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Dave Davis, MD Senior Director, Continuing Education and Improvement

invisible. 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.

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Dave Davis, MD Senior Director, Continuing Education and Improvement

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

  2. An outline: many questions, little time… • What are CME and CPD? Why are they ‘invisible’? • The ‘Does CME Work?’ question: the in- vitro perspective • 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 • So What? Recommendations to a thoughtful genetics audience: guidelines for the use of CME & CPD

  3. 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?

  4. 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)

  5. How have we changed…?

  6. What do we mean by…? • 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)...

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

  8. Database of Physician Education & Change: www.rdrb.utoronto.ca • 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

  9. 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) www.rdrb.utoronto.ca www.rdrb.utoronto.ca

  10. 1) About educational interventionsChanging Physician Performance - a systematic review of the effect of CME strategies JAMA1995;274:700-705 +

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

  12. 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

  13. 2) and about the learner-clinician • 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, 1996 • age • motivation • (dis)incentives • experience • time • environment • training • Emphasis on knowledge • Inability to detect needs, evaluate performance • ?self-directed learning • ?critical appraisal

  14. The self-assessment question Davis & co., JAMA 2006;296:1096-1102

  15. 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 Of 20 comparisons…..

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

  17. 3) About aligning the learner and educator: the Pathman-PROCEED model stages

  18. 3) About the cumulative effect of CCME/CPD “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, 2009

  19. Question # 3: • 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

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

  21. What causes the gap?The evidence-to-practice puzzle The clinician The evidence/guideline The educational delivery system • Health Care • System issues • Patient • Team members

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

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

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

  25. An emerging field; one concept, two terms • “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

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

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

  28. How an we use CME/CPD in evidence/message/guideline development in genetics? • 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) • secure buy-in; involve the end-user in guideline development/adaptation • employ adult learning principles in guideline statements (format, spacing, language) • consider recommending effective educational strategies in the guideline itself

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

  30. One attempt to fix the Message:The Guidelines Advisory Committee, Ontario (now the Center for Evidence-based practice) • 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

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

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

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

  34. Example #1: a new guideline describes the use of a new disease screening test…..

  35. Example #2: many primary care providers fail to use a simple genogram when taking patient history

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

  37. Participating medical schools and teaching hospitals have committed to: • 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.

  38. The Pathman-PROCEED model applied to AAMC’s BPBC campaign

  39. And a few final last words • 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.

  40. Dave’s contact info: • ddavis@aamc.org • www.aamc.org/initiatives/CME/ae4Q • www.rdrb.utoronto.ca

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