Trends in the use of pharmacotherapies for acute myocardial infarction among physicians who design and/or implement randomized trials versus physicians in routine clinical practice: the MILIS-TIMI experience

Background Although studies have documented that randomized, controlled tri als (RCTs) have a measurable influence on clinical practice, investigators have uncovered important deficiencies in the application of RCT findings to the management of acute myocardial infarction (AMI). Little is known about the extent to which physicians who design and/or implement clinical trials differ from physicians in routine practice in their translation of the lit erature. Methods Our aims were to (1) evaluate recent trends in selected treatments of AMI in relation to the publication of RCTs, statistical overviews, and t ask-force guidelines, and (2) compare prescribing practices in. AMI managem ent between physicians in routine clinical practice and physicians who desi gn and/or implement RCTs. We reviewed the use of aspirin, beta-blockers, an giotensin-converting enzyme inhibitors, and calcium channel blockers on ent ry and at discharge in patients enrolled in the MILIS, TIMI 1, 2, 4, 5, 6, and 9B trials with ST-elevation (and depression in MILIS) myocardial infarc tion for a period approaching 2 decades (August 1978 to September 1995). We hypothesized that physicians who participate in RCTs apply the findings of the published literature more promptly and thoroughly than physicians in r outine practice. Results Use of aspirin, beta-blockers, and angiotensin converting enzyme in hibitors exhibited a statistically significant time-related increase at dis charge and, excepting beta-blockers, at enrollment across the trials. Presc ription of calcium channel blockers showed a statistically significant decr ease at discharge only. For all medications under study, increases and decr eases in use associated with publication of clinical data occurred earlier and more steeply for the discharge cohort (prescriptions by physicians part icipating in RCTs) than for the enrollment cohort (prescriptions by physici ans iri routine practice). Recent prescribing practices (1994 to 1995) amon g RCT investigators and their colleagues have higher concordance with publi shed findings than those of physicians in routine practice. Conclusions Physicians who design and/or implement RCTs translate the resul ts of the medical literature more promptly and to a greeter extent than phy sicians in routine clinical practice. Differences between different physici an classes need to be studied further amid efforts to reconfigure health ca re delivery that currently favor more dominant roles for primary care physi cians.