Is physician engagement with Web-based CME associated with patients' baseline hemoglobin A1c levels? The Rural Diabetes Online Care study

The design and rationale of a multicenter real-world trial: The Southeastern Collaboration to Improve Blood Pressure Control in the US Black Belt - Addressing the Triple Threat

BACKGROUND

Impoverished African Americans (AA) with hypertension face poor health outcomes.

PURPOSE

To conduct a cluster-randomized trial testing two interventions, alone and in combination, to improve blood pressure (BP) control in AA with persistently uncontrolled hypertension.

METHODS

We engaged primary care practices serving rural Alabama and North Carolina residents, and in each practice we recruited approximately 25 AA adults with persistently uncontrolled hypertension (mean systolic BP >140 mmHg over the year prior to enrollment plus enrollment day BP assessed by research assistants ≥140/90 mmHg). Practices were randomized to peer coaching (PC), practice facilitation (PF), both PC and PF (PC + PF), or enhanced usual care (EUC). Coaches met with participants from PC and PC + PF practices weekly for 8 weeks then monthly over one year, discussing lifestyle changes, medication adherence, home monitoring, and communication with the healthcare team. Facilitators met with PF and PC + PF practices monthly to implement ≥1 quality improvement intervention in each of four domains. Data were collected at 0, 6, and 12 months.

RESULTS

We recruited 69 practices and 1596 participants; 18 practices (408 participants) were randomized to EUC, 16 (384 participants) to PF, 19 (424 participants) to PC, and 16 (380 participants) to PC + PF. Participants had mean age 57 years, 61% were women, and 56% reported annual income <$20,000.

LIMITATIONS

The PF intervention acts at the practice level, possibly missing intervention effects in trial participants. Neither PC nor PF currently has established clinical reimbursement mechanisms.

CONCLUSIONS

This trial will fill evidence gaps regarding practice-level vs. patient-level interventions for rural impoverished AA with uncontrolled hypertension.

Learner engagement and teaching effectiveness in livestreamed versus in-person CME

INTRODUCTION

Engaging learners in continuing medical education (CME) is challenging. Recently, CME courses have transitioned to livestreamed CME, with learners viewing live, in-person courses online. The authors aimed to (1) compare learner engagement and teaching effectiveness in livestreamed with in-person CME and (2) determine how livestream engagement and teaching effectiveness is associated with (A) interactivity metrics, (B) presentation characteristics and (C) medical knowledge.

METHODS

A 3-year, non-randomised study of in-person and livestream CME was performed. The course was in-person for 2018 but transitioned to livestream for 2020 and 2021. Learners completed the Learner Engagement Inventory and Teaching Effectiveness Instrument after each presentation. Both instruments were supported by content, internal structure and relations to other variables' validity evidence. Interactivity metrics included learner use of audience response, questions asked by learners and presentation views. Presentation characteristics included presentations using audience response, using pre/post-test format, time of day and words per slide. Medical knowledge was assessed by audience response. A repeated measures analysis of variance (anova) was used for comparisons and a mixed model approach for correlations.

RESULTS

A total of 159 learners (response rate 27%) completed questionnaires. Engagement did not significantly differ between in-person or livestream CME. (4.56 versus 4.53, p = 0.64, maximum 5 = highly engaged). However, teacher effectiveness scores were higher for in-person compared with livestream (4.77 versus 4.71 p = 0.01, maximum 5 = highly effective). For livestreamed courses, learner engagement was associated with presentation characteristics, including presentation using of audience response (yes = 4.57, no = 4.45, p < .0001), use of a pre/post-test (yes = 4.62, no = 4.54, p < .0001) and time of presentation (morning = 4.58, afternoon = 4.53, p = .0002). Significant associations were not seen for interactivity metrics or medical knowledge.

DISCUSSION

Livestreaming may be as engaging as in-person CME. Although teaching effectiveness in livestreaming was lower, this difference was small. CME course planners should consider offering livestream CME while exploring strategies to enhance teaching effectiveness in livestreamed settings.

Evaluation of Posttraumatic Stress Disorder and Acute Stress Disorder VA/DoD Clinical Practice Guidelines Training

INTRODUCTION

This study evaluated the use of an online learning platform [Joint Knowledge Online (JKO)] for dissemination of the Veterans Affairs and Department of Defense Clinical Practice Guidelines for Management of Posttraumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD). User satisfaction with the training program was assessed, users were asked to estimate their knowledge base about PTSD and ASD, and users provided comments about how they might use the course material in their clinical practice.

