Clinical evidence continuous medical education: a randomised educational trial of an open access e-learning program for transferring evidence-based information - ICEKUBE (Italian Clinical Evidence Knowledge Utilization Behaviour Evaluation) - study protocol

Use of the knowledge to action model improved physical therapist adherence to a common clinical practice guideline across multiple settings: a multisite case series

BACKGROUND

When a new guideline is published  there is a need to understand how its recommendations can best be implemented in real-world practice. Yet, guidelines are often published with little to no roadmap for organizations to follow to promote adherence to their recommendations. The purpose of this study was to evaluate the impact of using a common process model to implement a single clinical practice guideline across multiple physical therapy clinical settings.

METHODS

Five organizationally distinct sites with physical therapy services for patients with peripheral vestibular hypofunction participated. The Knowledge to Action model served as the foundation for implementation of a newly published guideline. Site leaders conducted preliminary gap surveys and face-to-face meetings to guide physical therapist stakeholders' identification of target-behaviors for improved guideline adherence. A 6-month multimodal implementation intervention included local opinion leaders, audit and feedback, fatigue-resistant reminders, and communities of practice. Therapist adherence to target-behaviors for the 6 months before and after the intervention was the primary outcome for behavior change.

RESULTS

Therapist participants at all sites indicated readiness for change and commitment to the project. Four sites with more experienced therapists selected similar target behaviors while the fifth, with more inexperienced therapists, identified different goals. Adherence to target behaviors was mixed. Among four sites with similar target behaviors, three had multiple areas of statistically significantly improved adherence and one site had limited improvement. Success was most common with behaviors related to documentation and offering patients low technology resources to support home exercise. A fifth site showed a trend toward improved therapist self-efficacy and therapist behavior change in one provider location.

CONCLUSIONS

The Knowledge to Action model provided a common process model for sites with diverse structures and needs to implement a guideline in practice. Multimodal, active interventions, with a focus on auditing adherence to therapist-selected target behaviors, feedback in collaborative monthly meetings, fatigue-resistant reminders, and developing communities of practice was associated with long-term improvement in adherence. Local rather than external opinion leaders, therapist availability for community building meetings, and rate of provider turnover likely impacted success in this model.

TRIAL REGISTRATION

This study does not report the results of a health care intervention on human participants.

Exploring Adult Learners' Viewpoints and Motivation Regarding Distance Learning in Medical Education

INTRODUCTION

Literature in education and training supports the notion that distance learning (DL) is the most effective mode of learning for health care workers to improve the quality of patient care. However, implementing DL requires pre-assessing learners' perspectives and attitudes for providing better delivery, essential support, and facilities. This study aimed to identify the viewpoints and attitudes of dental graduates toward DL in medical education and their point views of the effectiveness and efficacy of DL tools.

METHODS

A structured, self-administered questionnaire was distributed to registered adult graduates working in government- or private hospitals in a permanent position or for a long term (3 months or more). Data were collected and analyzed.

RESULTS

Two-thirds (67.9%) of the participants had previously attended a DL course. The highest ranked items on the participants' views on DL were ease of access, ability to take the course from any location, and be taught from anywhere in the world. Their perception of DL was analyzed in relation to gender and previous exposure to DL.

CONCLUSION

This investigation revealed a positive attitude among graduates on the effectiveness of DL. Most respondents appreciated DL's convenience in terms of time flexibility and online attendance. Residents' attitudes toward DL and DL characteristics are major factors to consider when instituting or planning for DL. Continuous medical education through DL will continue to generate considerable interest as an international movement.

Efficacy of adaptive e-learning for health professionals and students: a systematic review and meta-analysis

OBJECTIVE

Although adaptive e-learning environments (AEEs) can provide personalised instruction to health professional and students, their efficacy remains unclear. Therefore, this review aimed to identify, appraise and synthesise the evidence regarding the efficacy of AEEs in improving knowledge, skills and clinical behaviour in health professionals and students.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

CINAHL, EMBASE, ERIC, PsycINFO, PubMed and Web of Science from the first year of records to February 2019.

ELIGIBILITY CRITERIA

Controlled studies that evaluated the effect of an AEE on knowledge, skills or clinical behaviour in health professionals or students.

SCREENING, DATA EXTRACTION AND SYNTHESIS

Two authors screened studies, extracted data, assessed risk of bias and coded quality of evidence independently. AEEs were reviewed with regard to their topic, theoretical framework and adaptivity process. Studies were included in the meta-analysis if they had a non-adaptive e-learning environment control group and had no missing data. Effect sizes (ES) were pooled using a random effects model.

RESULTS

From a pool of 10 569 articles, we included 21 eligible studies enrolling 3684 health professionals and students. Clinical topics were mostly related to diagnostic testing, theoretical frameworks were varied and the adaptivity process was characterised by five subdomains: method, goals, timing, factors and types. The pooled ES was 0.70 for knowledge (95% CI -0.08 to 1.49; p.08) and 1.19 for skills (95% CI 0.59 to 1.79; p<0.00001). Risk of bias was generally high. Heterogeneity was large in all analyses.

