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Effective Medical Education: Insights From the Cochrane Library
Abstract
Unlabelled:
In 2006, the Accreditation Council for Continuing Medical Education highlighted the need for linking educational activities to changes in competence, performance, or patient outcomes. Hence, educational providers increasingly need to know what strategies are effective. The Cochrane Library is widely regarded as the best source of credible evidence concerning health care. The authors searched the Cochrane Database of Systematic Reviews (issue 4 for 2006) using the search terms "continuing medical education," "medical education," and "continuing education." They conducted a second complementary search of this database by review group (Effective Practice and Organization of Care). Finally, the authors examined the references of recent review articles for Cochrane reviews and found 9 relevant reviews. The most effective educational methods were the most interactive. Combined didactic presentations and workshops were more effective than traditional didactic presentations alone. Medical education was more effective when more than 1 intervention occurred, especially if these interventions occurred over an extended period. Targeted education should focus on changing a behavior that is simple, because effect size is inversely proportional to the complexity of the behavior. In the era of evidence-based medicine, interventions-including educational ones-should reflect the best available evidence. Cochrane reviews of randomized controlled trials of educational methods provide important guidance that often challenges traditional didactic approaches. Integrating the findings from the Cochrane reviews may allow continuing medical education to be more successful in bringing about changes to healthcare providers' behavior.
Target audience:
Obstetricians & Gynecologists, Family Physicians.
Learning objectives:
After completion of this article, the reader should be able to explain the scientific evidence concerning the effectiveness of various techniques used for continuing medical education, state the relative value of such techniques as traditional didactic lectures, conferences led by local opinion leaders, interactive workshops, and educational outreach visits, and identify the value and limitations of teaching critical appraisal skills.
... Ten knowledge syntheses considered the cost of CPD. 23,39,44,45,63,68,72,73,80,81 They addressed various aspects of costs, including how the cost of CPD programs can be a barrier for some participants. 72,73 The authors of some syntheses proposed that the cost-effectiveness of various interventions and implementation methods need to be considered when offering CPD programs. ...
... 23,39,44,45,63,68,72,73,80,81 They addressed various aspects of costs, including how the cost of CPD programs can be a barrier for some participants. 72,73 The authors of some syntheses proposed that the cost-effectiveness of various interventions and implementation methods need to be considered when offering CPD programs. 9,68 One challenge is that the literature rarely reports the cost of CPD programs. ...
Purpose:
Continuing professional development (CPD) programs, which aim to enhance health professionals' practice and improve patient outcomes, are offered to practitioners across the spectrum of health professions through both formal and informal learning activities. Various knowledge syntheses (or reviews) have attempted to summarize the CPD literature; however, these have primarily focused on continuing medical education or formal learning activities. Through this scoping review, the authors seek to answer the question, What is the current landscape of knowledge syntheses focused on the impact of CPD on health professionals' performance defined as behavior change and/or patient outcomes?
Method:
In September 2019, the authors searched PubMed, Embase, CINAHL, Scopus, ERIC, and PsycINFO for knowledge syntheses published between 2008 and 2019 that focused on independently practicing health professionals and reported outcomes at Kirkpatrick's levels 3 and/or 4.
Result:
Of the 7,157 citations retrieved from databases, 63 satisfied the inclusion criteria. Of these 63 syntheses, 38 (60%) included multicomponent approaches, and 27 (43%) incorporated eLearning interventions - either stand-alone or in combination with other interventions. While a majority of syntheses (n = 42 [67%]) reported outcomes affecting health care practitioners' behavior change and/or patient outcomes, most of the findings reported at Kirkpatrick level 4 were not statistically significant. Ten of the syntheses (16%) mentioned the cost of interventions though this was not their primary focus.
Conclusions:
Across health professions CPD is an umbrella term incorporating formal and informal approaches in a multi-component approach. eLearning is increasing in popularity but remains an emerging technology. Several of the knowledge syntheses highlighted concerns regarding both the financial and human costs of CPD offerings, and such costs are being increasingly addressed in the CPD literature.
... For example courses which have organisational backing and support (Bantwini 2009;Govranos and Newton, 2014;Stolee et al, 2005;Harris et al., 2007;Lee, 2011), attend to individualised learning needs (Schostak et al. 2010;Yee et al. 2014;Govranos and Newton, 2014), which employ a mix of delivery modes (Steginga et al., 2005;Martin et al., 2010;Hughes and Schindel 2010) are interactive, group or collaborative (Drexel 2011a(Drexel & 2011bStone et al.2014;Gray, 2014;Young and Newell, 2008) relate to everyday practice and are relevant to the learner at that point in time (Kjaer et al., 2014;Duff et al.2014;Rosen et al.2012;Ciaschi et al., 2011;Ross and Crumpler, 2007) seem more valued and more effective. The findings of the literature reviews concur, effective CPD is interactive, multi-method, multi-phase, multi-media (Bloom, 2005;Alvarez and Agra,2006;Satterlee, et al. 2008;Lam-Antoniades et al.2009;Mazmanian et al. 2009;Gijbels et al. 2010;Bluestone, et al. 2013;Firmstone et al.2013). ...
... A systematic review of 9 papers by Satterlee, et al., (2008) suggested that while combined didactic presentations and workshops were more effective than traditional didactic presentations alone, medical education was reported as more effective when more than one intervention occurred and especially if these interventions took place over an extended period. ...
... Continuing medical education is frequently provided in ineffective forms (10) with weak evaluation (19,74). Aiming for simple behavior changes through multiple interventions and interactive methods over an extended time period has been most effective (78). ...
... Patient safety is a relatively new field, and studies have often focused on demonstrating an initial impact; it is becoming necessary to demonstrate sustainability of change and longterm effectiveness (78). It may also be necessary to reconsider the level of evidence necessary to justify change: Does disclosure need to be shown to reduce error, or is it sufficient to show that it improves patient satisfaction without increasing harm? ...
Medical errors and adverse events are now recognized as major threats to both individual and public health worldwide. This review provides a broad perspective on major effective, established, or promising strategies to reduce medical errors and harm. Initiatives to improve safety can be conceptualized as a "safety onion" with layers of protection, depending on their degree of remove from the patient. Interventions discussed include those applied at the levels of the patient (patient engagement and disclosure), the caregiver (education, teamwork, and checklists), the local workplace (culture and workplace changes), and the system (information technology and incident reporting systems). Promising interventions include forcing functions, computerized prescriber order entry with decision support, checklists, standardized handoffs and simulation training. Many of the interventions described still lack strong evidence of benefit, but this should not hold back implementation. Rather, it should spur innovation accompanied by evaluation and publication to share the results.
... The research process includes the literature search, the selection of literature, the inclusion and exclusion of documentation, the evaluation of documentation, assessing the quality of the literature search by two reviewers and analyzing the quality of the data. [25,26,27,28] Study flow details are shown in Figure 2 Systematic literature review research flow chart. ...
More than 60% of the world’s countries do not have enough blood. According to the analysis report of blood donors recorded in the 2021 annual report of the Taiwan Blood Service Foundation. Taiwan’s blood donors also have hemoglobin disqualification issues, with 5.5% of them failing physical examinations before blood donation. The research method is a systematic review and comprehensive analysis of the literature. Meta-search has shown that long-term donors are faced with iron deficiency. Moderate iron intake by longterm blood donors can improve the impact on hemoglobin and ferritin. Significantly improve the delayed blood donation phenomenon of long-term blood donors.
... In summary, the body of evidence taken together indicates that the CanREACH program is effective and supports the wider dissemination of the original Reach Institute's PPP program with fidelity. 18 The health information is readily available to support the more extensive population-based evaluation plan outlined above in support of the provincial implementation of the CanREACH program. ...
Objective:
This paper presents a review of the current state of child and adolescent mental health literacy and provides current evidence of the economic impact of a pediatric mental health literacy (MHL) training program.
Methods:
Employing a case-series-comparison design, physician referrals to urgent and specialized mental health services were linked with patient-specific information comparing referrals from MHL participants and non-participating physicians. The economic impact analysis was based on changes in the admitted referral frequency and lengths of stay for the MHL group, compared to themselves pretraining, and over the same time period compared to non-participating physicians.
Results:
Average scheduled ambulatory admission rates per physician remained constant for trained and untrained pre-post groups. Average scheduled ambulatory admission wait time and length of stay reduced significantly post-training for MHL-trained physicians compared to pre-training and untrained physicians. In addition to reductions in length of stay, the total bed costs saving for emergency/inpatients admission deferrals was $2,932,112 or about $20,000 per MHL-trained physician.
Conclusion:
The estimated economic impact of the MHL training shows a substantial return on investment and supports wider implementation. The MHL training program should be a key feature of mental health reform strategies, as well as continuing and undergraduate medical education.
... Dentro de las cuales solo el 24% parece estar sustentado en evidencia confiable 33 . Estos hechos invitan a que nuestra comunidad reconozca las herramientas que provee la MBE y su adecuado uso 7 , además de la importancia de desarrollar investigación local capaz de proporcionar datos de alta calidad 34 . Las principales limitaciones del presente estudio tienen relación con la dificultad para cuantificar la carga asistencial en la práctica clínica local, con la ausencia de seguimiento y con la incapacidad para valorar la repercusión de intervenciones, como el desarrollo de GPC locales. ...
Introducción: Cerca del 10% de los ensayos clínicos publicados anualmente tienen relación con el cáncer, sin embargo, solo el 20% de las intervenciones relacionadas con el tratamiento de esta enfermedad están soportadas por un nivel de evidencia I. Objetivo: Valorar las actitudes y opiniones de los oncólogos/hematólogos hacia la medicina basada en evidencias (MBE) en Colombia. Diseño del estudio: Encuesta estructurada realizada a una serie de miembros de la Asociación Colombiana de Hematología y Oncología (ACHO), que incluyó preguntas respecto de las actitudes, opiniones y competencias en MBE. Resultados: Se recibieron 53 encuestas (tasa de respuesta del 46%, considerando la totalidad de los miembros adscritos a la ACHO). Hubo acuerdo en que el uso de la MBE mejora el cuidado de los pacientes (promedio 8, rango 4-10) y en que los especialistas deben familiarizarse con técnicas de evaluación crítica de la literatura médica (promedio 7, rango 4-9). El porcentaje que manifestó entender términos clave como número necesario para tratar (NNT), número necesario para generar daño (NNH), poder y nivel de evidencia fueron el 60%, 22%, 75% y 75%, respectivamente. Las guías de la NCCN (Clinical practice guidelines in oncology/hematology, National Comprehensive Cancer Network, EE. UU.) fueron usadas de manera regular por el 32% de los encuestados y, al menos, una vez por mes en el 38% de los casos. El 46% desconocía PubMed a fondo y el 40% lo usaba regularmente. El 76% no había realizado búsquedas en la base de datos Cochrane de revisiones sistemáticas y el 24% la había utilizado al menos una vez en su vida. La competencia de todos los encuestados para MBE se calculó en un 73% (desviación estándar de ±17%). Conclusión: Los oncólogos/hematólogos colombianos tienen una actitud favorable hacia la MBE. Es recomendable facilitar el entendimiento de la terminología y favorecer el uso de herramientas de la MBE a través de talleres, publicaciones y fuentes virtuales relacionadas con cáncer.
