Abstract
The effectiveness of recruiting local medical opinion leaders to improve quality of care is poorly understood. To evaluate a guideline-implementation intervention of clinician education by local opinion leaders and performance feedback to (1) increase use of lifesaving drugs (aspirin and thrombolytics in eligible elderly patients, beta-blockers in all eligible patients) for acute myocardial infarction (AMI), and (2) decrease use of a potentially harmful therapy (prophylactic lidocaine). Randomized controlled trial with hospital as the unit of randomization, intervention, and analysis. Thirty-seven community hospitals in Minnesota. All patients with AMI admitted to study hospitals over 10 months before (1992-1993, N=2409) or after (1995-1996, N=2938) the intervention. Using a validated survey, we identified opinion leaders at 20 experimental hospitals who influenced peers through small and large group discussions, informal consultations, and revisions of protocols and clinical pathways. They focused on (1) evidence (drug efficacy), (2) comparative performance, and (3) barriers to change. Control hospitals received mailed performance feedback. Hospital-specific changes before and after the intervention in the proportion of eligible patients receiving each study drug. Among experimental hospitals, the median change in the proportion of eligible elderly patients receiving aspirin was +0.13 (17% increase from 0.77 at baseline), compared with a change of -0.03 at control hospitals (P=.04). For beta-blockers, the respective changes were +0.31 (63% increase from 0.49 at baseline) vs +0.18 (30% increase from baseline) for controls (P=.02). Lidocaine use declined by about 50% in both groups. The intervention did not increase thrombolysis in the elderly (from 0.73 at baseline), but nearly two thirds of eligible nonrecipients were older than 85 years, had severe comorbidities, or presented after at least 6 hours. Working with opinion leaders and providing performance feedback can accelerate adoption of some beneficial AMI therapies (eg, aspirin, beta-blockers). Secular changes in knowledge and hospital protocols may extinguish outdated practices (eg, prophylactic lidocaine). However, it is more difficult to increase use of effective but riskier treatments (eg, thrombolysis) for frail elderly patients.
Highlights
Context.—The effectiveness of recruiting local medical opinion leaders to improve quality of care is poorly understood
Results.—Among experimental hospitals, the median change in the proportion of eligible elderly patients receiving aspirin was +0.13 (17% increase from 0.77 at baseline), compared with a change of −0.03 at control hospitals (P =.04)
Our previous report of baseline data at the 37 hospitals participating in this study indicated that only 53% of eligible patients received bblockers
Summary
Opinion leaders are not necessarily innovators or authority figures, but are trusted by their colleagues to evaluate new information and assess the value of new medical practices in the context of local group norms[3]; are approached frequently for clinical advice; have good listening skills[4]; and are perceived as clinically competent and caring.[5] Many researchers and policymakers advocate recruitingopinionleadersinongoingquality improvement efforts, in part because of the potential efficiency of capitalizing on local volunteers skilled in changing practice patterns.[6] Yet, evidence supporting such interventions is limited,[4,7,8] including only 1 randomized controlled trial (RCT). We sought to increase adherence to the national (American College of Cardiology/American Heart Association [ACC/AHA]) guidelines recommending (1) increased use of highly effective drugs for eligible AMI patients, ie, b-blockers in all patients and aspirin and thrombolysis in the elderly, and (2) reduced use of an ineffective treatment, ie, prophylactic lidocaine. Institutes of Health and Harvard Medical School because it used chart reviews to evaluate educational activities aimed at increasing adherence to accepted standards of care
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