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The Role of Clinical Opinion Leaders in Guideline Implementation and Quality Improvement^*

^* From the Healthcare Education and Research Foundation, St. Paul, MN.

Correspondence to: Catherine Borbas, PhD, MPH, Healthcare Education and Research Foundation, 2550 University Ave West, Suite 325 South, St. Paul, MN 55114; e-mail: Cborbas{at}herf-mn.org

	Abstract

TOP Abstract Introduction Theoretical Frameworks Relevant... Materials and Methods Results Conclusion References

 
Background: The lag between the publication of clinical and health-services research and the application of this information is substantial and delays health-care improvement. A wide range of corrective strategies are being used to address this issue.

Objectives: Evolution in the use of significant opinion leaders is described. Hospital quality improvement projects, undertaken by the Healthcare Education and Research Foundation (HERF), are used to illustrate the roles assumed by clinical opinion leaders. Specific theoretical frameworks are reviewed that are fundamental to successful implementation of opinion leader strategies, as well as key research on the use of clinical opinion leaders.

Results: Over the past 12 years, HERF has identified the need to address not only the information needs of clinicians and organizations but also the social and organizational factors that interfere with the application of research and guidelines. The complexity of this task cannot be underestimated. However, armed with well-developed guidelines and the opportunity to work within structured guideline implementation programs with well-defined objectives and systematically applied methods, HERF’s experience suggest local clinicians and communities can meet this challenge.

Key Words: clinical guidelines • clinical opinion leaders • quality improvement

	Introduction

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The lag between the publication of clinical and health-services research and the application of this information is substantial and delays health-care improvement.¹ Medical-specialty societies, federal health-care organizations, health plans, and health-care organizations are attempting to address this issue. A wide range of corrective strategies are being used, such as guideline programs, continuing medical education, self-instructed learning, audit and feedback of clinical information, provider reminder and computer support systems, financial incentive programs, and "academic detailing." Interventions that rely to some degree on clinical champions or also have been shown to be effective at influencing clinical behavior in certain situations and settings.^{2 3 4 5} However, it has been difficult to fully evaluate the effectiveness of opinion leader interventions due to the broad range of poorly defined and often oversimplified interventions that have been labeled as opinion leader strategies.

For the past 12 years, a nonprofit applied research organization in St. Paul, Minnesota, the Healthcare Education and Research Foundation (HERF), has implemented and tested many strategies designed to encourage clinicians to apply research and clinical guidelines in order to improve clinical care. Clinical opinion leaders have been centrally involved in all of these activities.^{6 7 8}

	Theoretical Frameworks Relevant to Clinical Behavior Change

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Diffusion Innovation Research
For the past 50 years, research has been undertaken to understand how and why certain types of innovations and changes are accepted or rejected. Innovation diffusion research isolates important characteristics of the innovation that influence individuals to change their behavior. Everett Rogers^{9 10} defines diffusion as the process by which (1) an innovation that is perceived as new by an individual or a group (2) is communicated through certain channels (3) over time (4) among the members of a social system. The rate of adoption often follows an s-shaped curve spreading through groups of individuals with certain characteristics (Table 1 ).

Adult Learning Theory
Programs designed to disseminate new information and change clinical behavior, such as guideline programs, continuing medical education, physician-profiling programs, and certain audit and feedback programs rely to some degree on adult-learning principles.^{11 12} Some clinical educational programs have been successful if done on a one-to-one basis, but many programs have had very limited success.^{11 12 13 14} In order to be more effective, guideline programs and other behavior change and quality improvement programs must go beyond traditional educational strategies and begin to incorporate concepts from other disciplines such as sociology and psychology, as well as from communication and marketing experts.

Social Influence Research
The research undertaken by psychologists and sociologists is relevant to clinical behavior change programs because it offers an understanding of why and how individuals and groups change, as well as the process of this change. Studies have shown that in certain circumstances, individuals subordinate their own judgments, beliefs, values, decision making, and behavior, and rely on the judgments of significant "reference groups" to which they belong or hope to belong.^{15 16 17 18}

It has been recognized for some time that informal communication networks exist within groups, and that certain members influence the beliefs, values, attitudes, and behaviors of other members: Lippitt et al²⁰ described "change agents" as individuals who promoted change within a group. Haveloch²¹ elaborated on this and described this role as one of a catalyst, process helper, or resource lender. Lewin²² referred to certain individuals as "gatekeepers" because they informally influenced a group by controlling access to information. In their study of the flow of new information into a research laboratory, Allen and Cohen²³ found that certain scientists within research laboratories served as informal consultants to their colleagues and acted as gatekeepers by determining which and what kind of information flowed to their colleagues were exposed to. Knowledge utilization and diffusion researchers describe "linking agents" or change agents who provide personal connections between the creator of an innovation or new knowledge and the ultimate user.¹⁹

It has been suggested that the judgements of group members are dependent on those of their reference group and its opinion leaders when a group is highly uncertain about a proposed change, when clear information is not available to them, and when the group is homogenous and highly cohesive.¹⁶ These factors are often present throughout the implementation of guidelines and quality improvement efforts. Therefore, these types of programs could be enhanced by a systematic process that identifies and capitalizes on the power of significant reference groups and informal opinion leaders.

