BACKGROUND: Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Local opinion leaders (OLs) are individuals perceived as credible and trustworthy, who disseminate and implement best evidence, for instance through informal one-to-one teaching or community outreach education visits. The use of OLs is a promising strategy to bridge evidence-practice gaps. This is an update of a Cochrane review published in 2011.
OBJECTIVES: To assess the effectiveness of local opinion leaders to improve healthcare professionals' compliance with evidence-based practice and patient outcomes.
SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers on 3 July 2018, together with searching reference lists of included studies and contacting experts in the field.
SELECTION CRITERIA: We considered randomised studies comparing the effects of local opinion leaders, either alone or with a single or more intervention(s) to disseminate evidence-based practice, with no intervention, a single intervention, or the same single or more intervention(s). Eligible studies were those reporting objective measures of professional performance, for example, the percentage of patients being prescribed a specific drug or health outcomes, or both. We included all studies independently of the method used to identify OLs.
DATA COLLECTION AND ANALYSIS: We used standard Cochrane procedures in this review. The main comparison was (i) between any intervention involving OLs (OLs alone, OLs with a single or more intervention(s)) versus any comparison intervention (no intervention, a single intervention, or the same single or more intervention(s)). We also made four secondary comparisons: ii) OLs alone versus no intervention, iii) OLs alone versus a single intervention, iv) OLs, with a single or more intervention(s) versus the same single or more intervention(s), and v) OLs with a single or more intervention(s) versus no intervention.
MAIN RESULTS: We included 24 studies, involving more than 337 hospitals, 350 primary care practices, 3005 healthcare professionals, and 29,167 patients (not all studies reported this information). A majority of studies were from North America, and all were conducted in high-income countries. Eighteen of these studies (21 comparisons, 71 compliance outcomes) contributed to the median adjusted risk difference (RD) for the main comparison. The median duration of follow-up was 12 months (range 2 to 30 months). The results suggested that the OL interventions probably improve healthcare professionals' compliance with evidence-based practice (10.8% absolute improvement in compliance, interquartile range (IQR): 3.5% to 14.6%; moderate-certainty evidence).Results for the secondary comparisons also suggested that OLs probably improve compliance with evidence-based practice (moderate-certainty evidence): i) OLs alone versus no intervention: RD (IQR): 9.15% (-0.3% to 15%); ii) OLs alone versus a single intervention: RD (range): 13.8% (12% to 15.5%); iii) OLs, with a single or more intervention(s) versus the same single or more intervention(s): RD (IQR): 7.1% (-1.4% to 19%); iv) OLs with a single or more intervention(s) versus no intervention: RD (IQR):10.25% (0.6% to 15.75%).It is uncertain if OLs alone, or in combination with other intervention(s), may lead to improved patient outcomes (3 studies; 5 dichotomous outcomes) since the certainty of evidence was very low. For two of the secondary comparisons, the IQR included the possibility of a small negative effect of the OL intervention. Possible explanations for the occasional negative effects are, for example, the possibility that the OLs may have prioritised some outcomes, at the expense of others, or that an unaccounted outcome difference at baseline, may have given a faulty impression of a negative effect of the intervention at follow-up. No study reported on costs or cost-effectiveness.We were unable to determine the comparative effectiveness of different approaches to identifying OLs, as most studies used the sociometric method. Nor could we determine which methods used by OLs to educate their peers were most effective, as the methods were poorly described in most studies. In addition, we could not determine whether OL teams were more effective than single OLs.
AUTHORS' CONCLUSIONS: Local opinion leaders alone, or in combination with other interventions, can be effective in promoting evidence-based practice, but the effectiveness varies both within and between studies.The effect on patient outcomes is uncertain. The costs and the cost-effectiveness of the intervention(s) is unknown. These results are based on heterogeneous studies differing in types of intervention, setting, and outcomes. In most studies, the role and actions of the OL were not clearly described, and we cannot, therefore, comment on strategies to enhance their effectiveness. It is also not clear whether the methods used to identify OLs are important for their effectiveness, or whether the effect differs if education is delivered by single OLs or by multidisciplinary OL teams. Further research may help us to understand how these factors affect the effectiveness of OLs.
ACHTERGROND EN DOEL: Zorgverlener aanhankelijkheid aan astmarichtlijnen is slecht. Het doel van deze studie was om het effect van interventie ter zorgverleners 'naleving astmarichtlijnen op gezondheidsproces en klinische resultaten verbeteren beoordelen.
Methode: Gegevensbronnen inbegrepen Medline, Embase, Cochrane Centraal Register of Controlled Trials, Cumulatieve Index to Nursing en Allied Health Literature, Educational Resources Information Center, PsycINFO, en onderzoek en ontwikkeling Resource Base in Continuing Medical Education tot juli 2012. Gepaarde onderzoekers onafhankelijk beoordeeld studie in aanmerking te komen. Onderzoekers geabstraheerd data sequentieel en onafhankelijk ingedeeld het bewijs.
