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Nimish Mehta, PhD, MBA; Sarah Williams, PhD Medscape, LLC, New York, NY, USA
objective
Advances in the treatment of cystic fibrosis (CF) have resulted in significant improvement in survival.[1] Ongoing developments involving therapies that target mutations in the CF transmembrane conductance regulator (CFTR) are encouraging and may lead to further improvement in patient outcomes. However, a number of challenges continue to face clinicians who treat patients with CF. These challenges include clinicians’ nonadherence to infection management guidelines and patients’ difficulty following treatment regimens that typically involve multiple therapies.[2] A study was conducted to determine if an online educational intervention designed to address these important gaps in the care of patients with CF could improve clinician practices.
methods
An activity titled Addressing Treatment Challenges in Cystic Fibrosis (http://www.medscape.org/viewarticle/814703) launched online on 11/25/2013. The intended goal of this activity was to provide education on the management of CF, including therapies directed at Pseudomonas and therapies that target CFTR.
This activity sought to overcome attitudinal and performance barriers to optimal outcomes in CF by improving clinician knowledge about the changing epidemiology of infections in CF and improving implentation of and adherence to guideline recommendations. The activity was intended for pulmonologists and other clinicians who provide care for patients with CF.
Instructional Method The format used to deliver this education was a video-based roundtable panel discussion conducted by expert faculty using synchronized slides, with built-in peer response to encourage participant interactivity and feedback. The format was designed to facilitate highly interactive dialogue among key opinion leaders, highlighting key study findings and recommendations on the treatment of CF. For learners wishing to view the program offline, a transcript and slides were made available for downloading/printing. In addition, this activity was available on the Medscape Mobile application, ensuring real-time access by the many clinicians who rely on mobile devices for educational and practice-related purposes and who increasingly access educational activities via their mobile devices for timely decisions at the point of care.
Assessment Method The effects of education were assessed in conjunction with Healthcare Performance Consulting, Inc. (HPC), using a Planned Change Assessment (PCA) survey. The PCA process allows for an immediate measure of activity outcomes as well as a delayed measure to identify actual behavior change (Figure 1). It also allows learners to be reminded of the program content and their intent to change 6 to 8 weeks after completing the educational intervention.
Initial Assessment: The initial survey administered upon completion of the educational activity asked:
•What will you do differently in your practice as a result of participating in this activity? •What do you perceive as barriers to making the above-selected changes in your practice?
The survey included practice changes consistent with the learning objectives. Data from a cohort of US-practicing pulmonologists, infectious disease specialists, pediatricians, and nurses who participated in the online educational intervention were collected through 2/2/2014 and evaluated.
Follow-Up Assessment: The follow-up survey was an online assessment of the intended changes from the initial PCA questionnaire and was administered approximately 6 to 8 weeks after the launch of the activity. All completers of the initial survey (as of that date) were sent an email invitation and link to the follow-up assessment. The PCA follow-up assessment included questions about completed changes and about barriers to change that learners may have encountered in their daily practice. Use of a unique respondent identifier on both the immediate PCA and the follow-up assessment allowed for direct matching of responses to both assessments. While not all learners completed both assessments, matching those who did helps reduce the chance of sampling bias when comparing the results of the assessments. Completers of the follow-up survey were invited to opt in to the follow-up interviews.
Follow-Up Interviews: Interviews were conducted with a sample of learners recruited from attendees who opted in from the follow-up assessment. These interviews were 20 to 30 minutes in length and were conducted by telephone. Participants were asked why certain changes were selected, whether the changes were made, and how the changes took place; they were also asked to identify barriers to making the changes. These qualitative interviews were conducted to validate and clarify the selected practice changes and actual barriers to change.
