Medical education with EMR-based reminders reduces antibiotic prescribing and dispensing for respiratory tract infections in Norway

It is known that British guidelines for otitis media support delayed antibiotic prescribing [1], and other countries have guidelines to reduce certain antibiotic prescribing for otitis media, for example, France [2]. Conversely, Finnish guidelines do not [3]. A 2013 Norwegian study published in the British Journal of General Practice compares the varying effectiveness of 2 interventions in delaying primary care antibiotic prescribing for respiratory tract infections, including otitis [4].

Notwithstanding a complicated design for recruiting and assigning general practitioners across multiple sites, this article offers several interesting features. First, it compares an education-only intervention with the same education enhanced by pop-up reminders of a physician’s own prescribing patterns in the electronic medical record (EMR), a nice reinforcement of the educational intervention for participating physicians. While not a focus of this post, I would like to mention a new Penn study of adherence to guidelines on otitis media using EMRs for decision support at Children’s Hospital of Philadelphia [5]. This shows interest in implementation science combined with continuing medical education (CME) for changing physicians’ practice patterns.

The Norwegian study featured here [4] data collected and linked data on prescribed and dispensed antibiotics from (a) 1 year before and (b) 1 year during the intervention, which allowed prescribing practice patterns to be displayed to physicians in the EMR at the point of prescribing antibiotics for a respiratory tract infection. It also collected pharmacy fill rates by patients, which I find interesting because it may offer insights into patients’ (or parents’) agreement with the need for the prescription, after any access barriers to medication adherence. 

Both study arms showed slightly reduced antibiotic prescribing from baseline (pre-intervention) rates: 1% reduction vs. 4% reduction in “approximated risk” (risk ratio, RR) in the education-only vs. education-plus-EMR study arms, respectively. Both results report very tight ranges around a 95% confidence interval (CI), increasing confidence in the findings. (It is further nice to see the CI reported instead of the p value, for those who often hesitate to report CI because of many readers’ greater familiarity with the p value.) While reporting of “risk ratio” may be used as simply a convenient and appropriate way of reporting epidemiological data, it seems to me that its use for reporting educational outcomes with practice data is unusual and perhaps a comment on antibiotic prescribing for these infections as a risk.

The authors find that upper respiratory tract infection, sinusitis, and otitis “gave highest odds for delayed prescribing and lowest odds for dispensing,” which led them to conclude that the greatest potential for “savings” is greatest for these infections, a comment that brings this CME study with implementation science into the context of health utilization research. The article offers freely accessible full text, so enjoy reading the study.

References cited:

1. Centre for Clinical Practice at NICE (UK). Respiratory Tract Infections - Antibiotic Prescribing: Prescribing of Antibiotics for Self-Limiting Respiratory Tract Infections in Adults and Children in Primary Care. London: National Institute for Health and Clinical Excellence (UK); 2008 Jul. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0010014/.
2. Levy C, Pereira M, Guedj R, et al. Impact of 2011 French guidelines on antibiotic prescription for acute otitis media in infants. Médecine Mal Infect. 2014;44(3):102-106. http://www.ncbi.nlm.nih.gov/pubmed/24630597.
3. [Update on current care guidelines: acute otitis media]. Duodecim. 2010;126(5):573-4. Finnish. http://www.ncbi.nlm.nih.gov/pubmed/20597310.
4. Hoye S, Gjelstad S, Lindbaek M. Effects on antibiotic dispensing rates of interventions to promote delayed prescribing for respiratory tract infections in primary care. Br J Gen Pract. 2013;63(616):e777-e786. http://bjgp.org/content/63/616/e777.full.pdf. [Featured Article]
5. Fiks AG, Zhang P, Localio AR, et al. Adoption of electronic medical record-based decision support for otitis media in children. Health Serv Res. 2015;50(2):489-513. http://www.ncbi.nlm.nih.gov/pubmed/25287670.  

MeSH *Major* terms: Anti-Bacterial Agents/therapeutic use*; Education, Medical, Continuing*; General Practice/statistics & numerical data*; Physician's Practice Patterns/statistics & numerical data*; Respiratory Tract Infections/drug therapy* 

Today's Landmark NHLBI SPRINT study results relate to this 2008 PI-CME article by Shershneva, Olson, et al

Today the National Heart, Lung, and Blood Institute (NHLBI) of the United States National Institutes of Health announced the early completion of the landmark SPRINT study into recommended systolic blood pressure, which was led by researchers in my own town, at Wake Forest University School of Medicine. Therefore I am featuring a hypertension performance-improvement CME study by Marianna Shershneva, Curt Olson, and others, whose care is a quality measure in this country and elsewhere.

