Strategies to implement change in health professional performance have variable impact. A potential explanation is that the barriers to implementation are different in different settings and at different times. Change may be more likely if the strategies were specifically chosen to address the identified barriers. Objectives To assess the effectiveness of strategies tailored to address specific, identified barriers to change in professional performance. The authors included 15 studies. For Comparison 1 (an intervention tailored to address identified barriers to change compared to no intervention or an intervention(s) not tailored to the barriers), there was no consistency in the results and the effect sizes varied both across and within studies. A meta-regression of a subset of the included studies, using a classical approach estimated a combined OR of 2.18 (95% CI: 1.09, 4.34), p = 0.026 in favour of tailored interventions. However, when a Bayesian approach was taken, meta-regression gave a combined OR of 2.27 (95% Credible Interval: 0.92, 4.75), which was not statistically significant.

Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes

BACKGROUND
Strategies to implement change in health professional performance have variable impact. A potential explanation is that the barriers to implementation are different in different settings and at different times. Change may be more likely if the strategies were specifically chosen to address the identified barriers.


OBJECTIVES
To assess the effectiveness of strategies tailored to address specific, identified barriers to change in professional performance.


SEARCH STRATEGY
We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register and pending files until end of December 2002. English language articles only were included.


SELECTION CRITERIA
Randomised controlled trials (RCTs) that reported objectively measured professional practice or health care outcomes in which at least one group received an intervention designed (or tailored) to address prospectively identified barriers to change.


DATA COLLECTION AND ANALYSIS
Two reviewers independently extracted data and assessed quality. We also contacted study authors to obtain any missing information. Quantitative and qualitative analyses were undertaken.


MAIN RESULTS
We included 15 studies. For Comparison 1 (an intervention tailored to address identified barriers to change compared to no intervention or an intervention(s) not tailored to the barriers), there was no consistency in the results and the effect sizes varied both across and within studies.A meta-regression of a subset of the included studies, using a classical approach estimated a combined OR of 2.18 (95% CI: 1.09, 4.34), p = 0.026 in favour of tailored interventions. However, when a Bayesian approach was taken, meta-regression gave a combined OR of 2.27 (95% Credible Interval: 0.92, 4.75), which was not statistically significant.


AUTHORS' CONCLUSIONS
Interventions tailored to prospectively identify barriers may improve care and patient outcomes. However, from the studies included in this review, we were unable to determine whether the barriers were valid, which were the most important barriers, whether all barriers were identified and if they had been addressed by the intervention chosen. Based on the evidence presented in this review, the effectiveness of tailored interventions remains uncertain and more rigorous trials (including process evaluations) are needed. Further research needs to address explicitly the questions of identifying and addressing barriers.

Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes.

ContextAlthough chest pain is widely considered a key symptom in the diagnosis
of myocardial infarction (MI), not all patients with MI present with chest
pain. The extent to which this phenomenon occurs is largely unknown.ObjectivesTo determine the frequency with which patients with MI present without
chest pain and to examine their subsequent management and outcome.DesignProspective observational study.Setting and PatientsA total of 434,877 patients with confirmed MI enrolled June 1994 to
March 1998 in the National Registry of Myocardial Infarction 2, which includes
1674 hospitals in the United States.Main Outcome MeasuresPrevalence of presentation without chest pain; clinical characteristics,
treatment, and mortality among MI patients without chest pain vs those with
chest pain.ResultsOf all patients diagnosed as having MI, 142,445 (33%) did not have chest
pain on presentation to the hospital. This group of MI patients was, on average,
7 years older than those with chest pain (74.2 vs 66.9 years), with a higher
proportion of women (49.0% vs 38.0%) and patients with diabetes mellitus (32.6%
vs 25.4%) or prior heart failure (26.4% vs 12.3%). Also, MI patients without
chest pain had a longer delay before hospital presentation (mean, 7.9 vs 5.3
hours), were less likely to be diagnosed as having confirmed MI at the time
of admission (22.2% vs 50.3%), and were less likely to receive thrombolysis
or primary angioplasty (25.3% vs 74.0%), aspirin (60.4% vs 84.5%), β-blockers
(28.0% vs 48.0%), or heparin (53.4% vs 83.2%). Myocardial infarction patients
without chest pain had a 23.3% in-hospital mortality rate compared with 9.3%
among patients with chest pain (adjusted odds ratio for mortality, 2.21 [95%
confidence interval, 2.17-2.26]).ConclusionsOur results suggest that patients without chest pain on presentation
represent a large segment of the MI population and are at increased risk for
delays in seeking medical attention, less aggressive treatments, and in-hospital
mortality.

https://jamanetwork.com/journals/jama/articlepdf/192825/JOC00166.pdf

Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain.

Objective : To assess trends in the use of self-report measures in research on adherence to practice guidelines since 1980, and to determine the impact of response bias on the validity of self-reports as measures of quality of care.

Methods : We conducted a MEDLINE search using defined search terms for the period 1980 to 1996. Included studies evaluated the adherence of (e.g. medical records), we compared self-reported and objective adherence rates (measured as per cent adherence). Evidence or response bias was defined as self-reported adherence significantly exceeding the objective measure at the 5% level.

