Attitudes, Knowledge and Practices of Physicians Related to EHDI

1. Attitudes, Knowledge and Practices of Physicians Related to EHDI National EHDI Conference Feb, 2006 Mary Pat Moeller, Ph.D. Boys Town National Research Hospital Karl White, Ph.D. Utah State University

2. Faculty Disclosure Information In the past 12 months, we have not had a significant financial interest or other relationship with the manufacturers of product or providers of the services that will be discussed in our presentation This presentation will not include discussion of pharmaceuticals or devices that have not been approved by the FDA nor will the presentation discuss unapproved or "off-label" uses of pharmaceuticals or devices.

3. Overview of Presentation • Project Rationale • Results of National Survey of 1,968 physicians • Implications for EHDI teams

4. Project Rationale • Newborns seen regularly by primary care physician • Key role in promoting follow up, making referrals and supporting families • Attitudes, Knowledge and Experiences influence behaviors • Need to understand physician perspectives

5. Project with Pediatricians Formal Focus Group Work (N=27) Pilot Focus Groups (N = 21) Internet Based Survey (N=263); Paper Survey (N = 1,968) Resource Development Field test, revise & disseminate NIDCD & MCHB supported

6. Themes from Focus Groups: Methods • Consider time constraints in daily practice & number of infants seen in practice life time; action oriented, just in time resources • Avoid dense content designed to make me an expert • Need for common language across disciplines • Low tech materials preferred by some

7. Themes from Focus Groups: Methods • Attend to credible sources of information (like AAP) • Avoid anecdotal in favor of evidence-based content • Use familiar formats (e.g., Grand Rounds, algorithms, patient education materials)…but consider how to challenge the “comfort zone?”

8. NHS PHYSICIAN SURVEY BTNRH and NCHAM Collaboration Mary Pat Moeller, Ph.D., Karl White, Ph.D., Lenore Shisler

9. Methods • Designed survey based on focus groups and internet responses • Field tested survey at medical society meetings; developed Spanish version • Invited state EHDI coordinators to participate • Mailed survey & cover letter; reminder postcard 2 weeks later

10. Survey Question Examples • Attitudes: • Do you think NHS causes parents undue anxiety or concern? • Do you believe UNHS is worth what it costs? • Please list any concerns you have about NHS, diagnosis and intervention.

11. Survey Questions Examples • Practices: • Approximately how many children with permanent hearing loss (EXCLUDING OTITIS MEDIA) have you had in your practice over the past 3 years? • List any specialists to whom you routinely refer the family of a child with permanent hearing loss (list the types of specialists).

12. Survey Question Examples • Knowledge: • What is your best estimate of the earliest age at which: • A child not passing the screening should be seen for follow up testing • A child can be definitively diagnosed with permanent hearing loss • A child can begin wearing hearing aids • A child with permanent hearing loss should be referred to early intervention • Enter age estimates _________________

13. States Involved in Survey of Physicians N = 21 States + Puerto Rico

14. Physician Survey: Demographics Gender: 53.2% Male 46.8% Female N = 1,968 Location: 62.5% Metro 24.1% Small town 13.3% Rural Moeller, White & Shisler, 2006

15. Practice Settings Private/Community Clinic 75.6% Hospital 10.4% Medical School/University 5.8% Other 3.6% Unknown 3.7%

16. Practice with 0-5 Population 0-10 years = 40.2% 11-20 years = 28.6% 21-30 years = 22.5% 31+ years = 8.7%

17. Children with SNHL in past three years of practice ENT X = 16.95

18. Importance of testing all newborns 3% Pediatricians; 6% Family Practice p < .001 4.4%

19. Does NHS cause undue parental anxiety?

20. Positive Findings: • Most of our physicians receive screening results (88.61% >) • But…12% of pediatricians and 17% of family physicians receive < 50% of results! • Most know that infants should be referred immediately for additional testing (89.2 < 3 mos >) • But…24.3% unsure NHS is worth what it costs

21. Concerns about NHS • Too many false positives • Costs outweigh benefits • Loss to follow up • Need for training • Unclear about procedures; complex • Inconclusive results • Need for parent education • Need for funding & better equipment