MATERIALS AND METHODS

A total of 4,442 users took at least one of three courses offered via JKO related to the PTSD Clinical Practice Guidelines (CPG) between July 1, 2019 and June 25, 2020. A total of 1,663 users took the post-test after the JKO courses and 235 applied to a second website (J7) which granted Continuing Education (CE) credits. Data were gathered from the JKO post-course survey, as well as the J7 course survey, which also asked for respondents' written comments.

RESULTS

User satisfaction was analyzed using the JKO survey Likert scale data for each course, and results found most users rated the courses as "good" or "great." Users were also asked to evaluate their knowledge about PTSD management before and after the course. Results from all three courses showed a statistically significant change in pre-post knowledge with a medium effect size. Thematic analysis was performed on the write-in comments from each course. Comments indicated participants found the assessment tools provided in the courses to be of particular value.

CONCLUSIONS

The VA/DoD's online learning platform (JKO) was a user-friendly, effective tool for training users on PTSD and ASD clinical practice guidelines. Users were satisfied with their experience of the trainings on JKO and improved their knowledge base about the CPG. This study did not evaluate patient data for CPG compliance, but the future study may benefit from these outcomes to demonstrate provider adherence to the guidelines.

Perceptions and behaviors of learner engagement with virtual educational platforms

Background

The COVID-19 pandemic has increased utilization of educational technology for surgical education. Our aim was to determine attitudes and behaviors of surgical education champions towards virtual educational platforms and learner engagement.

Methods

An electronic survey was distributed to all Association of Surgical Education members addressing i) methods of engagement in virtual learning ii) ways to improve engagement and iii) what influences engagement. Stratified analysis was used to evaluate differences in responses by age, gender, level of training and specialty.

Results

154 ASE members completed the survey (13% response rate). 88% respondents accessed virtual learning events at home. Most (87%) had joined a virtual learning event and then participated in another activity. 1 in 5 who did this did so “always” or “often”. Female respondents were more likely than males to join audio and then participate in another activity (62.3% v 37.7%, p = 0.04).

Conclusions

Virtual platforms do not automatically translate into increased learner engagement. Careful design of educational strategies is essential to increase and maintain learner engagement when utilizing virtual surgical education.

Patterns for Patient Engagement with the Hypertension Management and Effects of Electronic Health Care Provider Follow-up on These Patterns: Cluster Analysis

Background

Hypertension is a long-term medical condition. Electronic and mobile health care services can help patients to self-manage this condition. However, not all management is effective, possibly due to different levels of patient engagement (PE) with health care services. Health care provider follow-up is an intervention to promote PE and blood pressure (BP) control.

Objective

This study aimed to discover and characterize patterns of PE with a hypertension self-management app, investigate the effects of health care provider follow-up on PE, and identify the follow-up effects on BP in each PE pattern.

Methods

PE was represented as the number of days that a patient recorded self-measured BP per week. The study period was the first 4 weeks for a patient to engage in the hypertension management service. K-means algorithm was used to group patients by PE. There was compliance follow-up, regular follow-up, and abnormal follow-up in management. The follow-up effect was calculated by the change in PE (CPE) and the change in systolic blood pressure (CSBP, SBP) before and after each follow-up. Chi-square tests and z scores were used to ascertain the distribution of gender, age, education level, SBP, and the number of follow-ups in each cluster. The follow-up effect was identified by analysis of variances. Once a significant effect was detected, Bonferroni multiple comparisons were further conducted to identify the difference between 2 clusters.

Results

Patients were grouped into 4 clusters according to PE: (1) PE started low and dropped even lower (PELL), (2) PE started high and remained high (PEHH), (3) PE started high and dropped to low (PEHL), and (4) PE started low and rose to high (PELH). Significantly more patients over 60 years old were found in the PEHH cluster (P≤.05). Abnormal follow-up was significantly less frequent (P≤.05) in the PELL cluster. Compliance follow-up and regular follow-up can improve PE. In the clusters of PEHH and PELH, the improvement in PE in the first 3 weeks and the decrease in SBP in all 4 weeks were significant after follow-up. The SBP of the clusters of PELL and PELH decreased more (–6.1 mmHg and –8.4 mmHg) after follow-up in the first week.

Conclusions

Four distinct PE patterns were identified for patients engaging in the hypertension self-management app. Patients aged over 60 years had higher PE in terms of recording self-measured BP using the app. Once SBP reduced, patients with low PE tended to stop using the app, and a continued decline in PE occurred simultaneously with the increase in SBP. The duration and depth of the effect of health care provider follow-up were more significant in patients with high or increased engagement after follow-up.

