Local Opinion Leaders Research Articles

Successful polio eradication in Uttar Pradesh, India: the pivotal contribution of the Social Mobilization Network, an NGO/UNICEF collaboration

In Uttar Pradesh, India, in response to low routine immunization coverage and ongoing poliovirus circulation, a network of U.S.-based CORE Group member and local nongovernmental organizations partnered with UNICEF, creating the Social Mobilization Network (SMNet). The SMNet's goal was to improve access and reduce family and community resistance to vaccination. The partners trained thousands of mobilizers from high-risk communities to visit households, promote government-run child immunization services, track children's immunization history and encourage vaccination of children missing scheduled vaccinations, and mobilize local opinion leaders. Creative behavior change activities and materials promoted vaccination awareness and safety, household hygiene, sanitation, home diarrheal-disease control, and breastfeeding. Program decision-makers at all levels used household-level data that were aggregated at community and district levels, and senior staff provided rapid feedback and regular capacity-building supervision to field staff. Use of routine project data and targeted research findings offered insights into and informed innovative approaches to overcoming community concerns impacting immunization coverage. While the SMNet worked in the highest-risk, poorly served communities, data suggest that the immunization coverage in SMNet communities was often higher than overall coverage in the district. The partners' organizational and resource differences and complementary technical strengths posed both opportunities and challenges; overcoming them enhanced the partnership's success and contributions.

Implementation of Clinical Practice Guidelines for Ventilator-Associated Pneumonia

Ventilator-associated pneumonia is an important cause of morbidity and mortality in critically ill patients. Evidence-based clinical practice guidelines for the prevention, diagnosis, and treatment of ventilator-associated pneumonia may improve outcomes, but optimal methods to ensure implementation of guidelines in the intensive care unit are unclear. Hence, we determined the effect of educational sessions augmented with reminders, and led by local opinion leaders, as strategies to implement evidence-based ventilator-associated pneumonia guidelines on guideline concordance and ventilator-associated pneumonia rates. Two-year prospective, multicenter, time-series study conducted between June 2007 and December 2009. Eleven ICUs (ten in Canada, one in the United States); five academic and six community ICUs. At each site, 30 adult patients mechanically ventilated >48 hrs were enrolled during four data collection periods (baseline, 6, 15, and 24 months). Guideline recommendations for the prevention, diagnosis, and treatment of ventilator-associated pneumonia were implemented using a multifaceted intervention (education, reminders, local opinion leaders, and implementation teams) directed toward the entire multidisciplinary ICU team. Clinician exposure to the intervention was assessed at 6, 15, and 24 months after the introduction of this intervention. The main outcome measure was aggregate concordance with the 14 ventilator-associated pneumonia guideline recommendations. One thousand three hundred twenty patients were enrolled (330 in each study period). Clinician exposure to the multifaceted intervention was high and increased during the study: 86.7%, 93.3%, 95.8%, (p < .001), as did aggregate concordance (mean [SD]): 50.7% (6.1), 54.4% (7.1), 56.2% (5.9), 58.7% (6.7) (p = .007). Over the study period, ventilator-associated pneumonia rates decreased (events/330 patients): 47 (14.2%), 34 (10.3%), 38 (11.5%), 29 (8.8%) (p = .03). A 2-yr multifaceted intervention to enhance ventilator-associated pneumonia guideline uptake was associated with a significant increase in guideline concordance and a reduction in ventilator-associated pneumonia rates.

Educational interventions for primary healthcare professionals to promote the early diagnosis of cancer: a systematic review

Primary healthcare professionals seem to lack knowledge and skills in the area of diagnosing cancer which may lead to more advanced stage at diagnosis, poorer cancer survival figures and increased morbidity. The aim of this study was to examine the evidence of effectiveness of educational interventions for primary healthcare professionals to promote the early diagnosis of cancer. We searched bibliographic databases, the grey literature and reference lists for randomised controlled trials (RCTs) of educational interventions delivered at an individual clinician and practice level. We found sufficient evidence that interactive education, computerised reminder systems and audit and feedback delivered to clinicians may significantly increase several cancer detection measures in the short term and some evidence that they promote early diagnosis. Whilst educational outreach and local opinion leaders had some effect, formal education alone seemed ineffectual. Certain educational interventions delivered at a clinician as well as at a practice level may promote the early diagnosis of cancer in primary care. There is currently limited evidence for their long-term sustainability and effectiveness.

