Effectiveness of continuing medical education: a review of the evidence

Reducing patients' rate of frequent attendance through a training intervention for physicians

BACKGROUND

Frequent attendance is a common issue for primary care health centres. The phenomenon affects the quality of care, increases doctors' workloads and can lead to burnout.This study presents the results of an educational intervention for primary care physicians, aimed at helping them to decrease the prevalence rate of excessive attendance by patients at their centres.

METHODS

A training programme was carried out for 11 primary care doctors in Barcelona who had patient lists totalling 20,064 patients. The goal of the training was to provide the participating physicians with techniques to curb frequent attendance. Additionally, the programme sought to offer them strategies to prevent professional burnout and tools to better organize their everyday medical practice. The study used a quasi-experimental design for an evaluation of an educational intervention, featuring a pre-test assessment (before the training programme) and a post-test assessment (after the training programme), as well as comparison with a control group that did not undergo the training. The study assessed the effects of the programme on the rates of frequent attendance of patients served by the participating physicians. These rates were compared with those registered by the patients seen by the control group physicians over the same period.

RESULTS

Among the group of physicians who received the training, the mean prevalence of patients who qualified as frequent attenders decreased from 22% prior to the training programme to 8% after completion of the programme. In other words, 14% of patients (2,809) limited the frequency of their visits to primary care physicians after their physicians had completed the training programme. Meanwhile, the study recorded an average decrease of 3.1 visits per year by the patients of the physicians who had undergone the training. Statistically significant differences between this group and the control group were observed.

CONCLUSIONS

The educational intervention proved effective at helping primary care physicians to decrease their patients' rates of frequent attendance. It also contributes to the impact research of continuing education on doctors and their patients. We need to increase primary care spending from the current 14% to the 25%, to address this problem, among others.

Educational interventions for health professionals managing chronic obstructive pulmonary disease in primary care

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable health condition. COPD is associated with substantial burden on morbidity, mortality and healthcare resources.

OBJECTIVES

To review existing evidence for educational interventions delivered to health professionals managing COPD in the primary care setting.

SEARCH METHODS

We searched the Cochrane Airways Trials Register from inception to May 2021. The Register includes records from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED) and PsycINFO. We also searched online trial registries and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs. Eligible studies tested educational interventions aimed at any health professionals involved in the management of COPD in primary care. Educational interventions were defined as interventions aimed at upskilling, improving or refreshing existing knowledge of health professionals in the diagnosis and management of COPD.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data and assessed the risk of bias of included studies. We conducted meta-analyses where possible and used random-effects models to yield summary estimates of effect (mean differences (MDs) with 95% confidence intervals (CIs)). We performed narrative synthesis when meta-analysis was not possible. We assessed the overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were: 1) proportion of COPD diagnoses confirmed with spirometry; 2) proportion of patients with COPD referred to, participating in or completing pulmonary rehabilitation; and 3) proportion of patients with COPD prescribed respiratory medication consistent with guideline recommendations.

MAIN RESULTS

We identified 38 studies(22 cluster-RCTs and 16 RCTs) involving 4936 health professionals (reported in 19/38 studies) and 71,085 patient participants (reported in 25/38 studies). Thirty-six included studies evaluated interventions versus usual care; seven studies also reported a comparison between two or more interventions as part of a three- to five-arm RCT design. A range of simple to complex interventions were used across the studies, with common intervention features including education provided to health professionals via training sessions, workshops or online modules (31 studies), provision of practice support tools, tool kits and/or algorithms (10 studies), provision of guidelines (nine studies) and training on spirometry (five studies). Health professionals targeted by the interventions were most commonly general practitioners alone (20 studies) or in combination with nurses or allied health professionals (eight studies), and the majority of studies were conducted in general practice clinics. We identified performance bias as high risk for 33 studies. We also noted risk of selection, detection, attrition and reporting biases, although to a varying extent across studies. The evidence of efficacy was equivocal for all the three primary endpoints evaluated: 1) proportion of COPD diagnoses confirmed with spirometry (of the four studies that reported this outcome, two supported the intervention); 2) proportion of patients with COPD who are referred to, participate in or complete pulmonary rehabilitation (of the four studies that reported this outcome, two supported the intervention); and 3) proportion of patients with COPD prescribed respiratory medications consistent with guideline recommendations (12 studies reported this outcome, the majority evaluated multiple drug classes and reported a mixed effect). Additionally, the low quality of evidence and potential risk of bias make the interpretation more difficult. Moderate-quality evidence (downgraded due to risk of bias concerns) suggests that educational interventions for health professionals probably improve the proportion of patients with COPD vaccinated against influenza (three studies) and probably have little impact on the proportion of patients vaccinated against pneumococcal infection (two studies). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on the frequency of COPD exacerbations (10 studies). There was a high degree of heterogeneity in the reporting of health-related quality of life (HRQoL). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on HRQoL overall, and when using the COPD-specific HRQoL instrument, the St George's Respiratory Questionnaire (at six months MD 0.87, 95% CI -2.51 to 4.26; 2 studies, 406 participants, and at 12 months MD -0.43, 95% CI -1.52 to 0.67, 4 studies, 1646 participants; reduction in score indicates better health). Moderate-quality evidence suggests that educational interventions for health professionals may improve patient satisfaction with care (one study). We identified no studies that reported adverse outcomes.

