Current issues of ACP Journal Club are published in Annals of Internal Medicine

Quality Improvement

Small-group consensus process promoted influenza practice guidelines acceptance

ACP J Club. 1995 Sept-Oct;123:55. doi:10.7326/ACPJC-1995-123-2-055

Source Citation

Karuza J, Calkins E, Feather J, et al. Enhancing physician adoption of practice guidelines. Dissemination of influenza vaccination guideline using a small-group consensus process. Arch Intern Med. 1995 Mar 27;155:625-32.



To evaluate small-group consensus as a dissemination technique to promote the adoption of influenza vaccination practice guidelines.


2-year randomized controlled trial.


13 U.S. group practices.


51 primary care physicians (67% board-certified in internal medicine; 80% men) who were in group practice at the time of the intervention and had ≥ 5 noninstitutionalized patients who were ≥ 65 years of age and were seen at least once during the preceding 18 months. Follow-up was complete.


The group practices were allocated to an intervention arm (n = 23 physicians) or to a control arm (n = 28 physicians). Intervention group physicians attended a 1-hour small-group meeting during which a technical guideline dissemination lecture was presented by a physician specializing in the area of influenza vaccination and the elderly. The group then discussed the adoption of the guideline, including its importance and relevance, feedback on their level of performance during the previous year, implementation barriers and solutions, group prioritization of decisions, and physician buy-in. A facilitator ensured that each of the steps in the adoption process was discussed. Control physicians participated in a placebo intervention in which an unrelated health care topic was discussed and a chart review of patient records was done.

Main outcome measure

Change in vaccination rate assessed by reviewing as many as 45 randomly selected patient charts per physician, in both study arms, before and after the intervention. Changes in attitude and knowledge were also assessed using a questionnaire.

Main results

Before the intervention, the mean vaccination rates by physicians did not differ between the intervention and control groups (47.6% vs 46.5%, respectively; P > 0.70). The mean vaccination rate after the intervention was higher in the intervention group than in the control group (62.8% [SD 20.6%] vs 46.1% [SD 20.7%], P < 0.01). After controlling for baseline vaccination rates and using the practice group as the unit of analysis, the difference between groups was maintained (P < 0.05). Solutions implemented by practice groups and changes in attitude or knowledge measured by the questionnaires did not affect vaccination rate in the intervention group.


Small-group consensus was effective in promoting physician adoption of influenza vaccination practice guidelines.

Sources of funding: Bureau of Health Professions and the Agency for Health Care Policy and Research.

For article reprint: Dr. J. Karuza, Western New York Geriatric Education Center, Beck Hall, State University of New York-Buffalo, Buffalo, NY 14214, USA. FAX 716-878-6228.


Clinical practice guidelines have become increasingly common. Despite their burgeoning numbers, however, guidelines are not necessarily implemented (1). In fact, studies have shown that guidelines have been remarkably unsuccessful in influencing physician behavior (2, 3). This failure has resulted in requests for guidelines to be enforced by an external authority (2). Indeed, some insurance companies have announced that they would refuse to pay physicians who fail to comply with guidelines (1).

The study by Karuza and colleagues examines the effect of an educational intervention on the implementation of an influenza vaccination guideline. In the United States, the influenza vaccination rate in elderly persons is low (43% in 1988-1989) (4). The investigators used a comprehensive but brief educational intervention that included use of "opinion leaders," feedback on the physicians' vaccination rates before the intervention, and a buy-in process that committed the physicians to the guideline recommendation. After the 1-hour session, an obvious and substantial increase occurred in the rate of vaccination.

The intervention can be easily implemented in a primary care setting. The authors chose a less controversial guideline, on which consensus could be easily reached, and the effect was measured soon after the intervention. This small study supports the importance of physician commitment to achieving increased guideline compliance. It remains to be seen whether this technique would be useful in disseminating more complex guidelines, and whether its effect on compliance would last.

Amnon Lahad, MD
University of WashingtonSeattle, Washington, USA


1. Woolf SH. Practice guidelines: what the family physician should know. Am Fam Physician. 1995;51:1455-63.

2. Woolf SH. Practice guidelines: a new reality in medicine. III. Impact on patient care. Arch Intern Med. 1993;153:2646-55.

3. Greco PJ, Eisenberg JM. Changing physicians' practices. N Engl J Med. 1993;329:1271-3.

4. Influenza vaccination coverage levels in selected sites-United States, 1989. MMWR Morb Mortal Wkly Rep. 1990;39:159-67.