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Research:
Finlay A. McAlister, Miriam Fradette, Sumit R. Majumdar, Randall Williams, Michelle Graham, James McMeekin, William A. Ghali, Ross T. Tsuyuki, Merril L. Knudtson, and Jeremy Grimshaw
The Enhancing Secondary Prevention in Coronary Artery Disease trial
CMAJ 2009; 181: 897-904 [Abstract] [Full text] [PDF]
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[Read eLetter] Understanding why didn’t the intervention work
Noah M Ivers MD CCFP   (4 January 2010)

Understanding why didn’t the intervention work 4 January 2010
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Noah M Ivers MD CCFP
Women's College Hospital, University of Toronto

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Re: Understanding why didn’t the intervention work

noah.ivers{at}utoronto.ca Noah M Ivers MD CCFP

I would like to congratulate the authors of ESP-CAD(1) for their excellent design and thorough analysis of this cluster randomized control trial. It is true that the majority of chronic disease care in Canada (such as management of coronary artery disease) occurs in primary care and that there is room for improvement in how we manage these patients.(2) Therefore, there is a great need for ongoing work to determine how to best assist primary care providers to close the “quality-care-gap”. Reports from opinion leaders are an intuitively appealing tool to accomplish this goal.

As a family physician, two possible explanations come to mind for these surprisingly ‘negative’ results. First, since the patients had elective catheterizations, the primary care providers may have assumed ongoing follow-up with a cardiologist and they may have assumed that the cardiologist was responsible for secondary prevention prescriptions.(3) Secondly, with over 80% on a Statin, it is possible (or even likely) that these patients had other co-morbidities judged (by the physician or by the patient) to be of higher priority than reaching a maximal Statin dose (or a LDL < 2). After all, for many patients, (especially those with multiple co-morbidities,) what’s best for the disease is not always what’s best for the patient.(4)

Finally, I agree with the authors that simple interventions are worth testing, and I wonder if the team may have benefited from adding a qualitative component to this intervention. This may have allowed the team to identify barriers to prescribing for coronary artery disease(5) and to potentially adjust the intervention accordingly. The result could have been a perception that the intervention was ‘ground-up,’ (rather than ‘top -down,’) thereby leading to greater buy-in.(6) Another option may be to conduct interviews with the participating physicians after the intervention to learn more about why it did not work as expected. Even if a systematic assessment of barriers leads to an appropriate choice of intervention, we would know very little about how exactly to deliver it. Multi-arm RCTs such as ESP-CAD are greatly needed in quality improvement research and to answer the essential question, “does X work better this way or that way”? Given the appeal of opinion leader statements as a simple and potentially effective tool for quality improvement, what is needed now is additional work to better understand - possibly by considering relevant theoretical frameworks(7) - “how/when/why does X work”. With this information, we might decrease the chance of ‘negative’ trials in future.

References

(1)McAlister FA, et al. The Enhancing Secondary Prevention in Coronary Artery Disease trial. CMAJ. 2009 Epub Nov 23. doi:10.1503/cmaj.090917.

(2)Austin P. Tu JV, Ko DT, Alter DA. Factors associated with the use of evidence-based therapies after discharge among elderly patients with myocardial infarction CMAJ. 2008 Oct 21;179(9):901-8

(3)Kripalani S, LeFevre F, Phillips C, Williams M, Basaviah P, Baker D: Deficits in communication and information transfer between hospital- based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007, 297(8):831-841.

(4)Upshur RE, Tracy S. Chronicity and complexity: is what's good for the diseases always good for the patients? Can Fam Physician. 2008 Dec;54(12):1655-8.

(5)Kedward J, Dakin L. A qualitative study of barriers to the use of statins and the implementation of coronary heart disease prevention in primary care. Br J Gen Pract. 2003 Sep;53(494):684-9.

(6)Parker LE, de Pillis E, Altschuler A, Rubenstein LV, Meredith LS. Balancing participation and expertise: a comparison of locally and centrally managed health care quality improvement within primary care practices. Qual Health Res. 2007 Nov;17(9):1268-79.

(7)Walker A, Grimshaw JM, Johnston M, Pitts N, Steen N, Eccles MP: PRocess modelling in ImpleMEntation research: selecting a theoretical basis for interventions to change clinical practice. BMC Health Services Research 2003, 3:22.

Conflict of Interest:

None declared