AUTHORS' CONCLUSIONS

The evidence of efficacy was equivocal for educational interventions for health professionals in primary care on the proportion of COPD diagnoses confirmed with spirometry, the proportion of patients with COPD who participate in pulmonary rehabilitation, and the proportion of patients prescribed guideline-recommended COPD respiratory medications. Educational interventions for health professionals may improve influenza vaccination rates among patients with COPD and patient satisfaction with care. The quality of evidence for most outcomes was low or very low due to heterogeneity and methodological limitations of the studies included in the review, which means that there is uncertainty about the benefits of any currently published educational interventions for healthcare professionals to improve COPD management in primary care. Further well-designed RCTs are needed to investigate the effects of educational interventions delivered to health professionals managing COPD in the primary care setting.

Continuing education meetings and workshops: effects on professional practice and healthcare outcomes

BACKGROUND

Educational meetings are used widely by health personnel to provide continuing medical education and to promote implementation of innovations or translate new knowledge to change practice within healthcare systems. Previous reviews have concluded that educational meetings can result in small changes in behaviour, but that effects vary considerably. Investigations into which characteristics of educational meetings might lead to greater impact have yielded varying results, and factors that might explain heterogeneity in effects remain unclear. This is the second update of this Cochrane Review.

OBJECTIVES

• To assess the effects of educational meetings on professional practice and healthcare outcomes • To investigate factors that might explain the heterogeneity of these effects SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, ERIC, Science Citation Index Expanded (ISI Web of Knowledge), and Social Sciences Citation Index (last search in November 2016).

SELECTION CRITERIA

We sought randomised trials examining the effects of educational meetings on professional practice and patient outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. One review author assessed the certainty of evidence (GRADE) and discussed with a second review author. We included studies in the primary analysis that reported baseline data and that we judged to be at low or unclear risk of bias. For each comparison of dichotomous outcomes, we measured treatment effect as risk difference adjusted for baseline compliance. We expressed adjusted risk difference values as percentages, and we noted that values greater than zero favour educational meetings. For continuous outcomes, we measured treatment effect as per cent change relative to the control group mean post test, adjusted for baseline performance; we expressed values as percentages and noted that values greater than zero favour educational meetings. We report means and 95% confidence intervals (CIs) and, when appropriate, medians and interquartile ranges to facilitate comparisons to previous versions of this review. We analysed professional and patient outcomes separately and analysed 22 variables that were hypothesised a priori to explain heterogeneity. We explored heterogeneity by using univariate meta-regression and by inspecting violin plots.

MAIN RESULTS

We included 215 studies involving more than 28,167 health professionals, including 142 new studies for this update. Educational meetings as the single intervention or the main component of a multi-faceted intervention compared with no intervention • Probably slightly improve compliance with desired practice when compared with no intervention (65 comparisons, 7868 health professionals for dichotomous outcomes (adjusted risk difference 6.79%, 95% CI 6.62% to 6.97%; median 4.00%; interquartile range 0.29% to 13.00%); 28 comparisons, 2577 health professionals for continuous outcomes (adjusted relative percentage change 44.36%, 95% CI 41.98% to 46.75%; median 20.00%; interquartile range 6.00% to 65.00%)) • Probably slightly improve patient outcomes compared with no intervention (15 comparisons, 2530 health professionals for dichotomous outcomes (adjusted risk difference 3.30%, 95% CI 3.10% to 3.51%; median 0.10%; interquartile range 0.00% to 4.00%); 28 comparisons, 2294 health professionals for continuous outcomes (adjusted relative percentage change 8.35%, 95% CI 7.46% to 9.24%; median 2.00%; interquartile range -1.00% to 21.00%)) The certainty of evidence for this comparison is moderate. Educational meetings alone compared with other interventions • May improve compliance with desired practice when compared with other interventions (6 studies, 1402 health professionals for dichotomous outcomes (adjusted risk difference 9.99%, 95% CI 9.47% to 10.52%; median 16.5%; interquartile range 0.80% to 16.50%); 2 studies, 72 health professionals for continuous outcomes (adjusted relative percentage change 12.00%, 95% CI 9.16% to 14.84%; median 12.00%; interquartile range 0.00% to 24.00%)) No studies met the inclusion criteria for patient outcome measurements. The certainty of evidence for this comparison is low. Interactive educational meetings compared with didactic (lecture-based) educational meetings • We are uncertain of effects on compliance with desired practice (3 studies, 370 health professionals for dichotomous outcomes; 1 study, 192 health professionals for continuous outcomes) or on patient outcomes (1 study, 54 health professionals for continuous outcomes), as the certainty of evidence is very low Any other comparison of different formats and durations of educational meetings • We are uncertain of effects on compliance with desired practice (1 study, 19 health professionals for dichotomous outcomes; 1 study, 20 health professionals for continuous outcomes) or on patient outcomes (1 study, 113 health professionals for continuous outcomes), as the certainty of evidence is very low. Factors that might explain heterogeneity of effects Meta-regression suggests that larger estimates of effect are associated with studies judged to be at high risk of bias, with studies that had unit of analysis errors, and with studies in which the unit of analysis was the provider rather than the patient. Improved compliance with desired practice may be associated with: shorter meetings; poor baseline compliance; better attendance; shorter follow-up; professionals provided with additional take-home material; explicit building of educational meetings on theory; targeting of low- versus high-complexity behaviours; targeting of outcomes with high versus low importance; goal of increasing rather than decreasing behaviour; teaching by opinion leaders; and use of didactic versus interactive teaching methods. Pre-specified exploratory analyses of behaviour change techniques suggest that improved compliance with desired practice may be associated with use of a greater number of behaviour change techniques; goal-setting; provision of feedback; provision for social comparison; and provision for social support. Compliance may be decreased by the use of follow-up prompts, skills training, and barrier identification techniques.