CONCLUSIONS

AEEs appear particularly effective in improving skills in health professionals and students. The adaptivity process within AEEs may be more beneficial for learning skills rather than factual knowledge, which generates less cognitive load. Future research should report more clearly on the design and adaptivity process of AEEs, and target higher-level outcomes, such as clinical behaviour.

PROSPERO REGISTRATION NUMBER

CRD42017065585.

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.

Effectiveness of Adaptive E-Learning Environments on Knowledge, Competence, and Behavior in Health Professionals and Students: Protocol for a Systematic Review and Meta-Analysis

BACKGROUND

Adaptive e-learning environments (AEEs) can provide tailored instruction by adapting content, navigation, presentation, multimedia, and tools to each user's navigation behavior, individual objectives, knowledge, and preferences. AEEs can have various levels of complexity, ranging from systems using a simple adaptive functionality to systems using artificial intelligence. While AEEs are promising, their effectiveness for the education of health professionals and health professions students remains unclear.

OBJECTIVE

The purpose of this systematic review is to assess the effectiveness of AEEs in improving knowledge, competence, and behavior in health professionals and students.

METHODS

We will follow the Cochrane Collaboration and the Effective Practice and Organisation of Care (EPOC) Group guidelines on systematic review methodology. A systematic search of the literature will be conducted in 6 bibliographic databases (CINAHL, EMBASE, ERIC, PsycINFO, PubMed, and Web of Science) using the concepts "adaptive e-learning environments," "health professionals/students," and "effects on knowledge/skills/behavior." We will include randomized and nonrandomized controlled trials, in addition to controlled before-after, interrupted time series, and repeated measures studies published between 2005 and 2017. The title and the abstract of each study followed by a full-text assessment of potentially eligible studies will be independently screened by 2 review authors. Using the EPOC extraction form, 1 review author will conduct data extraction and a second author will validate the data extraction. The methodological quality of included studies will be independently assessed by 2 review authors using the EPOC risk of bias criteria. Included studies will be synthesized by a descriptive analysis. Where appropriate, data will be pooled using meta-analysis by applying the RevMan software version 5.1, considering the heterogeneity of studies.

RESULTS

The review is in progress. We plan to submit the results in the beginning of 2018.

CONCLUSION

Providing tailored instruction to health professionals and students is a priority in order to optimize learning and clinical outcomes. This systematic review will synthesize the best available evidence regarding the effectiveness of AEEs in improving knowledge, competence, and behavior in health professionals and students. It will provide guidance to policy makers, hospital managers, and researchers in terms of AEE development, implementation, and evaluation in health care.

Identifying the barriers and enablers in the implementation of the New Zealand and Australian Antenatal Corticosteroid Clinical Practice Guidelines

Background

The ineffective implementation of evidence based practice guidelines can mean that the best health outcomes are not achieved. This study examined the barriers and enablers to the uptake and implementation of the new bi-national (Australia and New Zealand) antenatal corticosteroid clinical practice guidelines among health professionals, using the Theoretical Domains Framework.

Methods

Semi-structured interviews or online questionnaires were conducted across four health professional groups and three district health boards in Auckland, New Zealand. The questions were constructed to reflect the 14 behavioural domains from the Theoretical Domains Framework. Relevant domains were identified by the presence of conflicting beliefs within a domain; the frequency of beliefs; and the likely strength of the impact of a belief on the behaviour using thematic analysis. The influence of health professional group and organisation on the different barriers and enablers identified were explored.

Results

Seventy-three health professionals completed either a semi-structured interview (n = 35) or on-line questionnaire (n = 38). Seven behavioural domains were identified as overarching enablers: belief about consequences; knowledge; social influences; environmental context and resource; belief about capabilities; social professional role and identity; and behavioural regulation. Five behavioural domains were identified as overarching barriers: environmental context and resources; knowledge; social influences; belief about consequences; and social professional role and identity. Differences in beliefs between individual health professional groups were identified within the domains: belief about consequences; social professional role and identity; and emotion. Organisational differences were identified within the domains: belief about consequences; social influences; and belief about capabilities.

Conclusion

This study has identified some of the enablers and barriers to implementation of the New Zealand and Australian Antenatal Corticosteroid Clinical Practice Guidelines using the validated Theoretical Domains Framework, as perceived by health professionals. We have identified differences between individual health professional groups and organisations. The identification of these behavioural determinants can be used to enhance an implementation strategy, assist in the design of interventions to achieve improved implementation and facilitate process evaluations to understand why or how change interventions are effective.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1858-8) contains supplementary material, which is available to authorized users.