Applying diffusion theory to destination stakeholder understanding of sustainable tourism development: a case from Thailand

The concept of sustainable tourism development is widely considered to be necessary for successful tourism development, but there is uncertainty over destination stakeholders’ understanding and thus ability to implement the concept. Utilising diffusion theory, this paper explores the diffusion of the sustainable tourism development concept among stakeholders in the tourism destination of Kret Island, Thailand. The primary data collection involved semi-structured, in-depth interviews undertaken with 10 local government authorities and 45 local residents, and data were analysed using content analysis. Interpersonal communication was the key channel for the concept's diffusion, and the involvement of opinion leaders, change agents and social networks in this diffusion was explored. Many local residents were laggards in the diffusion of sustainable tourism development thinking in comparison with local government and local opinion leaders. It is argued that both interpersonal and media communication and the identification of key actors in the community are needed to effectively diffuse sustainable tourism ideas among destination stakeholders. The results validate the use of diffusion theory as a means to understand the transfer of the sustainable tourism development concept among stakeholders, and they also provide information useful for the design of information dissemination programmes.

Clinicians’ Expectations of Web 2.0 as a Mechanism for Knowledge Transfer of Stroke Best Practices

BackgroundHealth professionals are increasingly encouraged to adopt an evidence-based practice to ensure greater efficiency of their services. To promote this practice, several strategies exist: distribution of educational materials, local consensus processes, educational outreach visits, local opinion leaders, and reminders. Despite these strategies, gaps continue to be observed between practice and scientific evidence. Therefore, it is important to implement innovative knowledge transfer strategies that will change health professionals’ practices. Through its interactive capacities, Web 2.0 applications are worth exploring. As an example, virtual communities of practice have already begun to influence professional practice.ObjectiveThis study was initially developed to help design a Web 2.0 platform for health professionals working with stroke patients. The aim was to gain a better understanding of professionals’ perceptions of Web 2.0 before the development of the platform.MethodsA qualitative study following a phenomenological approach was chosen. We conducted individual semi-structured interviews with clinicians and managers. Interview transcripts were subjected to a content analysis.ResultsTwenty-four female clinicians and managers in Quebec, Canada, aged 28-66 participated. Most participants identified knowledge transfer as the most useful outcome of a Web 2.0 platform. Respondents also expressed their need for a user-friendly platform. Accessibility to a computer and the Internet, features of the Web 2.0 platform, user support, technology skills, and previous technological experience were found to influence perceived ease of use and usefulness. Our results show that the perceived lack of time of health professionals has an influence on perceived behavioral intention to use it despite favorable perception of the usefulness of the Web 2.0 platform.ConclusionsIn conclusion, female health professionals in Quebec believe that Web 2.0 may be a useful mechanism for knowledge transfer. However, lack of time and lack of technological skills may limit their use of a future Web 2.0 platform. Further studies are required with other populations and in other regions to confirm these findings.

What factors influence the provision of preventive care by general dental practitioners?

What factors influence a general dental practitioner to offer preventive care to patients? A potential answer to this question is presented based on the findings of a qualitative study recently undertaken in general dental practice in Australia. A model of how practices come to be oriented towards preventive or restorative care is described, condensing all of the findings of the study into a single framework. Eight practices were studied and highlighted the interaction between two factors: leadership in practice and prioritisation of cultural, social and economic resources. In this model, dentists' leadership to reorient the prioritisation of resources towards preventive care was crucial. Ideally a whole practice changed to preventive philosophy, but change was also possible in a single dentist within a practice. Prioritisation of resources was also key and interacted with dentist leadership. Prioritisation could be seen in the reorganisation of space, routines and fee schedules. During this process, one key support factor for dentists was their external networks of trusted peers and respected practicing dentists. These peers were crucial for transferring preventive knowledge within small networks of dentists who trusted one another; their influence was reportedly more important than centrally produced guidelines or academic advice. In order to help dentists change their practices towards preventive care, the findings from our study suggest that it is important to intervene in these local networks by identifying local dental opinion leaders. During this study, the key conditions needed for practices to reorient to preventive care included the presence of a committed leader with a prevention-supportive peer network, and the reorientation of space, routines and fee schedules to support preventive practice.

