Researching Education for Health Providers

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Researching Education for Health Providers

• Kathi J. Kemper, MD, MPH
• Caryl J Guth Chair for Holistic and Integrative
  Medicine
• Professor, Pediatrics, Public Health Sciences,
  WFUSM

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Disclosure Financial Support from Pharmaceutical
Companies - none

• Specifically,
• NO honoraria from companies for participation in
  advisory board, consultancies, provision of
  patient data, enrolling patients in a trial or
  giving a presentation at a company-sponsored
  event
• NO financial or other support of research
  activities for myself or my staff
• NO travel, registration, accommodation or other
  support to attend conferences or meetings
• NO attendance at company sponsored meetings
  launching new drugs
• NO personal gifts, office gifts, meals or
  practice equipment from any companies
• NOT a PI or investigator on any clinical trials
  supported by a company
• No Receipt of free samples of any drugs or
  patient education materials from any company
• NO visits welcomed by representatives from any
  pharmaceutical company
• As per Lancet, 200636728

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Support gratefully acknowledged from

• NIH NCCAM 4/1/00 3/31/03 2003. R21
  (AT00213-01)
• Curriculum for Pediatric Herbs/Dietary
  Supplements
• NIH NCCAM 10/1/00 9/30/05. 25 (AT000538-01)
  Center for Pediatric Integrative Medical
  Education
• National Library of Medicine 2/1/04 1/31/06
  (extended Based Curriculum About Herbs and
  Dietary Supplements
• Fullerton Foundation. 11/1/04 10/31/05.
  Feasibility of Providing e-Curriculum on herbs
  and supplements for SC clinicians

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Research Structure
Interventions
Outcomes
Subjects
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Research Question - Subjects

• Health care providers
• Professionals
• MD, PA, PharmD, RD, RN, Acupuncturists,
  Chiropractors, Massage therapists, Healing Touch,
  Homeopathy
• Family and community
• Parents, Teachers

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Educational - Interventions

• Publish research about efficacy/safety
• Publish review articles
• Develop curricula
• Textbook chapters/Internet materials
• Role model desired behavior
• Write policy statements
• Influence thought leaders
• Create consumer demand (lay media)

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Educational -Outcomes

• Provider knowledge
• Provider attitudes/confidence
• Provider behavior
• Communication practices
• Medical record charting
• Actual referrals and recommendations
• Patient outcomes and satisfaction
• Health care use
• Cost of health care/ happiness/ productivity

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Example 1 New Curriculum

• Teaching pediatrics to family medicine residents
  using The Holistic Pediatrician as textbook
• Compare 3rd year residents from I program to C
  programs in Puget Sound
• Similar demographics, attitudes about CAM,
  referral to CAM (high in all groups)
• Only difference felt better prepared to answer
  pt questions used more herbs personally
• Problems sample size curricula is small in
  relation to learning experience large secular
  trends
• Kemper KJ. J Alt Comp Med, 1999 5(3) 261

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Example 2 Faculty Development

• Curriculum for faculty leaders and teaching
  fellows at Boston Childrens
• Seven 90 minute sessions very experiential, case
  based focus 4 topics HW QA final
  presentations that could serve to teach
  residents/students
• Improved Knowledge (62 ?84 correct on herbs
  60 ?98 on acupuncture) Confidence (?1.8 on 5
  point scale) Improved communication about herbs
  (50 ?75)
• Developed curriculum changed clinic forms
  changed standard lectures on asthma and ADHD
• Kemper Alt Ther, 2002 8(6) 70-73

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Example 3 Write Reviews and Texts

• Since 1996, have written over 20 review articles
  and chapters for Contemporary Pediatrics,
  Pediatric Annals, Clinical Pulmonary Medicine,
  Office Emergency Medicine, Oski, Nelsons,
  Berde/Schechter, Pizzo/Poplack, Osborne/DeWitt
• Lectures/Grand Rounds at more than 35
  institutions, AAP, Symposia Medicus,
• Outcomes????? Control group? Secular changes?
• Questions on Boards? Services covered by
  insurance? Physician confidence? AAP Section?