Kelman²⁴ discussed the following processes of social influence:

1. Compliance occurs when an individual accepts influence from a person or group in order to gain a favorable reaction from the other. In order to be sustained, this type of behavior change must be consistently monitored or it will revert to its original form.

2. Identification occurs when an individual assumes a behavior in order to establish or maintain a relationship with an individual or certain group held in high esteem. To be maintained, this type of behavior change is dependent on the durability of the power or prestige of the influencing person or group.

3. Internalization occurs when an individual accepts the influence of another or group and assumes a behavior because it is congruent with his beliefs and values. The content of the behavior is intrinsically rewarding to him. This is not always a "rational" decision, but it is congruent with the individual and his own orientation.

By guiding the selection of specific motivational strategies required for the maintenance of the changes, this framework is very relevant to planning guideline implementation and quality improvement efforts.

Clinical Opinion Leader Research
The influence of local, informal medical opinion leaders in the diffusion and adoption of medical innovations and refinements of medical practice has been recognized for almost half a century.^{1 25 26} Informal clinical opinion leaders tend to be those individuals who are respected sources of information, not as innovators but as early adopters who are well integrated with their peers in the medical community.¹ It must be stressed that these are informal leaders and not authority figures or physicians in administrative roles, but rather practicing physicians who work in settings similar to their colleagues, and "walk in their shoes."

Coleman et al²⁷ studied the flow of information among physicians and how innovations were adopted and implemented. By studying how tetracycline was adopted across communities, they concluded that interpersonal relations among physicians were the most important factors in the adoption process. Through their own informal contacts, certain physicians served as gatekeepers and determined what information and news about innovations reached their colleagues.

Wenrich and associates²⁸ identified "education influentials" in 21 community hospitals in Michigan. These physicians were sought out by their colleagues due to their position, personality, knowledge, influence, and interpersonal skills. Physicians reported that they informally turned to these influential colleagues for advice and information and patterned their clinical behavior after them. Thus, in effect, these individuals functioned as informal educators for their colleagues.

From 1976 to 1980, Ann Greer, an innovation-diffusion researcher, interviewed several hundred community hospital physicians and found that practice changes and decisions to accept new technology were anchored in the norms and relationships of local practice.¹ She described how local traditions, beliefs, and shared experiences guided practice behavior. She suggested that this phenomenon accounted for the wide practice variations across the country and the poor relationship between practice behavior and the published literature.

Similarly to earlier researchers, Greer¹ found that successful change was associated with the activities of certain local individuals known as opinion leaders or idea champions. She stressed that these were not innovators, were often therapeutically conservative, and judged new information in terms of group norms, local values, and realities of local practice.³⁰ These individuals made it possible for others to connect external knowledge and local context. They stimulated interaction among their colleagues and provided both technical clarification and social support.

Stross and Bole³⁰ found that easily completed surveys of community physicians could identify local physicians with informal influence among their peers and who served as informal mentors for specific areas of practice. For specific medical conditions or well-defined clinical practices, the physicians were asked to name colleagues to whom they turned for informal advice. The survey instrument consisted of three statements that described the following sets of personal characteristics that had been shown to be associated with opinion leaders³¹ : knowledge (eg, they were current and up to date, and demonstrated a high level of expertise); communication (eg, they enjoyed and were willing to share knowledge, they never seemed too busy to be helpful, and they offered clear and practical information); humanism (eg, caring physicians; they never talked down to their colleagues).

Lomas and colleagues⁴ undertook a randomized controlled trial with 76 physicians in 16 community hospitals in Canada to evaluate and compare the effectiveness of an audit and feedback intervention and an opinion leader educational intervention aimed at improving compliance with guidelines.

