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Flodgren G, O'Brien MA, Parmelli E, et al. Local opinion leaders: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2019 Jun 24;6:CD000125. doi: 10.1002/14651858.CD000125.pub5. (Systematic review)
Abstract

BACKGROUND: Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Local opinion leaders (OLs) are individuals perceived as credible and trustworthy, who disseminate and implement best evidence, for instance through informal one-to-one teaching or community outreach education visits. The use of OLs is a promising strategy to bridge evidence-practice gaps. This is an update of a Cochrane review published in 2011.

OBJECTIVES: To assess the effectiveness of local opinion leaders to improve healthcare professionals' compliance with evidence-based practice and patient outcomes.

SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers on 3 July 2018, together with searching reference lists of included studies and contacting experts in the field.

SELECTION CRITERIA: We considered randomised studies comparing the effects of local opinion leaders, either alone or with a single or more intervention(s) to disseminate evidence-based practice, with no intervention, a single intervention, or the same single or more intervention(s). Eligible studies were those reporting objective measures of professional performance, for example, the percentage of patients being prescribed a specific drug or health outcomes, or both. We included all studies independently of the method used to identify OLs.

DATA COLLECTION AND ANALYSIS: We used standard Cochrane procedures in this review. The main comparison was (i) between any intervention involving OLs (OLs alone, OLs with a single or more intervention(s)) versus any comparison intervention (no intervention, a single intervention, or the same single or more intervention(s)). We also made four secondary comparisons: ii) OLs alone versus no intervention, iii) OLs alone versus a single intervention, iv) OLs, with a single or more intervention(s) versus the same single or more intervention(s), and v) OLs with a single or more intervention(s) versus no intervention.

MAIN RESULTS: We included 24 studies, involving more than 337 hospitals, 350 primary care practices, 3005 healthcare professionals, and 29,167 patients (not all studies reported this information). A majority of studies were from North America, and all were conducted in high-income countries. Eighteen of these studies (21 comparisons, 71 compliance outcomes) contributed to the median adjusted risk difference (RD) for the main comparison. The median duration of follow-up was 12 months (range 2 to 30 months). The results suggested that the OL interventions probably improve healthcare professionals' compliance with evidence-based practice (10.8% absolute improvement in compliance, interquartile range (IQR): 3.5% to 14.6%; moderate-certainty evidence).Results for the secondary comparisons also suggested that OLs probably improve compliance with evidence-based practice (moderate-certainty evidence): i) OLs alone versus no intervention: RD (IQR): 9.15% (-0.3% to 15%); ii) OLs alone versus a single intervention: RD (range): 13.8% (12% to 15.5%); iii) OLs, with a single or more intervention(s) versus the same single or more intervention(s): RD (IQR): 7.1% (-1.4% to 19%); iv) OLs with a single or more intervention(s) versus no intervention: RD (IQR):10.25% (0.6% to 15.75%).It is uncertain if OLs alone, or in combination with other intervention(s), may lead to improved patient outcomes (3 studies; 5 dichotomous outcomes) since the certainty of evidence was very low. For two of the secondary comparisons, the IQR included the possibility of a small negative effect of the OL intervention. Possible explanations for the occasional negative effects are, for example, the possibility that the OLs may have prioritised some outcomes, at the expense of others, or that an unaccounted outcome difference at baseline, may have given a faulty impression of a negative effect of the intervention at follow-up. No study reported on costs or cost-effectiveness.We were unable to determine the comparative effectiveness of different approaches to identifying OLs, as most studies used the sociometric method. Nor could we determine which methods used by OLs to educate their peers were most effective, as the methods were poorly described in most studies. In addition, we could not determine whether OL teams were more effective than single OLs.

AUTHORS' CONCLUSIONS: Local opinion leaders alone, or in combination with other interventions, can be effective in promoting evidence-based practice, but the effectiveness varies both within and between studies.The effect on patient outcomes is uncertain. The costs and the cost-effectiveness of the intervention(s) is unknown. These results are based on heterogeneous studies differing in types of intervention, setting, and outcomes. In most studies, the role and actions of the OL were not clearly described, and we cannot, therefore, comment on strategies to enhance their effectiveness. It is also not clear whether the methods used to identify OLs are important for their effectiveness, or whether the effect differs if education is delivered by single OLs or by multidisciplinary OL teams. Further research may help us to understand how these factors affect the effectiveness of OLs.