RESULTATEN: Achtenzestig aanmerking studies werden ingedeeld naar interventie: ondersteuning van de besluitvorming, organisatorische veranderingen, feedback en controle, klinische farmacie ondersteuning, opleiding alleen, kwaliteitsverbetering / pay-for-performance multicomponentvezels, en alleen informatie. Half werden gerandomiseerde studies (n = 35). Er was matig bewijs voor verhoogde eisen van de controller medicijnen voor beslissingsondersteuning, feedback en audit, en klinische farmacie ondersteuning en laagwaardige bewijs voor organisatieverandering en meerdere componenten interventies. Matig bewijs ondersteunt het gebruik van de ondersteuning van de besluitvorming en de klinische farmacie interventies om de levering van de patiënt self-education/asthma actieplannen te verhogen. Matig bewijs ondersteunt het gebruik van de ondersteuning van de besluitvorming naar afdeling spoedeisende hulp bezoeken te verminderen, en low-grade bewijs suggereert is er geen voordeel voor deze uitkomst met organisatorische veranderingen, onderwijs alleen, en kwaliteitsverbetering / pay-for-performance.
CONCLUSIES: Besluit ondersteunende tools, feedback en audit, en klinische farmacie ondersteuning waren de meeste kans om provider aanhankelijkheid aan astma richtlijnen te verbeteren, zoals gemeten door middel van de gezondheidszorg proces uitkomsten. Er moet gezondheidszorg provider gerichte acties evalueren gestandaardiseerde resultaten.
OBJECTIVES: To synthesize the published literature on the effect of interventions designed to improve health care providers' adherence to asthma guidelines on: (1) health care process outcomes (Key Question 1); (2) clinical outcomes (Key Question 2); (3) health care processes that subsequently impact clinical outcomes (Key Question 3).
DATA SOURCES: Reports of studies from MEDLINE(®), Embase(®), Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL(®)), Educational Resources Information Center (ERIC(sm)), PsycINFO(®), and Research and Development Resource Base in Continuing Medical Education (RDRB/CME), up to July 2012.
REVIEW METHODS: Paired investigators independently reviewed each title, abstract, and full-text article to assess eligibility. Only comparative studies were eligible. Investigators abstracted data sequentially and independently graded the evidence.
RESULTS: A total of 73 studies were eligible for review. A slight majority of studies were conducted in the U.S. (n=38). We classified studies as assessing eight types of interventions: decision support, organizational change, feedback and audit, clinical pharmacy support, education only, quality improvement (QI)/pay-for-performance, multicomponent, and information only. Half of the studies were randomized trials (n=34), 29 were pre-post, and the remaining 10 were a variety of nonrandomized study designs. The studies took place exclusively in primary care settings. The most frequently cited health care process outcome was prescription of asthma controller medication (n=41), followed by provision of an asthma action plan (n=18), prescription of a peak flow meter (n=17), and self-management education (n=12). Common clinical outcomes included emergency department (ED) visits (n=30) and hospitalizations (n=27), followed by use of short-acting β2 agonists (n=9), missed school days (n=8), lung function tests (n=6), symptom days (n=6), quality of life (n=5), and urgent doctor visits (n=5). We identified 4 critical outcomes for which 68 studies provided information. There was moderate evidence for increased prescriptions of asthma controller medications using decision support, feedback and audit, and clinical pharmacy support interventions and low grade evidence for organizational change, multicomponent interventions. Moderate evidence supports the use of decision support and clinical pharmacy interventions to increase provision of patient self-education/asthma action plans; for the same outcome, low grade evidence supports the use of organizational change, feedback and audit, education only, quality improvement, and multicomponent interventions. Moderate grade evidence supports use of decision support tools to reduce ED visits/hospitalizations while low grade evidence suggests there is no benefit associated with organizational change, education only, and QI/pay-for-performance. Organizational change interventions provided no benefit for lost days of work/school. The evidence for the remainder of interventions was insufficient or low in strength.
CONCLUSIONS: There is low to moderate evidence to support the use of decision support tools, feedback and audit, and clinical pharmacy support to improve the adherence of health care providers to asthma guidelines, as measured through health care process outcomes, and to improve clinical outcomes. There is a need to further evaluate health care provider-targeted interventions with a focus on standardized measures of outcomes and more rigorous study designs.
OBJECTIVES: Randomized clinical trial (RCT) data reviewed for outcomes and processes associated with asthma educational and behavioral interventions provided by different types of health professionals.
METHODS: Cochrane Collaboration, MEDLINE, PUBMED, Google Scholar search from 1998 to 2009 identified 1650 articles regarding asthma educational and behavioral interventions resulting in 249 potential studies and following assessment produced a final sample of 50 RCTs.