Using a version of the previously described Stross and Bole survey,³⁰ this study identified local opinion leaders in the study setting and asked them to review obstetrical guidelines chosen for the study and agree to a series of mailings under their signature to all physicians who provided obstetrical care in their hospital. These mailings entailed visually attractive materials similar to "detailing sheets" about the focus guidelines, the full guideline text, a bibliography, plus letters of support for the guideline recommendations. The opinion leaders were asked to host meetings with V-BAC experts who were credible in the target communities. Finally, the opinion leaders were asked to maintain and enhance their typical formal and informal contacts with their colleagues during the 12-month intervention period. After 24 months, the trial of labor rates and V-BAC rates in the audit and feedback group were no different from those in the control group. However, for the groups on the opinion leader intervention, trial of labor rates were 46% higher and the V-BAC rates were 85% higher.

Soumerai and Avorn³² have developed a behavior change intervention, referred to as "academic detailing," that has successfully altered physicians’ prescribing patterns in a variety of clinical settings. This strategy adapted many principles from not only adult learning and previous opinion leader research but also from communication and marketing research. Soumerai and colleagues implemented very targeted clinical interventions by adapting for clinical settings marketing interventions that had been successful in other industries. Table 2 summarizes the six phrases typical of marketing interventions.³²

Case Study
Building on this research, in 1988 a project to improve the quality of AMI care in Minnesota was undertaken by Stephen Soumerai and the Healthcare Education and Research Foundation (HERF).⁸

Setting
HERF is a 501(c)3, nonprofit, applied research organization that provides a collaborative forum and technical expertise to address the overlapping quality of care interests and needs of Minnesota physicians, hospitals, health plans, and health-care purchasers. The mission of HERF is to improve the quality of Healthcare in Minnesota.

HERF is not involved in routine monitoring of care, but instead provides very intensive, condition-specific evaluations on topics of broad concern across the community. Using nationally developed and locally reviewed guidelines as a blueprint for these evaluations, HERF gathers data from hospitals, clinics, providers, health plans, and patients and then works with systematically identified, local clinical opinion leaders to present this information in a variety of formats, both oral and written, to well-identified target audiences. The participants then have the opportunity to evaluate and act on these findings and recommendations. Within 9 to 12 months, HERF initiates a second round of data collection to see if any changes in clinical behavior, organizational processes, and improvement in patient care have occurred (Fig 1 ). To date, six statewide projects have been undertaken (Table 3 ).

View larger version (17K): [in this window] [in a new window] [Download PPT slide]   Figure 1.. Overview of the HERF process.

	Materials and Methods

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The HERF staff (ie, specially trained coronary care unit, ICU, and emergency department nurses) collected very detailed information from patient records. Patient eligibility for the four study drugs was based on American College of Cardiology (ACC) and American Heart Association (AHA) guidelines.³³ The specific information collected is summarized in Table 4 .

In previous HERF studies, opinion leaders were chosen from among existing medical or quality improvement directors or by asking this group for candidates from their clinical staff. Opinion leaders selected from the medical and quality improvement directors group often lacked expertise and credibility in the particular clinical under study. Also, due to their administrative role, these physicians were often viewed skeptically by their colleagues. Opinion leaders who had been selected through an informal process of recommendations often lacked the necessary skills to sustain projects. These candidates offered good clinical expertise but often did not possess the other necessary traits (ie, communication skills and humanism) identified by the research of Stross and Bole.³¹ All physicians who treated AMI patients at the experimental hospitals were asked to identify physicians to whom they turned with questions about the care of AMI patients. This process identified cardiac opinion leaders who possessed not only clinical expertise, but also good interpersonal and communication skills. They also shared a genuine interest in working with their colleagues and an interest in participating in this project. This group had very frank and productive discussion among themselves and with the project staff. These clinicians had innate skills at knowing how to work effectively in their own hospitals and excellent skills for engaging others to creatively solve problems. The opinion leaders’ enthusiasm and obvious support for the project encouraged participation by their colleagues and reduced the typical amount of time required to create "buy-in" for this type of project.

Clinical opinion leaders we recruited for each experimental hospital and were asked to do the following:

1. Initially evaluate the nationally developed guidelines.

2. Help design the data collection and analysis methodology.

3. Assist with data analysis.

4. Review the aggregate data and knowledge and attitude survey results, and help the project team understand gaps between the knowledge and practice of the target audience.

5. Provide hospital-specific results to clinicians and staffs at the individual hospitals.

6. Help engage and stimulate hospital clinicians and staff to act on this information and develop improvement strategies.

