IMPROVING CLINICAL DECISIONS IN PAH MANAGEMENT: … · STUDY OBJECTIVES Patients with ... Order: Pulmonary Rehabilitation Program Start: Case-Speciﬁc PAH Replacement Regimens Follow-Up

Jelena S. Spyropoulos, PhD; Kelly Hanley, Martin Warters, Douglas Blevins, MD; Medscape, LLC, New York, NY, USA

IMPROVING CLINICAL DECISIONS IN PAH MANAGEMENT: SIMULATION IN CONTINUING EDUCATION

50%

0%

20%

40%

60%

80%

100%

Question #1 Question #2 Question #3 Question #4

% Correct Pre % Correct Post Relative % Change

75% 45% 107%

Nephrologists (n = 113)

87%

61%

88%82%

53%

40%

0%

20%

40%

60%

80%

100%



169% 105% 24% 165%

100%

79%71%

26% 27%

65%

24%

64%

Primary Care Physicians (n = 214)

35%

50%

53%

50%

0%

20%

40%

60%

80%

100%



75% 45% 107%


87%

61%

88%82%

53%

40%

0%

20%

40%

60%

80%

100%



169% 105% 24% 165%

100%

79%71%

26% 27%

65%

24%

64%


35%

50%

53%

STUDY OBJECTIVES

■ Patients with pulmonary arterial hypertension (PAH) are often not appropriately assessed and treated1

■ This study was conducted to determine if an online, simulation-based continuing medical education (CME) intervention could improve performance of pulmonologists and cardiologists in the management of patients with PAH

RESULTS

Significant improvements were observed after clinical guidance, related to patient assessment (Figure 2)

Case 1 (n=109 pulmonologists; n=161 cardiologists):

■ 16% absolute improvement among pulmonologists (77% pre-CG vs 93% post-CG; P <.001) and 18% improvement among cardiologists (58% vs 75%; P <.001) in orders for right heart catheterization

■ 55% improvement among pulmonologists (12% vs 67%; P <.001) and 43% improvement among cardiologists (7% vs 50%; P <.001) in ability to diagnose PAH type I

■ 17% improvement among pulmonologists (60% vs 77%; P =.002) and 11% improvement among cardiologists (61% vs 72%; P =.016) in orders for ventilation/perfusion scanning

■ 14% improvement among pulmonologists (39% vs 53%; P =.0014) and 25% improvement among cardiologists (23% vs 48%; P <.001) in ability to tailor initial PAH therapy based on patient characteristics


■ 11% absolute improvement among cardiologists (8 vs 19%; P <.001) in addition of oral prostacyclin pathway therapy

■ 17% improvement among pulmonologists (57% vs 74%; P =.015) In orders for patient education and counseling

■ The CME intervention consisted of 2 cases presented in a virtual patient simulation (VPS) platform that allowed learners to order laboratory tests, make diagnoses, and recommend treatments from a range of options matching the scope and depth of actual practice (Figure 1)2

■ The clinical decisions made by the learners in open field responses similar to electronic health records were analyzed using an artificial intelligence engine, and clinical guidance (CG) was then provided based on current evidence, guidelines and expert recommendations

■ Learner decisions were collected after CG and compared with each user’s baseline (pre-CG) decisions using a 2-tailed, paired t-test. P values were determined to assess significance of changes seen as a result of participating in the education

■ An overview of the cases is provided in Figure 1

■ The activity launched on July 28, 2016, and data were collected through September 1, 2016

METHODS

Case 2: Pulmonologists (n=70)

0% 40% 80%20% 60% 100%

Order: Interdisciplinary Team Coordination

Order: Patient Education and Counseling

Order: Pulmonary Rehabilitation Program

Start: Case-Specific PAH Replacement Regimens

Follow-Up Appointment in 12 weeks 51% 10%

52% 8%

58%

55%

7%

6%

80%

Case 2: Cardiologists (n=96)

0% 40% 80%20% 60% 100%






54% 16%

57%

57%

17%

14%

86%


0% 40% 80%20% 60% 100%






52% 8%

58%

55%

7%

6%

80%


0% 40% 80%20% 60% 100%






54% 16%

57%

57%

17%

14%

86%

FIGURE 4.