AUTHORS' CONCLUSIONS

Compared with no intervention, educational meetings as the main component of an intervention probably slightly improve professional practice and, to a lesser extent, patient outcomes. Educational meetings may improve compliance with desired practice to a greater extent than other kinds of behaviour change interventions, such as text messages, fees, or office systems. Our findings suggest that multi-strategy approaches might positively influence the effects of educational meetings. Additional trials of educational meetings compared with no intervention are unlikely to change the review findings; therefore we will not further update this review comparison in the future. However, we note that randomised trials comparing different types of education are needed.

Dentists' responses about the effectiveness of continuing education activities

OBJECTIVE

To report the responses of dentists about the effectiveness of continuing education (CE) activities.

METHODS

This cross-sectional study involved the administration of a pilot-tested questionnaire amongst dentists from different cities of the eastern province of Saudi Arabia. A calculated sample of dentists (n = 323) was approached in person to collect their responses about CE activities they attended during the last one year. Descriptive statistics and multivariate logistic regression analyses were performed.

RESULTS

The response rate was 79.5% as 257 dentists returned completed questionnaires. There were 54.9% male and 45.1% female participants (mean age 31.18 ± 12.4 years). The majority of participants reported an improvement in knowledge (79.8%), a motivation for learning (79.8%), and quality of dental care (73.9%) as a result of CE activities. More than two-thirds recognised the importance of CE courses for maintaining licensure in dentistry, and 91.1% felt the need to increase CE activities. Logistic regression models showed that male participants were less likely (OR = 0.48, P = 0.05) than female counterparts to report an improvement in clinical skills. Having a private job (OR = 2.38 P = 0.005) and >10 years since graduation (OR = 1.84, P = 0.05) were associated with an improvement in clinical skills. Believing in the importance of CE activities for maintaining licensure was significantly associated with the effectiveness of CE activities in improving knowledge (OR = 2.76, P = 0.01), clinical skills (OR = 2.02, P = 0.04) and patient satisfaction (OR = 2.22, P = 0.01).

CONCLUSION

The majority of dentists recognised that CE activities were effective in improving their knowledge, clinical practice, quality of patient care and motivation for learning.

Mental health literacy in primary care: Canadian Research and Education for the Advancement of Child Health (CanREACH)

The effectiveness of a continuing education programme in paediatric psychopharmacology designed for primary healthcare providers was objectively measured based on the assumption that training would lead to measurable changes in referral patterns and established clinical measures of referred patients. Using established, valid and reliable measures of clinical urgency embedded in to a regional healthcare system since 2002, the referrals to child and adolescent psychiatric services of physicians who participated in the training (n=99) were compared pretraining and post-training, and to non-participating/untrained referring physicians (n=7753) making referrals over the same time period. Referrals were analysed for evidence of change based on frequencies and measures of clinical urgency. Participants of the training programme also completed standardised baseline and outcome self-evaluations. Congruent with participants self-reported evaluative reports of improved knowledge and practice, analysis of referral frequency and the clinical urgency of referrals to paediatric psychiatric services over the study period indicated that trained physicians made more appropriate referrals (clinically more severe) and reduced referrals to emergency services. Quantitative clinical differences as completed by intake clinicians blind to referrals from the study group designations were observed within the trained physician group pretraining and post-training, and between the trained physician group and the unexposed physician group. The results illustrate a novel model for objectively measuring change among physicians based on training in paediatric mental health management.

