Improving Adherence to Dementia Guidelines through Education and Opinion Leaders

A Randomized, Controlled Trial

17 August 1999 | Volume 131 Issue 4 | Pages 237-246

Background: Educational methods that encourage physicians to adopt practice guidelines are needed.

Objective: To evaluate an educational strategy to increase neurologists' adherence to specialty society-endorsed practice recommendations.

Design: Randomized, controlled trial.

Setting: Six urban regions in New York State.

Participants: 417 neurologists.

Intervention: The educational strategy promoted six recommendations for evaluation and management of dementia. It included a mailed American Academy of Neurology continuing medical education course, practice-based tools, an interactive evidence-based American Academy of Neurology-sponsored seminar led by local opinion leaders, and follow-up mailings.

Measurements: Neurologists' adherence to guidelines was measured by using detailed clinical scenarios mailed to a baseline group 3 months before the intervention and to intervention and control groups 6 months after the intervention. In one region, patients' medical records were reviewed to determine concordance between neurologists' scenario responses and their actual care.

Results: Compared with neurologists in the baseline and control groups, neurologists in the intervention group were more adherent to three of the six recommendations: neuroimaging for patients with dementia only when certain criteria are present (odds ratio, 4.1 [95% CI, 1.9 to 8.9]), referral of all patients with dementia and their families to the Alzheimer's Association (odds ratio, 2.8 [CI, 1.7 to 4.8]), and encouragement of all patients and their families to enroll in the Alzheimer's Association Safe Return Program (odds ratio, 10.8 [CI, 3.5 to 33.2]). For the other three recommendations, adherence did not differ between the intervention and the nonintervention groups. Agreement between scenario responses and actual care ranged from 27% to 99% for the six recommendations and was 95% or more for three of the recommendations.

Conclusion: A multifaceted educational program can improve physician adoption of practice guidelines.

Author and Article Information

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.