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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 Secular changes in knowledge and hospital protocols may extinguish outdated practices (eg, prophylactic lidocaine).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 the citing paper
“Allocation concealment (selection bias) Unclear risk Method not described”
From Tailored interventions to address determinants of practice (2015) · cites this paper as Soumerai 1998
Experimental — accuracy not yet measuredIn the citing paper
“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 the citing paper
“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
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“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 the citing paper
“Baseline characteristics Low risk Patient characteristics were similar”
From Tailored interventions to address determinants of practice (2015) · cites this paper as Soumerai 1998
In the citing paper
“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 the citing paper
“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 the citing paper
“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 the citing paper
“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 the citing paper
“Baseline outcomes Low risk Baseline outcomes similar”
From Tailored interventions to address determinants of practice (2015) · cites this paper as Soumerai 1998
In the citing paper
“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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ACC/AHA guidelines for the management of patients with acute myocardial infarction
Ryan, T. J., Anderson, J. L., Antman, E. M., Braniff, B. A., Brooks, N. H., Califf, R. M., Hillis, L. D., Hiratzka, L. F., Rapaport, E., Riegel, B. J., et al. (1996) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(96)00392-0 · Cited by 1,962
Davis, D. A. (1995) · JAMA · doi:10.1001/jama.1995.03530090032018 · Cited by 1,763
The Diffusion of an Innovation Among Physicians
Coleman, J., Katz, E., & Menzel, H. (1957) · Sociometry · doi:10.2307/2785979 · Cited by 1,475
Judgement under Uncertainty: Heuristics and Biases
Kahneman, D. J., Slovic, P., & Tversky, A. (1985) · The British Journal for the Philosophy of Science · Cited by 1,361
Principles of Educational Outreach ('Academic Detailing') to Improve Clinical Decision Making
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Audit and feedback: effects on professional practice and healthcare outcomes
Ivers, N., Jamtvedt, G., Flottorp, S., Young, J. M., Odgaard-Jensen, J., French, S. D., O'Brien, M. A., Johansen, M., Grimshaw, J., & Oxman, A. D. (2012) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd000259.pub3 · Cited by 5,485
Clinical Practice Guidelines We Can Trust
Board on Health Care Services (2011) · National Academies Press eBooks · doi:10.17226/13058 · Cited by 3,146
Disseminating Innovations in Health Care
Berwick, D. M. (2003) · JAMA · doi:10.1001/jama.289.15.1969 · Cited by 1,878
Influentials, Networks, and Public Opinion Formation
Watts, D. J., & Dodds, P. S. (2007) · Journal of Consumer Research · doi:10.1086/518527 · Cited by 1,864
Best care at lower cost: the path to continuously learning health care in America
Smith, M. A., Saunders, R., Stuckhardt, L., & McGinnis, J. M. (2014) · Choice Reviews Online · doi:10.5860/choice.51-3277 · Cited by 1,358
Metadata
- 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
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