Influencing sceptical staff to become supporters of service improvement: a qualitative study of doctors' and managers' views.

OBJECTIVE: To explore scepticism and resistance towards changes in working practice designed to achieve service improvement. Two principal questions were studied: (1). why some people are sceptical or resistant towards improvement programmes and (2). what influences them to change their minds. METHODS: Semi-structured qualitative interviews were conducted with 19 clinicians and 19 managers who held national and regional roles in two national programmes of service improvement within the NHS involving systematic organisational changes in working practices: the National Booking Programme and the Cancer Services Collaborative (now the Cancer Services Collaborative Improvement Partnership). RESULTS: Scepticism and resistance exist in all staff groups, especially among medical staff. Reasons include personal reluctance to change, misunderstanding of the aims of improvement programmes, and a dislike of the methods by which programmes have been promoted. Sceptical staff can be influenced to become involved in improvement, but this usually takes time. Newly won support may be fragile, requiring ongoing evidence of benefits to be maintained. CONCLUSIONS: The support of health service staff, particularly doctors, is crucial to the spread and sustainability of the modernisation agenda. Scepticism and resistance are seen to hamper progress. Leaders of improvement initiatives need to recognise the impact of scepticism and resistance, and to consider ways in which staff can become positively engaged in change.

Use of coronary angiography and revascularization procedures following acute myocardial infarction. A European perspective.

AIMS: There is little evidence to inform routine practice in the use of coronary angiography and revascularization procedures after acute myocardial infarction. Large differences in the uptake of these procedures have been reported but representative data are scarce. Outcome studies have produced opposing conclusions concerning the impact of the high rate of these cardiac procedures. METHODS AND RESULTS: A population-based patient sampling approach was utilized to identify routine practice in representative samples from 11 European countries. Data were collected retrospectively on treatment in the 6 months following acute myocardial infarction (n=2807). There was wide variation in utilization of coronary angiography and revascularization procedures. Even after restricting the analysis to patients <65 years (n=1262), there remained a 6 13 fold variation in the use of these procedures. A decreased likelihood of undergoing these procedures was associated with older age. In addition, there was an independent and negative association between female sex and utilization of coronary angiography and coronary artery bypass grafting (CABG). CONCLUSION: The effect on patient outcome of the observed variation in use of these procedures is not known but has important cost and resource implications for the health services. Outcome research is needed to define patient selection criteria and to measure the cost-utility of different angiography and revascularization rates.

Beta-blockers and antithrombotic treatment for secondary prevention after acute myocardial infarction. Towards an understanding of factors influencing clinical practice. The European Secondary Prevention Study Group.

AIMS: Long-term beta-blockade reduced mortality after acute myocardial infarction by about a quarter in a series of published trials. Representative data on beta-blocker use for secondary prevention are scanty but indicate wide variations. We have analysed European practice, and sources of variation, by regional sampling of acute myocardial infarction patients admitted to hospital in 11 countries during the period January 1993-June 1994. METHODS AND RESULTS: Treatment data for 4035 representative patients were collected for the hospital phase and 6 months after discharge. A logistic regression model was developed to describe the predictors of beta-blocker use. In the 11 regional samples, 6-38% (20% overall) of patients had no recorded contraindications but were discharged without a beta-blocker. In the absence of perceived contraindications, there was a strong, independent negative association between age and odds of treatment (P < 0.001), and women were less likely to be treated than men (adjusted odds ratio 0.76, 95% CI 0.58-0.99). Discontinuation of beta-blocker treatment by 6 months was significantly less likely in regions where the proportion given such treatment at discharge was high. In contrast, use of antithrombotic agents in the samples was consistently high. CONCLUSIONS: There is persisting low use of beta-blocker secondary prophylaxis, particularly in the elderly and in women, not attributable to perceived contraindications or intolerance. Considerable regional variations persist despite shared trials evidence. Discharge treatment strongly influences long-term medication.

Utilisation of thrombolytic therapy in older patients with myocardial infarction.

Empirical evidence from many countries, obtained from sampling populations of patients admitted to hospital with acute myocardial infarction, has confirmed that elderly patients are significantly less likely to receive thrombolytic therapy. This difference persists after controlling for confounding factors such as admission delay and contraindications to thrombolysis. However, evidence supporting the efficacy of thrombolysis in reducing mortality after acute myocardial infarction is less clear cut in patients aged 75 years or above than in younger patients. These older patients are substantially under-represented in the clinical trials although they constitute one third of the clinical population. Observational studies indicate that older patients are at slightly higher risk than younger patients of experiencing haemorrhagic stroke after thrombolysis. It is, however, unlikely that efficacy and tolerability considerations alone account for the low use of thrombolytics in the elderly as similar trends are seen for other modalities of treatment of acute myocardial infarction. Since older patients have the highest mortality risk after myocardial infarction, they have the greatest potential gain from thrombolytic treatment, assuming a uniform treatment effect across age. The estimated cost effectiveness (cost per quality-adjusted life-year gained) improves with increasing age. It is concluded that patient age should not influence the treatment decision concerning thrombolysis. To ensure that elderly patients receive maximum benefit from this therapeutic advance requires attention to referral patterns from the community, speed of assessment in hospital and a clear treatment policy without age constraints. The effectiveness of these measures should be routinely audited.