Assessment Process and Data Samplefigure 1
Needs assessment and content development at Medscape
Surveys on clinical choices created by HPC and faculty
Immediate planned-change survey completed n=232 in audience as of
2/2/2014
2-month follow-up change survey completed
n=47
n=218 planned to make 622 changes (an average
of 2.9 changes each)
94% (n=44) completed 120 changes (an average
of 2.7 changes each)
n=10 follow-up interviews on change and barriers
results
A total of 232 US participants in the educational intervention completed the survey, which inquired about specific intended changes, and 218 (94%) indicated that they planned to make a total of 622 changes, or an average of 2.9 planned changes per participant. Of those 218 participants, 47 completed the follow-up survey 6 to 8 weeks later, 44 (94%) of whom reported making 120 changes in practice, or an average of 2.7 changes each. The remaining 3 participants (6%) indicated that they were already following best practice recommendations. Results of initial and follow-up assessment of specific changes in clinical practice and the percentage of those making each change are shown in Figures 2a and 2b. For the sample of participants who completed both the initial assessment and the follow-up assessment, a comparison of responses showed the changes that were made as intended and those that were difficult to make (Figure 3).
References 1. Cystic Fibrosis Foundation Patient Registry. Annual Data
Report 2012. Bethesda, Maryland. ©2013 Cystic Fibrosis Foundation.
2. Miroballi Y, Garber E, Jia H, et al; CF Infection Control Study Consortium. Infection control knowledge, attitudes, and practices among cystic fibrosis patients and their families. Pediatr Pulmonol. 2012;47:144-152.
Acknowledgements
The educational interventions and outcomes measurement were funded through an independent educational grant from Novartis. Outcomes study was developed by Healthcare Performance Consulting, Inc. Poster layout was provided by Christopher Clarke and Jonathan Yan of Medscape Education.
For more information, contact Nimish Mehta, PhD, MBA, Senior Director, Educational Strategy, Medscape, LLC, [email protected].
ConclusionsThe educational metrics gathered in this assessment are a strong indicator that this well-designed online instructional modality prompted changes in clinical performance, and shows that a 30-minute video roundtable discussion developed as part of a curriculum to address the clinical performance gaps in CF is a successful way to effect changes in practice. The fact that 94% of learners, upon follow-up, completed changes in practice indicates that this activity was highly successful at prompting practice change, and an average of 2.7 changes per learner indicates a large impact on clinical
practices. Participants were motivated to make measureable changes related to managing patients with CF commensurate with the learning objectives of the intervention. This activity was most effective at prompting clinicians to partner with patients and families and to integrate updated recommendations into practice. Barrier analysis shows that further education focused on overcoming challenges to patient adherence to the CF treatment regimen and addressing clinician concerns about antibiotic resistance when using chronic suppressive therapy is recommended.
Practice Changes in Cystic Fibrosis Management: Effectiveness of Continuing Education Practice Changes in Cystic Fibrosis Management: Effectiveness of Continuing Education
Intended Changes; Initial Assessmentfigure 2a
1. Stay up to date on new therapies so I can best integrate them into my patients’ care.
2. Review Cystic Fibrosis Foundation (CFF) care guidelines to ensure that office visits,
assessments, and treatments are completed in accordance with the recommendations.
3. Initiate pre-clinic CF team meetings to identify each patients’ clinical and
psychological needs.
4. Incorporate multi-disciplinary team members (nurse, dietician, social worker, etc.) onto the patients’ CF team to ensure coordinated care.
5. Use appropriate chronic antimicrobial therapy in patients over age 6, including
those with mild lung disease, to preserve lung function and reduce exacerbations.
6. Share short- and long-term health assessment trends with patients and/or
caregivers.
7. Provide education to patients and families about the need for and benefits of specific treatments,
and partner with them on strategies to achieve an acceptable treatment burden.
8. Other change(s)
9. This program confirmed my existing practices.
10. None of the above
“As a result of participating in this activity, I intend to...” (Select all that apply.) (n=232)
0% 20% 40% 60% 80% 100%
73%
47%
16%
32%
29%
29%
39%
2%
3%
14%
Changes Made; Follow-Up Assessmentfigure 2b
1. Stay up to date on new therapies so I can best integrate them into my patients’ care.
2. Review Cystic Fibrosis Foundation (CFF) care guidelines to ensure that office visits,
assessments, and treatments are completed in accordance with the recommendations.