Implementing the MOVE! Weight-Management Program in the Veterans Health Administration, 2007-2010: A Qualitative Study

One-third of US veterans receiving care at Veterans Health Administration (VHA) medical facilities are obese and, therefore, at higher risk for developing multiple chronic diseases. To address this problem, the VHA designed and nationally disseminated an evidence-based weight-management program (MOVE!). The objective of this study was to examine the organizational factors that aided or inhibited the implementation of MOVE! in 10 VHA medical facilities. Using a multiple, holistic case study design, we conducted 68 interviews with medical center program coordinators, physicians formally appointed as program champions, managers directly responsible for overseeing the program, clinicians from the program's multidisciplinary team, and primary care physicians identified by program coordinators as local opinion leaders. Qualitative data analysis involved coding, memorandum writing, and construction of data displays. Organizational readiness for change and having an innovation champion were most consistently the 2 factors associated with MOVE! implementation. Other organizational factors, such as management support and resource availability, were barriers to implementation or exerted mixed effects on implementation. Barriers did not prevent facilities from implementing MOVE! However, they were obstacles that had to be overcome, worked around, or accepted as limits on the program's scope or scale. Policy-directed implementation of clinical weight-management programs in health care facilities is challenging, especially when no new resources are available. Instituting powerful, mutually reinforcing organizational policies and practices may be necessary for consistent, high-quality implementation.

The 3C Study: Coverage cost and care of type 1 diabetes in China—Study design and implementation

Aim To describe coverage, cost and care of type 1 diabetes (T1D) in 2 regions of China – Beijing and Shantou – including: Estimating the numbers of people with T1D diabetes. Estimating the economic burden of T1D and financial barriers to care. Identifying scale of necessary government investment to improve health care coverage. Defining the burden of disease based on clinical outcomes. Describing the education and care experience of people with T1D with comparison to selected clinical practice guidelines. Describing the information processes associated with diabetes care and education. Methods This is a mixed-methods descriptive study with three arms – coverage, cost and care. It is taking place in 4 tertiary hospitals, 3 secondary hospitals and 4 primary health facilities in Beijing, and 2 tertiary hospitals, 2 secondary hospitals and 2 primary health centres in Shantou, China. Two additional hospitals are involved in the coverage arm of the study. T1D participants are recruited from a 3-year list generated by each hospital and from those attending the outpatient clinic or admitted to the inpatient ward. Participants also include health care professionals and government officials. To determine coverage of care, a list of people with T1D is being developed including information on diagnosis, age, sex and vital status. The age and sex distribution will be compared with the expected distribution. To estimate the economic burden of T1D three groups of costs will be calculated – direct medical costs, direct non-medical costs and indirect costs from different perspectives of analysis (patients and their families, health system, insurer and societal perspective). The data are being collected from people with T1D (patient–parents face-to-face interviews), hospital billing departments, medical records and government officials using a combined “top-down, bottom-up” approach developed to validate the data. Quality of life is assessed using the EQ-5D tool and burden of disease is measured based on clinical outcomes and complications. Standard care will be defined, costed and compared to the cost of current care identified within the study to determine the investment required to improve outcomes. The third arm includes three components – health policy, clinical care and education, and information management. Face-to-face, semi-structured interviews are conducted with people with T1D (for those <15 years of age parents are interviewed), health care professionals, senior hospital management and government officials. The core Summary of Diabetes Self-Care Activities Measure plus an additional 6 questions from the revised SDSCA scale are used to assess patient self-care. A medical records audit tool is used to assess care [7]. Clinical outcomes and self-care activities will be analysed for associations with care and education. Information management and care processes will be described using the Standard for Integration Definition for Function Modelling (IDEF0) [8]. Progress to date At the time of writing (early October) the 3-year case list includes 1269 people with type 1 diabetes from Beijing and 481 people for Shantou, a total of 1750. In addition, two hundred and twenty people with T1D or their parents participated in face-to-face interviews in Beijing and 183 in Shantou, a total of 403. Practical preliminary conclusions Key implementation considerations were identified early in the project. Project success is dependent on strong local partnerships with local opinion leaders and key officials. It is important that a physician is the first point of contact to build the case list and recruit participants. July, August and January are peak months for recruiting school-age children in the Children's Hospital as this is school vacation period when they are more likely to attend clinics.

