A conceptual model of CME to address disparities in depression care

Feasibility and Acceptability of a Neonatal Project ECHO (NeoECHO) as a Dissemination and Implementation Strategy to Prevent Necrotizing Enterocolitis

BACKGROUND

Caregivers in the neonatal intensive care unit (NICU) often determine care practices in silos, although access to learning communities can improve quality. Project ECHO, a telehealth-delivered mentoring intervention, provides specialists' expertise but not in the NICU until now. Necrotizing enterocolitis (NEC) prevention and timely recognition is one area where specialist support and engaging with a learning community could improve outcomes. NEC-Zero is one care bundle that aims to improve care quality by providing tools to implement NEC prevention in family-engaged ways.

AIMS

To examine the feasibility and acceptability of NeoECHO to disseminate NEC-Zero education and describe the intentions of internal facilitators (IFs) and clinicians to initiate quality improvement changes.

METHODS

This was a convergent mixed-methods study. Our team delivered the first neonatal adaptation of Project ECHO called "NeoECHO" to leverage facilitation as an implementation strategy to disseminate NEC-Zero evidence and support practice change.

RESULTS

Six IFs and seven NICUs participated. All units and IFs that began the series finished it. Of the 261 session attendees, 206 (79%) study evaluations were completed. Of those who completed evaluations, 89 (100%) completed at least one session and 29 (33%) completed three or more. Satisfaction was high. Participants appreciated the engaged and accessible format to learn from experts using real case examples and didactic sessions. Individuals and IFs reported intentions to adopt evidence based on NeoECHO.

LINKING EVIDENCE TO ACTION

NeoECHO was an acceptable and feasible way to engage under-resourced NICUs and share NEC-Zero evidence and tools. More research is needed to examine the impact of NeoECHO on care processes and patient outcomes.

Teaching Public and Population Health in Medical Education: An Evaluation Framework

Curriculum models and training activities in medical education have been markedly enhanced to prepare physicians to address the health needs of diverse populations and to advance health equity. While different teaching and experiential learning activities in the public health and population health sciences have been implemented, there is no existing framework to measure the effectiveness of public and population health (PPH) education in medical education programs. In 2015, the Association of American Medical Colleges established the Expert Panel on Public and Population Health in Medical Education, which convened 20 U.S. medical faculty members whose goal was to develop an evaluation framework adapted from the New World Kirkpatrick Model. Institutional leaders can use this framework to assess the effectiveness of PPH curricula for learners, faculty, and community partners. It may also assist institutions with identifying opportunities to improve the integration of PPH content into medical education programs. In this article, the authors present outcomes metrics and practical curricular or institutional illustrations at each Kirkpatrick training evaluation level to assist institutions with the measurement of (1) reaction to the PPH education content, (2) learning accomplished, (3) application of knowledge and skills to practice, and (4) outcomes achieved as a result of PPH education and practice. A fifth level was added to measure the benefit of PPH curricula on the health system and population health. The framework may assist with developing a locally relevant evaluation to further integrate and support PPH education at U.S. medical schools and teaching hospitals.

The majority of accredited continuing professional development activities do not target clinical behavior change

PURPOSE

Continually improving patient outcomes requires that physicians start new behaviors, stop old behaviors, or adjust how they practice medicine. Continuing professional development (CPD) is the method most commonly used by physicians to improve their knowledge and skills. However, despite regular physician attendance at these activities, change in clinical behavior is rarely observed. The authors sought to identify which of Bloom's domains (cognitive, affective, or psychomotor) are targeted by the learning objectives of CPD activities offered by medical associations, regulatory bodies, and academic institutions in the province of Quebec, Canada.

METHOD

The authors evaluated the objectives of 110 accredited CPD activities offered to physicians and other health professionals from November 2012 to March 2013. The objectives of each activity were extracted and classified into learning domains using Bloom's taxonomy.

RESULTS

Ninety-six percent of the learning objectives analyzed targeted the cognitive domain, which consists of six levels of increasing complexity: knowledge, comprehension, application, analysis, synthesis, and evaluation. Half (47%) targeted knowledge and comprehension, whereas only 26% aimed to improve skills in analysis, synthesis, and evaluation.

CONCLUSIONS

Most accredited CPD activities within this sample were generally not designed to promote clinical behavior change because the focus of these activities was on remembering and understanding information instead of preparing physicians to put knowledge into practice by analyzing information, evaluating new evidence, and planning operations that lead to behavior change. Educators and CPD providers should take advantage of well-established theories of health professional behavior change, such as sociocognitive theories, to develop their activities.

Educating family physicians to recognize and manage depression: where are we now?

OBJECTIVES

To consider what the barriers are to effective depression education; to understand what attitudes, knowledge, and skills doctors need to acquire, and finally to examine what we currently know about effective ways of training family physicians (FPs) about depression.

METHODS

A narrative review of the published literature compiled from searching reviews and original articles was conducted using the following key words: education, training, attitudes, depression, and primary care. Further relevant articles were identified from reference lists.

RESULTS

The identified barriers are FPs' attitudes and confidence toward recognizing and managing depression, the way in which they conceptualize depression, and the difficulties they face in implementing change in the systems in which they work. We, as educators, can identify what FPs need to know, and this should include novel ways of organizing care. However, of key importance is the need to address how more effective interventions may be provided, recognizing that FPs may be starting from many different points on 3 differing continua of attitude, skills, and knowledge in relation to depression.