The relationship between learner engagement and teaching effectiveness: a novel assessment of student engagement in continuing medical education

BACKGROUND

Continuing medical education (CME) often uses passive educational models including lectures. However, numerous studies have questioned the effectiveness of these less engaging educational strategies. Studies outside of CME suggest that engaged learning is associated with improved educational outcomes. However, measuring participants' engagement can be challenging. We developed and determined the validity evidence for a novel instrument to assess learner engagement in CME.

METHODS

We conducted a cross-sectional validation study at a large, didactic-style CME conference. Content validity evidence was established through review of literature and previously published engagement scales and conceptual frameworks on engagement, along with an iterative process involving experts in the field, to develop an eight-item Learner Engagement Instrument (LEI). Response process validity was established by vetting LEI items on item clarity and perceived meaning prior to implementation, as well as using a well-developed online platform with clear instructions. Internal structure validity evidence was based on factor analysis and calculating internal consistency reliability. Relations to other variables validity evidence was determined by examining associations between LEI and previously validated CME Teaching Effectiveness (CMETE) instrument scores. Following each presentation, all participants were invited to complete the LEI and the CMETE.

RESULTS

51 out of 206 participants completed the LEI and CMETE (response rate 25%) Correlations between the LEI and the CMETE overall scores were strong (r = 0.80). Internal consistency reliability for the LEI was excellent (Cronbach's alpha = 0.96). To support validity to internal structure, a factor analysis was performed and revealed a two dimensional instrument consisting of internal and external engagement domains. The internal consistency reliabilities were 0.96 for the internal engagement domain and 0.95 for the external engagement domain.

CONCLUSION

Engagement, as measured by the LEI, is strongly related to teaching effectiveness. The LEI is supported by robust validity evidence including content, response process, internal structure, and relations to other variables. Given the relationship between learner engagement and teaching effectiveness, identifying more engaging and interactive methods for teaching in CME is recommended.

Knowledge of physicians regarding the management of Type two Diabetes in a primary care setting: the impact of online continuous medical education

BACKGROUND

To explore the impact of an online continuing medical education (CME) program on physicians' knowledge about the management of type two diabetes.

METHODS

An online CME program was designed and uploaded in the CME platform, Department of Education, Ministry of health, Iran. A 28-item questionnaire was used for the assessment. In the beginning, a case scenario was introduced. Then, participants were asked to follow and answer to a pretest assessment. Details of the educational content were provided afterward. Finally, the participants took part in the same post-test exam 4 weeks later. The Wilcoxon matched-pairs signed-ranks test was used to compare the measurements. In addition, the Mann-Whitney test was applied to compare knowledge indices between the general practitioners (GPs) and internists.

RESULTS

Five hundred twenty-six primary care physicians participated in this study. There was a significant positive effect regarding diagnosis confirmation (10.3% difference, P = 0.0001). Moreover, a smaller effect was observed in relation to the importance of glycosylated hemoglobin (HbA1c) at diagnosis (5.2% difference, P = 0.0006). The effect was positive in relation to the self-reported HbA1c testing frequency: more than 90% of the participants answered correctly in the post-test exam (7.6% difference, P = 0.0001). Considering improved knowledge in the treatment of diabetes, there was a very significant difference in response to questions targeting advice on a healthy diet, and physical activity; 27.7% (P = 0.000), and 18.7% (P = 0.000), respectively. In addition, the program had a positive impact on various aspects of treatment with oral glucose-lowering drugs (OGLDs). Moreover, the intervention difference was 25, and 34.4% for the questions targeting the appropriate type of insulin, and insulin initiation regimen after OGLD failure. Subgroup analyses revealed that the intervention increased the rate of correct responses among the GPs in various domains of knowledge in diagnosis and treatment. The initial differences between the GPs and internists no longer remained significant after the intervention.

CONCLUSION

Knowledge of Iranian primary health care professionals in diabetes management has significant shortcomings. This is concerning because they are at the front line of patient care. We demonstrate the effectiveness of online CME on improving GPs knowledge in the management of type 2 diabetes.

Leveraging Providers' Preferences to Customize Instructional Content in Information and Communications Technology-Based Training Interventions: Retrospective Analysis of a Mobile Phone-Based Intervention in India

Background

Many public health programs and interventions across the world increasingly rely on using information and communications technology (ICT) tools to train and sensitize health professionals. However, the effects of such programs on provider knowledge, practice, and patient health outcomes have been inconsistent. One of the reasons for the varied effectiveness of these programs is the low and varying levels of provider engagement, which, in turn, could be because of the form and mode of content used. Tailoring instructional content could improve engagement, but it is expensive and logistically demanding to do so with traditional training

Objective

This study aimed to discover preferences among providers on the form (articles or videos), mode (featuring peers or experts), and length (short or long) of the instructional content; to quantify the extent to which differences in these preferences can explain variation in provider engagement with ICT-based training interventions; and to compare the power of content preferences to explain provider engagement against that of demographic variables.

