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Involving medical opinion leaders increases adherence to guidelines
EV ID E NCE- B ASED HE AL THCA RE MA NAGEME NT
Involving medical opinion leaders increases adherence to guidelines Abstracted from: Soumerai SB, McLaughlin TJ, Gurwitz JH, et al. Effect of local medical opinion leaders on quality of care for acute myocardial infarction. JAMA 1998;29:1358d1363
BACKGROUND Providing feedback alone to hospitals may not be sufficient to improve clinical practice. Involving medical opinion leaders directly in quality improvement projects might lead to better results. However, there has only been one randomized trial evaluating the ability of medical opinion leaders to change physicians’ behaviour. OBJECTIVE To determine whether medical opinion leaders can increase adherence to guidelines about use of drugs in patients with acute myocardial infraction (AMI).
Pre-intervention data were collected for the year prior to the intervention, and post-intervention data were collected for a year starting six months following randomization. LITERATURE REVIEW None stated; 44 references. OUTCOMES Baseline data and observational studies suggested that aspirin, beta-blockers, and thrombolytics (for the elderly) were underused and lidocaine overused in AMI patients. The outcome measure was change in the use of these drugs, consistent with the ACC/AHA guidelines, over the study period.
SETTING Thirty-seven hospitals in Minnesota. METHOD Randomized controlled trial, with randomization occurring at the hospital level. Medical opinion leaders were identified at treatment hospitals by surveying all cardiologists at these hospitals. Opinion leaders attended a one-day meeting at which American College of Cardiology (ACC) and American Heart Association (AHA) guidelines and the results of trials involving the use of drugs for AMI patients were discussed. Opinion leaders were also provided with feedback and educational materials regarding the appropriate use of drugs. Control hospitals were provided with feedback comparing use of drugs across hospitals, consistent with standard practice among the group of hospitals studied, but were not provided with any additional materials or communications. Data were collected by cardiac nurses from AMI patients’ charts.
Commentary It is reassuring when the results of a randomized control trial support the ‘gut feeling’ that doctors listen to respected peers. However, if recent clinical experience suggests otherwise, studies of large numbers of patients continue to take second place to that experience. Perhaps less reassuring is the amount of human and financial resource that needs to go into bringing about small change. However, this study adds to the increasing evidence to suggest that clinical guidelines supported by local opinion leaders can improve clinical care. It is salutary to note that
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Evidence-based Healthcare (1999) 3, 18
RESULTS Use of beta-blockers and aspirin increased in treatment hospitals relative to controls over the study period. Use of thrombolytics, however, was not affected by the intervention. Post-study discussions with cardiologists suggested that they were reluctant to use these drugs in frail, elderly patients, and that underuse of thrombolytics may not be as widespread as commonly believed. Overall, 73% of eligible elderly patients received thrombolytics. Use of lidocaine declined significantly at both treatment and control hospitals. AUTHORS’ CONCLUSIONS Medical opinion leaders can influence the behaviour of their peers, and be easily identified. When there is clear consensus regarding appropriate treatment, opinion leaders should be involved in quality improvement efforts.
given the careful design of this randomized control trial, one still gets the impression of looking into a black box and trying to tease out which elements really do bring about the change. It is inevitable in this field of health services research that randomized control trials will continue to inform, but never provide definitive answers. Professor Peter Littlejohns Health Care Evaluation Unit St George’s Hospital Medical School London, UK
^ 1999 Harcourt Brace & Co. Ltd
Involving medical opinion leaders increases adherence to guidelines Abstracted from: Soumerai SB, McLaughlin TJ, Gurwitz JH, et al. Effect of local medical opinion leaders on quality of care for acute myocardial infarction. JAMA 1998;29:1358d1363
BACKGROUND Providing feedback alone to hospitals may not be sufficient to improve clinical practice. Involving medical opinion leaders directly in quality improvement projects might lead to better results. However, there has only been one randomized trial evaluating the ability of medical opinion leaders to change physicians’ behaviour. OBJECTIVE To determine whether medical opinion leaders can increase adherence to guidelines about use of drugs in patients with acute myocardial infraction (AMI).
Pre-intervention data were collected for the year prior to the intervention, and post-intervention data were collected for a year starting six months following randomization. LITERATURE REVIEW None stated; 44 references. OUTCOMES Baseline data and observational studies suggested that aspirin, beta-blockers, and thrombolytics (for the elderly) were underused and lidocaine overused in AMI patients. The outcome measure was change in the use of these drugs, consistent with the ACC/AHA guidelines, over the study period.
SETTING Thirty-seven hospitals in Minnesota. METHOD Randomized controlled trial, with randomization occurring at the hospital level. Medical opinion leaders were identified at treatment hospitals by surveying all cardiologists at these hospitals. Opinion leaders attended a one-day meeting at which American College of Cardiology (ACC) and American Heart Association (AHA) guidelines and the results of trials involving the use of drugs for AMI patients were discussed. Opinion leaders were also provided with feedback and educational materials regarding the appropriate use of drugs. Control hospitals were provided with feedback comparing use of drugs across hospitals, consistent with standard practice among the group of hospitals studied, but were not provided with any additional materials or communications. Data were collected by cardiac nurses from AMI patients’ charts.
Commentary It is reassuring when the results of a randomized control trial support the ‘gut feeling’ that doctors listen to respected peers. However, if recent clinical experience suggests otherwise, studies of large numbers of patients continue to take second place to that experience. Perhaps less reassuring is the amount of human and financial resource that needs to go into bringing about small change. However, this study adds to the increasing evidence to suggest that clinical guidelines supported by local opinion leaders can improve clinical care. It is salutary to note that
18
Evidence-based Healthcare (1999) 3, 18
RESULTS Use of beta-blockers and aspirin increased in treatment hospitals relative to controls over the study period. Use of thrombolytics, however, was not affected by the intervention. Post-study discussions with cardiologists suggested that they were reluctant to use these drugs in frail, elderly patients, and that underuse of thrombolytics may not be as widespread as commonly believed. Overall, 73% of eligible elderly patients received thrombolytics. Use of lidocaine declined significantly at both treatment and control hospitals. AUTHORS’ CONCLUSIONS Medical opinion leaders can influence the behaviour of their peers, and be easily identified. When there is clear consensus regarding appropriate treatment, opinion leaders should be involved in quality improvement efforts.
given the careful design of this randomized control trial, one still gets the impression of looking into a black box and trying to tease out which elements really do bring about the change. It is inevitable in this field of health services research that randomized control trials will continue to inform, but never provide definitive answers. Professor Peter Littlejohns Health Care Evaluation Unit St George’s Hospital Medical School London, UK
^ 1999 Harcourt Brace & Co. Ltd