... The latter 2 are interactive methods considered to be the most effective teaching methods. 5 For skills-based learning, previous research has shown that discussion-based learning has positive outcomes in the development of practical skills and selfefficacy compared with lecture only. 6 By contrast, about two thirds of the students reported no exposure to skillsbased instruction such as skills clinics, simulated patients, or role play. ...
Introduction
Clinical guidelines support physician intervention consistent with the Ask, Advise, Assess, Assist, Arrange framework for adults who have obesity. However, weight management counseling curricula vary across medical schools. It is unknown how frequently students receive experiences in weight management counseling, such as instruction, observation, and direct experience.
Methods
A cross-sectional survey, conducted in 2017, of 730 third-year medical students in 8 U.S. medical schools assessed the frequency of direct patient, observational, and instructional weight management counseling experiences that were reported as summed scores with a range of 0‒18. Analysis was completed in 2017.
Results
Students reported the least experience with receiving instruction (6.5, SD=3.9), followed by direct patient experience (8.6, SD=4.8) and observational experiences (10.3, SD=5.0). During the preclinical years, 79% of students reported a total of ≤3 hours of combined weight management counseling instruction in the classroom, clinic, doctor's office, or hospital. The majority of the students (59%–76%) reported never receiving skills-based instruction for weight management counseling. Of the Ask, Advise, Assess, Assist, Arrange framework, scores were lowest for assisting the patient to achieve their agreed-upon goals (31%) and arranging follow-up contact (22%).
Conclusions
Overall exposure to weight management counseling was less than optimal. Medical school educators can work toward developing a more coordinated approach to weight management counseling.
... The ACT programme is based on the pedagogical concept of active learning, where students participate and interact with the learning process, as opposed to a passive flow of information from tutor to student. Combining workshop-style learning with didactic teaching is known to be more effective than traditional didactic lectures alone (Satterlee, et al., 2008). To date, there are a limited number of studies looking into the effectiveness of using blended or interactive methods to teach contraception. ...
Paper on contraception teaching through interactive workshops
That students loved and enjoyed.
... Cochrane Collaboration is an international organization that prepares, maintains, and offers available systematic reviews of health care interventions′ benefits/risks. The Cochrane Library is commonly considered to be the best source of credible healthcare evidence [16]. Systematic reviews use a transparent and systematic process to construct study questions, look for studies, evaluate their quality, and synthesize qualitative or quantitative results [17]. ...
A major blockade to support the evidence-based clinical decision-making is accurately and efficiently recognizing appropriate and scientifically rigorous studies in the biomedical literature. We trained a multi-layer perceptron (MLP) model on a dataset with two textual features, title and abstract. The dataset consisting of 7958 PubMed citations classified in two classes: scientific rigor and non-rigor, is used to train the proposed model. We compare our model with other promising machine learning models such as Support Vector Machine (SVM), Decision Tree, Random Forest, and Gradient Boosted Tree (GBT) approaches. Based on the higher cumulative score, deep learning was chosen and was tested on test datasets obtained by running a set of domain-specific queries. On the training dataset, the proposed deep learning model obtained significantly higher accuracy and AUC of 97.3% and 0.993, respectively, than the competitors, but was slightly lower in the recall of 95.1% as compared to GBT. The trained model sustained the performance of testing datasets. Unlike previous approaches, the proposed model does not require a human expert to create fresh annotated data; instead, we used studies cited in Cochrane reviews as a surrogate for quality studies in a clinical topic. We learn that deep learning methods are beneficial to use for biomedical literature classification. Not only do such methods minimize the workload in feature engineering, but they also show better performance on large and noisy data.
... paid to educational methods. Learnercentered and in teractive approaches are generally recommended [8,9]. Medical education is not only important to train healthcare workers, but the availability of medical ed ucation in remote areas is also suggested to be one of the factors to retain healthcare workers in underserved areas [10]. ...
In 2015, the World Health Organization announced its Sustainable Development Goals. This agenda contributes to reducing inequity in healthcare and improving health. In a world with major differences between countries, the following question should be asked: How can healthcare professionals in general (and radiologists in particular) from highincome countries (HIC) and lowand middleincome countries (LMIC) work together to improve global health? The purpose of this paper is to evaluate several recent crosscultural educational efforts in radiology in Azerbaijan and to formulate practical recommendations for radiology education and medical education in general carried out in LMICs by volunteers from HICs. Methods. From a series of four consecutive education projects, we analyzed the evaluation forms of two of the sessions. Furthermore, we evaluated all four education projects by systematic comparison and reflection on 21 items in the categories Background Information, People, and Practice. Results. To all items in the list, a reflection was added that included viewpoints from both visiting and host professionals. The evaluation forms demonstrated that the third education project with practical radiology content was valued higher than the fourth education project on quality management. The participants of both education projects would recommend projects like these to their own colleagues. We formulated recommendations for shortterm crosscultural education projects based on the systematic evaluation, the reflection, and the evaluation forms. Conclusion. This systematic evaluation of serial crosscultural radiology education efforts in Azerbaijan fills a gap in global health research. It is an example of evidencebased crosscultural teaching, and it identified recommendations for future projects. A key finding is the importance of serving the host country’s professionals by carefully assessing their needs. Educational efforts should be seen in the broader context of healthcare development.
... As a behaviour change intervention, one-to-one visits have shown to be more effective than group meetings with peer discussions. [6][7][8][9][10][11][12] The term AD has also been used to describe other approaches as group meetings and small seminars. [13][14][15] Both one-to-one visits and group meetings have advantages and disadvantages, as shown in Table 1. ...
Introduction:
Academic detailing is an interactive educational outreach to prescribers to present unbiased, non-commercial, evidence-based information, mostly about medications, with the goal of improving patient care. Academic detailing in Norway is an approach for providing continuing medical education to general practitioners (GPs). The basis of academic detailing is a one-to-one discussion between a trained health professional (the academic detailer) and the GP at the GP's workplace.
Method:
Our first campaign was named "Better use of non-steroidal anti-inflammatory drugs (NSAIDs)", which aim was to reduce the use of diclofenac due to the risk of serious cardiovascular adverse events. At the same time we advised the GPs to use naproxen as the drug of choice if an NSAID was needed. We did a one-to-one intervention in two cities, where a trained academic detailer met the GP during office hours. A total of 247 GPs were invited to participate and 213 visits (86%) were completed. This article reviews the theoretical framework underlying the method and describes the development and implementation of academic detailing to GPs in Norway.
Results:
More than 90% the participating GPs considered academic detailing a suitable method for providing up-to-date evidence-based, manufacturer-independent information, and nearly all would most likely or probably welcome another visit. After the intervention there was a reduction of diclofenac prescribing of 16% and 18%, respectively, in the two cities.
Conclusion:
We consider that academic detailing is a suitable method to bring the best available evidence to the point at which care is delivered, to achieve the best for the patients. According to the Norwegian GPs' evaluation, it is a key supplement to other methods of continuing medical education. To have maximum impact, it is important that academic detailing is practiced according to the consensus that has evolved in the USA and Australia.
... The intervention consisted of two 3-h seminars with time to review the information and practise in-between sessions. The rationale for this setup was that educational efforts on health care professionals have been shown to be most effective if they are mixed interactive and didactic, including at least two occasions over an extended period of time, and focusing on changing simple behaviors and outcomes that are likely to be perceived as serious [11,12]. The seminars were led by one internist (J.L.) and one clinical pharmacologist (S.M.W. or K.N.). ...
Purpose
To evaluate whether an educational intervention based on collegial discussions on patient cases could increase interns’ professional confidence in prescribing.
Methods
In a randomized controlled study at Sahlgrenska University Hospital, Gothenburg, Sweden, 69 interns (median age: 29 years, 54% female) were allocated to an intervention or control group. The intervention consisted of two 3-h seminars based on collegial discussions of patient cases focused on performing medication reviews. This included reconciling the drug treatment and ascertaining that it is reasonable given the patient’s current health status, as well as tips on practical handling of the medical records system and integrated decision support. Self-assessed confidence in performing medication reviews was evaluated with questionnaires distributed at baseline and at 6-month follow-up.
Results
Fifty-seven (83%) interns completed the questionnaires. Although the opposite was found at baseline, intervention interns, in comparison with controls, at follow-up, were more confident in performing medication reviews (4.3 ± 0.9 vs. 3.6 ± 1.3, P = 0.034; 1 = completely disagree to 5 = completely agree). At follow-up, the intervention participants had increased their confidence in prescribing to a greater extent compared with the control participants, including performing medication reviews as well as taking responsibility for the medication list at discharge: + 1.5/+ 1 vs ± 0 on the 5-point agreement scale (all P ≤ 0.01). Among other positive outcomes, the intervention increased the interns’ awareness of adverse effects as a potential cause of symptoms and their confidence in withdrawing a medication.
Conclusion
Structured collegial discussions on pharmacotherapy, even of a relatively short duration, can increase junior physicians’ professional confidence in prescribing medicines.
... Studies that have examined ECG education in various healthcare provider streams have generally focused on delivery via classroom lectures or handouts, with varying effect. [20][21][22][23] Online or web-based teaching has been shown to have comparable efficacy with more traditional lecture or workshop-based teaching in regard to ECGs. [24][25][26] It has been postulated that web-based training may, in fact, be more effective than traditional teaching methods. ...