Methods

We used data from a mobile phone–based intervention focused on improving tuberculosis diagnostic practices among 24,949 private providers from 5 specialties and 1734 cities over 1 year. Engagement time was used as the primary outcome to assess provider engagement. K-means clustering was used to segment providers based on the proportion of engagement time spent on content formats, modes, and lengths to discover their content preferences. The identified clusters were used to predict engagement time using a linear regression model. Subsequently, we compared the accuracy of the cluster-based prediction model with one based on demographic variables of providers (eg, specialty and geographic location).

Results

The average engagement time across all providers was 7.5 min (median 0, IQR 0-1.58). A total of 69.75% (17,401/24,949) of providers did not consume any content. The average engagement time for providers with nonzero engagement time was 24.8 min (median 4.9, IQR 2.2-10.1). We identified 4 clusters of providers with distinct preferences for form, mode, and length of content. These clusters explained a substantially higher proportion of the variation in engagement time compared with demographic variables (32.9% vs 1.0%) and yielded a more accurate prediction for the engagement time (root mean square error: 4.29 vs 5.21 and mean absolute error: 3.30 vs 4.26).

Conclusions

Providers participating in a mobile phone–based digital campaign have inherent preferences for instructional content. Targeting providers based on individual content preferences could result in higher provider engagement as compared to targeting providers based on demographic variables.

Physician engagement: a concept analysis

The term "physician engagement" is used quite frequently, yet it remains poorly defined and measured. The aim of this study is to clarify the term "physician engagement." This study used an eight step-method for conducting concept analyses created by Walker and Avant. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched on February 14, 2019. No limitations were put on the searches with regard to year or language. Results identify that the term "physician engagement" is regular participation of physicians in (1) deciding how their work is done, (2) making suggestions for improvement, (3) goal setting, (4) planning, and (5) monitoring of their performance in activities targeted at the micro (patient), meso (organization), and/or macro (health system) levels. The antecedents of "physician engagement" include accountability, communication, incentives, interpersonal relations, and opportunity. The results include improved outcomes such as data quality, efficiency, innovation, job satisfaction, patient satisfaction, and performance. Defining physician engagement enables physicians and health care administrators to better appreciate and more accurately measure engagement and understand how to better engage physicians.

Health professions digital education on clinical practice guidelines: a systematic review by Digital Health Education collaboration

BACKGROUND

Clinical practice guidelines are an important source of information, designed to help clinicians integrate research evidence into their clinical practice. Digital education is increasingly used for clinical practice guideline dissemination and adoption. Our aim was to evaluate the effectiveness of digital education in improving the adoption of clinical practice guidelines.

METHODS

We performed a systematic review and searched seven electronic databases from January 1990 to September 2018. Two reviewers independently screened studies, extracted data and assessed risk of bias. We included studies in any language evaluating the effectiveness of digital education on clinical practice guidelines compared to other forms of education or no intervention in healthcare professionals. We used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to assess the quality of the body of evidence.

RESULTS

Seventeen trials involving 2382 participants were included. The included studies were diverse with a largely unclear or high risk of bias. They mostly focused on physicians, evaluated computer-based interventions with limited interactivity and measured participants' knowledge and behaviour. With regard to knowledge, studies comparing the effect of digital education with no intervention showed a moderate, statistically significant difference in favour of digital education intervention (SMD = 0.85, 95% CI 0.16, 1.54; I² = 83%, n = 3, moderate quality of evidence). Studies comparing the effect of digital education with traditional learning on knowledge showed a small, statistically non-significant difference in favour of digital education (SMD = 0.23, 95% CI - 0.12, 0.59; I² = 34%, n = 3, moderate quality of evidence). Three studies measured participants' skills and reported mixed results. Of four studies measuring satisfaction, three studies favoured digital education over traditional learning. Of nine studies evaluating healthcare professionals' behaviour change, only one study comparing email-delivered, spaced education intervention to no intervention reported improvement in the intervention group. Of three studies reporting patient outcomes, only one study comparing email-delivered, spaced education games to non-interactive online resources reported modest improvement in the intervention group. The quality of evidence for outcomes other than knowledge was mostly judged as low due to risk of bias, imprecision and/or inconsistency.

