By Carole Drexel, PhD, CHCP; Kathy Merlo, CHCP; Leanne Berger; and Tom Sullivan, Rockpointe Corporation and Potomac Center for Medical Education
Alliance National Learning Competency 2.1
Implement CE activities/interventions to address healthcare professionals’ practice gapsand underlying learning needs by
- Identifying data and other sources that can help reveal healthcare professionals’ practice gaps and learning needs
- Using data and information related to healthcare professionals’ practice gaps and learning needs to design CE activities/interventions
- Developing learning objectives for CE activities/interventions that clearly describe theintended behavior/action of the learner after engaging in the CE activity/intervention
- Creating CE activities/interventions using formats that are selected based on objectives and expected results
- Creating interprofessional CE activities/interventions for the healthcare team
The prevalence of type 2 diabetes mellitus (T2DM) continues to rise at an alarming rate, and many patients are not reaching their HbA1c target goals.1 Analysis of National Health and Nutrition Examination Survey data collected between 2007 and 2010 showed that 47.5 percent of people older than 20 years with diabetes did not achieve HbA1c <7.0 percent.2
In addition, in 2014, 64 percent of patients older than 65 years of age with comorbid heart and kidney disease did not reach HbA1c <7 percent, per the National Committee on Quality Assurance.1 Uncertainties regarding the management of patients with comorbidities (e.g., cardiovascular disease or renal impairment) and the risk of hypoglycemia associated with several glucose-lowering therapies are common barriers to advancing treatment for T2DM in patients who are not reaching HbA1c goal. Another barrier to optimal patient outcomes is low engagement of patients, which prevents individualization of therapy and impacts patient adherence to their treatment regimen.
“Type 2 Diabetes Management: A Team Approach to Managing Hypoglycemia, Comorbidities, and Patient Challenges,” was a one-hour grand rounds activity series held in community hospitals.
The series was designed to educate clinicians on patient engagement strategies and guideline-based management of T2DM, specifically in patients with comorbidities or at a high risk for hypoglycemia.
This CME activity was held in 30 hospitals in 19 states between Nov. 11, 2014, and June 16, 2015.
The literature suggests that the most effective strategies for educational design contain a multidimensional approach, which includes rigorous and accurate assessment of need, and the use of active, varied and interactive learning approaches.3,4 The content for the series was entirely casebased and tailored to the needs of each hosting venue.
The curriculum included six patient case scenarios, with two cases per learning objective. Each host site selected one of the cases per learning objective (three cases total) at the recommendation of the institution’s department chair or clinicians.
Interactive questions also were presented to facilitate clinical thinking.
The outcomes methodology relies on assessment of responses to a series of case-vignette questions from a sample of HCPs who participated in the CME activity (participants) as compared to responses from a comparable, demographically matched group of HCPs who did not receive the education (nonparticipants).
Comparing the differences in response patterns between the participant and nonparticipant groups allowed for assessment of the following:
- whether the therapeutic choices of participants were consistent with the clinical evidence;
- whether practice choices of participants were different from those of nonparticipants;
- what barriers exist to the optimal management of T2DM; and
- which educational needs remain.
Outcomes and Analysis
A total of 1,182 learners (65 percent MDs, 13 percent NPs and 5 percent RDs/PharmDs) participated in the grand rounds series. On average, participants saw approximately 78 patients with T2DM every week.
The baseline clinical practice characteristics revealed that:
- only 41 percent of responding participants indicated that they always or frequently incorporated share decision making (SDM) in T2DM management, and
- 15 percent indicated that they did not know the definition of SDM.
In addition, 65 percent of responding participants indicated that they always or frequently evaluated the risk of hypoglycemia in their patients with T2DM and adjusted management as necessary to avoid hypoglycemic episodes.
The education was perceived as very impactful to the participants, successfully addressing their practice needs. Nearly all responding participants stated that the activity:
- ”provided me with tools/information to improve my practice” (98 percent);
- “better prepared me to care for my patients (98 percent); and
- “helped me to have a better understanding of the topic(s)” (99 percent).
Compared to nonparticipants, the activity favorably impacted the clinical decision making of the participants. Participants were more likely to account for the cardiovascular impact of glucose-lowering agents, as well as their effects on weight, their hypoglycemia risk and their contraindications when recommending treatment in a variety of patient scenarios. When presented with the case of a patient with T2DM and renal disease who was not at blood glucose goal, nonparticipants were three times more likely to choose a sulfonylurea, which is a drug associated with high hypoglycemia risk. Also, participants were nearly twice as likely to prescribe a dipeptidyl peptidase 4 inhibitor (DPP4-I) [participants, 54 percent; nonparticipants, 30 percent; P<0.0340] in the same patient. DPP4-I agents can be used in renal impairment with dose modifications, while other agents are associated with warnings or contraindications.
