Long-term outcomes of physician peer teaching

IMP2ART systematic review of education for healthcare professionals implementing supported self-management for asthma

Despite a robust evidence base for its effectiveness, implementation of supported self-management for asthma is suboptimal. Professional education is an implementation strategy with proven effectiveness, though the specific features linked with effectiveness are often unclear. We performed a systematic review of randomised controlled trials and controlled clinical trials (published from 1990 and updated to May 2017 using forward citation searching) to determine the effectiveness of professional education on asthma self-management support and identify features of effective initiatives. Primary outcomes reflected professional behaviour change (provision of asthma action plans) and patient outcomes (asthma control; unscheduled care). Data were coded using the Effective Practice and Organisation of Care Taxonomy, the Theoretical Domains Framework (TDF), and Bloom's Taxonomy and synthesised narratively. Of 15,637 articles identified, 18 (reporting 15 studies including 21 educational initiatives) met inclusion criteria. Risk of bias was high for five studies, and unclear for 10. Three of 6 initiatives improved action plan provision; 1/2 improved asthma control; and 2/7 reduced unscheduled care. Compared to ineffective initiatives, effective initiatives were more often coded as being guideline-based; involving local opinion leaders; including inter-professional education; and addressing the TDF domains 'social influences'; 'environmental context and resources'; 'behavioural regulation'; 'beliefs about consequences'; and 'social/professional role and identity'. Findings should be interpreted cautiously as many strategies were specified infrequently. However, identified features warrant further investigation as part of implementation strategies aiming to improve the provision of supported self-management for asthma.

Does cross-cultural communication training for physicians improve pediatric asthma outcomes? A randomized trial

OBJECTIVE

Adverse cross-cultural interactions are a persistent problem within medicine impacting minority patients' use of services and health outcomes. To test whether 1) enhancing the evidence-based Physician Asthma Care Education (PACE), a continuing medical education program, with cross cultural communication training (PACE Plus) would improve the asthma outcomes of African American and Latino/Hispanic children; and 2) whether PACE is effective in diverse groups of children.

METHODS

A three-arm randomized control trial was used to compare PACE Plus, PACE, and usual care. Participants were primary care physicians (n = 112) and their African American or Latino/Hispanic pediatric patients with persistent asthma (n = 867). The primary outcome of interest included changes in emergency department visits for asthma overtime, measured at baseline, and 9 and 21 months following the intervention. Other outcomes included hospitalizations, asthma symptom experience, caregiver asthma-related quality of life, and patient-provider communication measures.

RESULTS

Over the long term, PACE Plus physicians reported significant improvements in confidence and use of patient-centered communication and counseling techniques (p < 0.01) compared to PACE physicians. No other significant benefit in primary and secondary outcomes was observed in this trial.

CONCLUSION

PACE Plus did not show significant benefit in asthma-specific clinical outcomes. More trials and multi-component strategies continue to be needed to address complex risk factors and reduce disparities in asthma care.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01251523 December 1, 2010.

Asthma Patient Education: Partnership in Care

BACKGROUND

Asthma education is a necessary and critical component of asthma management.

METHODS

A review of the most-to-date global and national (US) guidelines and standards provides the basis for this concise asthma education primer.

RESULTS

Effective asthma education that yields enhanced long-term health outcomes is accomplished by the proper patient-specific knowledge and behavior change tools. Communication technique (quality) as well as asthma education content (quantity) should receive recurrent assessment by all healthcare team members.

CONCLUSION

Asthma education delivery can be easily planned for and routinely delivered, keeping the shared goals of patient and healthcare team in mind.

Systematic Review of Knowledge Translation Strategies to Promote Research Uptake in Child Health Settings

Strategies to assist evidence-based decision-making for healthcare professionals are crucial to ensure high quality patient care and outcomes. The goal of this systematic review was to identify and synthesize the evidence on knowledge translation interventions aimed at putting explicit research evidence into child health practice.

METHODS

A comprehensive search of thirteen electronic databases was conducted, restricted by date (1985-2011) and language (English). Articles were included if: 1) studies were randomized controlled trials (RCT), controlled clinical trials (CCT), or controlled before-and-after (CBA) studies; 2) target population was child health professionals; 3) interventions implemented research in child health practice; and 4) outcomes were measured at the professional/process, patient, or economic level. Two reviewers independently extracted data and assessed methodological quality. Study data were aggregated and analyzed using evidence tables.

RESULTS

Twenty-one studies (13 RCT, 2 CCT, 6 CBA) were included. The studies employed single (n=9) and multiple interventions (n=12). The methodological quality of the included studies was largely moderate (n=8) or weak (n=11). Of the studies with moderate to strong methodological quality ratings, three demonstrated consistent, positive effect(s) on the primary outcome(s); effective knowledge translation interventions were two single, non-educational interventions and one multiple, educational intervention.

