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EDITORIALS: Peter K Lindenauer Effects of quality improvement collaboratives BMJ 2008; 0: bmj.a216v1-216 [Full text]

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Randomised controlled trials have an important place in evaluating quality improvement initiatives.

Martin P Eccles, Jeremy M Grimshaw.   (12 July 2008)

Randomised controlled trials have an important place in evaluating quality improvement initiatives. 12 July 2008
Martin P Eccles, Professor of Clinical Effectiveness Newcastle University, 21 Claremont Place, Newcastle upon Tyne NE2 4AA, Jeremy M Grimshaw. Send response to journal: Re: Randomised controlled trials have an important place in evaluating quality improvement initiatives.	In his editorial1 Lindenauer questions the role of randomised controlled trials in evaluating quality improvement collaboratives. The choice of research design should be informed by the question that needs to be answered. At a stage where a complex intervention is being developed then a mix of qualitative and quantitative methods should be used to define the content of the intervention, the method(s) of delivery and presence and impact of any important effect modifiers. At the point that such an intervention is regarded as both understood and stable then it should be subject to an evaluation of its effects rather than just introduced. The risk of not evaluating is introducing ineffective and inefficient interventions that could waste scarce resources and a failure to learn from current QI efforts to optimise future activities. Auerbach et al2 argue persuasively for the use of the same standards of evaluation for quality improvement interventions as are applied to biomedical ones. At the point in a process of evaluation that the question is “what is the effect of this intervention and at what cost” then a pragmatic (often cluster) randomised controlled trial3 with its focus on a “real world” evaluation, is the optimum design.. However, such a design in no way precludes the simultaneous collection of the sort of data that Lindenauer suggests - data on the processes by which the intervention may achieve its effects or have them modified4,5,6. Such measures, informed by the intervention development stage, can be much more informative by virtue of having been collected within the same experimental context. Martin Eccles Jeremy Grimshaw References 1. Lindenauer PK. Effects of quality improvement collaboratives are difficult to measure using traditional biomedical research methods. BMJ 2008;336:1448-9. 2. Auerbach AD, Landefeld CS, Shojania KG. The Tension between Needing to Improve Care and Knowing How to Do It. The New England Journal of Medicine 2007; 357(6): 608-613. 3. Schwartz,D. Lellouch,J. Explanatory and pragmatic attitudes in therapeutical trials. Journal of Chronic Diseases 1967;20: 637-648. 4. Rousseau N, McColl E, Newton J, Grimshaw J, Eccles M. Practice based, longitudinal, qualitative interview study of computerised evidence based guidelines in primary care. BMJ 2003;326:314-322. 5. Ramsay CR, Eccles M, Grimshaw JM, Steen N. Assessing the long term effect of educational reminder messages on primary care radiology referrals. Clinical Radiology 2003;58:319-321. 6. Grimshaw JM, Zwarenstein M, Tetroe JM, Godin G, Graham ID, Lemyre L, Eccles MP, Johnston M, Francis JJ, Hux J, O'Rourke K, Legare F, Presseau J. Looking inside the black box: a theory-based process evaluation alongside a randomised controlled trial of printed educational materials (the Ontario printed educational message, OPEM) to improve referral and prescribing practices in primary care in Ontario, Canada. Implementation Science, 2007; 2: 38. Competing interests: None declared