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Improving Adherence to Dementia Guidelines through Education and Opinion Leaders: A Randomized, Controlled Trial

David R. Gifford, MD, MPH; Robert G. Holloway, MD, MPH; Martin R. Frankel, PhD; Carol L. Albright, MS; Rebecca Meyerson, MD; Robert C. Griggs, MD; and Barbara G. Vickrey, MD, MPH
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From Brown University School of Medicine, Providence, Rhode Island; University of Rochester, Rochester, New York; Baruch College, City University of New York, New York, New York; Albright Consulting, St. Paul, Minnesota; and University of California and Alzheimer's Disease Research Center of California, Los Angeles, California.

Disclaimer: The opinions contained in this paper represent the views of the authors only and do not necessarily reflect those of the American Academy of Neurology, New York State Department of Health, University of California, Brown University, or the University of Rochester.

Acknowledgments: The authors thank Ted Munsat, MD, for supporting the development of the proposal and carrying out the project; American Association of Neurology presidents Ken Viste, MD, and Steve Ringel, MD, for continuous support; Oliver Fein and Lewis Rowland for assistance; Elliott Mancall, MD, and Ann Lambert, who were instrumental in the production of the CONTINUUM Dementia Care course; and Richard Kravitz, MD, Alvin Mushlin, MD, Carol Dingleday, and Todd Gerber for critiquing sections of the course. They also thank the opinion leaders—Gerry Honch, MD, Ralph Jozefowicz, MD, John Wolf, MD, Stuart Factor, MD, Venkat Ramani, MD, Frederick Munschauer, MD, Linda Hershey, MD, Ronald Kanner, MD, Gary Kaplan, MD, Richard Libman, MD, Jerome Posner, MD, and Stanley Turhim, MD—and the other advisory panel members—Ken Kosik, MD, Steven Greenberg, MD, John Morris, MD, James Sabry, MD, Mary Anne Corasaniti, Bonnie Goldstein, Jenny Osborn, Jean Marks, Marvin Leroy, Mary Ann Richard, Karen Drumm, and John Jager. Finally, the authors thank Sue Rodmyre and Ashley Crittenden for coordination of the project at the American Academy of Neurology.

Grant Support: By a grant to the American Academy of Neurology from the New York State Department of Health (Albany, New York, Comptroller #C-012600).

Requests for Reprints: David R. Gifford, MD, MPH, Division of Geriatrics, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903; e-mail, David_Gifford@brown.edu.

Current Author Addresses: Dr. Gifford: Division of Geriatrics, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903.

Dr. Holloway: Mt. Hope Professional Building, 1351 Mt. Hope Avenue, Suite 216, Rochester, NY 14620.

Dr. Frankel: 14 Patricia Lane, Cos Cob, CT 06807.

Ms. Albright: 2031 Goodrich Avenue, St. Paul, MN 55105.

Dr. Meyerson: St. Mary's/Duluth Clinic, 400 East 3rd Street, Duluth, MN 55805.

Dr. Griggs: Department of Neurology, Box 673, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642.

Dr. Vickrey: University of California, Los Angeles, Department of Neurology, C-128 Reed Neurological Research Center, Box 951769, Los Angeles, CA 90095-1769.

Ann Intern Med. 1999;131(4):237-246. doi:10.7326/0003-4819-131-4-199908170-00002
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Many medical specialty societies devote substantial resources to the development and dissemination of practice guidelines. Studies suggest that passive dissemination (such as publication or mailing of guidelines) is ineffective in increasing adoption of recommendations into clinical practice (15). Educational efforts to increase physicians' adoption of guidelines are more likely to be effective when they are local, are multifaceted, and incorporate strategies that use a “social influence” model of change (12, 4, 69). In particular, opinion leaders—respected authorities within a medical community—have been shown to influence the adoption of guidelines (1, 7, 1011). However, despite the widespread development and endorsement of guidelines by specialty societies, little research has been done on the effectiveness of guideline implementation efforts (35, 12).

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Figure 1.
Participant flow and follow-up.nnnPCME

A random-number generator was used to assign 417 eligible neurologists to one of three groups of 139 neurologists each. The randomization scheme was concealed from all study personnel except the computer programmer and the project coordinator. A trend was seen for more neurologists to “drop out” of the study after randomization (that is, move) from the intervention group ( = 27) compared with the baseline ( = 14) and control ( = 14) groups ( = 0.1). Neurologists in the baseline and control groups were notified of the study when they received the survey; neurologists in the intervention group were informed at the start of the intervention. Among neurologists in the intervention group, 44% (49 of 112) attended a seminar; attendance ranged from 26% to 70% across the six study regions. Among the neurologists in the intervention group who responded to the survey and answered the question about reading the course, 42% (39 of 93) reported thoroughly reading some or all of the mailed continuing medical education ( ) dementia care course. The baseline group received the survey by mail 3 months before the start of the intervention, whereas the control and intervention groups received the survey approximately 6 months after the start of the intervention. More than 80% of participants in all three groups responded to the survey.

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Figure 2.
Association between intensity of exposure to intervention material and adherence to guidelines in the intervention group.PP

Results are shown for the three practice recommendations that had a significant effect on adherence. White bars represent neurologists who neither read the course nor attended the seminar; striped bars represent neurologists who read some or all of the course or attended the seminar; and black bars represent neurologists who both read some or all of the course and attended the seminar. Higher adherence and more intense exposure to the intervention for two recommendations were significantly associated ( < 0.001 for referral to the Alzheimer's Association and for referral to Safe Return Program), and a trend was seen for an association with use of neuroimaging ( = 0.1). The total sample size ranged from 91 to 92 for each analysis and was less than 95 because of missing values. Error bars represent upper bound of 95% CIs.

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