Case Method in COPD education for primary care physicians: study protocol for a cluster randomised controlled trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a common cause of morbidity and mortality worldwide. It is often undiagnosed and insufficiently managed. Effective forms of continuing medical education (CME) for primary care physicians (PCPs) are necessary to ensure the implementation of guidelines in clinical practice and, thus, improve patients' health.

METHODS

In this study, we will measure the effects of CME by Case Method and compare them against those of traditional lectures and no CME at all through an unblinded, cluster randomised controlled trial (CRCT). Thirty-three primary health care centres (PHCCs) in Stockholm, Sweden, with a total of 180 PCPs will be involved. Twenty-two primary PHCCs, will be cluster-randomised into: an intervention group who will receive CME by Case Method (n = 11) and a control group who will receive traditional lectures (n = 11). The remaining PHCCs (n = 11) will be a reference group and will receive no CME. From the intervention and control groups, 460 randomly selected patients with COPD in GOLD stages 2 and 3 will participate, while no patients will be recruited from the reference group. For the patients, smoking status, actual treatment and urgent visits to a health provider due to airway problems will be registered. For the PCPs, professional competence (i.e. knowledge and management skills) in COPD, will be measured using a questionnaire based on current guidelines and guideline implementation problems in clinical practice which has previously been described by the authors. Data will be collected at baseline and at follow-up, which will be after 1.5 years for the patients, and 1 year for the PCPs. Statistical methods for individual-level and cluster-level analyses will be used.

DISCUSSION

COPD is considered a particularly complex clinical challenge involving managing multimorbidity, symptom adaptation, and lifestyle problematisation. Case Method in CME for PCPs may contribute to a better understanding of the impact of COPD on patients' lives and, thus, improve their management of it. The present study is expected to contribute scientific knowledge about indicators for an effective CME in COPD that is tailor-made to primary care physicians.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT02213809 . Registered on 10 August 2014. Protocol version: Issue date: May 2014.

Assessing and enhancing quality through outcomes-based continuing professional development (CPD): a review of current practice

Numerous professional bodies have questioned whether traditional input-based continuing professional development (CPD) schemes are effective at measuring genuine learning and improving practice performance and patient health. The most commonly used type of long-established CPD activities, such as conferences, lectures and symposia, have been found to have a limited effect on improving practitioner competence and performance, and no significant effect on patient health outcomes. Additionally, it is thought that the impact of many CPD activities is reduced when they are undertaken in isolation outside of a defined structure of directed learning. In contrast, CPD activities which are interactive, encourage reflection on practice, provide opportunities to practice skills, involve multiple exposures, help practitioners to identify between current performance and a standard to be achieved, and are focused on outcomes, are the most effective at improving practice and patient health outcomes.

The Impact of CME

A review of the literature evaluating the effectiveness of Continuing Medical Education (CME) was undertaken using articles from 1935 to 1982.238 studies were reviewed and annotated using previously established and tested assessment criteria. These criteria included the following areas: the study design; the educational or administrative intervention; the evaluation maneuver used to assess the intervention's outcome; the health professionals used as subjects; andfinally, the educational and statistical significance of the study. It would appear that CMEinterventions when broadly defied, have an impact on physician competence and (less consistently though still in a positive direction) on physician performance and patient outcomes. Further research in both the methods and evaluation of CME is necessary.

A Continuing Pharmacy Education Program

A "nonequivalent control group" design was employed to measure the effectiveness of a continuing education program developed to enhance a communitypharmacist's ability to respond to requests for nonpre scription medication. Trained observers were used to unobtrusively measure the pharmacist's behavior before and after the educational event. Data analyses indicated a significant improvement in the partici pant pharmacists' abilities.

Dimensions of Motivation for Continuing Medical Education of Primary Care Physicians

The purpose of this study was to examine the reasons and underlying dimensions of the motivations ofprimary care physicians for participating in continuing medical education (CME). Physicians rated the importance of 18 reasons for participating in CME on a Motivation for Continuing Medical Education (MCME) Inventory. Results indicated that the most important reasons were maintaining competence, increasing knowledge and skills, staying up to date, and enhancing patient care. The least important reasons werefinancial gain and improving their professional image and work situation. Comparisons ofphysicians'reasonsfor CME with the desires of the public and legislative bodies revealed both similarities and differences. A principal components analysis of the MCME items yielded six relatively independent underlying motivational dimensions accounting for 71% of the total variance: Competence and Patient Care. Collegial Interaction, Professional Enhancement, Efficiency, Respite from Practice, and Legal Concerns. It is suggested that these motivational dimensions may be helpful in the planning of continuing medical education programs.

