Changing Health Care Provider Performance: the role of effective CME & CPD National Coalition for HP Education in Genetics, September 2011 Dave Davis, MD Senior Director, Continuing Education and Improvement Association of American Medical Colleges

Changing Health Care Provider Performance: the role of effective CME & CPD National Coalition for HP Education in Genetics, September 2011 Dave Davis, MD Senior Director, Continuing Education and Improvement Association of American Medical Colleges invisible

1. What are CME and CPD? Why are they ‘invisible’? 2. The ‘Does CME Work?’ question: the in- vitro perspective 3. Does CME work in the real world? - a look at the in-vivo, clinical care gap and its relationship to the world of genetics education 4. So What? Recommendations to a thoughtful genetics audience: guidelines for the use of CME & CPD An outline: many questions, little time…

Question #1 Some definitions: What do we mean by CME & CPD? ….by the terms diffusion, implementation? ….how have we changed in our thinking? Later….what is knowledge translation/implementation science?

What do we mean by ‘CPD and CME’? educational materials formal CME: lectures, small groups, courses outreach visits opinion leaders patient-mediated strategies audit/feedback reminders (paper, computerized, interactive, etc) comprehensive, QI- or practice-based interventions web-based tools, PDAs (borrowed from EPOC, Cochrane Collaboraitve)

What do we mean by ‘CPD and CME’? educational materials formal CME: lectures, small groups, courses outreach visits opinion leaders patient-mediated strategies audit/feedback reminders (paper, computerized, interactive, etc) comprehensive, QI- or practice-based interventions web-based tools, PDAs (borrowed from EPOC, Cochrane Collaboraitve)

Pedagogy (1940’s-50’s) Andragogy ( s) Informed Self-assessment Competency-based education (2000-) How have we changed…?

Diffusion: distribution of information and the practitioners’ natural unaided adoption of policies and practices Dissemination: communication of information to clinicians to improve their skills Implementation: putting a guideline in place, involves effective communication, overcomes barriers by administrative and educational techniques (after Lomas)... What do we mean by…?

Question # 2 “Does CME (CPD) Work?” The In Vitro Question (The Sackett question)

Database of Physician Education & Change: The Research and Development Resource Base - educational, clinical & health services literature supported by the American medical Association, the North American CME organizations, Royal College of Physicians and Surgeons of Canada, the University of Toronto and the Association of American colleges Now ~25,000 studies

12 metropolitan areas, roughly 30 conditions studied, >6,000 patient records examined Substandard care noted in 45% of clinical areas (of this, 46% underuse; 11% overuse) Little variation by region or by type of condition (chronic, acute), socioeconomic status Notable gaps in care in depression, alcohol abuse, diabetes care (about 45%), pneumonia (39%); Better care (>50% compliance with recommendations) noted in hypertension, cardiac care, but just NOTE: the inviible care gap (undiagnosed, undetected – e.g., smoking cessation, obesity counseling, care gap is HUGE)

1) About educational interventions Changing Physician Performance - a systematic review of the effect of CME strategies JAMA 1995;274:

Effective *Interactive Lecturing *Sequenced Sessions Accurate needs assessment Successful education has three elements – predisposing, enabling, reinforcing Not so Effective Didactic Teaching One-time only sessions The effect of formal CME - conferences, symposia, rounds, meetings, lectures

Needs Assessment appear to be important – the more the better (subjective needs, objective, gaps and barrier analysis) No evidence yet about long-term effects (well, some)Group size: no demonstrated effect Effective CME may follow Green’s PROCEED model - predisposing, enabling and reinforcing strategies Knowledge necessary but not sufficient for change Quantitative methodology necessary but not sufficient to understand change Other findings… NEW Multiple methods’ effect uncertain; print materials (simple messages) may not be so bad after all; consider the message; and consider the setting

age motivation (dis)incentives experience time environment training Emphasis on knowledge Inability to detect needs, evaluate performance ?self-directed learning ?critical appraisal The Pathman Model awareness: of a guideline, practice innovation, change agreement: with the innovation or guideline adoption: ‘trying out’ the new practice, irregularly adherence: abiding by the new practice on all appropriate occasions  Pathman, ) and about the learner-clinician

The self- assessment question Davis & co., JAMA 2006;296:

Of 20 comparisons….. 13 demonstrated little, no or an inverse relationship between self and external assessment: Examples: learning needs, EBM skills, simulated knee injections Note: inverse relationships between confidence noted by Leopold (knee injections), Fox (OSCE misperception) and Parker (knowledge-based FP exam) 7 demonstrated a positive relationship: Examples: cultural-linguistic competencies, global performance with dementia patients, comfort with psycho-social issues in family medicine

Just in case we miss the point: of 20 comparisons of self- assessments with external assessments

3) About aligning the learner and educator: the Pathman-PROCEED model stages Methods/ StagesAwarenessAgreementAdoptionAdherence Predisposing Enabling Reinforcing

“Despite the quality of the evidence of CME, it appears to be effective in the acquisition and retention of knowledge, skills, behaviors, and clinical outcomes” AHRQ EB report, Feb 2007 ACCP, CHEST, ) About the cumulative effect of CCME/CPD

Does CME/CPD work in the real world? In the world of effectiveness? Why or why not? The In Vivo Questions The Clinical Care Gap Overuse Underuse Misuse Chassin, 1998 Question # 3:

Current practice Ideal, evidence-based practice clinical care gap The clinical care gap clinical care gap

What causes the gap? What causes the gap? The evidence-to-practice puzzle The educational delivery system The clinician The evidence/guideline Health Care System issues PatientPatient Team membersTeam members

No time… No, Thursday’s out. How about never-is never good for you?