Results : We identified 326 studies of guideline adherence. The use of self-report measures of adherence increased from 18% of studies in 1980 to 41% of studies in 1985. Of the 10 studies that used both self-report and objective measurers, eight supported the existence of response bias in all self-reported measures. In 87% of 37 comparisons, self-reported adherence rates exceeded the objective rates, resulting in a median over-estimation of adherence of 27% (absolute difference).

Conclusions : Although self-reports may provide information regarding clinicians' knowledge of guideline recommendations, they are subject to bias and should not be used as the sole measure of guideline adherence.

Key words : clinical competence, physician practice patterns, practice guidelines, process assessment, quality assurance, quality of care measurement

Evidence of self-report bias in assessing adherence to guidelines.

Background Although increased attention has been paid to sex and racial differences in the management of myocardial infarction, it is unknown whether these differences have narrowed over time. Methods With the use of data from the National Registry of Myocardial Infarction, we examined sex and racial differences in the treatment of patients who were deemed to be “ideal candidates” for particular treatments and in deaths among 598,911 patients hospitalized with myocardial infarction between 1994 and 2002. Results In the unadjusted analysis, sex and racial differences were observed for rates of reperfusion therapy (for white men, white women, black men, and black women: 86.5, 83.3, 80.4, and 77.8 percent, respectively; P<0.001), use of aspirin (84.4, 78.7, 83.7, and 78.4 percent, respectively; P<0.001), use of beta-blockers (66.6, 62.9, 67.8, and 64.5 percent; P<0.001), and coronary angiography (69.1, 55.9, 64.0, and 55.0 percent; P<0.001). After multivariable adjustment, racial and sex differences persiste...

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Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002.

Background: Evidence-based guidelines for the treatment of patients with acute myocardial infarction (AMI) have been published and disseminated by the American College of Cardiology and the American Heart Association. Few studies have examined the rates of adherence to these guidelines in eligible populations and the influence of age and gender on highly effective AMI treatments in community hospital settings. Methods: Medical records of 2409 individuals admitted to 37 Minnesota hospitals between October 1992 and July 1993 for AMI, suspected AMI, or rule-out AMI, and meeting electrocardiographic, laboratory, and clinical criteria suggestive of AMI were reviewed to determine the proportion of eligible patients who received thrombolytic, β-blocker, aspirin, and lidocaine hydrochloride therapy. The effects of patient age, gender, and hospital teaching status on the use of these treatments were estimated using logistic regression models. Results: Eligibility for treatment ranged from 68% (n=1627) for aspirin therapy, 38% (n=906) for lidocaine therapy, and 30% (n=734) for thrombolytic therapy to 19% (n=447) for β-blocker therapy. Seventy-two percent of patients eligible to receive a thrombolytic agent received this therapy; 53% received β-blockers; 81% received aspirin; and 88% received lidocaine. Among patients ineligible for lidocaine therapy (n=1503), 20% received this agent. Use of study drugs was lower among eligible elderly patients, especially those older than 74 years (thrombolytic agent: odds ratio, 0.2; 95% confidence interval, 0.1 to 0.4; aspirin: odds ratio, 0.4, 95% confidence interval, 0.3 to 0.6;β-blocker: odds ratio, 0.4; 95% confidence interval, 0.2 to 0.8). Female gender was associated with lower levels of aspirin use among eligible patients (odds ratio, 0.7; 95% confidence interval, 0.6 to 0.9); and there was a trend toward lower levels of β-blocker and thrombolytic use among eligible women. Conclusions: Use of lifesaving therapies for eligible patients with AMI is higher than previously reported, particularly for aspirin and thrombolytic use in nonelderly patients. Lidocaine is still used inappropriately in a substantial proportion of patients with AMI. Increased adherence to AMI treatment guidelines is required for elderly patients and women. (Arch Intern Med. 1996;156:799-805)

/pdf/adherence-to-national-guidelines-for-drug-treatment-of-36zja04kff.pdf

Adherence to National Guidelines for Drug Treatment of Suspected Acute Myocardial Infarction: Evidence for Undertreatment in Women and the Elderly

In order to assess the effect of clinical training and didactic instruction on medical student attitudes toward managed care, we conducted a survey of all medical students at the midpoint of their third year clerkships at the University of Massachusetts Medical School. The students were exposed to clinical training in managed care settings and a 2-day required course on the principles underlying managed care. The main outcome measures were student attitudes toward the concepts of managed care, managed care organizations, and future careers in managed care. Students also assessed the attitudes of medical faculty toward managed care. Attitudes of students with previous clinical training in managed care settings did not differ from those of students without such exposure toward the concepts underlying managed care or managed care organizations and were less positive about careers in managed care. Student responses before and after the 2-day course on managed care demonstrated that attitudes moved in a significantly positive direction. Seventy-one percent of students reported that the opinions they had heard from medical faculty about managed care were negative. Preparing medical students to practice medicine effectively in managed care settings will require focused attention on managed care issues in the medical school curriculum and the combined efforts of academic health centers and managed care organizations.

Linda Casey

Papers

Adherence to National Guidelines for Drug Treatment of Suspected Acute Myocardial Infarction: Evidence for Undertreatment in Women and the Elderly

Introducing managed care to the medical school curriculum: effect on student attitudes.