CONCLUSIONS

Health professions digital education on clinical practice guidelines is at least as effective as traditional learning and more effective than no intervention in terms of knowledge. Most studies report little or no difference in healthcare professionals' behaviours and patient outcomes. The only intervention shown to improve healthcare professionals' behaviour and modestly patient outcomes was email-delivered, spaced education. Future research should evaluate interactive, simulation-based and spaced forms of digital education and report on outcomes such as skills, behaviour, patient outcomes and cost.

Digital Health Professions Education on Diabetes Management: Systematic Review by the Digital Health Education Collaboration

Background

There is a shortage of health care professionals competent in diabetes management worldwide. Digital education is increasingly used in educating health professionals on diabetes. Digital diabetes self-management education for patients has been shown to improve patients’ knowledge and outcomes. However, the effectiveness of digital education on diabetes management for health care professionals is still unknown.

Objective

The objective of this study was to assess the effectiveness and economic impact of digital education in improving health care professionals’ knowledge, skills, attitudes, satisfaction, and competencies. We also assessed its impact on patient outcomes and health care professionals’ behavior.

Methods

We included randomized controlled trials evaluating the impact of digitalized diabetes management education for health care professionals pre- and postregistration. Publications from 1990 to 2017 were searched in MEDLINE, EMBASE, Cochrane Library, PsycINFO, CINAHL, ERIC, and Web of Science. Screening, data extraction and risk of bias assessment were conducted independently by 2 authors.

Results

A total of 12 studies met the inclusion criteria. Studies were heterogeneous in terms of digital education modality, comparators, outcome measures, and intervention duration. Most studies comparing digital or blended education to traditional education reported significantly higher knowledge and skills scores in the intervention group. There was little or no between-group difference in patient outcomes or economic impact. Most studies were judged at a high or unclear risk of bias.

Conclusions

Digital education seems to be more effective than traditional education in improving diabetes management–related knowledge and skills. The paucity and low quality of the available evidence call for urgent and well-designed studies focusing on important outcomes such as health care professionals’ behavior, patient outcomes, and cost-effectiveness as well as its impact in diverse settings, including developing countries.

Innovations in Professional Inpatient Diabetes Education

PURPOSE OF REVIEW

In the rapidly evolving and complex field of inpatient diabetes, complex care teams of physicians, nurse practitioners, physician assistants, nurses, and pharmacists are challenged to remain well informed of the latest clinical treatments and health care trends. Traditional continuing medical education (CME) and continuing education unit (CEU) strategies that require travel and/or time away from work pose a major barrier. With advancements in technology, there are media and other electronic strategies for delivering CME/ CEU that may overcome these current challenges.

RECENT FINDINGS

Electronic and internet-based formats are growing due to their convenience, ease of use, lower cost, and ready access to large audiences. Some formats are already being used such as computer-based programs, simulations, and mobile CMEs and CEUs. Other strategies could be further explored including hospital credentialing, stewardship programs, and interdisciplinary health care professional education. However, there is little data on the utilization and efficacy of these newer formats. While traditional CME/CEU meetings prevail, there is a need and an emerging trend using electronic and internet based strategies that are particularly suited for inpatient diabetes education. These methods show great potential and deserve further exploration and development.

Engagement in an Online Cultural Competency Training

OBJECTIVES

Engagement with online cultural competency training has not been well studied. We examined knowledge, attitudes, and skills differences among medical students, physicians, and other professionals in an online cultural competency education program.

METHODS

A total of 1745 participants completed up to four online modules aimed at exploring stereotype, bias, diet, and religion among African American patients with hypertension. We examined knowledge, attitudes, and self-reported skills with 17 multiple-choice questions embedded in the 4 modules. Participants received comparative responses with their peers.

RESULTS

Between 75% and 84% of participants knew the definition of stereotype and <50% knew the definition of bias (47% students, 36% physicians, 33% others, P < 0.001). Most responded that minorities perceive bias (98%-100%) and believe that evidence exists showing that bias affects decision making (62%-69%). Although most perceive that religious and spiritual beliefs affect reaction to illness often (78% students, 68% physicians, 79% others, P < 0.001), few would ask about religious beliefs during a typical encounter (13% students, 16% physicians, 30% others, P < 0.001).

CONCLUSIONS

All of the participants struggled to define bias; however, most agreed that minorities perceive bias in the care they receive. We examined usage and interaction with the online content as a dimension of engagement.

E-learning for health professionals

BACKGROUND

The use of e-learning, defined as any educational intervention mediated electronically via the Internet, has steadily increased among health professionals worldwide. Several studies have attempted to measure the effects of e-learning in medical practice, which has often been associated with large positive effects when compared to no intervention and with small positive effects when compared with traditional learning (without access to e-learning). However, results are not conclusive.