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Example 4 Policies

• Pharmacy guidelines on use of home supply at
  Boston Childrens
• Pharmacy and Clinical guidelines to ask patients
  about use of CAM at WFUSM
• No discernable impact
• Need prospective study

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Example 5 Role model

• Role model inclusion of CAM at Boston Childrens
• Referrals to acupuncturist, massage, TT,
  hypnosis, MD (most for Ca and CF) (Kemper and
  Wornham. APAM, 2001 155 449-454)
• Charting in medical record review articles on
  charts
• 2100 consults in 5 years
• Outcome CPG for CF includes acupuncture and CF
  Family Services pays for RN time to do
  TT/HT/Reiki (Highfield et al. J Alt Comp Med,
  200511(2) 373)

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Traditional research Randomized Controlled Trials
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Many patients use herbs and supplements (HDS)

• 2nd most common CAM tx following prayer
• 40 - 60 of adults use multivitamins
• Women calcium, folate
• Infants, Children vitamin D, vit K
• 10 - 20 of kids use other HDS, especially kids
  with chronic or recurrent illnesses, e.g.,
  asthma, ADHD, autism, special health needs,
  chronic abdominal pain, cancer, allergies
• NOT routinely taught in health professions

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Health professionals want to know more about
herbs and supplements (HDS)

• Top rated topic among pediatricians in AAP
  survey 90 desire additional info.
• Popular in Family Medicine and Internal Medicine
  as well CME programs by UCSF/Harvard, Scripps
• Increasing numbers of review articles in many
  mainstream journals
• Kemper K, OConnor K. Amb Pediatr, 20044482-87
• http//www.contemporarypediatrics.com/contpeds/

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How to educate clinicians?

• Review articles (e.g. Contemporary Pediatrics)
• Meta-analyses
• Web sites (LHTF, ConsumerLabs, NMCD)
• Case reports
• Conference, lectures (Herbal Jeopardy, Grand
  Rounds)
• Detailing and bribes (think big Pharma)
• General media Time, Newsweek, 60 minutes

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Barriers to CE/ CME

• Time
• Money
• Credibility/Trust

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Pilot Study Boston

• BCH, MCPHS, LHTF collaboration
• 20 modules with links focus on herb per module
• Moderated Listserv 1-2 weekly
• 2 modules weekly X 10 weeks, sent by email
• Randomized cross-over
• Solicitations by email to Longwood area
  institutions (about 2000 emails sent) widely
  forwarded

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Baseline characteristics Boston study

• 537 enrolled (111 MD 30 RN 46 PharmD 350 RD)
  84 fac/practice 16 trainees
• Age 40 years 86 women 86 Caucasian
• 24 from Longwood area 76 out of area
• 66 had training about herbs in past year 7
  hours median
• 77 used H/DS themselves 4 or more days a week
  (MV, Ca, Vit E, Vit C, Vit B, echinacea,
  chamomile, soy, Mg all greater than 10)

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Baseline K, A, P Boston Pilot

• Knowledge 50 correct on 10 TF 10 MC (better
  for RD faculty/practice all less than 60 avg)
• Confidence average 4/10 possible
• Communication 1.4 / 4 possible, e.g., median
  percentage of patient encounters in last month
  talk about H/DS was 10
• Low scores on side effects and interactions

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Improvements AFTER Intervention Pilot Study

• Knowledge 3 points with Intervention vs. 1.4 for
  wait group, Plt0.01
• Confidence 2.6 vs. 0.6, Plt0.01
• Communication 0.21 vs -0.1, Plt0.01
• Similar improvements in wait list group when they
  got e-curriculum improvements sustained in
  initial Intervention group
• Questions will it work for MORE modules (40)?
  Can we do it by BOLUS vs. DRIP PUSH vs. PULL CE
  credit?
• Need more questions, especially on
  practice/communication

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Factorial Design for Curriculum Delivery
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Eligibility

• MD/PA
• RN/ARNP
• Pharm D, pharmacists
• RD, nutritionists
• Faculty, in-practice, in training
• Access email at least twice a week
• Agree to complete baseline and outcome
  questionnaires
• CME/CE credit 35 for 10 hours

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Recruitment

• Northwest Area Health Educ. Center e-mail
• NW AHEC mail brochures (Spring only)
• Medical schools, alumni offices, nursing schools,
  pharmacy schools, RD programs, SC AHEC (Spring
  only)
• Personal contacts, APA Listserv, Flyers at
  Scripps herb conference, CAHCIM (Spring only)

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Content

• 40 modules, sorted by diagnosis, problem in 10
  groups, e.g. oncology, cardiology, pulmonary,
  womens, pediatrics
• Over 300 links to evidence-based sources
• Moderated listserv
• Offered through NW AHEC CME/ CE offered for 10
  12 hours credit
• Same program offered in each of two semesters,
  Fall, 2004 and Spring, 2005 (RN CE)

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Primary Outcomes

• Drop-out rate (non-completion of outcome
  questionnaire)
• Changes in Knowledge, Confidence, Practice
• Feedback about course

