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Changing Clinical Practice: Local opinion leaders can influence practice changes
Lead author's name and fax: maryann.o'brien@hrcc.on.ca
Three-part Clinical Question: Does "who" delivers the educational information affect the impact achieved?
Search Terms: In Cochrane Database of Systematic Reviews: change practice.mp (26)
The Review: Data Sources: Cochrane Library, Medline, non-English sources, Research and Development Resource Base. Checked all reference lists, and through personal contacts.
Study Selection: Randomised trials. Local opinion leaders defined as "healthcare providers nominated by their colleagues as being educationally influential" The investigators must explicitly state the opinion leaders were identified by their colleagues.
Data Extraction: Trial, opinion leader definition and mode of action, outcome measure, impact of intervention described as number of times task performance was correct per patient or per episode of care. Eight trials found: allocation concealment not clear in six; follow up unclear in three; blinding adequate in two and unclear in six. The studies were multiple independent reviews of individual reports. Can't tell if they were tested for heterogeneity.
The Evidence: 1. Use of opinion leaders is more effective than no intervention: four studies. Varied from non-significant to substantial effect. 2. Use of local opinion leaders combined with other complementary interventions: one study. No significant difference. 3. Use of local opinion leaders is more effective than other interventions: 2 studies both comparing with audit and feedback. Local opinion leaders were more effective on each occasion.
Comments: 1) Do the methods allow accurate testing of the hypothesis? - YES 2) Do the statistical tests correctly test the results to allow differentiation of statistically significant results? - YES - Methodologically sound systematic review. 3) Are conclusions valid in light of the results? - YES 4) Did results get omitted, and why? - NO 5) Did they suggest areas of further research? YES - need to determine when use of local opinion leaders will be most beneficial, description of what they do and how they do it, and . 6) Did they make any recommendations based on the results and were they appropriate? - YES - If local opinion leaders can be identified they may be useful to promote changes in practice. However, from the available evidence it is not clear when or how (methods they use). 7) Is the study relevant to my clinical practice? YES - Provision of consistently good healthcare that continuously improves is our aim. We need to know what helps make changes to practice. A variety of patient problems were targeted: acute MI, cancer pain, osteoarthritis, rheumatoid arthritis, chronic lung disease, vaginal birth after LUSCS, labour and delivery, and urinary catheter care. 8) What level of evidence does this study represent? 1- 9) What grade of recommendation can I make on this result alone? B 10) What grade of recommendation can I make when this study is considered along with other available evidence? No additional evidence to be added. 11) Should I change my practice because of these results? Think about the definition. Opinion leaders in one practice environment, may not necessarily be leaders in another. For example a clinical director may be an "administrative leader" but may not necessarily also be the "opinion leader". 12) Should I audit my current practice because of these results? No, use this series of systematic reviews to decide what strategies will help you make changes to your practice. Then audit effects: remember to consider how to accurately record baseline activity.
Appraised by: Malcolm Daniel, Department of Anaesthesia, Glasgow Royal Infirmary; 22 September 2003 Email: md23s@udcf.gla.ac.uk Kill or Update By: September 2006
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