OBJECTIVES

To assess the effects of e-learning programmes versus traditional learning in licensed health professionals for improving patient outcomes or health professionals' behaviours, skills and knowledge.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and three trial registers up to July 2016, without any restrictions based on language or status of publication. We examined the reference lists of the included studies and other relevant reviews. If necessary, we contacted the study authors to collect additional information on studies.

SELECTION CRITERIA

Randomised trials assessing the effectiveness of e-learning versus traditional learning for health professionals. We excluded non-randomised trials and trials involving undergraduate health professionals.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data and assessed risk of bias. We graded the certainty of evidence for each outcome using the GRADE approach and standardised the outcome effects using relative risks (risk ratio (RR) or odds ratio (OR)) or standardised mean difference (SMD) when possible.

MAIN RESULTS

We included 16 randomised trials involving 5679 licensed health professionals (4759 mixed health professionals, 587 nurses, 300 doctors and 33 childcare health consultants).When compared with traditional learning at 12-month follow-up, low-certainty evidence suggests that e-learning may make little or no difference for the following patient outcomes: the proportion of patients with low-density lipoprotein (LDL) cholesterol of less than 100 mg/dL (adjusted difference 4.0%, 95% confidence interval (CI) -0.3 to 7.9, N = 6399 patients, 1 study) and the proportion with glycated haemoglobin level of less than 8% (adjusted difference 4.6%, 95% CI -1.5 to 9.8, 3114 patients, 1 study). At 3- to 12-month follow-up, low-certainty evidence indicates that e-learning may make little or no difference on the following behaviours in health professionals: screening for dyslipidaemia (OR 0.90, 95% CI 0.77 to 1.06, 6027 patients, 2 studies) and treatment for dyslipidaemia (OR 1.15, 95% CI 0.89 to 1.48, 5491 patients, 2 studies). It is uncertain whether e-learning improves or reduces health professionals' skills (2912 health professionals; 6 studies; very low-certainty evidence), and it may make little or no difference in health professionals' knowledge (3236 participants; 11 studies; low-certainty evidence).Due to the paucity of studies and data, we were unable to explore differences in effects across different subgroups. Owing to poor reporting, we were unable to collect sufficient information to complete a meaningful 'Risk of bias' assessment for most of the quality criteria. We evaluated the risk of bias as unclear for most studies, but we classified the largest trial as being at low risk of bias. Missing data represented a potential source of bias in several studies.

AUTHORS' CONCLUSIONS

When compared to traditional learning, e-learning may make little or no difference in patient outcomes or health professionals' behaviours, skills or knowledge. Even if e-learning could be more successful than traditional learning in particular medical education settings, general claims of it as inherently more effective than traditional learning may be misleading.

Practical guidelines for development of web-based interventions

Despite a recent high funding priority on technological aspects of research and a high potential impact of Web-based interventions on health, few guidelines for the development of Web-based interventions are currently available. In this article, we propose practical guidelines for development of Web-based interventions based on an empirical study and an integrative literature review. The empirical study aimed at development of a Web-based physical activity promotion program that was specifically tailored to Korean American midlife women. The literature review included a total of 202 articles that were retrieved through multiple databases. On the basis of the findings of the study and the literature review, we propose directions for development of Web-based interventions in the following steps: (1) meaningfulness and effectiveness, (2) target population, (3) theoretical basis/program theory, (4) focus and objectives, (5) components, (6) technological aspects, and (7) logistics for users. The guidelines could help promote further development of Web-based interventions at this early stage of Web-based interventions in nursing.

Shared care combined with telecare improves glycemic control of diabetic patients in a rural underserved community

OBJECTIVE

To investigate the effectiveness of shared care combined with telecare in type 2 diabetic patients in an underserved community in Asia.

RESEARCH DESIGN AND METHODS

In total, 95 patients with type 2 diabetes who had a glycosylated hemoglobin (HbA1c) level of >7% were recruited from six community health centers in remote areas in Changhua County, Taiwan. All patients were randomly divided into intervention (shared care combined with telecare) and usual-care groups and followed up for 6 months.

RESULTS

The decrease in HbA1c level was significantly greater in the intervention group than in the usual-care group (0.7 ± 1.3% versus 0.1 ± 1.0%, p=0.03). There were no significant differences in lipid profiles and blood pressure changes between the two groups.

CONCLUSIONS

Shared care combined with telecare could significantly reduce HbA1c levels in type 2 diabetic patients with poor glycemic control in underserved rural communities. Further studies should be conducted to clarify the target users and to develop cost-effective interventions.