Ratings
Original Articles included in this ReviewReviews that include this article
Discipline Area Score
Physician 5 / 7
Nurse 5 / 7
Comments from MORE raters

Nurse rater

This is a worthwhile update on an interesting topic. As it is mainly medical focused, it is of no direct interest.

Nurse rater

Interesting article but I doubt that anyone would read the entire publication due to the length.

Nurse rater

The review make important points about the role of leaders in the uptake and dissemination of evidence. It will be useful when designing education and research programs and highlights the importance of engaging all stakeholders in research dissemination and implementation processes.

Nurse rater

Nursing needs everyone, not just Opinion Leaders to get on board with EBP. This is how nursing can define its practice just as medicine did long ago.

Nurse rater

This is a very worthy concept that requires more evidence to support efficacy.

Nurse rater

A well-balanced review of several high quality papers which mostly focused on physicians from affluent areas. Although, there are some positive outcomes, much remains unclear as to whether the outcomes influenced quality of care or not.

Nurse rater

As an Education Specialist with a Pediatric background, I find this article has little relevance to my practice.

Nurse rater

The evidence is very slim that there is any effect from this. It seems as though the article is more a call for more evidence based research rather than a useful review.

Nurse rater

Very dated sources were used.

Nurse rater

It seems that "local opinion leaders" would not be as effective as "national opinion leaders". It would be interesting to compare the two groups.

Physician rater

Local opinion leaders and subject matter experts influence the healthcare system and its delivery. These experts are considered credible and trustworthy in a particular field. This study reviewed the effectiveness of local opinion leaders in improving healthcare professionals’ compliance with evidence-based practice and health outcomes. Delphi process has been used for this purpose. However, the results are heterogeneous and may differ in types of intervention, setting, and outcomes therefore difficult to compare. Since this field is evolving, future studies may help to clearly describe the role and utility of their opinion.

Physician rater

The study describes formally what most clinicians probably already believe. It's useful in illustrating the issues related to this type of research. However, it does not address how to measure/improve the qualities needed by effective opinion leaders, such as peer trust.

Physician rater

This Cochrane review of the impact of local opinion leaders on uptake of evidence based behaviours is not specific to Rheumatology (and perhaps it is unclear why it is being reviewed in Rheumatology). The review mostly demonstrates which local opinion leaders may have positive impacts, the data are weak on behaviour and even weaker on impacting outcomes. Although this is useful reference for those interested, it's unlikely to impact clinical care at this time.

Physician rater

This review on opinion leaders effect on different aspects of professional practice and health outcomes highlights that leader's opinion on effectiveness varied according different studies and its effect on patient outcomes was uncertain. Other issues as cost and cost effectiveness of interventions was not clearly established, according authors conclusions.

Physician rater

This is an update of a previous Cochrane Review, which demonstrates that local opinion leaders may help and facilitate practitioners adhere to evidence.

Physician rater

The notion that leaders can influence behavior is a very good start, but will need to be followed for the effect on long term carry over, and also if specific conditions and specialties are more prone to modification!

Physician rater

I would have expected these results.

Physician rater

The authors expressed significant reservations in the value of their findings.

Physician rater

This Cochrane review evaluated the effectiveness of local opinion leaders to improve provider compliance with evidence-based practice and patient outcomes. Opinion leader influence likely affects evidence-based practice and improves compliance, but there was insufficient evidence to determine whether this impacts patient-centered outcomes.

Physician rater

Perhaps, this is an important issue but the data are really not available to evaluate it properly. In terms of information that would be helpful to improving medical care, this reviewer does not see its importance.

Physician rater

Understanding the difficulty of designing researches to answer this question, it is expected that the results of a systematic review will not point to a practical conclusion.

Physician rater

This review shows that local opinion leaders (OL) alone or in combinations with other interventions can improve healthcare professionals' compliance with evidence-based practice, but not necessary patient outcomes. It seems that the role of OL in promoting evidence-based practice needs to be redefined.
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