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).
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
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.
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