Background
Accuracy of electrocardiogram (ECG) interpretation is important for identification of ST-elevation myocardial infarction (STEMI) by Emergency Medical Services (EMS) personnel who recognize STEMI in the field and activate the coronary catheterization laboratory. According to previous research, there is improvement in diagnosis of STEMIs for healthcare providers who read an average of > 20 ECGs per week. This study evaluated the effectiveness of online ECG modules on improving diagnostic accuracy.
Methods
EMS personnel received 25 ECGs per week to interpret via an online program. Diagnostic accuracy was assessed for improvement via completion of an ECG evaluation package before and after the intervention. Job satisfaction data were collected to determine the impact of the educational initiative.
Results
A total of 64 participants completed the study. Overall, there was an improvement in ECG diagnostic accuracy from 50.8% to 61.2% (95% confidence interval [CI], 7.7-13.2; P < 0.0001). Specifically, there was significant improvement in the diagnosis of STEMI (8.5%; 95% CI, 4.9-12.3; P < 0.003) and supraventricular tachycardia (39.0%; 95% CI, 17.2-60.8; P < 0.008), with a trend toward improvement in all other diagnoses. These effects were sustained to 3 months (9.6%; 95% CI, 6.4-12.7; P < 0.0001). Improvement was seen regardless of employment experience and training. There was no significant impact on job satisfaction.
Conclusions
ECG exposure remains an important factor in improving the accuracy of ECG diagnosis in EMS personnel. Online education modules provide an easily accessible way of improving ECG interpretation with the opportunity for positive downstream effects on patient outcomes and resource use.
... A prime example is the national oral health curriculum, Smiles for Life, designed with the intent of facilitating the integration of oral health into primary care provider training (Clark et al. 2010). While this curriculum provides a platform for education of primary care providers, evidence suggests multi-methods training, involving a combination of didactic training, observation of and applying recommended practices in-office might be effective in influencing physician behavior (Herndon et al. 2015;Rabiei et al. 2012;Satterlee et al. 2008). This type of training approach may be most influential in equipping the upcoming primary care workforce to address the oral health of pregnant women in the manner proposed by the national consensus statement. ...
Objectives Limited information exists on the extent oral health is addressed in the context of prenatal care. This study sought to investigate characteristics of primary care physicians (PCP) who provide oral health counseling to pregnant women. Methods The study relied upon data from the 2013 Survey of PCP on Oral Health. Provision of oral health counseling to pregnant women (sometimes vs. rarely/never) was the primary outcome. Covariates included respondents’ demographic and practice characteristics, oral health-related training, knowledge, attitudes, preparedness and clinical behaviors. The analytical strategy included bivariate tests and multivariable Poisson regression modeling, accounting for the survey design; inference was based upon marginal effects estimation. Results Two-thirds of PCP (233 out of 366 respondents) reported providing oral health counseling to pregnant women. In bivariate comparisons, female PCP, PCP with oral health-specific instruction during medical training, favorable oral health-related attitudes, behaviors, preparedness, and knowledge were more likely to provide counseling (p < 0.05). Multivariable analyses confirmed the independent associations of female gender [marginal effect = + 9.7 percentage points (p.p.); 95% confidence interval (CI) = 0.0–19.0], years in practice (− 0.4 p.p. for each added year; 95% CI = − 0.09 to 0.0), oral health continuing education (+ 13.2 p.p.; 95% CI = 2.6–23.8), preparedness (+ 23.0 p.p.; 95% CI = 16.9–29.0) and oral health counseling of adult patients with other conditions (+ 8.8 p.p.; 95% CI = 4.6–13.3) with prenatal oral health counseling. Conclusions for Practice A considerable proportion of PCP nationwide counsel pregnant patients on oral health. Provider attributes including education and preparedness appear as promising targets for interventions aimed to enhance pregnant women’s oral health and care.
... Workshop training may improve attendees' capacity, but knowledge and skills may not be transferred to other co-workers at the facility nor translated into provider practice or performance [14,15]. Various methods for continuing medical education and inservice training have established strong evidence on best practices for learning: repetition is correlated to higher retention of knowledge and skill, having the same setting for training as clinical practice is correlated with higher gains in skills and performance, simulation-based practice and interactive methods are more effective than didactic lecture [16][17][18][19]. ...
Background
Low-dose, high-frequency (LDHF) training is a new approach best practices to improve clinical knowledge, build and retain competency, and transfer skills into practice after training. LDHF training in Ghana is an opportunity to build health workforce capacity in critical areas of maternal and newborn health and translate improved capacity into better health outcomes.
Methods
This study examined the costs of an LDHF training approach for basic emergency obstetric and newborn care and calculates the incremental cost-effectiveness of the LDHF training program for health outcomes of newborn survival, compared to the status quo alternative of no training. The costs of LDHF were compared to costs of traditional workshop-based training per provider trained. Retrospective program cost analysis with activity-based costing was used to measure all resources of the LDHF training program over a 3-year analytic time horizon. Economic costs were estimated from financial records, informant interviews, and regional market prices. Health effects from the program’s impact evaluation were used to model lives saved and disability-adjusted life years (DALYs) averted. Uncertainty analysis included one-way and probabilistic sensitivity analysis to explore incremental cost-effectiveness results when fluctuating key parameters.
Results
For the 40 health facilities included in the evaluation, the total LDHF training cost was $823,134. During the follow-up period after the first LDHF training—1 year at each participating facility—approximately 544 lives were saved. With deterministic calculation, these findings translate to $1497.77 per life saved or $53.07 per DALY averted. Probabilistic sensitivity analysis, with mean incremental cost-effectiveness ratio of $54.79 per DALY averted ($24.42–$107.01), suggests the LDHF training program as compared to no training has 100% probability of being cost-effective above a willingness to pay threshold of $1480, Ghana’s gross national income per capita in 2015.
Conclusion
This study provides insight into the investment of LDHF training and value for money of this approach to training in-service providers on basic emergency obstetric and newborn care. The LDHF training approach should be considered for expansion in Ghana and integrated into existing in-service training programs and health system organizational structures for lower cost and more efficiency at scale.
... The effectiveness of each of these techniques is not entirely certain, but combined didactics with workshops appear to be superior to didactics alone. 14,15 Respondents felt that education research topics such as how to conduct literature reviews and working with Institutional Review Boards could be taught using electronic learning modules with limited interactivity. In general, electronic learning offers exciting opportunities for educators to move beyond being distributors of knowledge and skill to being true facilitators of knowledge/skill creation. ...
... Viene evidenziato inoltre che le metodiche formative tradizionali, affiancate da metodi interattivi, hanno effetti di miglioramento maggiori sui comportamenti professionali, rispetto all'esclusivo utilizzo di metodologie di formazione di tipo tradizionale. Questi risultati possono essere spiegati principalmente dal fatto che solitamente nella formazione residenziale vengono utilizzati metodi didattici passivi, che prevedono una trasmissione delle conoscenze ponendo i discenti in un ruolo prevalentemente di ascolto e di ricezione delle informazioni veicolate (Davis, 1998;Mazmanian & Davis, 2002;Grimshaw, Eccles, & Walker, 2002;Satterlee, Eggers, & Grimes, 2008). Gli interventi formativi tradizionali possono dunque agire come elementi predisponenti alla modificazione delle conoscenze e abilità. ...
Un modello di formazione continua in medicina basato sull’utilizzo di funzionalità di comunicazione e cooperazione integrate nel Fascicolo Sanitario Elettronico.
... Interactive strategies ranged from being guided to conduct a clinical project, 36 to journal club, 38 group discussions and activities, 35 to hands-on role-play of research concepts. 33 This phenomenon is well-known in the educational literature [40][41][42][43] but traditional didactic educational delivery nonetheless persists in many settings, as evidenced by the included studies. ...
Background:
Despite the importance of research literacy for nurses, many nurses report feeling unable to effectively read and understand research, which in turn results in lower research utilization in practice. Nurses themselves identify poor experiences with trying to understand and use research as factors that contribute to a reluctance to utilize research. This reluctance often leads nurses to seek other sources of information, such as colleagues, instead.
Objectives:
The objective of this review was to identify the effectiveness of research literacy interventions on the research literacy of registered nurses.
Inclusion criteria:
Registered nurses.Interventions of interest were those that evaluated the effectiveness of workplace educational programs or interventions conducted in a healthcare organization or tertiary-level educational facility aiming to improve or increase registered nurses' understanding of research literature.Outcomes of interest were research literacy, measured explicitly or as research knowledge, research understanding, use of research evidence in practice, and/or ability to critically appraise research.We considered experimental study designs such as randomized controlled trials, nonrandomized controlled trials, quasi-experimental, and before and after studies.
Search strategy:
A wide range of databases were searched in order to provide the most complete possible review of the evidence. Initial keywords used were: "research litera*", "research education", "research knowledge", "evidence-based practice education".
Methodological quality:
Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).
Data extraction:
Data were extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI.
Data synthesis:
Quantitative data would have been, if possible, pooled in statistical meta-analysis using the Cochrane Collaboration's Review Manager 5.2 software. As statistical pooling was not possible, the findings are presented in narrative form including tables and figures where appropriate to aid in data presentation.
Results:
The majority of included studies were single-group pre-test/post-test designs (n=7). One was a post-test only two-group comparison and two were two-group quasi-experimental studies. Included studies were conducted in Taiwan, Japan, Hong Kong, Australia, United Kingdom and United States. The total number of registered nurses in the included studies was 453. The educational interventions were conducted in universities (n=6) and healthcare facilities (n=4). Most included studies were published (n=9), with one unpublished study.
Conclusions:
The evidence on educational interventions, while not strong, is indicative of the types of interventions which are likely to be effective. Online or face-to-face interventions using interactive teaching strategies, such as activities, role-play and discussions, and which are underpinned by an appropriate behavioral or education theory, are likely to increase research literacy.
Implications for practice:
IMPLICATIONS FOR RESEARCH: More rigorous experimental studies of educational interventions for nurses' research literacy are warranted, in order to demonstrate the effectiveness of different course and program designs. Future studies should consider longer periods of follow-up to test the longevity of the effect, as education needs to have lasting effects to be beneficial to the recipients.
