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May 19, 2011

Annals of Family Medicine: Continuing Education on Cholesterol Guidelines Saves Lives

CME Conference 3 
Advances in medicine and health care improve the lives of millions of Americans each day.  Because of new treatments, tools, and medical devices, thousands of lives are saved and thousands more are living longer.  However, are new breakthroughs and innovations in medical technology the only thing saving lives? 

To answer this question, a recent article published in the Annals of Family Medicine sought to determine whether continuing medical education (CME) can also save lives. 

Background

The original study was conducted by Anna Kiessling, MD, PhD and Peter Henriksson, MD, PhD from the Division of Cardiovascular Medicine, Danderyd Hospital, Stockholm, Sweden, and Moira Lewitt, MD, PhD from the Karolinska Institutet, Stockholm, Sweden.

 

The study, entitled “Case-Based Training of Evidence-Based Clinical Practice in Primary Care and Decreased Mortality in Patients With Coronary Heart Disease,” investigated the 10-year mortality rates in a trial that tested a case-based intervention in primary care aimed at reducing the gap between evidence-based goals and clinical practice in patients with coronary heart disease (CHD).

Methods and Results

A prospective randomized controlled pragmatic trial was undertaken in a primary care setting. New evidence-based guidelines, with intensified lipid-lowering recommendations in CHD, were mailed to all general practitioners in the region and presented at a lecture in 1995. General practitioners and patients with CHD were assigned according to their primary health care center to 2 balanced groups and randomly allocated to usual care as a control or to an active intervention. General practitioners in the intervention group participated in repeated case-based training during a 2-year period. Patients whose CHD was treated by specialists served as an internal specialist comparison group. Altogether, 255 consecutive patients were included.

At 10 years, 22% of the patients in the intervention group had died as compared with 44% in the control group.  This difference was mainly due to reduced cardiovascular mortality in the intervention group.  In addition, the mortality rate of 22% in the intervention group was comparable to the rate of 23% seen in patients treated by a specialist.

As a result, the authors concluded that the “use of case-based training to implement evidence-based practice in primary care was associated with decreased mortality at 10 years in patients with CHD.”

Can CME Save Lives?

In an accompanying editorial, Dave Davis, MD, CCFP, looked at the “Results of a Swedish, Evidence-Based Continuing Education Intervention.”  Dr. Davis, of the Association of American Medical Colleges (AAMC), discussed how the randomized controlled trial of a case-based CME intervention was associated with decreased mortality in Swedish cardiac patients.

Dr. Davis noted that these findings are optimistic and show the benefits of CME programs that carefully plan and implement methodology on patient outcomes.  He also recognized that the “study allows many observations about evidence, physician practice, and the roles that an effective continuing education presence can occupy in health care and its quality and reform efforts, arenas in which this presence is often invisible, unconsidered, and neglected.”

Accordingly, Dr. Davis discusses several observations about CME, its effectiveness, and what we can learn about its role in health services, health care reform, and the implementation of best practice.

First, Dr. Davis recognizes that in the U.S. context, the picture of CME is often “confounded by the need for most physicians to claim credit by attending lectures—providing an equally inadequate view of the field.”  Instead, he asserts that the Kiessling et al study describes a more complete picture of the methods of an effective, multiphase physician continuing education intervention.

In Kiessling study, the intervention comprised a standard lecture, mailed distribution of guidelines to all participants versus an interactive, sequenced strategy in which randomly selected physicians practices participate in several case-based seminars separated by work experience.

The latter, more effective intervention permitted discussion of usual case presentations in the primary care setting, problem solving, and perhaps most importantly, learner engagement. He noted that the elements in Kiessling’s study “build on the literature supporting effective strategies—sequencing of learning activities, close attention to the adult learning principles of relevance, and engagement and interactivity.”  As a result, Dr. Davis explains that these elements more adequately define CME.

Second, Dr. Davis discussed the effectiveness of CME.  For many, he explains, “an effective educational intervention improves or optimizes the competence of physicians—their ability to demonstrate knowledge, skills, or attitudes in the test or educational environment.”  For many others, performance is the reference standard, i.e., the demonstrated behavior of clinicians in the work environment.   For Kiessling and her coauthors and perhaps for the health care system as a whole, however, “patient care outcomes form the ultimate proof of concept.”

Third, he discusses how we can know a CME program has been effective.  Dr. Davis explained that the Kiessling et al study was able to show the efficacy and effect of CME because it had many elements that made the research “exquisitely pragmatic.”  The researchers “paid attention to strict randomization and cross-group comparisons, possibilities of bias, trial design, and educational theory. It used proximal (laboratory values, medication usage), as well as distal (mortality), rates to track its effects. It used carefully applied biostatistical principles. It built from a knowledge platform in which the clinical evidence and level of recommendation are clear, well developed, and robust.

Fourth, Dr. Davis explained how the Kiessling study fits into the broader, U.S.-focused health care system.  He recognizes that CME has an “important and necessary role to play in health care delivery.”  To play an important and necessary role, Dr. Davis asserted that CME “cannot use exclusively ineffective, traditional methods, and it cannot exist in a world parallel to health care.” 

Instead, he explains that CME needs “to use effective methods, to be anchored in the health system, to build on valid learner and patient needs, and help develop a science of CME.”  Consequently, he noted that, “there is clear evidence that this transition is already occurring, at least among academic CME providers.

Discussion

Dr. Davis noted that “pills or new investigations by themselves that cannot save lives.”  Rather, we need “a holistic understanding of the journey that takes us from the development and localization of clinical evidence to its widespread and effective transmission and adoption, to ultimate patient outcomes—and the importance of effective continuing education or professional development of physicians in the process.”

Consequently, accredited CME providers have already begun implementing many of the elements demonstrated in the Kiessling et al study and have shifted their focus to outcomes.  For example, the 2006 Accreditation Council of Continuing Medical Education (ACCME) updated accreditation criteria requires accredited providers to set forth outcomes in their mission statements and measure effectiveness in achieving these goals. In addition, more than half of the 22 ACCME accreditation criteria either directly or indirectly address CME outcomes-related issues/results.

According to a recent report, “the CME enterprise has taken significant steps toward the development of reliable practices and systems to accurately measure the effectiveness of the interventions.” In fact, all accredited CME providers are now required to plan for and demonstrate their role in improving knowledge, competence, physician practice behaviors and/or patient health both at the activity level and more broadly. Additional changes include:

  • Formation of the peer-reviewed journal, CE Measure, in 2006, focusing on outcomes measurements of continuing healthcare education
  • Donald Moore’s reevaluation and update of the levels of outcomes measurements, which was supported in part by industry
  • The number of performance measurement posters and presentations at the Alliance for CME annual meetings doubled between 2005 and 2010
  • Outcomes-specific organizations and service offerings led by biostatisticians were introduced and have grown in number in the CME field
  • Outcomes measurements are now routine components of CME grant applications

If this study were done in the US it is likely to have similar results.  Pharmaceutical companies have given multiple millions in support of cholesterol education to aggressively lower cholesterol.  Overall this study shows that intervention beats ignorance hands down, regardless of who supports the education. 

Managing lipids has been a huge focus of CME education and this week the National Lipid Association’s Annual meeting, countless hours will be devoted to educating physicians on lowering cholesterol.

Conclusions

Ultimately, the Kiessling et al study shows that effective CME programs can save lives.  As Dr. Davis pointed out, even “if we cannot say that CME saves lives, we can certainly claim from this study and many others that there is a strong association.”  Accordingly, as CME providers continue to focus their educational activities and programs on outcomes, it is likely that more positive and optimistic results will follow. 

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