Association between participation and compliance with Continuing Medical Education and care production by physicians: a cross-sectional study

OBJECTIVE

Physician participation in Continuing Medical Education programs may be influenced by a number of factors. To evaluate the factors associated with compliance with the Continuing Medical Education requirements at a private hospital, we investigated whether physicians' activity, measured by volumes of admissions and procedures, was associated with obtaining 40 Continuing Medical Education credits (40 hours of activities) in a 12-month cycle.

METHODS

In an exclusive and non-mandatory Continuing Medical Education program, we collected physicians' numbers of hospital admissions and numbers of surgical procedures performed. We also analyzed data on physicians' time since graduation, age, and gender.

RESULTS

A total of 3,809 credentialed, free-standing, private practice physicians were evaluated. Univariate analysis showed that the Continuing Medical Education requirements were more likely to be achieved by male physicians (odds ratio 1.251; p=0.009) and who had a higher number of hospital admissions (odds ratio 1.022; p<0.001). Multivariate analysis showed that age and number of hospital admissions were associated with achievement of the Continuing Medical Education requirements. Each hospital admission increased the chance of achieving the requirements by 0.4%. Among physicians who performed surgical procedures, multivariate analysis showed that male physicians were 1.3 time more likely to achieve the Continuing Medical Education requirements than female physicians. Each surgical procedure performed increased the chance of achieving the requirements by 1.4%.

CONCLUSION

The numbers of admissions and number of surgical procedures performed by physicians at our hospital were associated with the likelihood of meeting the Continuing Medical Education requirements. These findings help to shed new light on our Continuing Medical Education program.

Continuing education meetings and workshops: effects on professional practice and health care outcomes

BACKGROUND

Educational meetings are widely used for continuing medical education. Previous reviews found that interactive workshops resulted in moderately large improvements in professional practice, whereas didactic sessions did not.

OBJECTIVES

To assess the effects of educational meetings on professional practice and healthcare outcomes.

SEARCH STRATEGY

We updated previous searches by searching the Cochrane Effective Practice and Organisation of Care Group Trials Register and pending file, from 1999 to March 2006.

SELECTION CRITERIA

Randomised controlled trials of educational meetings that reported an objective measure of professional practice or healthcare outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed study quality. Studies with a low or moderate risk of bias and that reported baseline data were included in the primary analysis. They were weighted according to the number of health professionals participating. For each comparison, we calculated the risk difference (RD) for dichotomous outcomes, adjusted for baseline compliance; and for continuous outcomes the percentage change relative to the control group average after the intervention, adjusted for baseline performance. Professional and patient outcomes were analysed separately. We considered 10 factors to explain heterogeneity of effect estimates using weighted meta-regression supplemented by visual analysis of bubble and box plots.

MAIN RESULTS

In updating the review, 49 new studies were identified for inclusion. A total of 81 trials involving more than 11,000 health professionals are now included in the review. Based on 30 trials (36 comparisons), the median adjusted RD in compliance with desired practice was 6% (interquartile range 1.8 to 15.9) when any intervention in which educational meetings were a component was compared to no intervention. Educational meetings alone had similar effects (median adjusted RD 6%, interquartile range 2.9 to 15.3; based on 21 comparisons in 19 trials). For continuous outcomes the median adjusted percentage change relative to control was 10% (interquartile range 8 to 32%; 5 trials). For patient outcomes the median adjusted RD in achievement of treatment goals was 3.0 (interquartile range 0.1 to 4.0; 5 trials). Based on univariate meta-regression analyses of the 36 comparisons with dichotomous outcomes for professional practice, higher attendance at the educational meetings was associated with larger adjusted RDs (P < 0.01); mixed interactive and didactic education meetings (median adjusted RD 13.6) were more effective than either didactic meetings (RD 6.9) or interactive meetings (RD 3.0). Educational meetings did not appear to be effective for complex behaviours (adjusted RD -0.3) compared to less complex behaviours; they appeared to be less effective for less serious outcomes (RD 2.9) than for more serious outcomes.

AUTHORS' CONCLUSIONS

Educational meetings alone or combined with other interventions, can improve professional practice and healthcare outcomes for the patients. The effect is most likely to be small and similar to other types of continuing medical education, such as audit and feedback, and educational outreach visits. Strategies to increase attendance at educational meetings, using mixed interactive and didactic formats, and focusing on outcomes that are likely to be perceived as serious may increase the effectiveness of educational meetings. Educational meetings alone are not likely to be effective for changing complex behaviours.

Does requiring continuing education units for professional licensing renewal assure quality patient care?

Although most states in the United States require health care professionals to complete continuing education units (CEUs) for licensure renewal, little evidence to date has established a relationship between completing CEUs and clinical competency. Considering the high cost of health care delivery and services, it would be prudent for both managers and consumers of health care to review the costs and benefits of requiring CEUs for professional licensing renewal. This study features an extensive review of the literature to analyze the supportive as well as the opposing views of mandatory CEUs for professional license renewal. Most of the studies reviewed reported almost no relationship between participation in traditional continuing education courses and improved patient outcomes. Several recommendations evolved out of this study for improving patient outcomes following the attendance of continuing education courses.

