Increased use of beta-blockers after acute myocardial infarction

Abstract

We thank Kizer and colleagues for emphasizing the message of our study, that guidelines, when appropriately implemented and locally adapted, are effective in modifying prescription patterns. These comments are welcome since the authors have much experience using clinical guidelines to improve the quality of care within a large health care organization, and since the results that they achieved are quite impressive. There is no single way to ensure the effective use of guidelines in everyday practice; therefore, organizations must use multifaceted interventions (1Thomson R. Lavender M. Madhok R. How to ensure that guidelines are effective.BMJ. 1995; 311: 237-242Crossref PubMed Scopus (163) Google Scholar, 2Grol R. Personal paper beliefs and evidence in changing clinical practice.BMJ. 1997; 315: 418-421Crossref PubMed Scopus (650) Google Scholar). The choice of strategies should be informed by the characteristics (size and complexity) of the organization, available resources, perceived barriers to care, and evidence about the effectiveness and efficiency of different strategies (3Feder C. Eccles M. Grol R. et al.Using clinical guidelines.BMJ. 1999; 318: 728-730Crossref PubMed Scopus (300) Google Scholar). The best available evidence comes from systematic reviews of rigorous evaluations of dissemination and implementation strategies, such as those by the Cochrane Effective Practice and Organization of Care Group, which has reviewed interventions designed to improve quality of care, including professional interventions (continuing medical education, audit and feedback, reminders), organizational interventions (eg, the expanded role of pharmacists), financial interventions (eg, professional incentives), and regulatory interventions (4The Cochrane Effective Practice and Organization of Care Review Group. The Cochrane database of systematic reviews. Issue 3. In: Bero L, Grilli R, Grimshaw JM, Osman AD, eds. Oxford: Update Software; 1998.Google Scholar). Various professional and organizational strategies can be used to overcome different barriers. For example, educational approaches may be appropriate when barriers are due to lack of knowledge, whereas audits may be useful when health care professionals are unaware of suboptimal practices. Reminders and patient-mediated interventions may be useful when health care professionals have problems processing information within consultations, and comparative feedback on performance (as underlined by Kizer and colleagues) may be a valuable stimulus to change, preferably if linked to the cyclical process of audit, with implementation of changes and subsequent review. Like Kizer and colleagues, we believe that the potential for guidelines to influence the quality of patient care is considerable, particularly when they are accompanied by evidence-based development, implementation, and evaluation strategies, and an overall culture of continuous quality improvement.