Abstract P129: Building Capacity with Opinion Leaders to Implement the VA Hospital-to-Home Initiative: CHF QUERI

Objectives: Reducing readmission rates for heart failure (HF) patients is the primary goal of the Department of Veteran Affairs and its' Chronic Heart Failure (CHF) QUERI. It is also the goal of Hospital to Home (H2H) national quality improvement (QI) initiative cosponsored by the American College of Cardiology and the Institute for Healthcare. In January 2010 the CHF QUERI through its HF Provider Network launched the “VA H2H” QI initiative to implement the national H2H initiative at the VA facilities. Based on the PARIHS framework and Rogers Diffusion of Innovation Theory the specific aim was to identify local opinion leaders (OLs) at each facility to help facilitate the implementation of the VA H2H initiative at own facility. Methods: Prior to launching the VA H2H we used the sociometric method to identify OLs. HF Network members from 61 facilities were asked to nominate up to 2 providers at own facility (physician / nurse / other) including self as the local OL. Based on their nominations OLs were identified preferably with a physician and nurse team and they were asked to participate in the VA H2H. In Month 4 and Month 6 all members were asked to complete a survey providing information about the projects (or interventions) recently initiated based on the VA H2H, planned based on the VA H2H, or ongoing not based on VA H2H initiative. Results: 70% of the facilities (n=43) responded with 1-2 nominations for OLs (n=82) and the remaining 30% facilities had no identified OLs. Survey results show that among the facilities with OLs, 79% initiated/planned projects based on the VA H2H initiative; 9% did not initiate/plan project based on the VA H2H initiative; and 12% were non-responders. These facilities with OLs reported a total of 161 projects: 27 initiated planned based on the VA H2H, 52 planned based on the VA H2H, and 82 ongoing projects not related to VA H2H. Facilities without identified OLs reported having only a total of 6 projects. Conclusions: Most VA facilities were able to identify OLs and then successfully implement the VA H2H initiative. Impact: Use of OLs may be effective in implementing non-mandated QI initiatives to improve care for all VA HF patients.

Oxytocin augmentation during labor: How to implement medical guidelines into clinical practise

Objective To describe an extensive process to implement guidelines for oxytocin use during labor and to report its effects on compliance to clinical practice guidelines after 1 year. Study design A multifaceted strategy was developed to involve all obstetric staff and identify possible local barriers to change in advance. The process lasted for more than 1 year. Main outcome measures To describe the implementation of oxytocin use according to the new guidelines, and to compare management in clinical practice with guideline recommendations from audits performed before and after the project. Results Identification of possible barriers to change, academic detailing, audits with feedback, and local opinion leaders were important factors for a successful process. Documentation of the indication for oxytocin use increased from 54% before, to 86% after the completion of the project ( P < 0.01). The percentage of incidents in which oxytocin augmentation was started before the diagnosis of labor dystocia was reduced from 40% to 11% ( P < 0.01). Improvement was found in the documentation of cardiotocography (from 5% to 58%, P < 0.01) and contraction frequency at the start of the infusion (from 23% to 63%, P < 0.01). Conclusions Our multifaceted strategy involved all obstetric staff, lasted for more than a year, and improved management of oxytocin use according to clinical guidelines. Established rules for documentation were used as a check list to monitor oxytocin use. However, audits with feedback need to continue for medical safety, and have been planned to take place every 6 months.

Local opinion leaders: effects on professional practice and health care outcomes.

Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Opinion leaders disseminating and implementing 'best evidence' is one method that holds promise as a strategy to bridge evidence-practice gaps. To assess the effectiveness of the use of local opinion leaders in improving professional practice and patient outcomes. We searched Cochrane EPOC Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, HMIC, Science Citation Index, Social Science Citation Index, ISI Conference Proceedings and World Cat Dissertations up to 5 May 2009. In addition, we searched reference lists of included articles. Studies eligible for inclusion were randomised controlled trials investigating the effectiveness of using opinion leaders to disseminate evidence-based practice and reporting objective measures of professional performance and/or health outcomes. Two review authors independently extracted data from each study and assessed its risk of bias. For each trial, we calculated the median risk difference (RD) for compliance with desired practice, adjusting for baseline where data were available. We reported the median adjusted RD for each of the main comparisons. We included 18 studies involving more than 296 hospitals and 318 PCPs. Fifteen studies (18 comparisons) contributed to the calculations of the median adjusted RD for the main comparisons. The effects of interventions varied across the 63 outcomes from 15% decrease in compliance to 72% increase in compliance with desired practice. The median adjusted RD for the main comparisons were: i) Opinion leaders compared to no intervention, +0.09; ii) Opinion leaders alone compared to a single intervention, +0.14; iii) Opinion leaders with one or more additional intervention(s) compared to the one or more additional intervention(s), +0.10; iv) Opinion leaders as part of multiple interventions compared to no intervention, +0.10. Overall, across all 18 studies the median adjusted RD was +0.12 representing a 12% absolute increase in compliance in the intervention group. Opinion leaders alone or in combination with other interventions may successfully promote evidence-based practice, but effectiveness varies both within and between studies. These results are based on heterogeneous studies differing in terms of type of intervention, setting, and outcomes measured. In most of the studies the role of the opinion leader was not clearly described, and it is therefore not possible to say what the best way is to optimise the effectiveness of opinion leaders.