“Information management is like having your mouth to a firehose” David Naylor, President, University of Toronto

What causes the gap? The clinician The evidence/guideline Health Care System issues Patient Team members the educational delivery the educational delivery System and knowledge translation/ implementation science

“ Knowledge translation is the effective and timely incorporation of evidence-based information into the practices of health professionals in such a way as to effect optimal health care outcomes and maximize the potential of the health system” –Adapted from the Canadian Institutes for Health Research definition, 2001 Implementation Science is the scientific study of methods to promote the systematic uptake of research findings and other evidence based practice into routine practice thus to improve the quality and effectiveness of health care and services...adapted from the NIH, USA An emerging field; one concept, two terms

Question #4: How do CME and CPD play a role in genetics & genetics education Question #4: How do CME and CPD play a role in genetics & genetics education ?

The guideline process: evidence-to- action The goal: effective implementation Evidence/message Development Implementation Effective CME/PD ‘ ‘ Consideration of clinician learning style, needs

The guideline process: evidence-to- action The goal: effective implementation Evidence/message Development Implementation Effective CME/PD ‘ ‘ Consideration of clinician learning style, needs

Recommendation #1: Guideline Development/adaptation Consider CME/CPD in any evidence development process: from learner and educational perspectives (for example, guard against knowledge overload, consider already-held knowledge) a. secure buy-in; involve the end-user in guideline development/adaptation b. employ adult learning principles in guideline statements (format, spacing, language) c. consider recommending effective educational strategies in the guideline itself How an we use CME/CPD in evidence/message/guideline development in genetics?

compatibility complexity cost relative advantage accessibility format patency of evidence, process of development opportunity; trial-ability ….educational issues to consider within the guideline, evidence itself

Joint body of the Ontario Medical Association and the Ministry of Health and Long term Care, Ontario Chooses a topic area; reviews all guidelines in that area; scores them by the Cluzeau/AGREE instrument Mounted them on a website –Quick, 30 second synopsis –Clear language –Appropriate format –Parallel patient synopsis –The apple-score One attempt to fix the Message: The Guidelines Advisory Committee, Ontario (now the Center for Evidence-based practice)

Recommendation # 2: Include CME/CPD in any guideline implementation strategy a) Consider the learner - mode of current learning - stage of awareness-adherence at which clinician- learners exist b) Consider effective educational strategies How an we use CME/CPD in genetics education ?

Formal CME Lectures, workshops, small groups Informal education Audit/Feedback Reminders Policy, CQI administrative techniques Print Patient Strategies Multiple Strategies M&M conferences Quality-based rounds Journal Club Team training Handover/off rounds The CPG implementation toolkit

Recommendation # 3: Consider CME/CPD in a staged fashion, depending on stage of adoption of information, by individuals, groups; use appropriate educational strategies How can we use CME/CPD in genetics education?

Example #1: a new guideline describes the use of a new disease screening test….. Methods/StagesAwarenessAgreementAdoptionAdherence Predisposing Print material, Lectures, Conferences Academic detailing, Media Interactive sequential sessions Enabling Small groups, opinion leaders Pt. education, workshops, opinion leaders Reinforcing Reminders, audit/feedback

Example #2: many primary care providers fail to use a simple genogram when taking patient history Methods/StagesAwarenessAgreementAdoptionAdherence Predisposing Print material,Patient education and advocacy Enabling Small groups, opinion leaders Pt. education, workshops, flow charts Reinforcing Reminders, audit/feedback

Launch, June 2011 Tools, resources, and support for AAMC members Collaborative learning sessions National Faculty Development Initiative Roughly 250 med schools & teaching hospitals participating Example #3: a national campaign: a project of the Association of American Medical Colleges

Teach quality and patient safety to the next generation of doctors Ensure safer surgery through use of surgical checklists Reduce infections from central lines using proven protocols Reduce hospital readmissions for high-risk patients Research, evaluate, and share new and improved practices. This list of commitments will grow over time. Participating medical schools and teaching hospitals have committed to:

The Pathman-PROCEED model applied to AAMC’s BPBC campaign Methods/StagesAwarenessAgreementAdoptionAdherence Predisposing s, Conferences, Media Group work at meetings, conference calls Enabling Learning collaboratives, workshops, Web-tools, webinars Reinforcing Reminders, audit/feedback, Awards Reminders, audit/feedback

How can we use CME/CPD in genetics education? Recommendation #4 When considering further research implications, add those related to changing physician –health professional performance relative to CME/CPD interventions, staging and learning

Large and growing body of evidence about the effect of CME/CPD now imbedded in models of change- no longer an invisible (and ineffective) intervention Huge clinical care gap, no less so in genetics Considerable support for consideration of CME/CPD practices and principles – based on best evidence. And a few final last words

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