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Demographics

• Eligible and enrolled 1268
• Age 40 years (younger in Spring, more students)
• Female 75
• Race 84 Caucasian 8 Asian 5 African
  American
• No demographic differences in 4 randomized groups

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Practice Characteristics,

• Profession
• Students/Trainees 31
• MD/PA 30
• RN 23
• RD 12
• PharmD 5
• Faculty/practice 57
• Seen pts in past 30 days 67
• Live in NC 47
• Use herbs 85 (MV, Ca, B Vits Vit C Vit E
  fish oil green tea flax seed Vit D folate
  glucosamine Mg CoQ10 iron) AVG 5.5
• NSD in 4 randomized groups

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Patient Epidemiology

• What percentage of your patients do you estimate
  currently use herbs or other dietary supplements?
• Range 0,100
• Mode 30
• Median 35

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Baseline Knowledge

• True/False 74
• Multiple choice 59
• Overall 66 correct at baseline

Note to help participants meet CE/CME
requirements of 70 correct at outcome, we made
questions easier than in Boston pilot study
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Confidence - baseline

• 19 questions
• Cronbachs alpha 0.91
• Score (Strongly Disagree 1 Strongly Agree
  5) Possible range 19, 95
• Average baseline score 52.5 18.2

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Fall, 2004 Baseline Practice Questions In last
30 days, in what percentage of your clinical
encounters have you

• Discussed with a pt or family, the use of H/DS?
  
• Median and mode 10
• Did you initiate discussion about HDS?
• Mode 0 median 30
• Ask about dose /frequency?
• Mode 0 median 10
• Ask about side effects?
• Median and mode 0
• Record use in medical record?
• Mode 0 median 20

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Practice / Communication (only for participants
who saw a patient in prior 30 days)

• 11 questions Score range 0, 10
• Cronbachs alpha, 0.84
• Baseline 2.20 1.92

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Completion rates for Fall, 2004
Completed
Didnt sign up for credit, N260 Completed 145
(56)
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1st FU Immediately after course Completers (780)
vs. Non-completers (487)

• No significant differences by
• Delivery strategy, or baseline communication
  practices

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Completers (780) vs. non-Completers (487)
Significantly Differ

• Age (42 vs 37 yrs)
• Gender (77 vs 71 women)
• Profession highest completion for Pharmacists
  and nutritionists (gt70) lowest for students
  (46)
• Clinically active (saw pts in last 30 days) (70
  vs 62)
• Paid CE fee (58 vs 27)
• Number of HDS used as baseline 5.7 vs 5.2
• Completers had higher knowledge and confidence at
  baseline

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Web Use PUSH vs PULL
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Most popular links
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LHTF Echinacea Example
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Improvements from Baseline to First, Immediate FU

• Knowledge, 22 increase to 89 correct
• Confidence, 10.5 points to 64.3
• Communication practices, 0.33, from 1.67 to 2.0
• All Plt0.01 significance

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Improvement with curriculum Knowledge Correct ?
from baseline to immediate follow-up
P0.3
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Improvements with curriculum Confidence (N735)
P0.9
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Improvements with Curriculum Communication
Practices (N440)
P0.4
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If delivery strategy didnt affect improvement,
what did?

• NOT gender
• YES, Knowledge affected by
• Paying CE fee (most important in regression
  analysis)
• Age lt30 or greater than 50
• Profession students, nutritionists, and nurses
  had bigger gains than MDs or PharmDs
• Using herbs. Those who used fewest at baseline
  improved the most

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Confidence most improved for

• Being a trainee (vs being in practice)
• Paying CE fee
• Being under 30 or over 50 years old
• Profession being a nurse or student vs being a
  nutritionist, or pharmacist

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Communication most improved for

• NOT affected by any predictor variable

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Positive Feedback from Participants

• "I enjoyed the course (and learned a lot)."
• Dr. Richard Theuer - Raleigh, NC
•  
• I'd just like to say how much I enjoyed having
  access to this great information through such an
  easy-to-use format as e-mail.  I not only learned
  a lot as I went along, but now I have a wonderful
  printable resource as well.  I've utilized some
  of the information already with my staff here in
  our practice.  Thank you for making this
  available!
• Elizabeth Richards, RN, MS - Asheville, NC
•  
• I have enjoyed this experience very much. I wish
  I had more time to spend with it. This has been
  most useful information.
• Russell Knop, MS, CSAC - Hillsborough, NC

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Constructive Feedback

• It was just too much for me to keep up
  overwhelming decrease number of modules and
  links smaller doses
• A little slower pace would have been helpful
  more time Too much information in a short
  period from a BOLUS participant
• better as an online instead of email program.
  I got only part of the emails. from someone who
  received PUSH