... 13 Our study suggests that one month of DBP may be insufficient, especially since we know from studies of continuing medical education that lecture formats cannot be relied on to correct deficiencies in resident education and are not successful in changing behavior after residency. 23 Programs vary enormously in the resources available for teaching and the types of experiences to which they expose residents. Some have a single DBP certified faculty member, while others have substantial programs and resources sufficient to support subspecialty fellowships. ...
Objective:
Since 1997 pediatric residencies have been required to provide a 4-week block rotation in developmental and behavioral pediatrics (DBP), but it is not known whether this has altered the care and management of children by practicing pediatricians. To compare the self-reported practice patterns of pediatricians who were trained with 4 or more weeks of DBP to the practice patterns of those who were trained for < 4 weeks.
Methods:
We used self-reported practices from the American Academy of Pediatrics Periodic Survey #85. Pediatricians were asked whether they never, sometimes or usually inquired about and screened for, and whether they treated/managed/co-managed ADHD, depression, anxiety, behavior problems and learning problems. They were also asked about a series of barriers to care. Analyses were weighted to account for low response rates.
Results:
Those with more DBP training were significantly more likely to treat/manage/co-manage depression, anxiety, behavior problems and learning problems, but were still doing so less than one third of the time. There were no differences in the care of patients with ADHD or in screening or inquiring about mental health conditions. Those with more training were more likely to perceive somewhat fewer barriers and to report more specific familiarity with some DSM criteria and some treatment modalities.
Conclusion:
Longer training is associated with more treatment, but significant deficits in self-reported practice remain, leaving much room for additional improvement in the training of clinicians in DBP.
... Various professions include, but are not limited to, physicians, nurses, physical therapists, dietitians, and pharmacists, and various specialties include family health/medicine, community health/medicine, internal medicine, physical medicine and rehabilitation, geriatrics, orthopedics, endocrinology, gynecology, rheumatology, and pediatrics. The most effective educational methods are the ones that are most interactive, such as didactic presentations along with workshops rather than didactic presentations alone, and are more effective when there are multiple interventions, especially occurring over an extended period of time [51]. The most effective educational strategies used multiple interventions, including exchange of printed materials with images, and two-way communications with educators who were respected and knowledgeable health professionals [52]. ...
A previous systematic review on osteoporosis knowledge published showed that only several studies investigated osteoporosis knowledge in health professionals, and it found that their knowledge was not as adequate and sufficient as it should be. Since then, studies published on osteoporosis knowledge among health professionals have also assessed and found that they still do not have adequate and sufficient osteoporosis knowledge. To increase and improve osteoporosis knowledge among health professionals, recommendations in osteoporosis education in the health professions, including the application of the cognitive load theory, online learning, problem-based learning, practical learning, simulation-based learning, interactive learning, and feedback are covered in order to ensure health professionals can have adequate and sufficient osteoporosis knowledge to best prevent and treat individuals with the disease.
... The curriculum is highly interactive, with multiple teaching modalities, supporting a recent Cochrane review highlighting the key components of medical education. 12 The curriculum was feasible and quickly adopted, both important considerations in a busy academic paediatric training programme This study has limitations. Survey data were not paired, limiting the ability to analyse individual participant improvements over time. ...
Background:
Motivational interviewing (MI) is a collaborative, evidence-based, person-centred counselling style for addressing ambivalence about behaviour change. Despite its proven effectiveness, there is little formal instruction of MI in paediatric training programmes.
Methods:
Second-year paediatric residents participated in a 4-hour MI workshop, followed by a 1-hour small group review course and hands-on supervision during their Adolescent Medicine rotation. After the MI workshop, and again after their refresher course, we assessed residents' attitudes and skill with written and online surveys, as well as with a modified Helpful Responses Questionnaire (HRQ).
Results:
Results revealed a statistically significant improvement in residents' confidence in eliciting health behaviour change [t-score(59) = 3.76, p = 0.008]. HRQ scores for all three clinical scenarios improved significantly following the workshop (p < 0.000). Residents most valued the interactive components of the workshop and review course, particularly the practice exercises, videos/video vignettes, feedback and coaching.
Discussion:
A standardised MI curriculum for paediatric residency training improved residents' confidence in eliciting health behaviour change and use of empathic, reflective language. The curriculum is both feasible and widely accepted by residents, with opportunities for residents to practise MI under supervision during resident training. In conclusion, providing a 4-hour MI workshop for paediatric residents, with reinforcement through a review course and clinical opportunities to practise MI under supervision, improved confidence in eliciting health behaviour change and the use of MI-consistent language. This innovative and time-sensitive effort could serve as a future model for MI training for paediatric residents. There is little formal instruction of MI in paediatric training programmes.
... La educación médica tradicional no refleja la mejor evidencia de docencia, por tanto, las técnicas actuales utilizadas necesitan ser mejoradas e innovarse (5) . Hay autores que refieren que la perspectiva y opinión de los médicos residentes es uno de los más importantes recursos para mejorar la calidad del programa ofrecido (6)(7)(8) . ...
In order to rate the medical residency training program from the perceptions of residents, a structured survey, based on international literature, was applied to 228 participants. 48.2% of residents rated their training as “good,” 36.4% as “fair” and 15.4% as “poor”. Most of the residents had low supervision while on call, were overworked and did not have rest after being on call. Having a good annual curriculum (OR: 8.5; 95% CI: 4.1 to 7.4) and university promotion of research (OR 2.4, 95% CI: 1.1 to 5.2) were independent factors associated with higher ratings of training. In conclusion, the rating of residents about their training is mostly good, but this percentage does not exceed 50%. Training authorities could use these results to propose improvements in training programs for medical residents in Peru
... Although the literature is inconclusive as to whether Internet-based CME options are superior to traditionalbased models, multiple studies have shown that this teaching model is effective at positively changing the clinical behaviors of PCPs (Bloom, 2005;Cook et al., 2008;Davis et al., 1999;Fordis et al., 2005;Mansouri & Lockyer, 2007;Satterlee, Eggers, & Grimes, 2008). The use of online resources is also associated with decreased healthcare spending, as one study found a six-fold reduction of inappropriate referrals after the completion of an online curriculum by nondermatologists (Gerbert et al., 2000). ...
Skin disorders account for a significant portion of cases managed by primary care practitioners (PCPs). However, previous studies show that PCPs are inadequately trained for this role and are significantly less effective than board-certified dermatologists with respect to the diagnosis and treatment of cutaneous disorders. This is most concerning in regard to life-threatening skin diseases such as malignant melanomas, which must be correctly diagnosed and treated in a timely manner. Increasing the coverage of cutaneous disorders during medical school and residency would likely improve the proficiency of future PCPs with respect to dermatological disorders. Similarly, practicing PCPs face a shortage of dermatology educational resources that are compatible with their busy schedules. To address this need, novel resources such as Internet-based continuing medical education courses, point-of-care decision support software, and teledermatology are being further developed to promote the delivery of precise and cost-effective healthcare in the primary care setting. In addition, the greater need for dermatology PCPs has been met with a rise in the role of dermatology nurse practitioners.
... Formal CME formats such as conferences, lectures, workshops or educational meetings and distributing educational materials have been identified as ineffective in changing healthcare providers' behaviours [17,19,20,23,25]. Evidence suggests that CME approaches that involve multiple exposures to educational material over time [17,18,26] and a combination of multiple educational techniques are effective in improving physicians' knowledge, attitudes and clinical outcomes [17][18][19][20]24,[26][27][28]. ...
AimsTo perform a systematic review of studies that have assessed the effectiveness of interventions designed to improve healthcare professionals’ care of patients with diabetes and to assess the effects of educational interventions targeted at general practitioners’ diabetes management.MethodsA computer search was conducted using the Cochrane Library, PubMed, Ovid MEDLINE, Scopus, EMBASE, Informit, Google scholar and ERIC from the earliest date of each database up until 2013. A supplementary review of reference lists from each article obtained was also carried out. Measured changes in general practitioners’ satisfaction, knowledge, practice behaviours and patient outcomes were recorded.ResultsThirteen out of 1255 studies met the eligibility criteria, but none was specifically conducted in rural or remote areas. Ten studies were randomized trials. Fewer than half of the studies (5/13, 38.5%) reported a significant improvement in at least one of the following outcome categories: satisfaction with the programme, knowledge and practice behaviour. There was little evidence of the impact of general practitioner educational interventions on patient outcomes. Of the five studies that examined patient outcomes, only one reported a positive impact: a reduction in patient HbA1c levels.Conclusions
Few studies examined the effectiveness of general practitioner Type 2 diabetes education in improving general practitioner satisfaction, knowledge, practices and/or patient outcomes. Evidence to support the effectiveness of education is partial and weak. To determine effective strategies for general practitioner education related to Type 2 diabetes, further well designed studies, accompanied by valid and reliable evaluation methods, are needed.This article is protected by copyright. All rights reserved.
... We know that the most effective medical educational methods are the most interactive ones and when more than one intervention occurs. Effectiveness increases in particular if these interventions are extended over time [22,23]. It would be interesting to know the effect of a mandatory gender medicine programme, which includes the aforementioned educational principles, on GP trainees gender awareness and knowledge. ...
The purpose of this study is to compare the change in general practitioner (GP) trainees’ gender awareness following a modular gender medicine programme or a mainstream gender medicine programme. In 2007, a prospective study was conducted in three cohorts of in total 207 GP trainees who entered GP training in the Netherlands. The outcome measure was the Nijmegen Gender Awareness in Medicine Scale and a 16-item gender knowledge questionnaire. Two gender medicine teaching methods were compared: a modular approach (n = 75) versus a mainstream approach (n = 72). Both strategies were compared with a control cohort (n = 60). Statistical analysis included analysis of variance and t-tests. The overall response rates for the modular, mainstream and control cohort were 78, 72 and 82 %, respectively. There was a significant difference in change in gender knowledge scores between the modular cohort compared with the mainstream and control cohort (p = 0.049). There were no statistical differences between the cohorts on gender sensitivity and gender role ideology. At entry and end, female GP trainees demonstrated significantly higher gender awareness than male GP trainees. A modular teaching method is not a more favourable educational method to teach gender medicine in GP training. Female GP trainees are more gender aware, but male GP trainees are not unaware of gender-related issues.
... Several systemic reviews that compared didactic instruction to a wide variety of teaching approaches also identified didactic instruction as a less effective educational technique [13][14][15]. ...
