Effects of 2 educational interventions on the management of hypertensive patients in primary health care

A Curriculum on Advanced Topics in Hypertension for Internal Medicine Residents

OBJECTIVES

Hypertension (HTN) affects nearly half of US adults. Our multi-institutional survey revealed that Internal Medicine residents lack proficiency in advanced HTN topics. We developed a curriculum to address knowledge gaps in these topics and aimed to assess the effects of the curriculum on residents' confidence, desire for future training, and knowledge in advanced HTN topics.

METHODS

HTN experts taught four advanced topics in HTN: conducting a workup for secondary HTN, managing HTN in chronic kidney disease, managing HTN in patients who are or may become pregnant, and managing hypertensive urgency (severe asymptomatic HTN) in the outpatient setting. The setting of the curriculum was an ambulatory educational half-day, during which residents rotated through small-group sessions dedicated to each HTN topic. We developed pre-, immediate post-, and 8 weeks postcurriculum surveys assessing residents' confidence and desire for future training in the four topics (4-point Likert scales), and multiple-choice quizzes to assess changes in knowledge. We used repeated-measures analysis of variance to compare means between time points for surveys and quizzes.

RESULTS

A total of 112 Internal Medicine residents participated in the curriculum. The mean confidence scores for all four topics increased from 1.79 to 2.61 precurriculum to 2.90 to 3.45 immediately postcurriculum (all P < 0.001) and remained higher (2.53-3.18) than precurriculum at 8 weeks postcurriculum (all P < 0.02). The mean desire for future training scores decreased from 2.74 to 2.96 precurriculum to 2.06 to 2.36 immediately postcurriculum (all P < 0.001 except for managing HTN in patients who are or may become pregnant, which was P = 0.17) and remained lower (2.08-2.36) than precurriculum at 8 weeks postcurriculum (all P ≤ 0.003). The mean knowledge score increased from 48% precurriculum to 62% immediate postcurriculum (P < 0.001) and remained higher (55%) than precurriculum at 8 weeks postcurriculum (P = 0.015).

CONCLUSIONS

A curriculum on advanced HTN topics produced durable gains in confidence and knowledge and partially satisfied the desire for future learning among Internal Medicine residents.

Evaluation of Continuing Professional Development for Physicians - Time for Change: A Scoping Review

Introduction

Evaluation of education interventions is essential for continuous improvement as it provides insights into how and why outcomes occur. Specifically, for physicians' continuing professional development (CPD) programs, which aim to upskill physicians in a range of practice-essential domains, evaluations are crucial to assure physicians' continuous development, enhanced patient care and safety. However, evaluations of health professions education (HPE) interventions tend to be outcomes focused, failing to capture how and why outcomes occur. This scoping review aimed to identify evaluation techniques used to evaluate CPD programs for physicians, and to determine how these techniques are being implemented as well as the their quality.

Methods

We searched PubMed, Embase, Web of Science, among others for English publications on evaluation of CPD programs for physicians, in the past decade. We used a data charting template to extract study details regarding the evaluation techniques and produced a checklist to assess the quality of the evaluations.

Results

101 studies were included; of which 91 studies did not use an evaluation framework. Our findings revealed shortcomings in the evaluations of CPD programs including lack of attention to: intervention processes; unintended outcomes and contextual factors; use of theory; evaluation framework use; and rationale for chosen evaluation method.

Discussion

Our findings highlighted major gaps in the evaluation techniques employed in physicians' CPD. Attention needs to be paid to evaluating both program processes and outcomes to illuminate how and why impacts are or are not occurring.

Trends in guideline implementation: an updated scoping review

BACKGROUND

Guidelines aim to support evidence-informed practice but are inconsistently used without implementation strategies. Our prior scoping review revealed that guideline implementation interventions were not selected and tailored based on processes known to enhance guideline uptake and impact. The purpose of this study was to update the prior scoping review.

METHODS

We searched MEDLINE, EMBASE, AMED, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews for studies published from 2014 to January 2021 that evaluated guideline implementation interventions. We screened studies in triplicate and extracted data in duplicate. We reported study and intervention characteristics and studies that achieved impact with summary statistics.

RESULTS

We included 118 studies that implemented guidelines on 16 clinical topics. With regard to implementation planning, 21% of studies referred to theories or frameworks, 50% pre-identified implementation barriers, and 36% engaged stakeholders in selecting or tailoring interventions. Studies that employed frameworks (n=25) most often used the theoretical domains framework (28%) or social cognitive theory (28%). Those that pre-identified barriers (n=59) most often consulted literature (60%). Those that engaged stakeholders (n=42) most often consulted healthcare professionals (79%). Common interventions included educating professionals about guidelines (44%) and information systems/technology (41%). Most studies employed multi-faceted interventions (75%). A total of 97 (82%) studies achieved impact (improvements in one or more reported outcomes) including 10 (40% of 25) studies that employed frameworks, 28 (47.45% of 59) studies that pre-identified barriers, 22 (52.38% of 42) studies that engaged stakeholders, and 21 (70% of 30) studies that employed single interventions.