Achieving cardiovascular health through continuing interprofessional development

In order to achieve cardiovascular health for all Canadians, the ACHIC (Achieving Cardiovascular Health in Canada) partnership advocates that health promotion for healthy lifestyles be incorporated into practice, and that the consistent messages and professional skills required to motivate patients and the public be acquired through interprofessional education and development. Professional education specialists are essential members of health care promotion teams with expertise to develop educational interventions that impact behaviours of health professionals and subsequent patient outcomes. Continuing medical education (CME) is in evolution to continuing professional development (CPD), and then to continuing inter-professional development (CID). Providers of health promotion, public health, and health care can work with health educators to complete the cascade of learning, change in practice, and improvement in patient outcomes. The Canadian health care system can empower Canadians to achieve cardiovascular health, the most important health challenge in the 21st century.

Guideline implementation: what the literature doesn't tell us

BACKGROUND

Despite large numbers of studies and literature reviews about guideline implementation, it remains unclear whether and how clinical guidelines can be used to improve the quality of medical care. This study sought to learn whether these studies and reviews have recognized the importance of systems thinking and organizational change for implementation.

METHODS

A literature search was conducted for systematic reviews of guideline implementation or practice improvement studies. Each review was studied for the extent to which it identified or discussed the value of systems changes, organizational support, practice environmental factors, and use of a change process.

RESULTS

Forty-seven good-quality systematic reviews were found. They largely concurred that using reminders and perhaps using feedback in the course of clinical encounters were the most effective ways of implementing guidelines. However, these same reviews rarely identified these strategies as systems changes, and there was little discussion about any need for organizational support or attention to various environmental variables that might affect implementation. The change process required to introduce a new or changed practice system received even less attention.

CONCLUSION

Reviews of guideline implementation trials have focused on how to change the behavior of individual clinicians. There has been little attention to the impact of practice systems or organizational support of clinician behavior, the process by which change is produced, or the role of the practice environmental context within which change is being attempted. New attention to these issues may help us to better understand and undertake the process of improving medical care delivery.

Effectiveness of a Sonography Distance-Learning Event for Continuing Medical Education Credit

Continuing education for sonographers is a requiremeint for them to maintain their national registry. Satellite teleconferences are an example of a distance-learning activity that provides access ad information to sonographers regardliess of the location of the participant. The difficulty with this type of continuing medical education activity is that it is unmeasured for satisfaction, relevance, and knowledge gain for sonographers. Using previous research into effective physician continuing medical education, a study was designed as an investigation of the effectiveness of a commercially sponsored distance-learning event.

The results of this study suggest that a more structurd: study is necessary to validate satisfaction and relevance scores for this type of continuing medical education activity for all job titles. It is also important to begin to describe the efetiveness of continuing education distance-learning events for sonographers and other allied medical professionals.

Impact studies in continuing education for health professionals. A critique of the research syntheses

Documenting impact has been a continual pursuit in continuing education (CE) for health professionals. Hundreds of primary impact studies have been published, along with 16 impact study syntheses that have sought to generalize about the effectiveness of CE and sometimes how and why the effects occur. This article describes and critiques the methodology of the 16 syntheses and summarizes their findings. A first wave of syntheses established a general causal connection between CE and impacts, but explained impact variability only in the dependent variable-knowledge, competence, performance, or outcome. A second wave added a search for causal explanation through analysis of variables that moderate impact. This wave has begun to identify the most appropriate types of programs for promoting performance changes. The article concludes by suggesting questions and methods for future primary studies and meta-analyses, including improved experimental and meta-analytical methods, along with case and naturalistic studies and action research.

Dissemination of effectiveness and outcomes research

Effectiveness and outcomes research seeks to improve patients' health outcomes by improving the quality of the health care they receive. Dissemination of the findings of such research is a necessary step in that process. This paper reviews what is known about designing and disseminating effective information packages aimed at health care providers (mainly physicians), where effectiveness means promoting behavior change on the part of practitioners that leads to better patient care. Practice-relevant research information is delivered to providers through publication of results from randomized clinical trials, dissemination of consensus recommendations, development and use of computer-based aids to clinical decision making, and provision of continuing medical education. Each of these areas offers numerous examples of the exceedingly modest behavioral response that can be expected from the mere provision of information. The literature also offers some principles that may improve the chances for success, including the desirability of techniques that involve face-to-face interaction, promoting the active involvement of the learner, repeating the message, making recommendations explicit and relevant to clinical practice, and making use of opinion leaders and peer influence. Little basic research has been done on providers' motivations and actual decision-making processes. Research aimed at furthering a behavioral science of providers could yield new insights on effective dissemination strategies as well.