In-service training represents a significant financial investment for supporting continued competence of the health care workforce. An integrative review of the education and training literature was conducted to identify effective training approaches for health worker continuing professional education (CPE) and what evidence exists of outcomes derived from CPE.
A literature review was conducted from multiple databases including PubMed, the Cochrane Library and Cumulative Index to Nursing and Allied Health Literature (CINAHL) between May and June 2011. The initial review of titles and abstracts produced 244 results. Articles selected for analysis after two quality reviews consisted of systematic reviews, randomized controlled trials (RCTs) and programme evaluations published in peer-reviewed journals from 2000 to 2011 in the English language. The articles analysed included 37 systematic reviews and 32 RCTs. The research questions focused on the evidence supporting educational techniques, frequency, setting and media used to deliver instruction for continuing health professional education.
The evidence suggests the use of multiple techniques that allow for interaction and enable learners to process and apply information. Case-based learning, clinical simulations, practice and feedback are identified as effective educational techniques. Didactic techniques that involve passive instruction, such as reading or lecture, have been found to have little or no impact on learning outcomes. Repetitive interventions, rather than single interventions, were shown to be superior for learning outcomes. Settings similar to the workplace improved skill acquisition and performance. Computer-based learning can be equally or more effective than live instruction and more cost efficient if effective techniques are used. Effective techniques can lead to improvements in knowledge and skill outcomes and clinical practice behaviours, but there is less evidence directly linking CPE to improved clinical outcomes. Very limited quality data are available from low- to middle-income countries.
Educational techniques are critical to learning outcomes. Targeted, repetitive interventions can result in better learning outcomes. Setting should be selected to support relevant and realistic practice and increase efficiency. Media should be selected based on the potential to support effective educational techniques and efficiency of instruction. CPE can lead to improved learning outcomes if effective techniques are used. Limited data indicate that there may also be an effect on improving clinical practice behaviours. The research agenda calls for well-constructed evaluations of culturally appropriate combinations of technique, setting, frequency and media, developed for and tested among all levels of health workers in low- and middle-income countries.
... Recent new insights in effective medical education support this strategy. [23] For our training programme it means that we interrelate and clarify gender issues for health conditions in actual contact with patients (e.g., knowledge, judgement, norms). We try to identify and discuss factors that impede change in behaviour toward gender issues (e.g., gender stereotyped perceptions). ...
... For example, when they learned about Leary's rose as a model for communication in one-on-one teaching, in the next session that model was used to learn more about personality disorders in daily GP practice. The course design was based upon educational standards to maximize the educational effect, using different interactive teaching techniques, workshops, peer groups and role-playing (Steinert et al. 2006;Satterlee 2008). ...
Background:
Integrating continuing medical education (CME) and faculty development (FD) into a single course can save time for physicians with teaching responsibilities. However, little is known about the effectiveness of integrated courses.
Aim:
To determine if there are differences in effectiveness between the CME and FD items as they were integrated in one course.
Methods:
Using the commitment-to-change model to assess plans for change from all participants and reported implementation of plans three month after courses. This model is suitable for stimulating and assessing effectiveness of CME. Unplanned changes were also recorded.
Results:
One hundred and twenty-seven respondents (of 182 participants) referred to 266 planned changes (out of 384), of which 168 (63%) were reported as implemented. Furthermore, 83 non-planned changes were indicated. In total 251 changes were reported and demonstrated that CME as well as FD items were effective.
Conclusions:
This study reveals that integrating CME and FD into a single course is highly effective in changing physicians' medical practice as well as teaching practice. Although all course items were effective, participants choose more FD items than CME, so future research has to focus on which variables determine those choices.
... Elsewhere, it has been reported that the most effective educational methods were the most interactive. 21 Electronic Voting Systems may help in this regard, as they are used for education in a variety of disciplines and claim to encourage student participation in lectures. However, Duggan et al 22 did not find that the use of electronic voting system technology in large group lectures offered significant advantages over the more conventional lecture format. ...
To identify medical students' perceptions of their learning strategies including, learning habits, resources, and preferred teaching methods, in the Department of Surgery (DOS) of the King Abdulaziz University-Faculty of Medicine (KAU-FoM), in Jeddah, Saudi Arabia.
A cross-sectional descriptive study which was designed to identify students' perceptions of their learning in the DOS of the KAU-FoM. A questionnaire was administered to a random group of 549 medical students, to explore student perceptions of their learning strategies including methods of learning and learning resources.
The majority believed that clinical session attendance is always important compared with lectures (88.9% vs 21.9%). Nevertheless, clinical sessions were selected as the third source of learning after learning from assigned textbooks and previous examination model answers. The majority (74.1%) believed that self-instruction at home is the preferred method of learning.
Student perspectives should be taken into consideration prior to any future reforms of curriculum. Reforms should adopt a "think globally; act locally" educational strategy based on learner needs.
... The effectiveness of CME at changing provider performance has recently been called into question (Davis et al., 1999). A systematic review of the effects of different approaches to medical education has recently been completed by the Cochrane Collaboration and synthesized by others; traditional didactic lectures were found to be less effective than those supplemented by participant interactions (Marinopoulos et al., 2007;Satterlee, Eggers, & Grimes, 2008). The dissemination effort for The Heart Truth Professional Education Campaign completed in these three states also included several of these additional strategies, such as problembased learning cases, standardized interviews, problem-based learning cases for medical students, and interactive training in brief motivational interventions. ...
Background:
The Heart Truth Professional Education Campaign was developed to facilitate education of health care providers in evidence-based strategies to prevent cardiovascular disease (CVD) in women.
Methods:
As part of the 3-year campaign, lectures based on the American Heart Association's evidence-based guidelines for CVD prevention in women were presented by local speakers to healthcare providers and students in three high-risk states: Delaware, Ohio, and New York. Participants' responses to pretest and posttest questions about CVD in women are presented. We performed t-test and multivariable linear regression to assess the influence of provider characteristics on baseline knowledge and knowledge change after the lecture.
Results:
Between 2008 and 2011, 2,995 healthcare providers, students, and other participants completed the baseline assessment. Knowledge scores at baseline were highest for physicians, with obstetrician/gynecologists scoring lowest (63%) and cardiologists highest (76%). Nurses had intermediate total knowledge (56%) and students had the lowest total knowledge (49%) at baseline. Pre- and post-lecture assessments were completed by 1,893 (63%) of attendees. Scores were significantly higher after the educational lecture (p ≤ .001), with greater increase for those with lower baseline scores. Baseline knowledge of the use of statins, hormone therapy, and antioxidants, as well as approaches to smoking cessation and treatment of hypertension, differed by provider type.
Conclusion:
Tailoring of lectures for non-physician audiences may be beneficial given differences in baseline knowledge. More emphasis is needed on statin use for all providers and on smoking cessation and treatment of hypertension for nurses, students, and other healthcare professionals.
... This identified effective strategies for implementation of guidelines, including establishing small group education sessions with patients, clinician prompts and decision aids, audit and feedback, and external facilitation [21]. Educational interventions that are interactive, provided feedback to participants, include an objective assessment of education needs and involve small groups are more likely to be effective [22,23]. Small group interventions are most effective because they combine evidence-based material with peer influ- ence [24] . ...
Background
There are significant gaps in the implementation and uptake of evidence-based guideline recommendations for cardiovascular disease (CVD) and diabetes in Australian general practice. This study protocol describes the methodology for a cluster randomised trial to evaluate the effectiveness of a model that aims to improve the implementation of these guidelines in Australian general practice developed by a collaboration between researchers, non-government organisations, and the profession.
Methods
We hypothesise that the intervention will alter the behaviour of clinicians and patients resulting in improvements of recording of lifestyle and physiological risk factors (by 20%) and increased adherence to guideline recommendations for: the management of CVD and diabetes risk factors (by 20%); and lifestyle and physiological risk factors of patients at risk (by 5%). Thirty-two general practices will be randomised in a 1:1 allocation to receive either the intervention or continue with usual care, after stratification by state. The intervention will be delivered through: small group education; audit of patient records to determine preventive care; and practice facilitation visits adapted to the needs of the practices. Outcome data will be extracted from electronic medical records and patient questionnaires, and qualitative evaluation from provider and patient interviews.
Discussion
We plan to disseminate study findings widely and directly inform implementation strategies by governments, professional bodies, and non-government organisations including the partner organisations.
No one doubts the significant variation in the practice of transfusion medicine. Common examples are the variability in transfusion thresholds and the use of tranexamic acid for surgery with likely high blood loss despite evidence‐based standards. There is a long history of applying different strategies to address this variation, including education, clinical guidelines, audit and feedback, but the effectiveness and cost‐effectiveness of these initiatives remains unclear. Advances in computerised decision support systems and the application of novel electronic capabilities offer alternative approaches to improving transfusion practice. In England, the National Institute for Health and Care Research funded a Blood and Transplant Research Unit (BTRU) programme focussing on ‘A data‐enabled programme of research to improve transfusion practices’. The overarching aim of the BTRU is to accelerate the development of data‐driven methods to optimise the use of blood and transfusion alternatives, and to integrate them within routine practice to improve patient outcomes. One particular area of focus is implementation science to address variation in practice.
Background: Many primary care providers (PCPs) in the Veterans Health Administration need updated clinical training in women's health. The objective was to design, implement, and evaluate a training program to increase participants' comfort with and provision of care to women Veterans, and foster practice changes in women's health care at their local institutions. Methods: The Women's Health Mini-Residency was developed as a multi-day training program, based on principles of adult learning, wherein knowledge gleaned through didactic presentations was solidified during small-group case study discussions and further enhanced by hands-on training and creation of a facility-specific action plan to improve women Veterans' care. Pre, post, and 6-month surveys assessed attendees' comfort with and provision of care to women. The 6-month survey also queried changes in practice, promulgation of program content, and action plan progress. Results: From 2008 to 2019, 2912 PCPs attended 26 programs. A total of 2423 (83.2%) completed pretraining and 2324 (79.3%) completed post-training surveys. The 6-month survey was sent to the 645 attendees from the first 14 programs; 297 (46.1%) responded. Comparison of pre-post responses indicated significant gains in comfort managing all 19 content areas. Six-month data showed some degradation, but comfort remained significantly improved from baseline. At 6 months, participants also reported increases in providing care to women, including performing more breast and pelvic examinations, dissemination of program content to colleagues, and progress on action plans. Conclusions: This interactive program appears to have been successful in improving PCPs' comfort in providing care for women Veterans and empowering them to implement institutional change.
