPs prescribed antibiotic tre‑ atment in correct duration, matching the data from the literature (16). Several studies investigated only the use of antibiotics and not accompanying medications (16‑20,28) which should not be ignored since 80.2 % of FPs in our study prescribed more than one medica‑ tion. Regarding additional medications, the guidelines only mention anti‑pyre‑ tics/analgesics (23). There is no suffici‑ ent scientific basis yet for prescribing expectorants, cough syrups, bronchodi‑ lators and mucolytics (29). Proper pharmacological treatment of pneumonia was prescribed by 252 (53.1 %) of FPs. Due to different inclusi‑ on criteria for patients and differences in the strictness of criteria for proper tre‑ atment, it is hard to compare our results to other studies. The main reason for inadequate treatment was the prescripti‑ on of a wrong antibiotic (mostly amoxi‑ cillin with clavulanic acid). All FPs prescribed sick leave, the ma‑ jority (45.1 %) in the duration of 7–10 days, which corresponds to a proper du‑ ration of antibiotic therapy (23). The gu ‑ idelines do not include information re‑ garding sick leave and its duration, which prevents us from evaluating the relevan‑ cy of our findings (23‑25,30). Foreign studies show differences in the duration of sick leave among countries, but they roughly match our results (16,22). The Slovenian guidelines advise pa‑ tient checkup after 2–3 days (23), which corresponds to the British guidelines (af‑ ter 2 days, sooner in case of exacerbati‑ on of the condition) (25). All FPs prescri‑ bed a checkup but approximately half of them too late. In the French study, only 71 % of FPs prescribed a checkup (16). A low percentage of FPs who have managed the patient properly from start to finish (3.2 %) is due to numerous cri‑ teria demanded simultaneously in order for the management to be considered as adequate. Especially noteworthy are the order of a complete blood count with differential, prescription of amoxicillin with clavulanic acid and belated chec‑ kup order. It is estimated that ordering a complete blood count with differen‑ tial does not have a considerable ne‑ gative impact on the quality of patient management but it still increases the expenses. On the other hand, an incor‑ rect prescription of antibiotic is a criti‑ cal deviation since it increases bacteria resistance, along with belated checkup order, which potentially endangers the patient’s health in case of exacerbation of the condition. Ordering more diagno‑ stic tests was also the reason for negative association between female gender and adequate diagnostics. Similarly, FPs ol‑ der than 45 years prescribed amoxicillin with clavulanic acid and belated checkup order more often and were therefore less likely to perform adequate treatment and checkup. We can hypothesize that this is because older FPs are less often vocationally trained, rely more on expe‑ rience or are less familiar with the guide‑ lines (10,12,13). The response rate was relatively high, 475/1212 (39.2 %), and was lowered by po‑ orer response from residents (16.3 %) in‑ vited to participate mainly via the list of e‑mail addresses. According to the data from the Medical Chamber of Slovenia, our study included 35.3 % of all FPs wor‑ king in family practices in Slovenia in 2017/2018, and as many as 44 % of all FPs, excluding residents. The sample of FPs in this study is bigger than in similar studies done in Slovenia before (12,13), and the inclusion of residents presents an additional advantage. The main advantages of this study are the many parameters considered in the The management of patients with pneumonia in family medicine in Slovenia 147 IzvIrnI znanstvenI članek management of pneumonia in family practices. Factors that are otherwise ra‑ rely a subject of studies (referrals, non‑ ‑pharmacological treatment, duration of pharmacological treatment, checkup and sick leave) were included. By using a clinical vignette, all FPs were treating the same patient, allowing us to present differences among individual FPs. A weak point of the research is a low response rate from the residents (16.3 %) which decreases the relevance of the data for this group and the relevance of the comparison between specialists and residents. Secondly, the characteristics of FPs under consideration in our model explain a variance of up to 20 % in the adequacy of management. This means that there are other influencing factors present, which can be subjects of future studies. 5 Conclusion The established great variability in the patient management indicates a need for an improvement in the adherence to the guidelines; possible solutions may be in practice‑oriented education, expert me‑ etings and specially customized guideli‑ nes for family practice. Data from this study can be the ba‑ sis for further research regarding other factors that influence FP’s decisions, rea‑ sons for FPs’ failure to follow guidelines, and for developing customised guideli‑ nes for family practices. 6 Acknowledgments We are sincerely grateful to our men‑ tor, Assoc. Prof Zalika Klemenc‑Ketiš, for all her professional help, guidance, beneficial advice and support in con‑ ducting the research. We are also grate‑ ful to Andreja Basle from the Medical Chamber of Slovenia, who helped us by integrating residents in the research. 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