Non-clinical interventions for reducing unnecessary caesarean section

Caesarean section rates are steadily increasing globally. The factors contributing to these observed increases are complex. Non-clinical interventions, those applied independent of patient care in a clinical encounter, may have a role in reducing unnecessary caesarean sections. To evaluate the effectiveness and safety of non-clinical interventions for reducing unnecessary caesarean sections. We searched the following electronic databases: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (29 March 2010), the Cochrane Pregnancy and Childbirth Group Specialised Register (29 March 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 2); MEDLINE (1950 to March 2010); EMBASE (1947 to March 2010) and CINAHL (1982 to March 2010). We included randomised controlled trials (RCTs), quasi-experimental studies, controlled clinical trials (CCTs), controlled before and after studies (CBAs) with at least two intervention and control sites, and interrupted time series analyses (ITS) where the intervention time was clearly defined and there were at least three data points before and three after the intervention. Studies evaluated non-clinical interventions to reduce unnecessary caesarean section rates. Participants included pregnant women and their families, healthcare providers who work with expectant mothers, communities and advocacy groups. Three review authors independently assessed the quality and abstracted data of all eligible studies using a standardised data extraction form, modified from the Cochrane EPOC checklists. We contacted study authors for additional information. We included 16 studies in this review.Six studies specifically targeted pregnant women. Two RCTs were shown to be effective in reducing caesarean section rates: a nurse-led relaxation training programme for women with a fear or anxiety of childbirth and birth preparation sessions. However, both RCTs were small in size and targeted younger mothers with their first pregnancies. There is insufficient evidence that prenatal education and support programmes, computer patient decision-aids, decision-aid booklets and intensive group therapy are effective.Ten studies targeted health professionals. Three of these studies were effective in reducing caesarean section rates. A cluster-RCT of guideline implementation with mandatory second opinion resulted in a small, statistically significant reduction in total caesarean section rates (adjusted risk difference (RD) -1.9; 95% confidence interval (CI) -3.8 to -0.1); this reduction was predominately in intrapartum sections. An ITS study of mandatory second opinion and peer review feedback at department meetings found statistically significant results at 48 months for reducing repeat caesarean section rates (change in level was -6.4%; 95% CI -9.7% to -3.1% and change in slope -1.14%; 95% CI -1.9% to -0.3%) but not for total caesarean section rates. A cluster-RCT of guideline implementation with support from local opinion leaders increased the proportion of women with a previous caesarean section being offered a trial of labour (absolute difference 16.8%) and the number who had a vaginal birth (VBAC rates) (absolute difference 13.5%). The P values are, however, not reported due to unit of analysis errors. There was insufficient evidence that audit and feedback, training of public health nurses, insurance reform, external peer review and legislative changes are effective. Implementation of guidelines with mandatory second opinion can lead to a small reduction in caesarean section rates, predominately in intrapartum sections. Peer review, including pre-caesarean consultation, mandatory secondary opinion and postcaesarean surveillance can lead to a reduction in repeat caesarean section rates. Guidelines disseminated with endorsement and support from local opinion leaders may increase the proportion of women with previous caesarean sections being offered a trial of labour in certain settings. Nurse-led relaxation classes and birth preparation classes may reduce caesarean section rates in low-risk pregnancies.