CONCLUSIONS

This multidisciplinary systematic review in child health setting identified effective knowledge translation strategies assessed by the most rigorous research designs. Given the overall poor quality of the research literature, specific recommendations were made to improve knowledge translation efforts in child health.

National standards for asthma self-management education

BACKGROUND

Asthma education reimbursement continues to be an issue in the United States. Among the greatest barriers is the lack of a standardized curriculum for asthma self-management education recognized by a physician society, non-physician health care professional society or association, or other appropriate source. The applicable Current Procedural Terminology codes for self-management education and training are 98960 through 98962, stating that "if a practitioner has created a training curriculum for educating patients on management of their medical condition, he or she may employ a non-physician health care professional to provide education using a standardized curriculum for patients with that disease." Without a standardized curriculum, reimbursement from payers is beyond reach.

OBJECTIVE

Representatives from the Joint Council of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; American Academy of Allergy, Asthma, and Immunology; American Lung Association; American Thoracic Society; National Asthma Educator Certification Board; American College of Chest Physicians; and Association of Asthma Educators gathered to write a standardized curriculum as a guideline for payer reimbursement.

METHODS

The Task Force began with a review of the American Lung Association and American Thoracic Society's Operational Standards for Asthma Education. Board members of the National Asthma Educator Certification Board incorporated comments, rationale, and references into the document.

RESULTS

This document is the result of final reviews of the standards completed by the Task Force and national health care professional organizations in September 2014.

CONCLUSION

This document meets the requirements of Current Procedural Terminology codes 98960 through 98962 and establishes the minimum standard for asthma self-management education when teaching patients or caregivers how to effectively manage asthma in conjunction with the professional health care team.

How do physicians and trainers experience outcome-based education in "Rational prescribing"?

Background

Continuing medical education (CME) is compulsory in Iran, but has shown limitations in terms of educational style and format. Outcome-based education (OBE) has been proposed internationally to create links to physicians’ actual practices. We designed an outcome-based educational intervention for general physicians in primary care (GPs). Positive outcomes on GPs’ knowledge, skills and performance in the field of rational prescribing were found and have been reported.

The specific purpose of this study was to explore the perceptions of the GPs and trainers, who participated in the outcome-based education on rational prescribing.

Methods

All nine trainers in the educational programme and 12 general physicians (out of 58) were invited to individual interviews four months after participation in the CME program. Semi-structured open-ended interviews were carried out. Qualitative content analysis was used to explore the text and to interpret meaning and intention.

Results

There was a widespread agreement that the programme improved the participants’ knowledge and skills to a higher extent than previously attended programmes. Trainers emphasized the effect of outcome-based education on their educational planning, teaching and assessment methods, while the general physicians’ challenges were how to adapt their learning in the real work environment considering social and economical barriers. Self-described attitudes and reported practice changed towards more rational prescribing.

Conclusions

Outcome-based CME seems attractive and additionally useful for general physicians in Iran and could be an effective approach when creating CME programmes to improve general physicians’ performance. Similar approaches could be considered in other contexts both regionally and globally.

Translation of an evidence-based asthma intervention: Physician Asthma Care Education (PACE) in the United States and Australia

BACKGROUND

Physician Asthma Care Education (PACE) is a programme developed in the USA to improve paediatric asthma outcomes.

AIMS

To examine translation of PACE to Australia.

METHODS

The RE-AIM framework was used to assess translation. Demographic characteristics and findings regarding clinical asthma outcomes from PACE randomised clinical trials in both countries were examined. Qualitative content analysis was used to examine fidelity to intervention components.

RESULTS

Both iterations of PACE reached similar target audiences (general practice physicians and paediatric patients with asthma); however, in the USA, more children with persistent disease were enrolled. In both countries, participation comprised approximately 10% of eligible physicians and 25% of patients. In both countries, PACE deployed well-known local physicians and behavioural scientists as facilitators. Sponsorship of the programme was provided by professional associations and government agencies. Fidelity to essential programme elements was observed, but PACE Australia workshops included additional components. Similar outcomes included improvements in clinician confidence in developing short-term and long-term care plans, prescribing inhaled corticosteroids, and providing written management instructions to patients. No additional time was spent in the patient visit compared with controls. US PACE realised reductions in symptoms and healthcare use, results that could not be confirmed in Australia because of limitations in follow-up time and sample sizes. US PACE is maintained through a National Heart, Lung, and Blood Institute website. Development of maintenance strategies for PACE Australia is underway.

CONCLUSIONS

Based on criteria of the RE-AIM framework, the US version of PACE has been successfully translated for use in Australia.

General practitioners' prescribing behaviour as a determinant of poor persistence with inhaled corticosteroids in children with respiratory symptoms: mixed methods study

OBJECTIVES

To evaluate general practitioners' (GPs') prescribing behaviour as a determinant of persistence with and adherence to inhaled corticosteroids (ICS) in children.

