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January 06, 2011

Journal of Clinical Hypertension: CME Learners Provide Better Patient Care

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There has been much discussion and study regarding the role of continuing medical education (CME) in improving patient care. Physicians who are educated about the latest advances in evidence-based practice will make more informed treatment decisions, resulting in improved patient outcomes.

However, before physicians and health care providers can receive education through CME programs that will improve patient care, CME providers must first identify diseases and conditions where there are significant gaps in treatment, suboptimal patient outcomes, or confusion among health care providers. Identifying such areas where there are needs for physician education is an extremely detailed and rigorous scientific and evidence-based process. Consequently, one area that has consistently remained at the forefront of CME is hypertension.

The number of individuals affected by hypertension in the United States is steadily increasing as the population ages and the obesity epidemic continues. Currently, it is estimated that more than 74 million Americans have been diagnosed with hypertension, and approximately 53 million Americans have pre-hypertension. Over the next 10 to 15 years, the prevalence of hypertension is expected to increase, affecting more than 100 million Americans.

As demonstrated by the data above, there is clearly a significant need for physicians to better address patients with hypertension. Thus far, doctors have responded to this need by developing a number of treatment strategies over the years. One of those approaches, effective control of blood pressure (BP) with antihypertensive drug therapy, has been associated with reductions in the incidence of heart failure (>50%), stroke (35%–40%), and myocardial infarction.

Given the success of using antihypertensive drug therapy, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines provided an evidence-based approach to the prevention and management of hypertension. The JNC 7 guidelines identify specific goals and ranges of BP levels for patients. However, an analysis of medical records from 6 community-based hospitals revealed that overall adherence to JNC 7 guidelines was only 53.5%. Moreover, despite these target goals and treatment recommendations, approximately two thirds of hypertensive patients are not meeting blood pressure BP goals defined by JNC 7.

To address this gap in care, the Potomac Center for Continuing Medical Education (PCME), through an educational grant funded by Novartis, implemented a novel, live, highly intensive, case-based educational initiative called “STOP Hypertension NOW! Recognize & Manage Your High-risk Patients.” The outcomes of this CME program were recently discussed in an article entitled, “Highly Interactive Multi-Session Programs Impact Physician Behavior on Hypertension Management: Outcomes of a New CME Model,” published in the Journal of Clinical Hypertension.

According to the article, the quality of education index indicated that individuals who participated in “STOP Hypertension NOW! Recognize & Manage Your High-risk Patients” produced by Rockpointe and accredited by the Potomac Center for Medical Education were “52% more likely to practice guideline-driven and evidence-based medicine than those who did not participate in the CME activity.”

Background

The CME initiative, which began in October of 2009, consisted of a series of 6 regional 4-hour meetings designed to address existing knowledge, competency, and performance gaps in hypertension diagnosis and management in the primary care community. The 6 regional programs had a total of 588 participants, and the average attendance for each program was 98 participants. 67% of participants were physicians (MDs⁄DOs), 23% were nurses, and 10% were physician assistants. The programs took place in cities across the East Coast.

The CME activity was designed to address the Institute of Medicine (IOM) competencies of providing patient-centered care and employing evidence-based practice. The regional series was developed by key opinion leaders in hypertension and was based on a core curriculum, with customization of each mini-conference to highlight the unique challenges and statistics in a particular region. The program was not part of a larger conference, and participation was completely voluntary.

In deciding how to design their program, the authors review of literature found that “the most effective strategies for educational design contain a multidimensional approach: rigorous and accurate assessment of need, use of active and varied learning approaches, and an evidence-based curriculum that focuses on overcoming barriers to change.”

Accordingly, PCME created an agenda for these mini-conferences that was divided into three 1-hour teaching modules, respectively focusing on diagnosis and management, sex and ethnic disparities, hypertension in the elderly, and nonadherence to antihypertensive regimens. Each module included two 20-minute didactic lectures, followed by a case study discussion. The format emphasized attendee-faculty interaction during the lectures and the case study discussions and incorporated the use of an audience response system (ARS) and frequent question-and-answer sessions. PCME designed the program this way because literature has shown that “a change in physician practice is more likely with interventions that are multifaceted, interactive, and consistent with the perceived needs of the learner.”