When asked which cardiovascular disease risk factor may be improved with the use of sodium-glucose co-transporter 2 inhibitor (SGLT2-I) therapy, significantly (P<0.0321) more participants (51 percent) than nonparticipants (27 percent) chose the correct response of blood pressure (Table 1). In addition, significantly (P<0.0270) more participants (78 percent) compared to nonparticipants (54 percent) were aware of the risk factors that could prevent the safe use of SGLT2-I. Participants also tended to be better able to make management decisions to reduce the risk of weight gain, which is consistent with a trend of enhanced participant confidence with the use of DPP4-I.
An effect size was calculated to determine the amount of difference between the evidence-based responses of the participants and nonparticipants. In this case, it was estimated that the 1,182 clinicians who participated in the grand rounds series were 51.6 percent more likely than nonparticipants to provide evidence-based and guideline-driven care.
Barriers to care were similar between participants and non-participants regarding low patient adherence to medication, medication selection and dosage adjustment for renal insufficiency, complexity of treating patients with multiple comorbidities, inadequate communication between multidisciplinary care providers and difficulty keeping pace with guidelines. In addition, both groups reported similar unfamiliarity with patient-engagement techniques.
Confidence levels in using DPP4-I, managing patients with comorbid renal disease, and managing patients with cardiovascular risk factors or comorbid cardiovascular disease was similar in both participant and nonparticipant groups (Figure 1). However, participants had greater confidence in their ability to involve patients in decision making [participants (92 percent) and nonparticipants (79 percent)]. These findings are particularly interesting, as the baseline practice assessment showed that a low proportion of clinicians regularly engaged patients in decision - making.
Also, when presented with case-based scenarios, only about two-thirds of participants and nonparticipants applied strategies to engage patients. These data contrast with the fact that “unfamiliarity with patient-engagement techniques” was reported as a “significant” to “very significant” barrier to patient care by both participants and nonparticipants. We interpreted these findings to indicate that, while clinicians are likely aware that patient engagement should be part of their regular approach to patient care, they lack adequate training to do so; therefore, they do not incorporate patient engagement into their routine care of T2DM patients.
Participation in an interactive, case-based grand rounds activity was associated with increased HCP knowledge and competence in the management of T2DM. It was also associated with a 51 percent increased likelihood that patients would receive evidence-based care from participating physicians, specifically in the context of comorbidities, renal impairment, cardiovascular risk and the need to limit weight gain. Participation in the grand rounds series has the potential to improve T2DM patient care during 92,196 patient visits each month to participating clinicians.
Based on the clinicians’ survey and interviews with leading faculty, the CME providers assumed that the benefits of incretin-based agents on weight are well known. However, our data indicated that community clinicians’ educational needs differed from those of clinicians in university or large settings. We found that community-based clinicians continued to demonstrate “basic” educational needs, and this should be considered when designing future CME education for community clinicians.
The discrepancy between reported confidence levels of clinicians in engaging their patients and how little they actually utilized patient-engagement techniques illustrates a continuing need to identify the root cause of this clinical gap. Our findings point to a problem with competence, as opposed to knowledge or confidence. Clinicians know they should engage their patients, but they do not know how to properly do so. These findings demonstrate that carefully identifying root causes can help CME providers design education that will have the most impact.
We believe that the large impact of the activity was a direct result of the original format of the education. Sites were able to customize the lectures based on their internal educational needs. This means that the content spoke directly to the needs of clinicians and their patients. This format is somewhat similar to the self-directed learning model. Giving each site the opportunity to choose the educational topics meant that patient cases presented were likely to be encountered by practicing clinicians in attendance, adding to the relevance of the education.
This experience suggests that the flexibility to tailor a grand rounds presentation to the needs of the venue is key to appropriately and successfully educating community physicians. This type of education is valuable for CME providers, the clinicians they seek to educate, and the patients who will ultimately be treated.
The educational series, “Type 2 Diabetes Management: A Team Approach to Managing Hypoglycemia, Comorbidities, and Patient Challenges,” was supported by an educational grant from Merck & Co. Inc.
- National Committee for Quality Assurance. Improving quality and patient experience. The State of Health Care Quality 2015. October 2015.
- Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: US Department of Health and Human Services; 2014.
- Davis D, Evans M, Jadad A et al. The case for knowledge translation: shortening the journey from evidence to effect. BMJ. 2003;327:33-35.
- Davis D, O’Brien MAT, Freemantle N et al. Impact of formal continuing medical education. JAMA. 1999;282:867-874.