Local opinion leaders effects on professional practice and health care outcomes
This commentary is now outdated and has been replaced by a new commentary. It is included in RHL for archival purposes only. It may be cited as: Souza JP. Local opinion leaders: effects on professional practice and health-care outcomes: RHL commentary (last revised: 17 July 2007 The WHO Reproductive Health Library; Geneva: World Health Organization.
RHL Commentary by Souza JP
1. EVIDENCE SUMMARY
Is the use of a local opinion leader effective in improving practices of health-care professionals and patient outcomes? To answer this question, the reviewers updated in 2007 (1) a previous version of the Cochrane review (2). They used a comprehensive search strategy and included 12 randomized controlled trials. The reviewers critically appraised the included studies, assessed heterogeneity between trials and performed subgroup and sensitivity analysis. Among the included trials the risk of bias was considered moderate or high in 11 studies. But, the effectiveness of the opinion leader intervention was lower in studies considered to be at high risk of bias.
Eleven studies were carried out in developed countries (United States and Canada) and one in China (Hong Kong, Special Administrative Region). The target of the intervention was physicians (nine trials), nurses (two trials) and physicians, nurses and midwives (one trial). Most of the trials evaluated interventions delivered in hospitals. Unfortunately, the educational methods that opinions leaders used could not be reliably assessed due to the limited information in most studies.
The main comparisons performed were: opinion leaders versus no intervention, opinion leaders versus single intervention, opinion leaders with additional intervention versus additional intervention, and opinion leaders as part of multiple interventions versus no intervention. The main outcome studied was compliance with a proposed practice, including evidence-based practices. The review found that the use of opinion leaders increased compliance with the proposed practice; the median adjusted risk difference indicates a 10% absolute decrease in non-compliance in the opinion leaders group.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
A substantial proportion of patients worldwide are not treated with the best existing practice for their condition. Ineffective, unsafe or harmful practices are still part of regular care in many settings. The use of beneficial and effective forms of care (e.g. magnesium sulfate for eclampsia or selective rather than routine episiotomy) should be optimized worldwide.
Translating scientific evidence into health policy and practice is fundamental to improving health-care outcomes. In the last decade, implementing best practices (evidence-based, patient-centered and cost–effective) has become a major global goal. Although there is a need to ensure that evidence-based practices are used in both developed and developing countries, use of evidence-based health care is more relevant in developing countries and among socioeconomically disadvantaged groups, where health-care resources are scarce and it is crucial to use the limited resources well (3).
2.2. Applicability of the results
This review evaluated a strategy for implementing evidence-based practices. The use of local opinion leaders was shown to be effective in improving compliance with best practices.
The vast majority of the studies reviewed (10 out of 11) were conducted in developed countries. The educational methods that opinions leaders used in these studies have not been satisfactorily evaluated in the review. The studies included in the review were mainly focused on physician’s behaviour and hospital facilities. It is not known whether the effect of local leaders varies in different in developing-country settings or varies according to health-care profession or level of health-care facility.
2.3. Implementation of the intervention
First, it is important to identify the practices that need to be replaced by evidence-based practices. Systematic reviews are essential for this task. RHL, along with the Cochrane Collaboration, evidence-based journals, professional associations and governmental and nongovernmental organizations can play a major role in this.
A multifaceted strategy, including audit and feedback and use of local opinion leaders, seems to be effective for improving reproductive health care (2, 4). The first key step in using local opinion leaders as promoters of best practices is to identify such leaders. The second step is to raise awareness among the staff about the best practices selected for introduction, while motivating and persuading the staff to use the best practices; it is equally important to support the efforts of the opinion leaders (5). Defining priorities for interventions (i.e. eliminating forms of care likely to be harmful or implementing selected beneficial forms of care) can probably be useful.
Further research on the effectiveness of strategies for implementation of best practices is still needed, with emphasis on strategies suitable for developing-country settings. Also warranted are further trials of the effectiveness of opinion leaders and of the methods used by them to facilitate the implementation of evidence-based practices.
Sources of support: University of Campinas, Campinas, Brazil.
- Doumit G, Gattellari M, Grimshaw J, O'Brien MA. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2007;Issue 1. Art. No.: CD000125. DOI: 10.1002/14651858.CD000125.pub3.
- O'Brien MA, Oxman AD, Haynes RB, Davis DA, Freemantle N, Harvey EL. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 1999;Issue 1. Art. No.: CD000125; DOI: 10.1002/14651858.CD000125.
- Aaserud M, Lewin S, Innvaer S, Paulsen EJ, Dahlgren AT, Trommald M, et al. Translating research into policy and practice in developing countries: a case study of magnesium sulphate for pre-eclampsia. BMC Health Serv Res 2005;5:68. Medline
- Chaillet N, Dubé E, Dugas M, Audibert F, Tourigny C, Fraser WD, et al. Evidence-based strategies for implementing guidelines in obstetrics: a systematic review. Obstet Gynecol 2006;108:1234-45. Medline
- Kravitz RL, Krackhardt D, Melnikow J, Franz CE, Gilbert WM, Zach A, et al. Networked for change? Identifying obstetric opinion leaders and assessing their opinions on caesarean delivery. Soc Sci Med 2003;57:2423-34. Medline
This document should be cited as: Souza JP. Local opinion leaders: effects on professional practice and health-care outcomes: RHL commentary (last revised: 17 July 2007 The WHO Reproductive Health Library; Geneva: World Health Organization.