Thrombolytic eligibility in acute myocardial infarction patients admitted to Norwegian hospitals.

We characterised the population of acute myocardial infarction patients admitted to Norwegian hospitals and quantified the actual use and potential maximal use of thrombolytic therapy. Data were collected by medical record review of all acute myocardial infarction patients discharged from hospital in April and May 1993 in Health region 1. The clinical population differed significantly from the patients recruited to the thrombolytic clinical trials. Patients were more likely to have ST depression on admission (23% vs. 7%) and to be over 74 years (42% vs. 10%) than in the trials. A fifth of patients presented more than 12 h after symptom onset (or time indeterminate). Thrombolysis was given to 32% of patients, mainly utilising streptokinase. Late presentation or diagnostic difficulty appeared to be the main reasons for non- thrombolysis. Approximately 50% of the clinical population were eligible for thrombolysis. Eligibility for thrombolytic therapy was therefore severely restricted by the presenting characteristics of the clinical population. Substantial numbers of patients belonged to subgroups where the reported benefit from thrombolysis is equivocal. Uncertainty remains on the extrapolation of the trials evidence to those subgroups who were under-represented in the clinical trials.

Selection factors for the use of thrombolytic treatment in acute myocardial infarction: a population based study of current practice in the United Kingdom. The European Secondary Prevention Study Group.

OBJECTIVES: To identify and rank the factors that currently limit the use of thrombolytic treatment in patients admitted to hospital with acute myocardial infarction. DESIGN: Weighted sampling study with retrospective data retrieval from clinical records. SETTING: All hospitals within the Trent region providing acute general medical services. PATIENTS: Random sample of 420 patients admitted during February-April 1993 who had acute myocardial infarction as the main discharge diagnosis. MAIN OUTCOME MEASURES: Treatment odds ratios (and 95% confidence intervals (CI)) for the use of thrombolysis in patient groups defined by relevant clinical characteristics. RESULTS: The patient population was older and less likely to have ST segment elevation on the initial electrocardiogram than patients entered into the randomised trials of thrombolysis. Thrombolytic treatment was given to 49% of patients (SE 2.4%). After controlling for negative associations with a history of stroke (treatment odds ratio 0.18 (95% CI 0.04 to 0.53)) and peptic ulcer (odds ratio 0.52 (95% CI 0.26 to 1.01)) use of thrombolysis decreased with increasing patient age. This was particularly noticeable for those aged > 74 years (odds ratio 0.17 (95% CI 0.05 to 0.51)) relative to those aged < 65 years. Thrombolysis was less likely to be used in patients with ST depression (odds ratio 0.22 (95% CI 0.11 to 0.41)) or bundle branch block (odds ratio 0.18 (95% CI 0.07 to 0.44)) than in those with ST elevation on the initial electrocardiogram. Delay from symptom onset to admission was more than 12 h in 15% of patients. CONCLUSIONS: The patient population admitted to hospital with acute myocardial infarction differs in several respects from the samples that have been included in the trials of thrombolysis. The main factors limiting wider use of thrombolysis are diagnostic uncertainty at admission and delayed presentation. Perceived clinical contraindications to treatment are of lesser importance. There is evident reluctance to use thrombolytic treatment in older patients, who were substantially under-represented in the clinical trials.

Impact of clinical trials on clinical practice: example of thrombolysis for acute myocardial infarction.

Little is known about incorporation of new knowledge from randomised clinical trials into clinical practice. Thrombolytic therapy was shown to reduce the mortality of acute myocardial infarction in several large trials published during 1986-88. To examine the effect of these data on clinical practice, we analysed the supply of thrombolytic drugs in a representative English region (population 4.7 million) in 1987-92. During the study period there were over 10,000 hospital admissions per year in the region for acute myocardial infarction. From a very low initial level, thrombolytic drug use rose slowly for several years after publication of the trial results and reached a plateau in 1991-92. Rates of use per 1000 patients admitted with myocardial infarction varied almost six-fold between districts in 1989-90 and over two-fold in 1991-92. Level of use attained by districts in the latter period was strongly associated with the extent of their previous participation in multicentre trials of thrombolysis (p = 0.003); we estimate that 35-50% of patients admitted with acute myocardial infarction were receiving thrombolytics. The full potential of thrombolytic treatment has still not been achieved in routine care and the limiting factors need to be defined.