This PI-CME study was published in 2008, before most educational providers who now have outcomes-reporting capacities were able to study educational outcomes within a clinical context. Marianna Shershneva, M.D., Ph.D., is Building Block Leader for Quality Metrics of the Alliance's Quality Improvement Education (ACEhp QIE) Initiative, and Curtis Olson, Ph.D., has been guiding our field through his influence and tenure as Editor-in-Chief of the Journal of Continuing Education in the Health Professions. With their coauthors, Elizabeth Mullikin and Anne-Sophie Loos, we have a nice study for historical review that might have escaped attention on this day because the article title does not specify hypertension.

Consider this excerpt from the abstract, which lays out the opportunities for quality improvement professionals and clinical educators to work together for better patient care: "Although QI practices and CME approaches have been recognized for years, what emerges from their integration is largely unfamiliar, because it requires the collaboration of CME providers and stakeholders within the health care systems who traditionally have not worked together and may not have the same understanding of QI issues to close performance gaps." This was an observational case study with nine clinicians completing the study, and while we could wish for a larger sample, we should agree with the authors that "PI CME required unprecedented collaboration between CME planners and QI stakeholders to enable change in clinical practice." Let's applaud the effort and enjoy the three core findings that you'll see if you access this article.

This is a FREE article in PubMed Central, and I encourage you to review it for findings on physicians' practice patterns that have bearing on today's news from NHLBI. Thanks to the National Library of Medicine reviewers of articles for their assignments to this article's medical subject headings (MeSH terms), without which this article may not have risen to most noteworthy mention after today's NHLBI news. And by the way, proving the relevance of this sort of work to our nation, this study was also funded by two NIH grants.

References Cited: Shershneva MB, Mullikin EA, Loose A-S, Olson CA. Learning to collaborate: a case study of performance improvement CME. J Contin Educ Health Prof. 2008;28(3):140-147. doi:10.1002/chp.181.
NHLBI. Landmark NIH study shows intensive blood pressure management may save lives: lower blood pressure target greatly reduces cardiovascular complications and deaths in older adults [press release]. NHLBI Website. http://www.nih.gov/news/health/sep2015/nhlbi-11.htm. Accessed September 11, 2015.
Reboussin D, NHLBI, NIDDK, NINDS, and NIA. Systolic Blood Pressure Intervention Trial (SPRINT). NCT01206062. ClinicalTrials.gov Website. https://clinicaltrials.gov/ct2/show/NCT01206062. Accessed Accessed September 11, 2015.
MeSH *Major* Terms: Education, Medical, Continuing/standards; Hypertension/prevention & control; Physician's Practice Patterns; Quality Assurance, Health Care.

ACEhp’s President Ed Dellert Co-Authored COPD CME Mayo Clinic Article With Robust Follow-Up Data

Mayo Clinic Proceedings published this free 2012 article by SG Adams (University of Texas Health Science Center) and colleagues on an educational change intervention on chronic obstructive pulmonary disease (COPD) among primary care clinic. What’s more, our own Alliance for CE in the Health Professions president, Ed Dellert, is a co-author!

There was a clear educational gap among target clinicians: The authors report that, “before the program, 173 of 320 participants (54.1%) had never used the Global Initiative for Chronic Obstructive Lung Disease recommendations for COPD.” Those of us who collect educational outcomes data can applaud the tremendous follow-up survey’s response rate of 48.7% of the 313 participants. We all struggle with the problematic use of self reported performance data in CEhp outcomes articles; the authors even acknowledge this, stating, “physician self assessment is unreliable” (Methods). Yet, this article is impressive because of its inclusion of the word “completely: “Of the follow-up survey respondents, 92 of 132 (69.7%) reported completely implementing at least one clinical practice change.” This helps us appreciate the knowledge and comprehension data reported as increasing significantly, as well as the value of improved self-confidence developed through CME/CEhp. Confidence is a measure of competence (Moore’s Level 4), and competence is, to me, “the glue that sticks” knowledge to performance-in-practice. 

The initiative featured systematic instructional design methods using the Analysis, Design, Development, Implementation, and Evaluation (ADDIE) approach. This construct was followed by a team of educators and medical experts from multiple disciplines, particularly from the American College of Chest Physicians and American Academy of Nurse Practitioners. Especially interesting for us instructional designers, the team used “self-directed learning” and “case and problem-based learning” before ever beginning “lecture-based learning” (Table 1), indicating that they incorporated the benefits of exploration in scientific learning that ideally occurs before the didactic introduction of terms (per the Learning Cycle teaching model). 