The project team presented the aggregate clinical findings and the results of the knowledge and attitude survey to the opinion leader group, in order to solicit possible causes of gaps between knowledge and practice. The group openly shared their personal beliefs, attitudes, and experiences that influenced their care of AMI patients and identified specific motivational factors (eg, personal, interpersonal, organizational, and patient factors) that influenced clinicians’ practice and ability to apply the ACC/AHA guidelines. This information guided the preparation of hospital reports, presentations, and strategies for working with the hospitals to develop improvement strategies.

Hospital-specific reports were prepared comparing the findings for each hospital with the remainder of the group. For hospitals in the experimental group, the clinical opinion leaders worked with HERF staff and hospital staff to identify the best methods to disseminate and analyze the hospital-specific information, and to engage appropriate clinical and administrative staff and key clinical and administrative committees (eg, department meetings, service line teams) and help them act on the findings to improve care.

At each hospital, the comparative information was presented to key groups and individuals in a very interactive fashion by the hospital opinion leader. At these meetings, the opinion leader, HERF staff, and hospital staff members did the following: (1) reviewed the gaps between knowledge and practice, (2) identified possible hospital-specific reasons for these gaps and potential barriers to application of the guideline, and (3) developed specific improvement strategies for each organization to address these findings. In order to focus on improvement strategies, HERF staff summarized these discussions for the hospital by preparing a grid that classified barriers to improvement into one of six categories. See Tables 5 , 6 .

This latter category of barriers was the most difficult to deal with, since hospital quality improvement staff, clinicians, and other staff were often poorly trained or equipped to readily discuss and address these types of problems. Consequently, these types of issues often become very ingrained and part of "local tradition."

The opinion leaders and HERF staff were very involved with the experimental hospitals, coordinating and initiating, when necessary, appropriate meetings, reports, or other resources to mobilize and facilitate improvement activities for the hospital. Not only clinicians, but hospital administrators and hospital system leadership also were actively engaged in helping stimulate and encourage the effort. The control hospitals did not receive any additional support, and opinion leaders were not recruited to promote use of the information. However, similar to the experimental hospitals, control hospitals received a report on their findings compared to the remainder of the group. The hospitals had the opportunity to act on their information from December of 1994 to July of 1995. The second round of medical record data collection was then initiated to evaluate the effect of these activities.

	Results

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The effectiveness of this intervention was determined by analysis of preintervention vs postintervention changes in (1) the proportion of eligible patients receiving each of the effective drug categories, and (2) the proportion of patients without indication who received lidocaine.

Overall, the intervention resulted in a significant increase in aspirin and ß-blocker use. Among experimental hospitals, the median change in the proportion of eligible elderly receiving aspirin was + 0.13 (17% increase over the baseline proportion of 0.77), as compared with the median change of - 0.03 at control hospitals (p = 0.04). Fourteen of 17 experimental hospitals with at least seven eligible patients both preintervention and postintervention exhibited a positive change in aspirin use, as compared with only 5 of 13 control hospitals. There was a strong secular decline in nonindicated lidocaine use at all hospitals, which overwhelmed any potential intervention effects. There was approximate 50% reduction in the proportion of ineligible patients receiving lidocaine to about 10% postintervention in both experimental and control hospitals. Although the number of hospitals and thrombolytic-eligible elderly patients in the control group was too low to yield stable estimates of changes in thrombolysis, the intervention did not increase thrombolytic use in eligible elderly patients at experimental hospitals. Table 7 summarizes the survey findings. A more detailed description of the methods and results of this study has been reported elsewhere.⁸

	Conclusion

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Projects undertaken by HERF have consistently relied on local clinical opinion leaders to not only endorse but also to lend their expertise to implementing guideline and quality improvement projects. Opinion leaders’ influence, expertise, interpersonal skills, understanding of local practice, and frank advice about why gaps exist between guideline knowledge and practice have been essential to the success of the project.

In 1988, HERF’s initial projects were based on the assumption that in order to improve care, clinicians primarily needed more concise information and user-friendly formats and systems to help them apply research findings, guidelines, and other practice recommendations. However, over the past 12 years, projects have increasingly been designed to address not only the information needs of clinicians and organizations, but also the social and organizational factors that interfere with application of research and guidelines. The complexity of this task cannot be underestimated and must be recognized and addressed if guidelines and research are to be successfully implemented. However, HERF projects have suggested that, armed with well-developed guidelines and given the opportunity to work within structured guideline implementation programs with well-defined objectives and systematically applied methods, local clinicians and communities can meet this challenge.

	Footnotes

 
Abbreviations: ACC = American College of Cardiology; AHA = American Heart Association; AMI = acute myocardial infarction; HERF = Healthcare Education and Research Foundation; V-BAC = vaginal birth after cesarean

	References

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