Objectives
This national study identified the rotations in which pediatric residents received training in the assessment and treatment of behavioral/mental health (B/MH) problems, and examined associations between learning B/MH skills during multiple clinical rotations and resident-reported interest in B/MH issues.
Methods
Cross-sectional survey of applicants for the initial American Board of Pediatrics certifying exam (62.4% response rate; 1555 eligible respondents). Respondents reported their overall interest in B/MH issues, and specified where they had received training in 7 B/MH assessment skills and 8 treatment skills. Logistic regression models were estimated to identify associations between learning B/MH assessment and treatment skills in multiple clinical rotations and resident-reported B/MH interest, adjusting for respondent characteristics.
Results
Respondents reported continuity clinic as the predominant site of B/MH learning, followed by development-behavioral and adolescent rotations. Multi-site learning varied across B/MH skills, ranging from 45.1 % (n=678) for using rating scales to titrate medications to 82.1% (n=1234) for eliciting parent concerns. 946 (63.2%) reported having overall interest in B/MH issues. Adjusting for respondent characteristics, learning the majority of B/MH skills in >1 rotation was associated with an increased odds of B/MH interest for both assessment and treatment domains (aOR=1.46, 95% CI 1.16-1.83 for assessment skills and aOR=1.36, 95% CI 1.09-1.69 for treatment skills).
Conclusions
The majority of residents report learning B/MH skills in continuity clinic, with substantial variation in the proportion learning these skills in more than one rotation. Teaching B/MH skills during multiple clinical rotations may enhance resident interest in B/MH care delivery for children.
https://kce.fgov.be/en/impact-of-academic-detailing-on-primary-care-physicians
https://kce.fgov.be/en/a-first-step-towards-measuring-the-performance-of-the-belgian-healthcare-system
Introduction:
With increasing electronic health record (EHR) use, providers are talking less with one another. Now, many rely on EHRs, informal emails, or texts, introducing fragmentation and new data security challenges with new communication strategies. We aimed to examine the impact of a physician champion educational outreach intervention to promote electronic provider-to-provider communication in a large academic multispecialty group.
Methods:
Physician champions provided educational outreach to 16 academic departments, using 10-minute case-based presentations. Online surveys assessed communication preferences and practices. Electronic health record queries counted EHR messaging use before and after intervention. Descriptive statistics compared responses by specialty (z-test). Paired responses with pre-post data were compared using chi-square tests. Time series analysis assessed EHR messaging rates before intervention versus after intervention.
Results:
Five hundred seventeen providers responded to the postoutreach survey. Eighty-six percent were familiar with EHR messaging tool and 78% knew how to use it after intervention. Among practitioner groups, Family Medicine preferred EHR messaging the most (62%). Groups who declined outreach least preferred it (26%). Among 88 respondents with paired pre-post intervention surveys, familiarity rose (79-96%), and self-reported use increased (66-88%).
Conclusions:
Physician champion educational outreach increased the use of the secure provider-to-provider EHR messaging tool.
Continuing education (CE) that strives to improve patient care in a complex health care system requires a different paradigm than CE that seeks to improve clinician knowledge and competence in an educational setting. A new paradigm for CE is necessary in order to change clinician behavior and to improve patient outcomes in an increasingly patient-centered, quality-oriented care context. The authors assert that a new paradigm should focus attention on an expanded and prioritized list of educational outcomes, starting with those that directly affect patients. Other important components of the paradigm should provide educational leaders with guidance about what interventions work, reasons why interventions work, and what contextual factors may influence the impact of interventions. Once fully developed, a new paradigm will be helpful to educators in designing and implementing more effective CE, an essential component of quality improvement efforts, and in supporting policy trends and in promoting CE scholarship. The purpose of this article is to rekindle interest in CE theory and to suggest key components of a new paradigm.
Objectives:
The objective of this study was to evaluate the impact of an educational intervention on ED discharge opioid analgesic (OA) prescribing.
Methods:
A brief, one-on-one, educational intervention was delivered to ED OA prescribers by an ED clinical champion. The percentage of patients receiving (i) written advice regarding appropriate oxycodone use, (ii) written or verbal advice regarding appropriate post-discharge follow up and (iii) written general practitioner notification that oxycodone had been prescribed were determined pre- and post-intervention, through review of electronic patient records and structured patient telephone interviews conducted 3-7 days after ED attendance. Secondary outcomes included total amount prescribed and use of non-OA therapies. ED OA prescribers were surveyed to evaluate perceived effectiveness and intervention acceptability.
Results:
A total of 30 ED OA prescribers received the 5-min intervention. Pre- and post-intervention, 80 and 81 patients were interviewed, respectively. Percentage of patients given written OA information increased from 10% to 22% (P = 0.04) and those receiving follow-up advice increased from 61 to 94% (P < 0.01). General practitioner notification of OA prescription increased from 15% to 88% (P < 0.01). Risk ratio for achieving all three end-points was 7.5 (95% confidence interval 1.8-32, P = 0.01). Median total amount of oxycodone prescribed/patient decreased from 100mg to 50mg (P = 0.04). Non-OA therapies were used by 49% of pre-intervention and 85% of post-intervention patients (P = <0.01). All ED OA prescribers agreed the intervention would change their prescribing practices; 70% deemed the intervention appropriate for delivery in their work environment.
Conclusion:
A brief, one-on-one educational intervention targeting ED OA prescribers was well received by clinicians and associated with improved quality of OA prescribing.
Background.:
Motivational interviewing (MI) is an effective tool to help clinicians with facilitating behavioural changes in many diseases and conditions. However, different forms of MI are required in different health care settings and for different clinicians. Although general practitioners (GPs) play a major role in Type 2 diabetes management, the effects of MI delivered by GPs intended to change the behaviours of their Type 2 diabetes patients and GP outcomes, defined as GP knowledge, satisfaction and practice behaviours, have not been systematically reviewed.
Methods.:
An electronic search was conducted through Cochrane Library, Scopus, ProQuest, Wiley Online Library, Ovid MEDLINE, PubMed, CINAHL, MEDLINE Complete and Google Scholar from the earliest date of each database to 2017. Reference lists from each article obtained were reviewed. Measured changes in GP satisfaction, knowledge, and practice behaviours, and patient outcomes were recorded.
Results.:
Eight out of 1882 studies met the criteria for inclusion. Six studies examined the effects of MI on Type 2 diabetes patient outcomes, only one of which examined its effects on GP outcomes. Two-thirds of the studies (4/6) found a significant improvement in at least one of the following patient outcomes: total cholesterol, low-density lipoproteins, fasting blood glucose, HbA1c, body mass index, blood pressure, waist circumference and physical activity. The effects of MI on GP outcomes yielded mixed results.
Conclusions.:
Few studies have examined evidence for the effectiveness of MI delivered by GPs to Type 2 diabetes patients. Evidence to support the effectiveness of MI on GP and patient outcomes is weak. Further quality studies are needed to examine the effects of MI on GP and patient outcomes.
In order to rate the medical residency training program from the perceptions of residents, a structured survey, based on international literature, was applied to 228 participants. 48.2% of residents rated their training as good, 36.4% as fair and 15.4% as poor. Most of the residents had low supervision while on call, were overworked and did not have rest after being on call. Having a good annual curriculum (OR: 8.5; 95% CI: 4.1 to 7.4) and university promotion of research (OR 2.4, 95% CI: 1.1 to 5.2) were independent factors associated with higher ratings of training. In conclusion, the rating of residents about their training is mostly good, but this percentage does not exceed 50%. Training authorities could use these results to propose improvements in training programs for medical residents in Peru.
The number of Americans aged 65 and older is projected to increase from 35 to 88.5 million in the first half of the 21st century. However, there is a serious gap between the number of health care and social service practitioners needed to work with the aging and the number available and trained to do so. We review current research on what works in engaging students in geriatric and gerontological work. We then present three projects from the Weinberg Caregiver Initiative as illustrations of innovative caregiver programming building on community-based partnerships which successfully incorporate aspects of best practices in gerontological education to increase student interest in work with the aging populations, while serving older adults and their caregivers.
To determine the characteristics of curricula for teaching the content of clinical practice guidelines (CPGs) in psychiatric residency and child and adolescent fellowship programs as well as to determine if and how the learning of CPG content is applied in clinical care settings.
We conducted a national online survey of directors of general psychiatry residency and child and adolescent fellowship programs in the USA. The survey questionnaire included 13 brief questions about the characteristics used to teach CPGs in the programs, as well as two demographic questions about each program and director. Descriptive statistics were reported for each questionnaire item by program classification (i.e., child and adolescent vs. general psychiatry).
The survey response rate was 49.8 % (146 out of 293). Just 23 % of programs reported having written goals and objectives related to teaching CPGs. The most frequently taught aspect of CPGs was their content (72 % of programs). Didactic sessions were the most frequently employed teaching strategy (79 % of programs). Regarding the application of CPG learning in treatment care settings, just 16 % of programs applied algorithms in care settings, and 15 % performed evaluations to determine consistency between CPG recommendations and care delivery. Only 8 % of programs utilized audit and feedback to residents about their adherence to CPGs. Faculty time constraints and insufficient interest were the leading barriers (39 % and 33 % of programs, respectively) to CPG teaching, although 38 % reported no barriers. However, child and adolescent programs less commonly identified insufficient interest among faculty as a barrier to teaching CPGs compared to general programs (20 % vs. 43 %). Moreover, compared to general programs, child and adolescent fellowship programs taught more aspects of CPGs, used more educational activities to teach the content of specific CPGs, and used more methods to evaluate the teaching of CPGs.
Although the majority of programs provided some teaching of CPGs, the rigorousness of the teaching approaches was limited, especially attempts to evaluate the extent and effectiveness of their use in clinical care. Child and adolescent fellowship programs provided more extensive teaching and evaluation related to CPGs.
Background:
The patient-centered medical home is a model for delivering primary care in the United States. Primary care clinicians and their staffs require assistance in understanding the innovation and in applying it to practice.
Purposes:
The purpose of this article is to describe and to critique a continuing education program that is relevant to, and will become more common in, primary care.
