Elsevier

American Heart Journal

Volume 153, Issue 1, January 2007, Pages 22.e1-22.e8
American Heart Journal

Clinical Investigation
Acute Ischemic Heart Disease
Impact of opinion leader–endorsed evidence summaries on the quality of prescribing for patients with cardiovascular disease: A randomized controlled trial

https://doi.org/10.1016/j.ahj.2006.07.030Get rights and content

Background

Local opinion leaders are educationally and socially influential physicians. Although they can accelerate the adoption of new evidence in hospitals, their impact on the quality of prescribing for outpatients has only been examined by a few studies. We hypothesized that an intervention consisting of patient-specific one-page evidence summaries, generated and endorsed by local opinion leaders, would improve prescribing of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in heart failure (HF) and that of statins in ischemic heart disease (IHD).

Methods

We conducted a community-based randomized controlled trial in patients with HF (not receiving ACE inhibitors or ARBs) and those with IHD (not receiving statins) who were recruited from 40 pharmacies and allocated either to the opinion leader intervention or to usual care based on randomization of their primary care physician. The primary outcome was an increase in the use of efficacious therapies (ACE inhibitors or ARBs in HF and statins in IHD) within 6 months; the secondary outcomes were prescribing changes for HF or IHD.

Results

A total of 171 patients participated in the study; 87 were allocated to the intervention, whereas 84 were assigned to the control group. The median age of the participants was 75 years; 103 (60%) were female, 54 (32%) had HF, and 117 (68%) had IHD. Overall, 21 (24%) intervention patients started receiving an efficacious medication within 6 months, as compared with 15 (18%) control subjects (relative risk of improvement 1.32, 95% CI 0.73-2.40, P = .31). In the HF subgroup, 38% of the intervention patients started receiving an ACE inhibitor or ARB therapy, as compared with 20% of control subjects (relative risk of improvement 1.90, 95% CI 0.76-4.72, P = .15). In the IHD subgroup, 17% of the intervention patients and 17% of the control subjects started receiving statin therapy (P = .97).

Conclusions

The influence of local opinion leaders may be useful for improving the quality of cardiovascular prescribing in the community, but the benefits are likely modest and may be disease specific. Further studies on this method are warranted.

Section snippets

Methods

The study's rationale and design have been published1 and are thus only summarized in this article. It was approved by the University of Alberta Ethics Board.

Results

The study was conducted from January 2002 through June 2005. The flow of participant selection is illustrated in Figure 1. We screened 2897 patients (1279 with HF and 1147 with IHD) to recruit 171 patients. The primary reason for exclusion was current or previous use of study medications, noted in more than 75% of the screened patients. For HF, 884 (69%) patients were already taking an ACE inhibitor or an ARB and 119 (9%) had previously been dispensed one of these agents and then discontinued

Discussion

The quality of care for patients with cardiovascular diseases remains suboptimal, and innovative strategies need to be developed—and tested in controlled studies—if quality is to improve. In a randomized controlled trial conducted in a fee-for-service setting, we tested the hypothesis that local opinion leaders could accelerate the adoption of cardiovascular evidence by primary care physicians. Overall, our intervention led to a small and statistically nonsignificant 6% absolute improvement in

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    This study was supported by grants from the AHFMR (Alberta Heritage Foundation for Medical Research; Edmonton, Alberta, Canada) and the Institute of Health Economics. Drs Majumdar and McAlister received salary awards from the AHFMR and the Canadian Institutes of Health Research (Ottawa, Ontario, Canada). Drs McAlister and Tsuyuki are supported by the Merck Frosst/Aventis Chair in Patient Health Management.

    Trial Registry: ISRCTN26365328 and NCT00175279.

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