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More Feedback

• .. internet links were very helpful. Ability
  to go into any amount of depth on any topic.
• I learned about several resources of which I
  was not aware.
• The modules were a fast read I could choose to
  access or not access links. I can go at my
  own pace.
• Excellent format thorough coverage. I really
  liked the case study approach
• affordable way to get CE
• Sharing and talking to colleagues about what I
  was learning Reading questions from other
  practitioners

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Requests

• More courses like this
• Ongoing updates on the same topic
• Printed reference materials to accompany the
  course
• Patient handouts
• Searchable index for topics
• Clinical tools for recording patients use of HDS
• Provide course and references in Spanish

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Initial impact study citation

• Kemper KJ, Gardiner P, Gobble J, Mitra A, Woods
  C.Randomized Controlled Trial Comparing Four
  Strategies for Delivering e-Curriculum to Health
  Care Professionals ISRCTN88148532. BMC Med
  Educ. 2006 Jan 116(1)2

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Long-term Follow-Up

• October November, 2006
• Approximately 6 10 months after completing the
  Spring or Fall curriculum, we emailed the same
  follow-up questions to all enrollees
• Four reminders
• Free enrollment in another on-line class on herbs
• Of 780 who completed the first follow-up, 385
  (49) completed long-term followup

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Long term completers (N385) versus
Non-completers (N395)

• Non-Completers and completers did not differ in
  average age (42 years), gender, race, self-rated
  computer expertise (4.3 on 7 point scale),
  knowledge, confidence, herb use or communication
  practices at baseline, being a trainee (vs in
  practice), intervention group, spring (vs fall)
  enrollment or professional group or having paid
  for CE/CME, ie NO DIFFERENCE on ANY MEASURED
  BASELINE PARAMETER

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Changes from baseline and first follow-up

• Knowledge (N385)
• From baseline 67.7 to 78.8 (10.1 pts, Plt0.001)
• Initial FU 89.8 to 78.8 (-12.1, Plt0.001)
• Confidence (N385)
• From baseline 53.7 to 66.9 (13.2, Plt0.001)
• From initial FU 64.5 to 66.9 (2.3, P0.009)
• Communication (N182)
• From baseline 2.6 to 3.6 (1.0, Plt0.001)
• From initial FU 3.3 to 3.6 (0.3, P0.007)

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Long term completers (N385)
Plt0.001 by Wilcoxon
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Confidence Among Long-term Completers (N385)
Plt0.001 by Wilcoxon
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Communication Practices in Long-term Completers
(N182)
Plt 0.001 by Wilcoxon
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Changes over time

• NOT affected by delivery strategy
• Initial bivariate analyses suggest differences
  for
• Knowledge by profession, age, herb use, seeing
  patients, paying for CE/CME
• Confidence by profession, practice, age, herb
  use, seeing patients, paying for CE/CME
• Communication - NSD

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Conclusions so Far

• More web use with push
• More drop outs if no-pay
• Link usage declines over time
• LHTF favored want handouts want indexing and
  hard copies booklets?
• Randomization worked curriculum works
  regardless of delivery strategy,
• Confidence and communication continue to increase
  after course, but little meaningful improvement
  in communication

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Next Steps?

• Currently, we are providing 12 on-line classes,
  each one hour long, free for medical students
  here, fees for everyone else
• Market comparison of KNOWLEDGE-oriented versus
  BEHAVIOR oriented classes
• Preliminary view of impact on Confidence and
  Communication
• Over 500 enrolled since 12/05

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Next study questions (grant submitted 10/05 for
7/06 start)

• Impact of B versus K curriculum
• Impact of one versus higher doses of classes
• Impact at 1 and 6 months
• Impact of required versus elective
• Impact on self-reported versus chart review of
  behavior
• Two parts
• Pt 1 RCT of 1600 clinicians (K vs B 1 and 6
  months)
• Pt 2 RCT of 75 RNs at NCBH (required vs
  elective chart review)

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Conclusions

• CAM education for multidisciplinary professionals
  is feasible high interest by women
• Role modeling is effective
• Few technical problems with web-based data entry
  or content delivery harder to do email delivery
• Few problems with SPAM Listserv works well even
  for very LARGE numbers of enrollees
• Coordinating teamwork over different campuses and
  specialties
• Impact of review articles, chapters, talks is
  harder to measure
• Need cost-benefit analyses!
• Need to look at patient outcomes.
• Educational research is fun, challenging
• And fundable.!

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THANK YOU!!!!