Using multiple imputations to accommodate time-outs in online interventions

BACKGROUND

Accurately estimating the period of time that individuals are exposed to online intervention content is important for understanding program engagement. This can be calculated from time-stamped data reflecting navigation to and from individual webpages. Prolonged periods of inactivity are commonly handled with a time-out feature and assigned a prespecified exposure duration. Unfortunately, this practice can lead to biased results describing program exposure.

OBJECTIVE

The aim of the study was to describe how multiple imputations can be used to better account for the time spent viewing webpages that result in a prolonged period of inactivity or a time-out.

METHODS

To illustrate this method, we present data on time-outs collected from the Q(2) randomized smoking cessation trial. For this analysis, we evaluate the effects on intervention exposure of receiving content written in a prescriptive versus motivational tone. Using multiple imputations, we created five complete datasets in which the time spent viewing webpages that resulted in a time-out were replaced with values estimated with imputation models. We calculated standard errors using Rubin's formulas to account for the variability due to the imputations. We also illustrate how current methods of accounting for time-outs (excluding timed-out page views or assigning an arbitrary viewing time) can influence conclusions about participant engagement.

RESULTS

A total of 63.00% (1175/1865) of participants accessed the online intervention in the Q(2) trial. Of the 6592 unique page views, 683 (10.36%, 683/6592) resulted in a time-out. The median time spent viewing webpages that did not result in a time-out was 1.07 minutes. Assuming participants did not spend any time viewing a webpage that resulted in a time-out, no difference between the two message tones was observed (ratio of mean time online: 0.87, 95% CI 0.75-1.02). Assigning 30 minutes of viewing time to all page views that resulted in a time-out concludes that participants who received content in a motivational tone spent less time viewing content (ratio of mean time online: 0.86, 95% CI 0.77-0.98) than those participants who received content in a prescriptive tone. Using multiple imputations to account for time-outs concludes that there is no difference in participant engagement between the two message tones (ratio of mean time online: 0.87; 95% CI 0.75-1.01).

CONCLUSIONS

The analytic technique chosen can significantly affect conclusions about online intervention engagement. We propose a standardized methodology in which time spent viewing webpages that result in a time-out is treated as missing information and corrected with multiple imputations.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00992264; http://clinicaltrials.gov/ct2/show/NCT00992264 (Archived by WebCite at http://www.webcitation.org/6Kw5m8EkP).

Web-based self-management support training for health professionals: a pilot study

OBJECTIVE

To evaluate a web-based self-management training for health professionals. Patients spend 99% of their time outside the healthcare system. Thus self-management support from health professionals is central to optimal care. Our objective was to teach health professionals the skills to provide this support.

METHODS

Primary care residents and practicing providers enrolled in six groups. Each group received four web-based interactive training sessions derived from self-efficacy theory. Retrospective-pre/post assessed changes in self-management beliefs and confidence. Wilcoxon signed-rank tests with Bonferroni correction compared responses. Focus groups solicited qualitative feedback.

RESULTS

Fifty-seven residents and providers across the United States enrolled. Residents demonstrated positive changes on all belief questions (P 0.001-0.012). Practicing providers had a non-significant positive change on one and significant changes on the remainder (P 0.001-0.018). Both types of participants demonstrated significant increases on confidence questions regarding their ability to support self-management (P<0.01 for all). Participants described learned techniques as being useful, reducing burnout, and increasing acceptance of patient involvement in care planning.

CONCLUSION

The web-based self-management support training for health professionals was feasible and changed beliefs and confidence.

PRACTICE IMPLICATIONS

The program may maximize patient self-management by increasing provider self-efficacy and skill for self-management support.

Quality of diabetes mellitus care by rural primary care physicians

PURPOSE

To explore the relationship between degree of rurality and glucose (hemoglobin A1c), blood pressure (BP), and lipid (LDL) control among patients with diabetes.

METHODS

Descriptive study; 1,649 patients in 205 rural practices in the United States. Patients' residence ZIP codes defined degree of rurality (Rural-Urban Commuting Areas codes). Outcomes were measures of acceptable control (A1c < = 9%, BP < 140/90 mmHg, LDL < 130 mg/dL) and optimal control (A1c < 7%, BP < 130/80 mmHg, LDL < 100 mg/dL). Statistical significance was set at P < .008 (Bonferroni's correction).