% Pre Guidance % Total % Relative Change P-Value

Follow-Up Appointment in 12 weeks 51% 61% 20% 0.072

Order: Interdisciplinary Team Coordination 52% 60% 16% 0.121

Order: Patient Education and Counseling 58% 66% 13% 0.148

Order: Pulmonary Rehabilitation Program 55% 61% 11% 0.189

Start: Case-Specific PAH Replacement Regimens 80% 82% 3% 0.356


Follow-Up Appointment in 12 weeks 51% 67% 31% 0.028

Order: Interdisciplinary Team Coordination 54% 70% 29% 0.026

Order: Patient Education and Counseling 57% 74% 30% 0.015

Order: Pulmonary Rehabilitation Program 57% 71% 25% 0.037

Start: Case-Specific PAH Replacement Regimens 86% 86% 0% 0.500 Scan here to view this poster online.

Acknowledgments:

This CME-certified activity was supported by an independent educational grant from Actelion Pharmaceuticals, Ltd.

For more information contact Jelena Spyropoulos, PhD, Director of Clinical Strategy, Medscape, LLC at [email protected].

■ This study demonstrates that VPS, which immerses and engages the specialists for an authentic and practical learning experience, can improve evidence-based clinical decisions of specialists related to the management of PAH

■ This assessment also suggests that additional education is warranted on appropriate patient assessment to characterize patients with PAH, diagnostic testing, tailoring therapy, and use of patient-centered management approaches to improve care

Clinical implicationsUsing VPS-based CME to improve performance of pulmonologists and cardiologists has the potential to translate into improvements in clinical care and patient outcomes

CONCLUSIONS

References1. Farber HW, Miller DP, Meltzer LA, McGoon MD.

Treatment of patients with pulmonary arterial hypertension at the time of death or deterioration to functional class IV: insights from the REVEAL Registry. J Heart Lung Transplant. 2013;32(11):1114-1122.

2. Park MH and Preston IR. Pulmonary disease management: how would you treat this patient? Medscape Education, July 28, 2016. Accessed March 31, 2017.