The program had several educational objectives for participants to achieve, such as describing the effectiveness of various drug classes as they relate to different patient populations and citing the JNC 7 hypertension guideline recommendations for patients with compelling indications.

Results

To measure the impact of the CME program, evidence-based case vignettes were developed to assess whether the diagnostic and therapeutic choices of participants were consistent with clinical evidence presented in the context of the educational activity. The case vignettes were also used to determine whether the practice choices of participants were different from those of nonparticipants.

Surveys were then distributed to physicians who attended the CME program (participants) onsite, during participant registration, and then collected from the participants immediately after the educational activity. A total of 115 surveys were collected from participants, from which 50 surveys were randomly selected for further analysis. Surveys were also distributed to 50 primary care physicians who did not participate in the program (nonparticipants) via e-mail.

Analysis and comparison of the survey results from participants and nonparticipants showed that participants chose evidence-based answers more frequently than nonparticipants to questions related to:

  • JNC 7 guideline recommendations
  • Appropriate antihypertensive therapy use in specific patients (those with compelling indications, elderly patients, and individuals at risk for stroke), and
  • Strategies to improve adherence to antihypertensive regimens.

The analysis also found that:

  • Participants demonstrated a higher level of competency compared with nonparticipants;
  • A significantly greater number of participants (78%) vs. nonparticipants (51%) were capable of selecting the appropriate BP goal for the specified patient; and
  • A greater portion of participants was able to select the most appropriate pharmacotherapy regimen for specific patients.

Based on the average number of patients with hypertension seen weekly by the 588 health care providers who attended the educational activity, the authors concluded that the data indicate that at least 22,304 hypertensive patients are 52% more likely to receive evidence-based care than those seen by health care providers who did not participate in the activity.

Discussion

The instructional approach used in the STOPHypertension NOW!  conference series was different than the traditional didactic presentations of many CME programs. These mini-conferences were highly interactive, with the agenda broken into teaching modules. Each module emphasized faculty-participant interactions via discussion of clinical practice preferences and responses to knowledge or competency-based ARS questions and ample time for open discussion. Lectures were brief, focusing on data that were most applicable to practice.

This format ensured that the presentations were short and crisp, with rapid changes in topic to avoid monotony and keep the audience alert and engaged, as emphasized in a variety of instructional models. This approach allowed for approximately 600 physicians to receive the education, hence impacting the care of more than 22,000 patients. This CME activity was also associated with a projected increase in physician performance, as physicians who attended this educational activity are 52% more likely to provide evidence-based medicine to their patients, as indicated by the education index.

One of the weaknesses from the study is that participants completed the case vignette surveys directly after the program, thereby capturing immediate improvements in knowledge, competency, and intention to change practice behavior. PCME chose to collect the completed survey immediately after the program to promote physician willingness to participate. However, the authors acknowledged that doing so might have increased the educational impact level.

Another potential weakness that the authors identified was that a pharmaceutical company provided the funding for the program. However, the authors asserted that a lack of objectivity in the current CME environment is highly unlikely because CME providers “are placed under strict scrutiny from the accredited bodies to provide certified CME that is fair balanced and free of commercial bias.” Specifically, strict and specific processes have been implemented that require the development of CME content in absence of industry influence and peer review of the content, which guarantee absence of commercial bias.

Accordingly, the authors explained that the in creating the program, PCME “required that the steering committee members and faculty presenters disclose all financial relationships or affiliation with any commercial entity to the audience to ensure full transparency.” In addition, “random selection of the survey participants ensured the objectivity of the data reported in this study.”

Conclusion

Ultimately, the outcomes presented in the article showed that “participation in a half-day, highly interactive CME activity was associated with increased physician knowledge in the management of hypertension, as well as increased likelihood for patients to receive evidence-based care by the physicians who participated.” Participation was also associated with a high likelihood for practice change and making guideline-driven and evidence-based decisions to positively impact patient care.

The authors further concluded that the “data contribute to increase the current understanding of the effect of CME on physician knowledge, competency, and performance, and highlight the importance of CME in improving patient care.” Accordingly, the data project an impact on physician behavior and strongly support the benefits of CME for improving the delivery of guideline-recommended patient care.

Disclosure

I am one of the authors of the paper and am proud and honored to work on this CME program.  It is encouraging to know that our work makes a difference in patient lives.

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