FINDINGS

Although the proportion of patients with reasonable A1c control worsened by increasing degree of rurality, the differences were not statistically significant (urban 90%, large rural 88%, small rural 85%, isolated rural 83%; P = .10); mean A1c values also increased by degree of rurality, although not statistically significant (urban 7.2 [SD 1.6], large rural 7.3 [SD 1.7], small rural 7.5 [SD 1.8], isolated rural 7.5 [SD 1.9]; P = .16). We observed no differences between degree of rural and reasonable BP or LDL control (P = .42, P = .23, respectively) or optimal A1c or BP control (P = .52, P = .65, respectively). Optimal and mean LDL values worsened as rurality increased (P = .08, P = .029, respectively).

CONCLUSIONS

In patients with diabetes who seek care in the rural Southern United States, we observed no relationship between degree of rurality of patients' residence and traditional measures of quality of care. Further examination of the trends and explanatory factors for relative worsening of metabolic control by increasing degree of rurality is warranted.

Medication intensification in diabetes in rural primary care: a cluster-randomised effectiveness trial

OBJECTIVE

To determine the effectiveness of a provider-based intervention to improve medication intensification among patients with diabetes.

DESIGN

Effectiveness cluster-randomised trial. Baseline and follow-up cross-sections of diabetes physicians' patients.

SETTING

Eleven U.S. Southeastern states, 2006-2008.

PARTICIPANTS

205 Rural primary care physicians, 95 completed the study.

INTERVENTION

Multicomponent interactive intervention including web-based continuing medical education (CME), performance feedback and quality improvement tools.

PRIMARY OUTCOME MEASURES

Medication intensification, a dose increase of an existing medication or the addition of a new class of medication for glucose, blood pressure and lipids control on any of the three most recent office visits.

RESULTS

Of 364 physicians attempting to register, 102 were randomised to the intervention and 103 to the control arms; 95 physicians (intervention, n=48; control, n=47) provided data on their 1182 of their patients at baseline (intervention, n=715; control, n=467) and 945 patients at follow-up (intervention, n=479; control, n=466). For A1c control, medication intensification increased in both groups (intervention, pre 26.4% vs post 32.6%, p=0.022; control, pre 24.8% vs post 31.1%, p=0.033) (intervention, adjusted OR (AOR) 1.37; 95% CI 1.06 to 1.76; control, AOR 1.41 (95% CI 1.06 to 1.89)); however, we observed no incremental benefit solely due to the intervention (group-by-time interaction, p=0.948). Among patients with the worst glucose control (A1c >9%), intensification increased in both groups (intervention, pre 34.8% vs post 62.5%, p=0.002; control, pre 35.7% vs post 61.4%, p=0.008).

CONCLUSIONS

A wide-reach, low-intensity, web-based interactive multicomponent intervention had no significant incremental effect on medication intensification for control of glucose, blood pressure or lipids for patients with diabetes of physicians practising in the rural Southeastern USA.

TRIAL REGISTRATION

NCT00403091.

A web-based diabetes intervention for physician: a cluster-randomized effectiveness trial

OBJECTIVE

To determine the effectiveness of a provider-based education and implementation intervention for improving diabetes control.

DESIGN

Cluster-randomized trial with baseline and follow-up cross sections of diabetes patients in each participating physician's practice.

SETTING

Eleven US Southeastern states, 2006-08.

PARTICIPANTS

Two hundred and five rural primary care physicians.

INTERVENTION

Multi-component interactive intervention including Web-based continuing medical education, performance feedback and quality improvement tools. Primary Outcome Measures 'Acceptable control' [hemoglobin A1c ≤9%, blood pressure (BP) <140/90 mmHg, low-density lipoprotein cholesterol (LDL) <130 mg/dl] and 'optimal control' (A1c <7%, BP <130/80 mmHg, LDL <100 mg/dl).

RESULTS

Of 364 physicians attempting to register, 205 were randomized to the intervention (n= 102) or control arms (n= 103). Baseline and follow-up data were provided by 95 physicians (2127 patients). The proportion of patients with A1c ≤9% was similar at baseline and follow-up in both the control [adjusted odds ratio (AOR): 0.94; 95% confidence interval (CI): 0.61, 1.47] and intervention arms [AOR: 1.16 (95% CI: 0.80, 1.69)]; BP <140/90 mmHg and LDL <130 mg/dl were also similar at both measurement points (P= 0.66, P= 0.46; respectively). We observed no significant effect on diabetes control attributable to the intervention for any of the primary outcome measures. Intervention physicians engaged with the Website over a median of 64.7 weeks [interquartile range (IQR): 45.4-81.8) for a median total of 37 min (IQR: 16-66).

CONCLUSIONS

A wide-reach, low-intensity, Web-based interactive multi-component intervention did not improve control of glucose, BP or lipids for patients with diabetes of physicians practicing in the rural Southeastern US.