Update of strategies to translate evidence from cochrane musculoskeletal group systematic reviews for use by various audiences

For rheumatology research to have a real influence on health and well-being, evidence must be tailored to inform the decisions of various audiences. The Cochrane Musculoskeletal Group (CMSG), one of 53 groups of the not-for-profit international Cochrane Collaboration, prepares, maintains, and disseminates systematic reviews of treatments for musculoskeletal diseases. While systematic reviews provided by the CMSG fill a major gap in meeting the need for high-quality evidence syntheses, our work does not end at the completion of a review. The term "knowledge translation" (KT) refers to the activities involved in bringing research evidence to various audiences in a useful form so it can be used to support decision making and improve practices. Systematic reviews give careful consideration to research methods and analysis. Because the review is often long and detailed, the clinically relevant results may not be apparent or in the optimal form for use by patients and their healthcare practitioners. This paper describes 10 formats, many of them new, for ways that evidence from Cochrane Reviews can be translated with the intention of meeting the needs of various audiences, including patients and their families, practitioners, policy makers, the press, and members of the public (the "5 Ps"). Current and future knowledge tools include summary of findings tables, patient decision aids, plain language summaries, press releases, clinical scenarios in general medical journals, frequently asked questions (Cochrane Clinical Answers), podcasts, Twitter messages, Journal Club materials, and the use of storytelling and narratives to support continuing medical education. Future plans are outlined to explore ways of improving the influence and usefulness of systematic reviews by providing results in formats suitable to our varied audiences.

Physician social capital and the reported adoption of evidence-based medicine: exploring the role of structural holes

The present study explores the role that professional networks play in the propensity of hospital physicians to adopt and implement evidence-based medicine (EBM) into clinical practice. Using attributional and relational data collected from a sample of 207 physicians in six Italian National Health Service hospitals, social network techniques were used to analyze the structure of the networks representing professional interactions among the surveyed hospital physicians. Ordinal logistic regression was applied to analyze the association between the structural features of physicians' networks and their self-reported propensity to implement EBM into daily practice. Physicians who were highly constrained in their interpersonal networks were less likely to report adopting EBM, suggesting that the cohesion induced by social interactions may hamper, rather than foster, the diffusion of scientific information within professional groups. We discuss the implications of the observed interaction patterns for hospital administrators and policy makers.

Impact of the Italian continuing medical education program on the research production of a transplantation center: a preliminary analysis

In Italy, a Continuing Medical Education (CME) program that engages about one million health professionals involved with different roles in National Health Service (physicians, nurses, biologists, pharmacologists, psychologists, veterinarians, technicians, etc) became officially mandatory on January 1, 2008. In Italy, the traditional form of acquiring CME credits is to attend lectures and conferences, while the main structured online service was dismissed in November 2008. The Italian Ministry of Health required health professionals to obtain 50 credits/y, with no obligation toward scientific production. In this study, we have preliminarily evaluated the potential impact of a compulsory CME program on the research production of our transplantation center. We selected the research products published by surgeons (n = 10) and university researchers (n = 2) who were on duty in our center from 1995 to 2007. For this period, PubMed returned 89 research products with at least one surgeon/researcher of our center as author/coauthor. The mean number of published research products/y was 6.84 +/- 4.5. The number of expected research products for 2008 and 2009 on the basis of a time series analysis applied to the period 1995 to 2007 was 12.35 and 12.91, respectively. A search in PubMed restricted to 2008 and 2009 (from January 1 to November 23) returned in both years eight research products. Considering that in our center there was no increase in volume activities or changes in whole working processes, it seems reasonable to assume that the new compulsory, time-consuming Italian CME program may have played a role in the decline of scientific production. A systematic monitoring should be started with the aim to investigate the potential impact of the Italian CME program on biomedical research output, especially for centers and disciplinary areas mainly involved in clinical research.

Knowledge transfer for the management of dementia: a cluster randomised trial of blended learning in general practice

Background

The implementation of new medical knowledge into general practice is a complex process. Blended learning may offer an effective and efficient educational intervention to reduce the knowledge-to-practice gap. The aim of this study was to compare knowledge acquisition about dementia management between a blended learning approach using online modules in addition to quality circles (QCs) and QCs alone.

Methods

In this cluster-randomised trial with QCs as clusters and general practitioners (GPs) as participants, 389 GPs from 26 QCs in the western part of Germany were invited to participate. Data on the GPs' knowledge were obtained at three points in time by means of a questionnaire survey. Primary outcome was the knowledge gain before and after the interventions. A subgroup analysis of the users of the online modules was performed.

Results

166 GPs were available for analysis and filled out a knowledge test at least two times. A significant increase of knowledge was found in both groups that indicated positive learning effects of both approaches. However, there was no significant difference between the groups. A subgroup analysis of the GPs who self-reported that they had actually used the online modules showed that they had a significant increase in their knowledge scores.

Conclusion

A blended learning approach was not superior to a QCs approach for improving knowledge about dementia management. However, a subgroup of GPs who were motivated to actually use the online modules had a gain in knowledge.

Trial registration

Current Controlled Trials ISRCTN36550981.