RESULTS: Approaches, intended outcomes, and program providers vary greatly. No rationale provided in study reports for the selection of specific outcomes, program providers, or program components. Health care utilization and symptom control have been the most common outcomes assessed. Specific providers favor particular teaching approaches. Multidisciplinary teams have been the most frequent providers of asthma interventions. Physician-led interventions were most successful for outcomes related to the use of health care. Multidisciplinary teams were best in achieving symptom reduction and quality of life. Lay persons were best in achieving self-management/self-efficacy outcomes. Components most frequently employed in successful programs are skills to improve patient-clinician communication and education to enhance patient self-management. Fifty percent of interventions achieved reduction in the use of health care and one-third in symptom control. A combination approach including self-management and patient-clinician communication involving multidisciplinary team members may have the greatest effect on most outcomes.
CONCLUSIONS: The extent to which and how different providers achieve asthma outcomes through educational and behavioral interventions is emerging from recent studies. Health care use and symptom control are evolving as the gold standard for intervention outcomes. Development of self-management and clinician-patient communication skills are program components associated with success across outcomes and providers.
Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Local opinion leaders (OLs) are individuals perceived as credible and trustworthy, who disseminate and implement best evidence, for instance through informal one-to-one teaching or community outreach education visits. The use of OLs is a promising strategy to bridge evidence-practice gaps. This is an update of a Cochrane review published in 2011.
OBJECTIVES:
To assess the effectiveness of local opinion leaders to improve healthcare professionals' compliance with evidence-based practice and patient outcomes.
SEARCH METHODS:
We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers on 3 July 2018, together with searching reference lists of included studies and contacting experts in the field.
SELECTION CRITERIA:
We considered randomised studies comparing the effects of local opinion leaders, either alone or with a single or more intervention(s) to disseminate evidence-based practice, with no intervention, a single intervention, or the same single or more intervention(s). Eligible studies were those reporting objective measures of professional performance, for example, the percentage of patients being prescribed a specific drug or health outcomes, or both. We included all studies independently of the method used to identify OLs.
DATA COLLECTION AND ANALYSIS:
We used standard Cochrane procedures in this review. The main comparison was (i) between any intervention involving OLs (OLs alone, OLs with a single or more intervention(s)) versus any comparison intervention (no intervention, a single intervention, or the same single or more intervention(s)). We also made four secondary comparisons: ii) OLs alone versus no intervention, iii) OLs alone versus a single intervention, iv) OLs, with a single or more intervention(s) versus the same single or more intervention(s), and v) OLs with a single or more intervention(s) versus no intervention.
MAIN RESULTS:
We included 24 studies, involving more than 337 hospitals, 350 primary care practices, 3005 healthcare professionals, and 29,167 patients (not all studies reported this information). A majority of studies were from North America, and all were conducted in high-income countries. Eighteen of these studies (21 comparisons, 71 compliance outcomes) contributed to the median adjusted risk difference (RD) for the main comparison. The median duration of follow-up was 12 months (range 2 to 30 months). The results suggested that the OL interventions probably improve healthcare professionals' compliance with evidence-based practice (10.8% absolute improvement in compliance, interquartile range (IQR): 3.5% to 14.6%; moderate-certainty evidence).Results for the secondary comparisons also suggested that OLs probably improve compliance with evidence-based practice (moderate-certainty evidence): i) OLs alone versus no intervention: RD (IQR): 9.15% (-0.3% to 15%); ii) OLs alone versus a single intervention: RD (range): 13.8% (12% to 15.5%); iii) OLs, with a single or more intervention(s) versus the same single or more intervention(s): RD (IQR): 7.1% (-1.4% to 19%); iv) OLs with a single or more intervention(s) versus no intervention: RD (IQR):10.25% (0.6% to 15.75%).It is uncertain if OLs alone, or in combination with other intervention(s), may lead to improved patient outcomes (3 studies; 5 dichotomous outcomes) since the certainty of evidence was very low. For two of the secondary comparisons, the IQR included the possibility of a small negative effect of the OL intervention. Possible explanations for the occasional negative effects are, for example, the possibility that the OLs may have prioritised some outcomes, at the expense of others, or that an unaccounted outcome difference at baseline, may have given a faulty impression of a negative effect of the intervention at follow-up. No study reported on costs or cost-effectiveness.We were unable to determine the comparative effectiveness of different approaches to identifying OLs, as most studies used the sociometric method. Nor could we determine which methods used by OLs to educate their peers were most effective, as the methods were poorly described in most studies. In addition, we could not determine whether OL teams were more effective than single OLs.
AUTHORS' CONCLUSIONS:
Local opinion leaders alone, or in combination with other interventions, can be effective in promoting evidence-based practice, but the effectiveness varies both within and between studies.The effect on patient outcomes is uncertain. The costs and the cost-effectiveness of the intervention(s) is unknown. These results are based on heterogeneous studies differing in types of intervention, setting, and outcomes. In most studies, the role and actions of the OL were not clearly described, and we cannot, therefore, comment on strategies to enhance their effectiveness. It is also not clear whether the methods used to identify OLs are important for their effectiveness, or whether the effect differs if education is delivered by single OLs or by multidisciplinary OL teams. Further research may help us to understand how these factors affect the effectiveness of OLs.
