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.