Critical appraisal of continuing medical education in the rheumatic diseases for primary care physicians

OBJECTIVE

To critically appraise evidence of the effectiveness of continuing medical education (CME) in rheumatic diseases for primary care physicians.

METHODS

Three physicians independently applied preset criteria to evaluated CME interventions published between January 1966 and August 1993.

RESULT

Eight of 166 articles identified were critically appraised, 7 of which had positive results. Marked heterogeneity in educational interventions, evaluative methods, and outcomes was noted.

CONCLUSION

Despite generally positive results, weak methodology precludes drawing firm conclusions about the effectiveness of CME in rheumatic diseases.

Evaluation of a continuing education intervention "Periodontics in General Practice"

Evidence exists that some dentists may be failing to perform adequate periodontal diagnostic and preventive care for their patients. Continuing education (CE) is an avenue that is frequently employed as a strategy to alter the style of practice. This paper presents an evaluation of a year-long continuing education intervention "Periodontics in General Practice", conducted among randomly selected private general dental practices in Adelaide, South Australia. The CE intervention featured a 1-day seminar, bi-monthly newsletters, individualised 3-monthly comparative feedback, and technical assistance. The study employed a longitudinal quasi-experimental design, which allowed for evaluation of the effectiveness of the intervention among practices employing hygienists (n = 12) and not employing dental hygienists (n = 12), taking into account the covariates of baseline level of provision of periodontal services, the practice's level of participation in the intervention and attendance at other CE courses in periodontics over the year. A comparison group of practice (n = 12) did not participate in the intervention over the year. Patient record audits, conducted at baseline and at 12 months, provided data for the evaluation of the effect of the intervention on the recording of periodontal diagnostic, preventive and treatment items. Practices participating in the intervention showed increases in the percentage of records containing at least one periodontal diagnostic notation, and those practices employing hygienists showed an increase in the percentage of records with at least one preventive notation and one treatment item.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of a warning about putative adverse events on drug prescribing in general practice

Many studies have looked at factors influencing doctors' prescribing. None have done this during a time when prescribers have been just made aware of potential serious adverse events that might be caused by a commonly prescribed medication. A controversy over the safety of Fenoterol (Boehringer Ingelheim) in 1989 provided an opportunity for such a study in general practice. Practitioners were exposed to conflicting and changing views from authoritative sources, patient concerns raised by the coverage of the issue in the news media, and a need to maintain patients on effective therapy. The study demonstrated that the majority of general practitioners would act promptly and conservatively when faced with uncertainty about the safety of the medication they prescribed.

The Impact of an Educational Program on Provision of Services to Ethnically Diverse Elders

The Stanford Geriatric Education Center cosponsored a conference to train service providers to work more effectively with a culturally diverse population of elders. At the end of the conference, participants identified specific new strategies their agencies should implement to increase their effectiveness with ethnic elders. A telephone follow-up 6 months later reached 44 of the 55 participants. They reported an average of 6 implemented strategies from an average of 10 originally identified; 86% reported 2 or more strategies implemented. Over half of the respondents reported successfully recruiting and promoting new ethnic staff and volunteers.

ESPRE: a knowledge-based system to support platelet transfusion decisions

ESPRE is a knowledge-based system which aids in the review of requests for platelet transfusions in the hospital blood bank. It is a microcomputer-based decision support system written in LISP and utilizes a hybrid frame and rule architecture. By automatically obtaining most of the required patient data directly from the hospital's main laboratory computers via a direct link, very little keyboard entry is required. Assessment of time trends computed from the data constitutes an important aspect of this system. To aid the blood bank personnel in deciding on the appropriateness of the requested transfusion, the system provides an explanatory report which includes a list of patient-specific data, a list of the conditions for which a transfusion would be appropriate for the particular patient (given the clinical condition), and the conclusions drawn by the system. In an early clinical evaluation of ESPRE, out of a random sample of 75 platelet transfusion requests, there were only three disagreements between ESPRE and blood bank personnel.

Influence of continuing medical education workshops on participant learning

The challenge of assessing the effectiveness of continuing medical education (CME) programs is formidable and intriguing. Two workshops on program factors affecting resident recruitment, conducted at annual meetings of the American Association of Directors of Psychiatric Residency Training, were evaluated for their influence on participant learning. Based on pre- and post-workshop questionnaires, participant perceptions and attitudes changed as a result of the workshop experience. The changes closely paralleled the planned and spontaneous discussion content. In describing the workshop-related changes, factors affecting residency program recruitment and aspects of CME program evaluation are discussed. A suggestion for enhancing workshop evaluations is incorporated.

When does information change practitioners' behavior?