22. Confidence in Counseling Parents following Screening 11%

23. Risk for late onset SNHL

24. Referral to Specialists 9.7

25. Follow Up & Intervention 41.5% 27%

26. Ages at which….(1-3-6?) Diagnosis Hearing Aids Early Intervention

27. Candidates for Cochlear Implants 48.5

28. Confidence in Talking with Parents about…

29. Did your training prepare you?

30. Primary Sources of Info on NHS Frequent Internet Use = 51.7%

31. Policy Statement Awareness

32. Continuing Medical Education: Most Successful Methods • Learning linked to clinical practice (including tests of knowledge & evaluation of clinical practice needs) • Educational meetings with interactive components • Outreach events • Use of multiple interventions (e.g., Outreach + reminders; Grand rounds with case study discussion + reminders) Davis, et al, 1995; Davis & Maxmanian, 2002

33. CME: What does the literature say? • Specific problem or issue (e.g., question about a patient) • General problem (gaps in skills; knowledge related to new technology) • Cognitive dissonance (comparison with peers) • Intrinsic factorsDr. B. Schuster (2002)

34. Adult Learning Methods • Diverse learning styles • Prefer activities that are:-Problem centered-Meaningful to life situation-Focused on immediacy of applicationBrookfield, 1986

35. Protocol for f/u Early intervention Contacts for more information Screening for late onset SNHL Patient Education Resources Impact of HL on language Screening at well-child visits Hearing Aids and cochlear implants Genetics and hearing loss Counseling families about screening results Screening methods Topics Judged as Needs (In prioritized order):

36. Useful Resources

37. Most Recommended Resources • Protocol cards • Patient brochures • Web sites • On-line CME* • Peer education • Grand rounds materials

38. Less Recommended Resources • CDs or DVDs to use in patient education • Videotapes to use in parent education …but some offices prefer this type of material …reinforces need for multiple avenues

39. Big Picture: Physicians • Positive changes seen, but more education is needed • “One size” will not fit all; multiple strategies are needed • “Just in time” resources; protocol steps • Action-oriented resources focused on medical management, family counseling • Many topics “needed” but at a manageable level • Additional resources (e.g., peer education and internet) needed

40. Next Steps: • Manuscript (in preparation) • Work with National Nursing, PA and Nurse Practitioner Groups • National Midwife organizations • Sound Health Connections Conference held in Oct, 2005 • Action plans developed

41. Focus Group Themes: Consequences • NPs and nurses need no convincing about the developmental consequences of hearing loss • But they want resources to educate families that “tell people why you need to care about this.” • Barrier: “My child is not sick. He looks fine. It’s “just” a hearing loss.

42. Focus Group Themes: Role of Experience • Limited experience with confirmed hearing loss in infants • Considerable experience with babies who pass second screening • Leads to some “complacency” or minimizing a “refer” in talking with families • Reporting barriers: “Most often we are under the assumption – which is a bad assumption – that if they were not told anything, then it was a pass.”

43. Focus Group Themes: Social Barriers • Practical strategies for Medicaid families: • Recognize effects of “radar screen” • Increase monitoring (WIC form, checklist) • Combine with immunization visits • Increase public awareness • Resources to make consequences clear

44. Timing of the information “bookends”…prenatal (classes or OB) and 2 day call; 2 week check Don’t rely only on the hospital-based discussions Moms are “overwhelmed, concerned with other issues” Time is limited in office visits Can be a barrier to continuity of care (“I just pass the buck”) Other pressing issues may lower this one “on the radar screen” Need resources that are sensitive to the time demands Focus Group Themes: Time Barriers

45. Focus Group Themes: Target Groups • Audiences that need to learn with us: • The Public! (example: lead) • Specialists: OB, ENT, Lamaze Class Teachers • Parents • Day Care Workers • School Nurses • Newborn Nursery Workers • Office Staff (triage, med techs) • Nursing Training Programs

46. Journal articles Newsletters Ad in journals Curriculum for prenatal classes Courses with CEUs Prenatal packets Simple language for parents; PSAs Nurse to nurse educational materials Simulations (demonstrate importance!) On line resources (English & Spanish) Local organization meetings Outreach with lunch Booth at conference Educational CDs Free materials Orientation packets Recommended Educational Strategies

47. Additional Project Collaborators • Lenore Shisler, NCHAM • William Eiserman, NCHAM • Marjorie Brennan, BTNRH • Leisha Eiten, BTNRH • Joyce Bunger, Creighton University • Russell Smith, University of Nebraska • Diane Schmidt, BTNRH • Roger Harpster, BTNRH • Tom Behringer, NCHAM