CONCLUSIONS

Compared to our prior review, this review found that more studies used processes to select and tailor interventions, and a wider array of types of interventions across the Mazza taxonomy. Given that most studies achieved impact, this might reinforce the need for implementation planning. However, even studies that did not plan implementation achieved impact. Similarly, even single interventions achieved impact. Thus, a future systematic review based on this data is warranted to establish if the use of frameworks, barrier identification, stakeholder engagement, and multi-faceted interventions are associated with impact.

TRIAL REGISTRATION

The protocol was registered with Open Science Framework ( https://osf.io/4nxpr ) and published in JBI Evidence Synthesis.

Tackling the challenge of the impact of continuing education: An evidence synthesis charting a global, cross-professional shift away from counting hours

INTRODUCTION

Health professionals worldwide are required to maintain their knowledge and skills through continuing education. However, there is limited evidence that the accumulation of hours of educational activity enhances practice. The aim of this study was to review evidence of the impact of continuing professional development (CPD), best educational practice and new models of CPD requirements.

METHODS

We conducted a rapid evidence synthesis, reviewing literature and websites on continuing education for healthcare and non-healthcare professionals.

RESULTS

We extracted data from 184 publications. Evidence of changed practice and improved patient care is uncommon in studies of CPD. What evidence there is suggests that activities are more likely to have impact if a combination of methods is used and if they are aligned with learning needs. Impact is also affected by the learner and their work environment. In terms of CPD requirements, we identified three models: input-based; outcomes-based and mixed models. We found a clear shift from quantitative, time-serving, input-models to outcomes-focused models which emphasise the identification of learning needs, selection of educational activity relevant to practice and reflection on practice improvement. Across a range of professions, recently updated CPD regulations no longer require registrants to accumulate CPD hours/points/credits.

CONCLUSION

Outcomes-based models support registrants' engagement in relevant, meaningful CPD which holds greater potential to positively impact on practice and strengthen patient safety. In funding this study, the UK General Dental Council exemplifies its commitment to reviewing its CPD requirments.

Interventions targeting hypertension and diabetes mellitus at community and primary healthcare level in low- and middle-income countries:a scoping review

BACKGROUND

Hypertension (HTN) and diabetes mellitus (DM) are highly prevalent in low- and middle-income countries (LMIC) and a leading cause of morbidity and mortality. Recent evidence on effectiveness of primary care interventions has attracted renewed calls for their implementation. This review aims to synthesize evidence pertaining to primary care interventions on these two diseases, evaluated and tested in LMICs.

METHODS

Two reviewers conducted an electronic search of three databases (Pubmed, EMBASE and Web of Science) and screened for eligible articles. Interventions covering health promotion, prevention, treatment, or rehabilitation activities at the PHC or community level were included. Studies published in English, French, Portuguese and Spanish, from January 2007 to January 2017, were included. Key extraction variables included the 12 criteria identified by the Template for Intervention Description and Replication (TIDieR) checklist and guide. The Innovative Care for Chronic Conditions Framework (ICCCF) was used to guide analysis and reporting of results.

RESULTS

198 articles were analyzed. The strategies focused on healthcare service organization (76.5%), community level (9.7 %), creating a positive policy environment (3.6%) and strategies covering multiple domains (10.2%). Studies included related to the following topics: description or testing of interventions (n=81; 41.3%), implementation or evaluation projects (n=42; 21.4%), quality improvement initiatives (n=15; 7.7%), screening and prevention efforts (n=26; 13.2%), management of HTN or DM (n=13; 6.6%), integrated health services (n=10; 5.1%), knowledge and attitude surveys (n=5; 2.5%), cost-effective lab tests (n=2; 1%) and policy making efforts (n=2; 1%). Most studies reported interventions by non-specialists (n=86; 43.4%) and multidisciplinary teams (n=49; 25.5%).

CONCLUSION

Only 198 articles were found over a 10 year period which demonstrates the limited published research on highly prevalent diseases in LMIC. This review shows the variety and complexity of approaches that have been tested to address HTN and DM in LMICs and highlights the elements of interventions needed to be addressed in order to strengthen delivery of care. Most studies reported little information regarding implementation processes to allow replication. Given the need for multi-component complex interventions, study designs and evaluation techniques will need to be adapted by including process evaluations versus simply effectiveness or outcome evaluations.