Programs that disseminate information to health care practitioners often do so partly to encourage appropriate changes in practice. However, merely providing information is seldom enough to accomplish such changes. If information transfer programs are to influence practice, they must be designed to maximize the conditions facilitating change. Reliance on a diffusion model for thinking about how information reaches practitioners has led researchers to over-emphasize the importance of exposure to information and ignore other factors that determine whether change will occur, such as practitioners' motivation to change, the context in which clinical decisions are made, and how information is presented. The fact that successful dissemination will not necessarily produce change also has implications for how information transfer programs should be monitored and evaluated.

Impacts of professional education in diabetes on trainees' reports

Over a three-year period, 202 nurses and dietitians attended professional edu cation courses conducted at the Diabetes Research and Training Center. The courses were designed to develop trainee knowledge and skill for diabetes management and to guide the expansion of patient education programs. Trainees' satisfaction with the course components was high and knowledge changes were significant. Sixty-one percent of the trainees returned a follow- up survey indicating im provements in counseling and teaching skills. Trainees' reports indicated greatest progress in areas over which they had most direct control.

Professional education may have positive effects on trainee knowledge, teaching preparation and counseling skills, and patient education programs.

Evaluating a workshop model for improving diabetes patient education programs: is it really successful?

Over a threx-year period, 54 health professionals at tended three two-day workshops designed to improve diabetes patient education programs, par ticularly program manage ment and evaluation of skills. A commitment-to- change strategy was used to determine the long-term effectiveness of the workshops. Fifty-nine per cent overall of the com mitments to change were reported as attained in the six-month follow-up surveys. The evidence suggests not only that the workshops were suc cessful, but that measurable changes in participants' programs can be attained in a cost- effective manner.

Evaluation of continuing education in the health professions. The state of the art

In this article the author discusses three "levels" of the state of the art: the "ideal," for program evaluation; the "practical," with political limitations; and the "actual," for current practices. Starting with a review of the developmental stages of effectiveness variables (from attendance and "happiness' through professional performance and patient outcomes), the article updates a review by Lloyd and Abrahamson (1979) and then discusses current practices. Evaluation as a potential contamination factor leads into consideration of evaluation versus research. Finally a review of "lessons learned" over the last twenty years introduces a look ahead into exploitation of the state of the art.

Determining physicians' performance. Continuing medical education and other interacting variables

Participation in formal continuing medical education (CME) is required by many organizations and state governments as the foremost means of assuring the quality of medical care. Analysis of the literature reveals that CME in all its forms is effective in improving competence, i.e., the ability to provide good care. However, that competence is not regularly reflected in physicians' habitual performance in the care of patients. A number of factors are known to narrow the gap between competence and performance, including clear specification of standards, individual feedback on actual performance, and a professional environment conductive to the maintenance of high standards. In the presence of such factors, CME can improve physicians' performance when directed to objectively identified deficiencies. However, public assurance of the quality of medical care can only be provided through certification that individual physicians' performance conforms to contemporary valid standards.

Changes in physician behavior and cost savings associated with organizational recommendations on the use of "routine" chest X rays and multichannel blood tests

Group Health Cooperative (GHC) of Puget Sound is a prepaid health plan with 285,000 enrollees and 340 physicians. In 1978 a "criterion analysis" approach was instituted to develop medical staff recommendations about preventive care. By 1979, two recommendations evolved discouraging the "routine" use of: (a) chest X rays (CXR) and (b) multichannel blood tests (MCBT) in asymptomatic adults at "routine" physical exams. An extensive educational campaign was conducted to change physician behavior in use of these tests. Usage patterns were measured both before and after the recommendations and educational programs. A fivefold fall in "nonindicated" use of CXR and a 1.5-fold fall in MCBT occurred. A cost savings of $166,582 (annually) resulted from this diminution in "nonindicated" testing. The decision-making process and educational campaign technology hold promise for GHC's preventive medicine program in the future. These results may have applicability to other health care organizations.

Competencies for continuing education faculty in the health professions

Formal pre- and postdoctoral health professional education and continuing health professional education are different in their designs, contents, and respective student bodies. Faculty must, therefore, acquire and use an appropriate teaching approach for each group. The competencies necessary in a continuing education setting may be unique to this setting or they may be modifications of skills used in the formal setting. They include: assessing needs, designing curricula, employing a learner-centered approach, insuring relevance, establishing a learning set, using flexible and varied methods, individualizing, and evaluating. This paper provides descriptions of rationales for these competencies.

An evaluation of the impact of a continuing education course in diabetes

This article represents the results of an evaluation of a continuing education program for dietitians. The evaluation was built into the program at its inception and involved an assessment of participant satisfaction, short-term knowledge gain and a follow-up assessment of self-reported behavior change. The results of this evaluation indicate that the course did, indeed, impact on both knowledge and behavior. In addition, however, the evaluation also uncovered some problems in planning which minimized the potential impact of this course. These results suggest that there should be increased attention to rigorous educational needs assessment and both process and impact program evaluations in order to determine approaches to education that could make more effective use of the resources available for continuing education in health care.