3. Initiate pre-clinic CF team meetings to identify each patients’ clinical and
psychological needs.
4. Incorporate multi-disciplinary team members (nurse, dietician, social worker, etc.) onto the patients’ CF team to ensure coordinated care.
5. Use appropriate chronic antimicrobial therapy in patients over age 6, including
those with mild lung disease, to preserve lung function and reduce exacerbations.
6. Share short- and long-term health assessment trends with patients and/or
caregivers.
7. Provide education to patients and families about the need for and benefits of specific treatments,
and partner with them on strategies to achieve an acceptable treatment burden.
8. Other change(s)
Please indicate what you are doing differently as a result of participating in this program. (Select all that apply.) (n=44)
0% 20% 40% 60% 80% 100%
77%
50%
16%
36%
36%
18%
39%
0%
Change Comparisonfigure 3
1. Stay up to date on new therapies so I can best integrate them into my patients’ care.
2. Review Cystic Fibrosis Foundation (CFF) care guidelines to ensure that office visits,
assessments, and treatments are completed in accordance with the recommendations.
3. Initiate pre-clinic CF team meetings to identify each patients’ clinical and
psychological needs.
4. Incorporate multi-disciplinary team members (nurse, dietician, social worker, etc.) onto the patients’ CF team to ensure coordinated care.
5. Use appropriate chronic antimicrobial therapy in patients over age 6, including
those with mild lung disease, to preserve lung function and reduce exacerbations.
6. Share short- and long-term health assessment trends with patients and/or
caregivers.
7. Provide education to patients and families about the need for and benefits of specific treatments,
and partner with them on strategies to achieve an acceptable treatment burden.
Immediate Post-Activity vs Long-Term Follow-Up (n=13)
0% 20% 40% 60% 80% 100%Immediate Post-Activity
Long-Term Follow-Up
77%77%
46%31%
15%15%
38%46%
31%46%
46%8%
46%54%
Average Impact of Barriers Encounteredfigure 4
1. I am unsure of the current recommendations for the management of cystic fibrosis.
2. I do not agree with the current recommendations for managing CF.
3. I do not have the time to devote to learning about upcoming novel therapeutics for CF.
4. I need better tools (checklists, reminders, electronic medical record, etc.) to ensure
evidence-based care.
5. Patients/caregivers are unwilling to adhere to the complex regimen required to manage CF.
6. I am concerned about antibiotic resistance when using chronic suppressive therapy in
patients, particularly those with mild disease.
7. I do not have time for pre-clinic team meetings.
8. I do not have access to a robust multi-disciplinary team.
9. I have not had time since the activity to make desired changes in practice.
Please indicate any barriers that may have prevented you from making changes (or additional changes) in practice and the extent to which they
impacted practice change. (0 = no barrier, 5 = high barrier) (n=45)
0 1 2 3 4 5
1.7
2.0
2.6
2.5
1.8
2.0
1.5
0.9
1.7
Barriers Analysis showed that further education focusing on overcoming challenges to patient adherence to the CF treatment regimen and clinician concerns about antibiotic resistance when using chronic suppressive therapy is recommended (Figure 4).
Follow-Up Interviews: Knowledge Gains:
“I learned new information on the newer inhaler medication. I didn’t know about different formulations, powder.”
“The emphasis on newer inhaled antibiotics and the discussion on transitioning pediatric CF patients to the CF adult setting.”
“Newer antibiotic medications are assisting patients with regimens that are convenient to their lifestyle.”
“The new guidelines for CF and the information on avoidance of transmission of infection.”
“I learned that the inhaled form of antibiotics, with or without oral medications, for 4 weeks is a good way to treat and would make a difference. Aerosol therapy is speedier.”
Practice Changes: “Talking to family about getting genetic testing.”
“The newer drugs are on my radar screen. When they are approved, I will add them to my treatment options.”
“I plan to introduce Pseudomonas infection eradication strategies based on EPIC and other trials.”
“I am using inhaled medications chronically. This can improve quality of life. The program raised my consciousness about treatments for Pseudomonas and the infection’s complications to patients.”
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