Case method learning for general practitioners reduces cholesterol concentrations in coronary artery disease
QUESTION: In patients with coronary artery disease, is case method learning (CML) for general practitioners (GPs) based on clinical practice guidelines (CPGs) more effective at reducing cholesterol concentrations than conventional introduction of CPGs for secondary prevention of coronary artery disease?
Design
Cluster randomised (allocation concealed*), blinded (GPs, patients, data collectors, and data analysts/statisticians),* controlled trial with 2 years of follow up.
Patients
88 patients ≤70 years of age (mean age 62 y, 85% men) with an objective diagnosis of coronary artery disease. Exclusion criteria included other life threatening diseases and moving out of the catchment area. Follow up was 89%.
Intervention
The 14 primary healthcare centres in Södertälje were divided into 2 matched and balanced groups (“clusters”) taking into account geographic location, physician numbers, physician relationships, patient volume, and the socioeconomic status of the patient populations. Subsequently, 1 group (“cluster”) each was allocated to CML for GPs (26 GPs, n=43) or CPGs only (28 GPs, n=45). Guidelines on secondary prevention of coronary artery disease were presented and distributed at a local lecture to all GPs. GPs allocated to CML attended 3–4 CML seminars at their primary healthcare centres during a 2 year period.
Main outcome measures
Change from baseline in cholesterol concentrations at 2 years.
Main results
Analysis was by intention to treat. At 2 years, reduction in low density lipoprotein cholesterol and total cholesterol concentrations was greater in the CML for GPs group than in the CPG group (table).
Conclusion
In patients with coronary artery disease, case method learning for general practitioners reduced cholesterol concentrations more than conventional introduction of practice guidelines for secondary prevention of coronary artery disease did.
Commentary
CPGs have the potential to improve patient care. Implementation, however, is a major challenge. The CML described in this study by Kiessling and Henriksson showed not only improved knowledge of the guideline among physicians, but a measurable improvement in a patient oriented outcome. Case based learning has been shown to be a superior learning modality in other settings as well.1 Which particular aspects of the CML were responsible for the improvement in knowledge and outcomes is uncertain. For example, it is possible that the effectiveness of the CML could be explained simply by having a locally well known clinical champion who could give credibility to the guidelines such that practitioners were more likely to trust the content. CML may also take the CPGs a step further in modelling the application of the content in more real life circumstances. A caveat in interpreting this study, however, is the possibility that the method of cluster randomisation was insufficient to eliminate confounding, because there were only 2 clusters.
Many different ways of implementing guidelines have been shown to be effective.2 Didactic lectures and mailed unsolicited materials were weak interventions. Moderately effective methods were audit/feedback directed at particular providers and administered by peers or opinion leaders (profiling). The strongest interventions were reminders, academic detailing, and multimodality interventions. Whether coupling the case method to any of these other methods, as part of a multimodality intervention, provides added value remains to be determined, but this method certainly has face validity as an effective method that could be applied in any setting, for any CPG, and for any type of medical provider.
Case method learning for general practitioners (CML) v conventional introduction of clinical practice guidelines (CPG) for secondary prevention of coronary artery disease at 2 years†
QUESTION: In patients with coronary artery disease, is case method learning (CML) for general practitioners (GPs) based on clinical practice guidelines (CPGs) more effective at reducing cholesterol concentrations than conventional introduction of CPGs for secondary prevention of coronary artery disease?
Footnotes
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Sources of funding: Stockholm County Council and Karolinska Institute.
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For correspondence: Dr P Henriksson, Danderyd University Hospital and Karolinska Institute, Stockholm, Sweden. Peter.Henriksson{at}med.ds.sll.se