Methods:
A multifaceted educational strategy prepared 20 primary care private practices to achieve National Committee for Quality Assurance Level 3 recognition as Patient-Centered Medical Homes.
Results:
Eighteen (90%) practices submitted an application to the National Committee for Quality Assurance. On the first submission attempt, 13 of 18 (72%) achieved Level 3 recognition and 5 (28%) achieved Level 1 recognition.
Conclusion:
An interactive multifaceted educational strategy can be successful in preparing primary care practices for Patient-Centered Medical Homes recognition, but the strategy may not ensure transformation. Future educational activities should consider an expanded outcomes framework and the evidence of effective continuing education to be more successful with recognition and transformation.
Education is a cornerstone of antimicrobial stewardships programs, because 50% of inappropriate antimicrobial prescriptions are a consequence of an imbalance between the high levels of knowledge required for the appropriate use of antibiotics and the scarce training offered to medical specialists. For this reason, programs optimizing antimicrobial (PROA) are essentially based on support and educational activities for prescribers. The educational activities are difficult to evaluate. In our country, the application of educational activities in antimicrobial training programs is very heterogeneous, although it has improved in recent years. We recommend the following educational measures, which are prioritized in order of effectiveness. Interactive educational interventions are the most effective. These are non-compulsory interventions based on real prescriptions in clinical practice and include educational outreach visits, audits and counseling interviews with feedback and multifaceted interventions. Passive educational strategies, with posters, newsletters, and dissemination of guidelines, are only marginally effective in changing antimicrobial prescribing practices and have not shown a sustained effect. These measures need extensive professional involvement and should be combined with more active approaches. Currently, interventions can be enhanced with some teaching tools in electronic format. Both interactive and passive educational measures should be integrated into the PROA and should have institutional support. Finally, we recommend including antimicrobials in the training plans of all clinical specialties.
Racial and ethnic disparities in the United States exist along the entire continuum of mental health care, from access and use of services to the quality and outcomes of care. Efforts to address these inequities in mental health care have focused on adapting evidence-based treatments to clients' diverse cultural backgrounds. Yet, like many evidence-based treatments, culturally adapted interventions remain largely unused in usual care settings. We propose that a viable avenue to address this critical question is to create a dialogue between the fields of implementation science and cultural adaptation. In this paper, we discuss how integrating these two fields can make significant contributions to reducing racial and ethnic disparities in mental health care.
The use of cultural adaptation models in implementation science can deepen the explicit attention to culture, particularly at the client and provider levels, in implementation studies making evidence-based treatments more responsive to the needs and preferences of diverse populations. The integration of both fields can help clarify and specify what to adapt in order to achieve optimal balance between adaptation and fidelity, and address important implementation outcomes (e.g., acceptability, appropriateness). A dialogue between both fields can help clarify the knowledge, skills and roles of who should facilitate the process of implementation, particularly when cultural adaptations are needed. The ecological perspective of implementation science provides an expanded lens to examine how contextual factors impact how treatments (adapted or not) are ultimately used and sustained in usual care settings. Integrating both fields can also help specify when in the implementation process adaptations may be considered in order to enhance the adoption and sustainability of evidence-based treatments.
Implementation science and cultural adaptation bring valuable insights and methods to how and to what extent treatments and/or context should be customized to enhance the implementation of evidence-based treatments across settings and populations. Developing a two-way street between these two fields can provide a better avenue for moving the best available treatments into practice and for helping to reduce racial and ethnic disparities in mental health care.
Context Although physicians report spending a considerable amount of time in
continuing medical education (CME) activities, studies have shown a sizable
difference between real and ideal performance, suggesting a lack of effect
of formal CME.Objective To review, collate, and interpret the effect of formal CME interventions
on physician performance and health care outcomes.Data Sources Sources included searches of the complete Research and Development Resource
Base in Continuing Medical Education and the Specialised Register of the Cochrane
Effective Practice and Organisation of Care Group, supplemented by searches
of MEDLINE from 1993 to January 1999.Study Selection Studies were included in the analyses if they were randomized controlled
trials of formal didactic and/or interactive CME interventions (conferences,
courses, rounds, meetings, symposia, lectures, and other formats) in which
at least 50% of the participants were practicing physicians. Fourteen of 64
studies identified met these criteria and were included in the analyses. Articles
were reviewed independently by 3 of the authors.Data Extraction Determinations were made about the nature of the CME intervention (didactic,
interactive, or mixed), its occurrence as a 1-time or sequenced event, and
other information about its educational content and format. Two of 3 reviewers
independently applied all inclusion/exclusion criteria. Data were then subjected
to meta-analytic techniques.Data Synthesis The 14 studies generated 17 interventions fitting our criteria. Nine
generated positive changes in professional practice, and 3 of 4 interventions
altered health care outcomes in 1 or more measures. In 7 studies, sufficient
data were available for effect sizes to be calculated; overall, no significant
effect of these educational methods was detected (standardized effect size,
0.34; 95% confidence interval [CI], −0.22 to 0.97). However, interactive
and mixed educational sessions were associated with a significant effect on
practice (standardized effect size, 0.67; 95% CI, 0.01-1.45).Conclusions Our data show some evidence that interactive CME sessions that enhance
participant activity and provide the opportunity to practice skills can effect
change in professional practice and, on occasion, health care outcomes. Based
on a small number of well-conducted trials, didactic sessions do not appear
to be effective in changing physician performance.
It has long been recognized that investigators frequently fail to report their research findings (Dickersin, 1990). Chalmers (1990) has suggested that this failure represents scientific misconduct since volunteers who consent to participate in research, and agencies that provide funding support for investigations, do so with the understanding that the work will make a contribution to knowledge. Clearly, knowledge that is not disseminated is not making a "contribution". This failure to publish is not only inappropriate scientific conduct, it also influences the information available for interpretation by the scientific community. Of course, if research is left randomly unpublished, there is less information available, but that information is unbiased. We now have solid evidence that failure to publish is not a random event; rather, publication is dramatically influenced by the direction and strength of research findings (Dickersin et al., 1987, 1992; Dickersin & Min, 1993; Easterbrook et al., 1991; Simes, 1986). This tendency of editors and reviewers to accept manuscripts submitted by investigators based on the strength and direction of the research findings is termed "publication bias". The problem has been under discussion for many years and has recently been studied directly in medicine and public health. This article will review the major evidence available regarding publication bias and will suggest measures for overcoming the problem.
To determine whether reminder cards in medical records enhance the effectiveness of audit with feedback in improving the care of patients taking long term benzodiazepine drugs.
Randomised trial, practices receiving feedback only in one group and practices receiving feedback plus reminder cards in the other group.
18 general practices in Leicestershire.
Random samples of patients who had been taking a benzodiazepine anxiolytic or hypnotic drug for four weeks or longer.
Entries in medical records indicating compliance with five criteria of care: assessment of suitability for withdrawal; being told about dependency; withdrawal being recommended; withdrawal or continuing medication; and a consultation with the general practitioner in the past year. Data were collected before and after feedback or feedback plus reminders.
Of a total population of 125,846 registered with the 18 practices, 2409 (1.9%) had been taking a benzodiazepine for four weeks or longer. Of the 742 in the first samples, 543 (73.2%) were women, the mean (SD) age was 68.7 (14.9) years, and they had been taking a benzodiazepine for 10.1 (6.7) years. The number of patients whose care complied with the criteria rose after the interventions to implement change. The increase was greater in practices receiving feedback plus reminders for only two of the five criteria "told about dependency" increasing from 52 (11.1%) to 118 (25.8%) in the feedback only group, and from 27 (10.5%) to 184 (43.0%) in the feedback plus reminders group; odds ratio (OR) 1.46 (95% confidence interval (95% CI) 1.32 to 5.21); and "consulted in the past year" increasing from 434 (93.1%) to 411 (95.8%) in the feedback only group and 255 (96.6%) to 400 (99.8%) in the feedback plus reminders group, OR (95% CI) 13.5 (2.01 to 330.3).
Reminder cards had only a limited effect and cannot be recommended for routine use. There were improvements in the care of patients of both groups of practices and further studies are indicated to determine the impact of both systematically developed criteria and reminders embedded into restructured medical records.
Although physicians report spending a considerable amount of time in continuing medical education (CME) activities, studies have shown a sizable difference between real and ideal performance, suggesting a lack of effect of formal CME.
To review, collate, and interpret the effect of formal CME interventions on physician performance and health care outcomes.
Sources included searches of the complete Research and Development Resource Base in Continuing Medical Education and the Specialised Register of the Cochrane Effective Practice and Organisation of Care Group, supplemented by searches of MEDLINE from 1993 to January 1999.
Studies were included in the analyses if they were randomized controlled trials of formal didactic and/or interactive CME interventions (conferences, courses, rounds, meetings, symposia, lectures, and other formats) in which at least 50% of the participants were practicing physicians. Fourteen of 64 studies identified met these criteria and were included in the analyses. Articles were reviewed independently by 3 of the authors.
Determinations were made about the nature of the CME intervention (didactic, interactive, or mixed), its occurrence as a 1-time or sequenced event, and other information about its educational content and format. Two of 3 reviewers independently applied all inclusion/exclusion criteria. Data were then subjected to meta-analytic techniques.
The 14 studies generated 17 interventions fitting our criteria. Nine generated positive changes in professional practice, and 3 of 4 interventions altered health care outcomes in 1 or more measures. In 7 studies, sufficient data were available for effect sizes to be calculated; overall, no significant effect of these educational methods was detected (standardized effect size, 0.34; 95% confidence interval [CI], -0.22 to 0.97). However, interactive and mixed educational sessions were associated with a significant effect on practice (standardized effect size, 0.67; 95% CI, 0.01-1.45).
Our data show some evidence that interactive CME sessions that enhance participant activity and provide the opportunity to practice skills can effect change in professional practice and, on occasion, health care outcomes. Based on a small number of well-conducted trials, didactic sessions do not appear to be effective in changing physician performance.
A core activity of evidence-based practice is the search for and appraisal of evidence on specific clinical issues. Clinicians vary in their competence in this process; we therefore developed a 16-item checklist for quality of content (relevance and validity) and presentation (useability, attribution, currency and contact details). This was applied to a set of 55 consecutive appraisals conducted by clinicians and posted at a web-based medical journal club site.
