Effect of local medical opinion leaders on quality of care for acute myocardial infarction: a randomized controlled trial

JAMA. 1998 May 6;279(17):1358-63. doi: 10.1001/jama.279.17.1358.


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 Secular changes in knowledge and hospital protocols may extinguish outdated practices (eg, prophylactic lidocaine).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.

Publication types

  • Clinical Trial
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adrenergic beta-Antagonists / therapeutic use
  • Anti-Arrhythmia Agents / therapeutic use
  • Aspirin / therapeutic use
  • Cardiology / standards*
  • Cardiology / trends
  • Cardiology Service, Hospital / standards*
  • Critical Pathways
  • Drug Utilization / standards*
  • Drug Utilization / trends
  • Fibrinolytic Agents / therapeutic use
  • Guideline Adherence*
  • Hospitals, Community / standards
  • Humans
  • Interprofessional Relations
  • Lidocaine / therapeutic use
  • Minnesota
  • Myocardial Infarction / drug therapy
  • Myocardial Infarction / therapy*
  • Platelet Aggregation Inhibitors / therapeutic use
  • Practice Guidelines as Topic
  • Quality of Health Care*
  • Statistics, Nonparametric
  • Thrombolytic Therapy


  • Adrenergic beta-Antagonists
  • Anti-Arrhythmia Agents
  • Fibrinolytic Agents
  • Platelet Aggregation Inhibitors
  • Lidocaine
  • Aspirin