To challenge medical educators, I ask that we all continue to look for and share CEhp studies that feature professional instructional design that other clinical sites and educational teams can reproduce. This will help us highlight Why We Matter. So I close with the image that my educational outcomes colleague, Wendy Turell, tweeted (@WTevalu8), showing Ed Dellert discussing Why We Matter at the Alliance Industry Summit in May 2015. 

PubMed: http://www.ncbi.nlm.nih.gov/pubmed/22958990
PubMed Central: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538496/
MeSH *Major* terms: Clinical Competence; Education, Medical, Continuing; Physicians, Primary Care/education; Pulmonary Disease, Chronic Obstructive/diagnosis; Pulmonary Disease, Chronic Obstructive/therapy

Back to School: See How Clinical Continuing Education Has Improved Health Care Quality – Proven in Peer-Reviewed Journals!

We often hear that there is little evidence of CME’s success in teaching clinicians relevant strategies for better patient care, for changing practice through education, and for connecting with the quality improvement (QI) movement. Witness the current initiatives of the Alliance for Continuing Education in the Health Profession (ACEhp), “Why We Matter” and the 10-year Roadmap and 10 complementary Building Blocks of the Quality Improvement Education (QIE) Initiative. While Davis and others have noted historical effectiveness of CEhp, such as in this 1992 article, later articles by Bloom, Davis, and Ratanawongsa have questioned CME effectiveness (e.g., in 1995 and 2005) and identified reporting inconsistencies that reduce the validity of CME outcomes reports.

It is true that our reporting of CEhp methods and outcomes has need of greater readership and better reporting. Yet CME, performance improvement (PI), interprofessional education (IPE), and education-driven QI projects already have many achievements reported, in both initiative-level outcomes reports and the published, peer-reviewed literature. Going beyond JCEHP, where articles feature methods and case studies for improving clinical education, and CE Measure, which reports on-the-ground initiatives and specific outcomes data, we see that clinical journals and meetings are publishing increasing numbers of CEhp studies. What’s more, reporting of these achievements is certain to grow after the ACEhp QIE Initiative launches its custom version of the SQUIRE tool this month, at September 2015’s Alliance Quality Symposium. The SQUIRE tool, created by the group developing Standards for Quality Improvement Reporting Excellence, will help all of us doing CEhp research design our studies and publish our findings in a standardized manner … for later meta-analyses of into CME/CEhp effectiveness as a mechanism for quality improvement.

Today our goal is to show the past effectiveness of CEhp initiatives in published educational outcomes studies, as we prepare—as a profession—to begin reporting CME and IPE initiatives with greater rigor, and to illustrate the effectiveness of certified clinical education by accredited providers on a greater scale. Therefore, Don Harting, my friend and colleague who specializes in medical education needs assessments, and I have embarked on a “Back-to-School” campaign to highlight published articles where CME, IPE, PI, and QI initiatives worked to change clinicians’ behavior or improve performance in routine, clinical practice. Don featured 15 of our 30 articles on Twitter (@CME_Scout) and his blog from August 17 – August 31, 2015, and I will be posting to publicize another 15 articles at @SHB_CMEedit and this blog from September 1 – September 15, 2015. You can sign up to receive a summary report of the published studies we feature by following fullcirclece.blogspot.com, or find me in person at the Alliance Quality Symposium at the end of September.

We want you to take away these messages from this campaign, so let me encourage you to put yourself in the first person and say these motivational statements:

• I can talk about CEhp initiatives that were effective in improving the quality of health care
• There is evidence in the peer-reviewed literature to prove CEhp effectiveness
• I am ready to read CEhp outcomes studies, to help me learn to prepare my own (if you are not sure you’re ready, check out the 12-article research and statistics series in the ACEhp Almanac, which started in February 2015)
• My group’s CEhp outcomes data do not have to show change to be worth publishing, i.e., it’s okay to publish negative findings because I am a dispassionate researcher of clinical education
• I can find clinical and educational journals to whom to submit my CME outcomes data
• My CEhp work in content and faculty development, instructional design, and outcomes analysis matters

Now don’t you feel better? Not sure? Ready to go? Follow our tweets, read the articles or their abstracts, and then say these points to yourself again. 

Finally, to promote articles showing the achievements of the continuing education profession in improvement health care quality, we have a contest where you can Retweet to Win (see rules) by sharing our featured articles with your network of CEhp professionals. Harting Communications LLC is offering a $100 Amazon gift card as first prize, and Full Circle Clinical Education, Inc, is offering a $50 Amazon gift card as second prize!

Remember to follow us on Twitter @SHB_CMEedit and @CME_Scout so that you can notified via direct message if you win! And tell Don and me whether this service campaign supporting awareness of CEhp effectiveness was helpful to you. 

Good luck, happy reading, and enjoy! 

Best wishes, and thanks for viewing my updates, 

Sandra