Introducing a nursing guideline on depression in dementia: A multiple case study on influencing factors

BackgroundSuccessfully introducing care innovations depends on the type of care setting, the intervention and specific circumstances. In this study the factors influencing the introduction of an evidence based nursing guideline on depression in psychogeriatric nursing home residents were studied. MethodsA mixed methods multiple case study design was used. The cases consisted of nine psychogeriatric wards participating in the intervention group of a controlled clinical trial. Eight types of data source (qualitative and quantitative) were used in the analyses. Triangulation of researchers, data and methods took place. Factors were categorized according to their organizational level: nursing home management (level 1), nursing team (level 2), CNAs (level 3), and residents (level 4). ResultsFactors influencing guideline introduction were mainly found at the levels of the nursing home management and the nursing team. Most factors concern stability of the organization and team (e.g. the inhibiting effects of reorganizations and other innovations), motivation (e.g. the facilitating presence of an opinion leader) and compatibility with current practice and vision (e.g. a facilitating emotion-oriented care vision). Factors influencing a successful application of the guideline are mainly found at CNA and resident level. At CNA level most factors relate to an emotion-oriented care vision (e.g. having a warm and creative personality). At resident level inhibiting factors mainly concern the residents’ health status (e.g. feeling sick and/or having much pain). Important facilitating factors are positive attitudes of relatives and observing a reduction of depression severity. ConclusionsSpecial facilitating factors for the guideline introduction and application seem to be the presence of a local opinion leader and the positive attitudes of relatives. Together they can motivate a nursing team in using the guideline. After a successful introduction of the guideline it's important to focus on its consolidation in daily practice.

Barriers to implementation of isoniazid preventive therapy in HIV clinics: a qualitative study

Despite good evidence that isoniazid preventive therapy (IPT) reduces incidence of tuberculosis among people with HIV infection, implementation of IPT is low. This study aimed to describe barriers to IPT implementation from healthcare provider and patient perspectives in a donor-funded HIV care programme in Gauteng province, South Africa, in which IPT is recommended, but delivery is variable. A qualitative study using in-depth interviews and a focus group discussion. We conducted interviews with 22 clinic staff and 20 patients from 10 purposively selected HIV clinics, and a staff focus group discussion. Staff were questioned on their knowledge and experience of IPT, and asked about barriers to its use. Patients were asked for their opinions about taking IPT. Healthcare workers reported the primary barrier to IPT use was lack of knowledge and experience. Prescribers were unaware of the benefits of IPT and unclear about guidelines. The belief that existing screening tools are inaccurate in HIV-infected individuals and the need to refer patients to separate clinics for tuberculosis screening also emerged as barriers. No patients had heard of IPT. Barriers to the widespread use of IPT primarily derived from healthcare workers, in particular, lack of experience among physicians. In addition to overcoming operational barriers, a change in healthcare worker perception is needed if IPT is to be widely used; we suggest local clinical opinion leaders could help achieve this.

P58– Active implementation is required even with fully automatic decision support service

PRIMARY TRACK: Guideline implementation SECONDARY TRACK: Computer-based decision support BACKGROUND (INTRODUCTION): The Evidence-Based Medicine electronic Decision Support service (EBMeDS) integrated within the Electronic Health Record (EHR) was introduced into clinical practice in one primary care health center in June 2009. Patient-specific automatic reminders and diagnosis-based guideline links are shown on computer screen to physicians, nurses, and physiotherapists (45 in total), when they use the EHR. The aim was to find out what the professionals think helps or hinders the implementation and use of automatic reminders after six months use. LEARNING OBJECTIVES (TRAINING GOALS): 1. Identify health care professionals’ opinions of use of an automatic decision support service. 2. Find out potential barriers and facilitators for the implementation of automatic reminders. METHODS: We convened three focus groups of 12 professionals: six physicians, five nurses, and one physiotherapist. A broad discussion theme was used, and the group discussion was audio-taped and transcribed. The data were analyzed using a content analysis. RESULTS: The majority of the participants reported only limited usage of the EBMeDS service. The guideline links were used most, regardless of the professional background. Physicians discussed practical problems at the time of introduction of the system, though not related to the system. In particular, slowness of the EHR was considered a major problem. A significant issue was the clear delay (3 months) from learning about the system to starting to use it. More education and a local opinion leader were desired to help uptake in the future. DISCUSSION (CONCLUSION): The study indicates that active and maybe even repeated implementation efforts should be used on uptake of even an automatic decision support service. TARGET AUDIENCE(S): 1. Guideline implementer 2. Developer of guideline-based products 3. Quality improvement manager/facilitator 4. Medical providers and executives 5. Allied health professionals 6. Nurses P59– Clinical guidelines from PDF-format to modern computer-based decision support Anne Hilde Rosv Rosvik, MDS (Presenter) (The Norwegian Electronic Library of Health, Oslo, Norway); Thomas Gauperaa (The National Knowledge Centre for Health, Oslo, Norway); Runar Eggen (The Norwegian Electronic Library of Health, Oslo, Norway); Reidun Kvaernbraaten (The National Knowledge Centre for Health, Oslo, Norway)