DESIGN

Prospective observational study of persistence with and adherence to ICS followed by a focus group study of the GPs prescribing this treatment.

SETTING

7 primary care practices in the area of Zwolle, the Netherlands.

PARTICIPANTS

134 children aged 2-12 years had been prescribed ICS in the year before the study started by their 19 GPs.

MAIN OUTCOME MEASURES

Patterns and motives of GPs' prescribing behaviour and the relationship with persistence with and adherence to ICS.

RESULTS

GPs' prescribing behaviour was characterised by prescribing short courses of ICS to children with various respiratory symptoms without follow-up for making a diagnosis of asthma. This was driven by the GPs' pragmatic approach to deal with the large number of children with respiratory symptoms, and by beliefs about ICS which differed from currently available evidence. This prescribing behaviour was the main reason why 68 (51%) children did not persist with the use of ICS. In children with persistent use of ICS and a GP's advice to use ICS on a daily basis, the median (IQR) adherence was 70% (41-84%), and was similar for patients with persistent asthma and children lacking a diagnosis or symptoms of asthma.

CONCLUSIONS

Inappropriate prescription of ICS to children by GPs is common and drives the lack of persistence with ICS therapy in primary care. This finding should be taken into account when interpreting data from large prescription database studies. Improving primary healthcare providers' knowledge and competence in diagnosing and managing asthma in children is needed.

Childhood asthma: considerations for primary care practice and chronic disease management in the village of care

Childhood asthma is at historically high levels, with significant morbidity and mortality. Despite more than two decades of improved understanding of childhood asthma care and the evolution of beneficial medications, widespread control remains poor, leading to suboptimal patient outcomes and quality of life. This lack of control results in excessive emergency department use, hospitalizations, and inappropriate and/or unnecessary costs to the health care system. Advanced practice models that incorporate community-based approaches and services for childhood asthma are needed. Innovative, community-included methods of care to address the burden of childhood asthma may provide examples for care of other chronic diseases.

Influence of education on primary care physicians' knowledge on childhood allergy as a systemic disease and the atopic march

BACKGROUND

There are many educational events for physicians in different countries covering one or some of the allergic diseases. Most of these educational events have been reported to improve care by the physicians. The aim of this study was to determine the baseline knowledge of general practitioners (GP) regarding the systemic nature of childhood allergy and atopic march, and to assess the influence of an educational event on this baseline knowledge.

METHODS

Two hundred and two GPs from five different cities in Turkey who attended education seminars were enrolled. All GPs were received the questionnaire both before and after the seminar. The questionnaire had statements about the systemic nature of childhood allergies and the atopic march, and GPs were asked to mark their degree of agreement as (completely true, partially true, wrong).

RESULTS

Mean age of GPs was 38.6±6.0 years. Mean duration after graduation from medical faculty was 13.9±6.5 years. There was significant improvement in answers after education. The statement "Frequency of allergic rhinitis and asthma is not as high as expected in children with atopic dermatitis" was regarded "wrong" by 60.9% but increased to 94.3% after the education (p<0.001). Systemic nature of allergy was approved by 72.8%, which increased to 99% after the education (p<0.001). Adrenalin as first line treatment in anaphylaxis treatment was appreciated by a higher number of GPs with the education (p<0.001).

CONCLUSION

Many GPs lack updated information about the systemic nature of paediatric allergic diseases and a single educational event may improve their knowledge significantly.

Characteristics of successful asthma programs

OBJECTIVE

We identified characteristics of interventions associated with positive asthma outcomes to understand how programs can be improved.

METHODS

We identified asthma interventions from the peer-reviewed literature or through a nomination process for unpublished programs. Initially, we identified 532 interventions. Of those, 223 met our eligibility criteria (e.g., focus on asthma, completed an evaluation, and demonstrated at least one asthma-related health outcome) and provided information on program components and processes, administration, evaluation, and findings through telephone interviews, program documents, and published reports. We analyzed bivariate relationships between programmatic factors and outcomes using Chi-square statistics, Fisher's exact tests, and unconditional logistic regression. We confirmed findings for all programs by analyzing the subset with published results in peer-reviewed journals.

RESULTS

Our findings indicated that programs were more likely to report a positive impact on health outcomes if they (1) were community based, (2) engaged the participation of community-based organizations, (3) provided program components in a clinical setting, (4) provided asthma training to health-care providers, (5) collaborated with other organizations and institutions and with government agencies, (6) designed a program for a specific racial/ethnic group, (7) tailored content or delivery based on individual health or educational needs, and (8) conducted environmental assessments and tailored interventions based on these assessments.

CONCLUSIONS

Positive asthma outcomes were associated with specific program characteristics: being community centered, clinically connected, and continuously collaborative. Program developers and implementers who build these characteristics into their interventions will be more likely to realize desired asthma outcomes.