CONCLUSIONS

We have to not only ensure that the content of what we teach is perceived as relevant to primary care but also review exactly how we go about providing it, using methods that will engage and stimulate doctors at differing stages of readiness to acquire new attitudes, skills, and knowledge about depression. However, we still need to find better ways of helping FPs to recognize and acknowledge their educational needs. Further research is also required to thoroughly evaluate these novel approaches to tailoring educational interventions.

Developing a theory-based instrument to assess the impact of continuing professional development activities on clinical practice: a study protocol

Background

Continuing professional development (CPD) is one of the principal means by which health professionals (i.e. primary care physicians and specialists) maintain, improve, and broaden the knowledge and skills required for optimal patient care and safety. However, the lack of a widely accepted instrument to assess the impact of CPD activities on clinical practice thwarts researchers' comparisons of the effectiveness of CPD activities. Using an integrated model for the study of healthcare professionals' behaviour, our objective is to develop a theory-based, valid, reliable global instrument to assess the impact of accredited CPD activities on clinical practice.

Methods

Phase 1: We will analyze the instruments identified in a systematic review of factors influencing health professionals' behaviours using criteria that reflect the literature on measurement development and CPD decision makers' priorities. The outcome of this phase will be an inventory of instruments based on social cognitive theories. Phase 2: Working from this inventory, the most relevant instruments and their related items for assessing the concepts listed in the integrated model will be selected. Through an e-Delphi process, we will verify whether these instruments are acceptable, what aspects need revision, and whether important items are missing and should be added. The outcome of this phase will be a new global instrument integrating the most relevant tools to fit our integrated model of healthcare professionals' behaviour. Phase 3: Two data collections are planned: (1) a test-retest of the new instrument, including item analysis, to assess its reliability and (2) a study using the instrument before and after CPD activities with a randomly selected control group to explore the instrument's mere-measurement effect. Phase 4: We will conduct individual interviews and focus groups with key stakeholders to identify anticipated barriers and enablers for implementing the new instrument in CPD practice. Phase 5: Drawing on the results from the previous phases, we will use consensus-building methods to develop with the decision makers a plan to implement the new instrument.

Discussion

This project proposes to give stakeholders a theory-based global instrument to validly and reliably measure the impacts of CPD activities on clinical practice, thus laying the groundwork for more targeted and effective knowledge-translation interventions in the future.

Training nursing staff to recognize depression in home healthcare

OBJECTIVES

To describe the implementation and acceptability of the TRaining In the Assessment of Depression (TRIAD) intervention, which has been tested in a randomized trial. The primary aim of TRIAD is to improve the ability of homecare nurses to detect depression in medically ill, older adult homecare patients.

DESIGN

Description of the important components of TRIAD, its implementation, and evaluation results from nurse surveys.

SETTING

Three certified home healthcare agencies in Westchester County, New York.

PARTICIPANTS

Thirty-six homecare nurses.

INTERVENTION

Participants randomly assigned to TRIAD (n=17) were provided with the opportunity to observe and practice patient interviewing. The approach focused on clinically meaningful identification of the two "gateway" symptoms of depression and is consistent with the newly revised Medicare mandatory Outcome and Assessment Information Set (OASIS-C). Control group participants (n=19) received no training beyond that which agencies may have provided routinely.

MEASUREMENTS

Baseline and 1-year nurse confidence in depression detection, and postintervention acceptability ratings of the TRIAD intervention.

RESULTS

Participants randomized to the TRIAD intervention reported a statistically significant increase in confidence in assessing for depression mood (P<.001), whereas the usual care group's confidence remained unchanged (P=.34) 1 year later.

CONCLUSION

An educational program designed to improve depression detection by giving nurses the skills and confidence to integrate depression assessment into the context of routine care can be successfully implemented with homecare agency support. The authors discuss the intervention in terms of OASIS-C and the "real world" realities of intervention implementation.

Theory in practice: helping providers address depression in diabetes care

INTRODUCTION

A continuing education (CE) program based on the theory of planned behavior was designed to understand and improve health care providers' practice patterns in screening, assessing, and treating and/or referring patients with diabetes for depression treatment.

METHODS

Participants completed assessments of attitudes, confidence, intentions, and behaviors regarding depression management at 3 time points: immediately prior to the CE program (baseline), immediately after the CE program (posttest) and 6 weeks after the CE program (follow-up).

RESULTS

Ninety-eight providers attended the CE program: 71 completed the baseline assessment, 66 completed the posttest assessment, and 37 completed the 6-week follow-up. Compared to baseline, at posttest providers reported significantly more favorable attitudes, fewer negative attitudes, greater confidence, and greater intention to address depression with their diabetes patients. At the 6-week follow-up, participants reported a marginally significant increase in educating patients about depression, but no other depression management practices changed. Intention to change and confidence predicted some depression practice patterns at follow-up. Fewer barriers were a consistent predictor of depression practice patterns at follow-up.

DISCUSSION

In the short term, provider attitudes, confidence, and intentions to address depression with their patients improved. Intentions, confidence, and especially barriers are important intervention targets.

Achieving desired results and improved outcomes: integrating planning and assessment throughout learning activities

Most physicians believe that to provide the best possible care to their patients, they must commit to continuous learning. For the most part, it appears the learning activities currently available to physicians do not provide opportunities for meaningful continuous learning. At the same time there have been increasing concerns about the quality of health care, and a variety of groups within organized medicine have proposed approaches to address issues of physician competence and performance. The authors question whether CME will be accepted as a full partner in these new approaches if providers continue to use current approaches to planning and assessing CME. A conceptual model is proposed for planning and assessing continuous learning for physicians that the authors believe will help CME planners address issues of physician competence, physician performance, and patient health status.