Effect of Local Medical Opinion Leaders on Quality of Care for Acute Myocardial Infarction: A Randomized Controlled Trial
Open accessAbstract
CONTEXT: 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). DESIGN: Randomized controlled trial with hospital as the unit of randomization, intervention, and analysis. SETTING: Thirty-seven community hospitals in Minnesota. PATIENTS: All patients with AMI admitted to study hospitals over 10 months before (1992-1993, N=2409) or after (1995-1996, N=2938) the intervention. 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. MAIN OUTCOME MEASURES: 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 Secular changes in knowledge and hospital protocols may extinguish outdated practices (eg, prophylactic lidocaine).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.
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In Soumerai 1998, blinding of outcome assessment was at unclear risk of bias.
“Blinding of outcome assessment (detection bias) All outcomes Unclear risk It is not clear if the data collectors were blinded”
From Tailored interventions to address determinants of practice (2015) · cites this paper as Soumerai 1998
In Soumerai 1998, random sequence generation was at unclear risk of bias.
“Random sequence generation (selection bias) Unclear risk Method of sequence generation not described”
From Tailored interventions to address determinants of practice (2015) · cites this paper as Soumerai 1998
In Soumerai 1998, contamination was at low risk of bias.
“Contamination Low risk Hospitals were randomised, large cities being randomised as clusters to avoid contamination”
From Tailored interventions to address determinants of practice (2015) · cites this paper as Soumerai 1998
In Soumerai 1998, baseline characteristics were at low risk of bias.
“Baseline characteristics Low risk Patient characteristics were similar”
From Tailored interventions to address determinants of practice (2015) · cites this paper as Soumerai 1998
In Soumerai 1998, selective reporting was at low risk of bias.
“Selective reporting (reporting bias) Low risk Appropriate outcomes reported”
From Tailored interventions to address determinants of practice (2015) · cites this paper as Soumerai 1998
In Soumerai 1998, overall risk of bias was unclear.
“Risk of bias overall Unclear risk 4 criteria unclear risk”
From Tailored interventions to address determinants of practice (2015) · cites this paper as Soumerai 1998
In Soumerai 1998, allocation concealment was at unclear risk of bias.
“Allocation concealment (selection bias) Unclear risk Method not described”
From Tailored interventions to address determinants of practice (2015) · cites this paper as Soumerai 1998
In Soumerai 1998, other bias was at low risk of bias.
“Other bias Low risk Baseline patient characteristics were similar. Contamination unlikely”
From Tailored interventions to address determinants of practice (2015) · cites this paper as Soumerai 1998
In Soumerai 1998, incomplete outcome data was at low risk of bias.
“Incomplete outcome data (attrition bias) All outcomes Low risk No hospitals were reported as withdrawing”
From Tailored interventions to address determinants of practice (2015) · cites this paper as Soumerai 1998
In Soumerai 1998, baseline outcomes were at low risk of bias.
“Baseline outcomes Low risk Baseline outcomes similar”
From Tailored interventions to address determinants of practice (2015) · cites this paper as Soumerai 1998
Soumerai 1998 found improvements in two of four outcomes related to management of acute myocardial infarction (median adjusted RD = 8.5; no overall P value presented).
“Soumerai 1998 found improvements in two of four outcomes related to management of acute myocardial infarction (median adjusted RD = 8.5; no overall P value presented).”
From Audit and feedback: effects on professional practice and healthcare outcomes (2012) · cites this paper as Soumerai 1998
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- Authors
- Soumerai, S. B., McLaughlin, T. J., Gurwitz, J. H., Guadagnoli, E., Hauptman, P. J., Borbas, C., Morris, N., McLaughlin, B., Gao, X., Willison, D. J., Asinger, R., & Gobel, F.
- Affiliations
- Harvard University (US)
- University of Massachusetts Chan Medical School (US)
- McMaster University (CA)
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 1998-05-06
- Volume
- 279
- Issue
- 17
- Pages
- 1358
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- OpenAlex
- W2052012471
- Cited by
- 479
- References
- 43
- Citations by year
- 2026: 2 · 2025: 2 · 2024: 5 · 2023: 4 · 2022: 2 · 2021: 7 · 2020: 6 · 2019: 11 · 2018: 5 · 2017: 7 · 2016: 7 · 2015: 11 · 2014: 14 · 2013: 10 · 2012: 10
- FWCI
- 33.47
- Type
- journal article
- Language
- en
- Open access
- green
- nrs.harvard.edu
- Licence
- cc-by
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- Digital Access to Scholarship at Harvard (DASH) (Harvard University) (submittedVersion, cc-by)
- The Journal of the American Medical Association (JAMA) Network (American Medical Association) (submittedVersion)
- Funders
- Agency for Healthcare Research and Quality (HSO7357)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Acute Myocardial Infarction Research
- Keywords
- acute myocardial infarction, guideline implementation, clinician education, performance feedback, aspirin, beta-blockers, thrombolysis, quality of care, community hospitals, elderly patients, care pathways, peer influence, barriers to change, medication use, secondary prevention, evidence-based practice adoption, 1990s
- MeSH terms
- Adrenergic beta-Antagonists, Anti-Arrhythmia Agents, Aspirin, Cardiology, Drug Utilization, Fibrinolytic Agents, Hospitals, Community, Humans, Interprofessional Relations, Lidocaine, Minnesota, Myocardial Infarction, Platelet Aggregation Inhibitors, Quality of Health Care, Thrombolytic Therapy, Cardiology Service, Hospital, Practice Guidelines as Topic, Statistics, Nonparametric, Critical Pathways, Guideline Adherence
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
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