50%

0%

20%

40%

60%

80%

100%



75% 45% 107%


87%

61%

88%82%

53%

40%

0%

20%

40%

60%

80%

100%



169% 105% 24% 165%

100%

79%71%

26% 27%

65%

24%

64%


35%

50%

53%

50%

0%

20%

40%

60%

80%

100%



75% 45% 107%


87%

61%

88%82%

53%

40%

0%

20%

40%

60%

80%

100%



169% 105% 24% 165%

100%

79%71%

26% 27%

65%

24%

64%


35%

50%

53%


0% 40% 80%20% 60% 100%

Diagnose: PAH-Type 1 (Idiopathic) 12% 55%

Start: Case-based treatment options 39% 15%

Diagnose: WHO Functional AssessmentClass lll 61%


0% 40% 80%20% 60% 100%





0% 40% 80%20% 60% 100%





0% 40% 80%20% 60% 100%




FIGURE 3. Clinical Decisions Related to Diagnosis and Tailoring Therapy for PAH


Diagnose: PAH-Type 1 (Idiopathic) 12% 67% 462% 0.000

Diagnose: WHO Functional Assessment Class lll 1% 62% 6700% 0.000

Start: Case-based treatment options 39% 53% 38% 0.014


Diagnose: PAH-Type 1 (Idiopathic) 7% 50% 567% 0.000

Diagnose: WHO Functional Assessment Class lll 0% 45% 0.000

Start: Case-based treatment options 23% 48% 108% 0.000



0% 40% 80%20% 60% 100%

0% 40% 80%20% 60% 100%

Order: Ventilation/Perfusion Lung Scan 60% 17%

Order: Right Heart Catheterization (RHC) 77% 16%

Order: Six Minute Walk Test (6MWT) 72% 14%

Order: HIV ELISA 40% 33%

Order: Exhaled NO (Nitric Oxide) 20% 30%

Order: 2-D Echocardiogram 73% 15%

Order: ECG 61% 14%


0% 40% 80%20% 60% 100%

Order: ECG 68% 6%


Order: Antinuclear Antibody (ANA)Panel 5

63% 18%



0% 40% 80%20% 60% 100%








52% 16%



0% 40% 80%20% 60% 100%

0% 40% 80%20% 60% 100%







Order: ECG 61% 14%


0% 40% 80%20% 60% 100%

Order: ECG 68% 6%



63% 18%



0% 40% 80%20% 60% 100%








52% 16%



0% 40% 80%20% 60% 100%

0% 40% 80%20% 60% 100%







Order: ECG 61% 14%


0% 40% 80%20% 60% 100%

Order: ECG 68% 6%



63% 18%



0% 40% 80%20% 60% 100%








52% 16%

FIGURE 2. Clinical Decisions Related to Patient Assessment


Order: 2-D Echocardiogram 73% 88% 20% 0.003

Order: Antinuclear Antibody (ANA) Panel 5 63% 82% 29% 0.001

Order: Exhaled NO (Nitric Oxide) 20% 50% 150% 0.000

Order: HIV ELISA 40% 73% 82% 0.000

Order: Right Heart Catheterization (RHC) 77% 93% 20% 0.000

Order: Six Minute Walk Test (6MWT) 72% 86% 19% 0.005


Order: ECG 61% 76% 23% 0.033



Order: ECG 68% 74% 9% 0.170



Order: 2-D Echocardiogram 88% 93% 6% 0.067

Order: Antinuclear Antibody (ANA) Panel 5 52% 67% 30% 0.002

Order: Exhaled NO (Nitric Oxide) 39% 60% 56% 0.000

Order: HIV ELISA 37% 59% 58% 0.000

Order: Right Heart Catheterization (RHC) 58% 75% 29% 0.001


CASE #1: JOEL A.“ I have a very active job, and lately it’s been difficult for me because I feel so out of breath.”

CASE #2: ELSA B.“ I’m still having trouble breathing when I try to exercise or have to get somewhere in a hurry. I’m not sure if my medication is really helping”

50%

0%

20%

40%

60%

80%

100%



75% 45% 107%


87%

61%

88%82%

53%

40%

0%

20%

40%

60%

80%

100%



169% 105% 24% 165%

100%

79%71%

26% 27%

65%

24%

64%


35%

50%

53%

PATIENT STATS

Age 55

Gender Male

Weight 94.30 kg

Height 180.3 cm

BMI 29

Allergies None

PATIENT STATS

Age 47

Gender Female

Weight 85.30 kg

Height 177.8 cm

BMI 27

Allergies None

FIGURE 1: Overview of Patient Cases

Significant improvements were observed after CG, related to diagnosing and tailoring treatment for PAH (Figure 3).


■ 14% improvement among pulmonologists (39% vs 53%; P =.014) and 25% improvement among cardiologists (23% vs 48%; P <.001) in ability to tailor initial PAH therapy based on patient characteristics

Significant improvements were observed after CG, related to the use of patient-centered care in PAH (Figure 4).


■ 17% improvement among pulmonologists (57% vs 74%; P =.015) In orders for patient education and counseling

50%

0%

20%

40%

60%

80%

100%



75% 45% 107%


87%

61%

88%82%

53%

40%

0%

20%

40%

60%

80%

100%



169% 105% 24% 165%

100%

79%71%

26% 27%

65%

24%

64%


35%

50%

53%

50%

0%

20%

40%

60%

80%

100%



75% 45% 107%


87%

61%

88%82%

53%

40%

0%

20%

40%

60%

80%

100%



169% 105% 24% 165%

100%

79%71%

26% 27%

65%

24%

64%


35%

50%

53%

Documents

IMPROVING CLINICAL DECISIONS IN PAH MANAGEMENT: … · STUDY OBJECTIVES Patients with ... Order: Pulmonary Rehabilitation Program Start: Case-Speciﬁc PAH Replacement Regimens Follow-Up