Collaborative Care for Depressed Patients With Chronic Medical Conditions: A Randomized Trial in Puerto Rico

Collaborative Care for Depressed Patients With Chronic Medical Conditions: A Randomized Trial in Puerto Rico

Changing Physician Practice: An Evaluation of Knowledge Transfer Strategies to Enhance Physician Documentation of Cancer Stage

This paper describes the knowledge transfer strategies used by Cancer Care Ontario, in partnership with 14 regional cancer centres, with the aim of improving the cancer stage data in Ontario. As physicians are directly responsible for the documentation of cancer stage, the success of this initiative is directly related to improvements in physician documentation practices. Knowledge transfer strategies included the use of local opinion leaders, educational sessions, and audit/feedback loops. Evaluation results reveal an increase in the provincial cancer stage data from 30 to 68%. The information presented here will be of interest to organizations implementing practice changes requiring physician engagement.

Abstract ED06-02: Effective resources for recruitment for cancer prevention research

Abstract ED06-02: Effective resources for recruitment for cancer prevention research

The Enhancing Secondary Prevention in Coronary Artery Disease trial

Proven efficacious therapies are sometimes underused in patients with chronic cardiac conditions, resulting in suboptimal outcomes. We evaluated whether evidence summaries, which were either unsigned or signed by local opinion leaders, improved the quality of secondary prevention care delivered by primary care physicians of patients with coronary artery disease. We performed a randomized trial, clustered at the level of the primary care physician, with 3 study arms: control, unsigned statements or opinion leader statements. The statements were faxed to primary care physicians of adults with coronary artery disease at the time of elective cardiac catheterization. The primary outcome was improvement in statin management (initiation or dose increase) 6 months after catheterization. We enrolled 480 adults from 252 practices. Although statin use was high at baseline (n=316 [66%]), most patients were taking a low dose (mean 32% of the guideline-recommended dose), and their low-density lipoprotein (LDL) cholesterol levels were elevated (mean 3.09 mmol/L). Six months after catheterization, statin management had improved in 79 of 157 patients (50%) in the control arm, 85 of 158 (54%) patients in the unsigned statement group (adjusted odds ratio [OR] 1.18, 95% CI 0.71-1.94, p=0.52) and 99 of 165 (60%) patients in the opinion leader statement group (adjusted OR 1.51, 95% CI 0.94-2.42, p=0.09). The mean fasting LDL cholesterol levels after 6 months were similar in all 3 study arms: 2.35 (standard deviation [SD] 0.86) mmol/L in the control arm compared with 2.24 (SD 0.73) among those in the opinion leader group (p=0.48) and 2.19 (SD 0.68) in the unsigned statement group (p=0.32). Faxed evidence reminders for primary care physicians, even when endorsed by local opinion leaders, were insufficient to optimize the quality of care for adults with coronary artery disease. ClinicalTrials.gov trial register no. NCT00175240.

Implementing a standardized community-based cardiovascular risk assessment program in 20 Ontario communities

The aim of the study is to describe the implementation of the Cardiovascular Health Awareness Program (CHAP) in 20 mid-sized communities across Ontario, Canada, and identify key factors in the successful multi-site delivery of a collaborative cardiovascular risk assessment and management program. Lead organizations were identified and contracted following a request for proposals. An Implementation Guide detailed steps in community mobilization and delivery of volunteer-led pharmacy-based cardiovascular risk assessment sessions. Process data were collected through final reports; a debriefing meeting; and interviews with program staff. All 20 communities successfully implemented CHAP. Overall, 99% (338/341) of family physicians agreed to receive assessment results and 89% (129/145) of pharmacies held sessions. Five hundred and seventy-seven volunteers conducted 27,358 risk assessments for 15,889 unique participants. Essential program components were consistently included, however, variations in materials, processes and support occurred. Factors in program success included: local expertise, centralized support, identification and engagement of local physician and pharmacist opinion leaders and a balance of standardization and flexibility. Monitoring delivery of a multi-community cardiovascular risk assessment program yielded key factors in program success to inform development of a sustainable and transferable model.