Effect of local medical opinion leaders on quality of care for acute myocardial infarction: a randomized controlled trial.
BACKGROUND
The effectiveness of recruiting local medical opinion leaders to improve quality of care is poorly understood.


OBJECTIVE
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).


METHODS
Randomized controlled trial with hospital as the unit of randomization, intervention, and analysis.


METHODS
Thirty-seven community hospitals in Minnesota.


METHODS
All patients with AMI admitted to study hospitals over 10 months before (1992-1993, N=2409) or after (1995-1996, N=2938) the intervention.


METHODS
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.


METHODS
Hospital-specific changes before and after the intervention in the proportion of eligible patients receiving each study drug.


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). 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.


CONCLUSIONS
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 Secular changes in knowledge and hospital protocols may extinguish outdated practices (eg, prophylactic lidocaine).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.
Soumerai
S B
SB
Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA 02215, USA. soumerai@warren.med.harvard.edu
McLaughlin
T J
TJ
Gurwitz
J H
JH
Guadagnoli
E
E
Hauptman
P J
PJ
Borbas
C
C
Morris
N
N
McLaughlin
B
B
Gao
X
X
Willison
D J
DJ
Asinger
R
R
Gobel
F
F
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001241:Aspirin / Q000627:therapeutic use; D002309:Cardiology / Q000592:standards* / Q000639:trends; D016507:Cardiology Service, Hospital / Q000592:standards*; D019091:Critical Pathways; D004363:Drug Utilization / Q000592:standards* / Q000639:trends; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D019983:Guideline Adherence; D006764:Hospitals, Community / Q000592:standards; D006801:Humans; D007400:Interprofessional Relations; D008012:Lidocaine / Q000627:therapeutic use; D008910:Minnesota; D009203:Myocardial Infarction / Q000188:drug therapy / Q000628:therapy*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D011787:Quality of Health Care; D018709:Statistics, Nonparametric; D015912:Thrombolytic Therapy
D000319:Adrenergic beta-Antagonists; D000889:Anti-Arrhythmia Agents; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D008012:Lidocaine; D001241:Aspirin