Questions were well formulated in 51/55 (92%) of the appraisals. However, 22% of appraisals missed the most relevant articles to answer the clinical question. Validity of articles was well appraised, with methodological information and data accurately extracted in 84% and accurate conversion to clinically meaningful summary statistics in 87%. The appraisals were presented in a useable way with appropriate and clear bottom-lines stated in 95%.
The weakest link in production of good-quality critical appraisals was identification of relevant articles. This should be a focus for evidence-based medicine and critical appraisal skills.
Our primary objective in this study was to measure family physicians' knowledge of the key elements that go into assessing the validity and interpreting the results in three different types of studies: i) a randomized controlled trial (RCT); ii) a study evaluating a diagnostic test; and iii) a systematic review (SR). Our secondary objectives were to determine the relationship between the above skills and age, gender, and type of practice.
We obtained a random sample of 1000 family physicians in Ontario from the College of Family Physicians of Canada database. These physicians were sent a questionnaire in the mail with follow-up mailings to non-responders at 3 and 8 weeks. The questionnaire was designed to measure knowledge and understanding of the basic concepts of critical appraisal skills. Based on the responses to the questions an Evidence Based Medicine (EBM) Knowledge Score was determined for each physician.
A response rate of 30.2% was achieved. The respondents were younger and more likely to be recent graduates than the population of Ontario Family Physicians as a whole. This was an expected outcome. Just over 50% of respondents were able to answer questions concerning the critical appraisal of methods and the interpretation of results of research articles satisfactorily. The average score on the 12-point EBM Knowledge Scale was 6.4. The younger physicians scored higher than the older physicians, and academic physicians scored higher than community-based physicians. Scores of male and female physicians did not differ.
We have shown that in a population of physicians which is younger than the general population of physicians, about 50% have reasonable knowledge regarding the critical appraisal of the methods and the interpretation of results of a research article. In general, younger physicians were more knowledgeable than were older physicians. EBM principles were felt to be important to the practice of medicine by 95% of respondents.
Some strategies to change the practice or behaviour of health care professionals are successful in improving health care while others are not. One explanation may be that there are different barriers to change in different settings and at different times. Change may be more likely if the strategies are specifically chosen to address the identified barriers. Barriers could be related to the individual (e.g. uncertainty about the risks of a procedure); related to social issues (e.g. peer pressure to perform a certain way); or related to the organisation (e.g. no access to equipment). And to successfully change behaviour, barriers should be identified and a strategy developed to overcome those barriers. In other words, it is thought that strategies tailored to overcome barriers should be more effective to change behaviour than non-tailored strategies or no strategy at all. Fifteen studies evaluated tailored strategies for behaviour change in health care professionals. The results were mixed. It is therefore, unclear whether tailored strategies are more effective than non-tailored strategies or no strategy. Due to a small number of studies, it is also not possible to determine whether strategies tailored to overcome organisational barriers are more effective than those that were not. It is also not clear whether all barriers or important barriers were identified and addressed by the strategies. More research about how to identify and overcome barriers is needed.
It's about integrating individual clinical expertise and the best external evidenceEvidence based medicine, whose philosophical origins extend back to mid-19th century Paris and earlier, remains a hot topic for clinicians, public health practitioners, purchasers, planners, and the public. There are now frequent workshops in how to practice and teach it (one sponsored by the BMJ will be held in London on 24 April); undergraduate1 and postgraduate2 training programmes are incorporating it3 (or pondering how to do so); British centres for evidence based practice have been established or planned in adult medicine, child health, surgery, pathology, pharmacotherapy, nursing, general practice, and dentistry; the Cochrane Collaboration and Britain's Centre for Review and Dissemination in York are providing systematic reviews of the effects of health care; new evidence based practice journals are being launched; and it has become a common topic in the lay media. But enthusiasm has been mixed with some negative reaction.4 5 6 Criticism has ranged from evidence based medicine being old hat to it being a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom. As evidence based medicine continues to evolve and adapt, now is a useful time to refine the discussion of what it is and what it is not.Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The …
BACKGROUND: Critical appraisal is the process of assessing and interpreting evidence by systematically considering its validity, results and relevance to an individual's work. Within the last decade critical appraisal has been added as a topic to many medical school and UK Royal College curricula, and several continuing professional development ventures have been funded to provide further training. OBJECTIVES: To assess the effects of teaching critical appraisal skills to health professionals, on the process of care, patient outcomes and knowledge of health professionals. SEARCH STRATEGY: We searched The Cochrane Library (to Issue 2 2000), MEDLINE (1966 to 1997), EMBASE (1980 to 1997), Eric (1966 to 1997), Cinahl (1982 to 1997), Lisa (1976 to 1997), Sigle (1980 to 1997), Science Citation Index (1981 to 1997), PsycLit (1974 to 1997), the world-wide-web, and reference lists of articles. We also contacted major medical education centres. SELECTION CRITERIA: Randomised trials, controlled clinical trials, controlled before and after studies and interrupted time series analyses of educational interventions teaching critical appraisal to health professionals. The outcomes were: process of care; patient mortality, quality of life, and satisfaction; and health professional knowledge/awareness based upon objective, standardised, validated instruments. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and three reviewers independently assessed study quality. MAIN RESULTS: One USA hospital-based randomised trial was included involving 44 doctors. The outcome assessed was critical appraisal knowledge. Process of care, patient health or attitude/awareness outcomes were not assessed. Critical appraisal teaching was reported to have resulted in a 25% improvement (adjusted figure) in critical appraisal knowledge in the intervention group compared to a 6% improvement in the control group, which was statistically significant (p=0.02). REVIEWER'S CONCLUSIONS: There is evidence that critical appraisal teaching has positive effects on participants' knowledge, but as only one study met the inclusion criteria the validity of drawing general conclusions about the effects of teaching critical appraisal is debatable. There are large gaps in the evidence as to whether teaching critical appraisal impacts on decision-making or patient outcomes. It is also unclear whether the size of benefit seen is large enough to be of practical significance, or whether this varies according to participant background or teaching method. The evidence supporting all outcomes is weakened by the generally poorly designed, executed and reported studies that we found.
BACKGROUND. Increasing recognition of the failure to translate research findings into practice has led to greater awareness of the importance of using active dissemination and implementation strategies. Although there is a growing body of research evidence about the effectiveness of different strategies, this is not easily accessible to policy makers and professionals. OBJECTIVES. To identify, appraise, and synthesize systematic reviews of professional educational or quality assurance interventions to improve quality of care. RESEARCH DESIGN. An overview was made of systematic reviews of professional behavior change interventions published between 1966 and 1998. RESULTS. Forty-one reviews were identified covering a wide range of interventions and behaviors. In general, passive approaches are generally ineffective and unlikely to result in behavior change. Most other interventions are effective under some circumstances; none are effective under all circumstances. Promising approaches include educational outreach (for prescribing), and reminders. Multifaceted interventions targeting different barriers to change are more likely to be effective than single interventions. CONCLUSIONS. Although the current evidence base is incomplete, it provides valuable insights into the likely effectiveness of different interventions. Future quality improvement or educational activities should be informed by the findings of systematic reviews of professional behavior change interventions.
WHERE SHOULD a physician look to find accurate, up-to-date information about the effectiveness of a variety of clinical interventions? At the bedside or in the office, physicians should have instantaneous, up-to-date assistance from an affordable, universally available database of systematic reviews of the best evidence from clinical trials. Unfortunately, the physician who tries to seek the best evidence is often thwarted. Textbooks and reviews are often unreliable and years out of date.1 The searcher may find the MEDLINE database, surely one of the greatest achievements of US medicine, daunting and incomplete. Although well over 1 million clinical trials have been conducted, hundreds of thousands remain
See also pp 1942 and 1962. unpublished or are hard to find and may be in various languages. In the unlikely event that the physician finds all the relevant trials of a treatment, these are rarely accompanied by any comprehensive systematic review attempting to
Knowledge-translation (KT) activities, including continuing education, should be informed by the totality of available research evidence. Systematic reviews are a generic methodology used to synthesize evidence from a broad range of research methods addressing different questions. Over the past decade, there has been a dramatic increase in the availability of systematic reviews that could support KT activities. However, the conduct of systematic reviews is technically challenging, and it is not surprising that the quality of available reviews is variable. In addition, unless attempts are made to update systematic reviews, they rapidly become out of date. The Cochrane Collaboration is a unique, worldwide, not-for-profit organization that aims to help people make well-informed decisions about all forms of health care by preparing, maintaining, and promoting the accessibility of systematic reviews of the effects of health care interventions. Globally, over 13, 000 consumers, clinicians, policymakers, and researchers are involved with The Cochrane Collaboration and have to date produced over 2, 500 systematic reviews that can be used to inform KT activities. The Cochrane Collaboration publishes its reviews quarterly in The Cochrane Library. Cochrane reviews have been used to develop a number of KT-derivative products for professionals, consumers, and policymakers. Whereas most Cochrane Review groups focus on specific clinical areas, the Cochrane Effective Practice and Organisation of Care Group undertakes reviews of interventions to improve health care delivery and health care systems, including reviews of different KT activities. We summarize the activities of The Cochrane Collaboration and how these can contribute to KT activities.
Introduction:
We undertook a meta-analysis of the Continuing Medical Education (CME) outcome literature to examine the effect of moderator variables on physician knowledge, performance, and patient outcomes.
Methods:
A literature search of MEDLINE and ERIC was conducted for randomized controlled trials and experimental design studies of CME outcomes in which physicians were a major group. CME moderator variables included the types of intervention, the types and number of participants, time, and the number of intervention sessions held over time.
Results:
Thirty-one studies met the eligibility criteria, generating 61 interventions. The overall sample-size weighted effect size for all 61 interventions was r = 0.28 (0.18). The analysis of CME moderator variables showed that active and mixed methods had medium effect sizes (r = 0.33 [0.33], r = 0.33 [0.26], respectively), and passive methods had a small effect size (r = 0.20 [0.16], confidence interval 0.15, 0.26). There was a positive correlation between the effect size and the length of the interventions (r = 0.33) and between multiple interventions over time (r = 0.36). There was a negative correlation between the effect size and programs that involved multiple disciplines (r = -0.18) and the number of participants (r = -0.13). The correlation between the effect size and the length of time for outcome assessment was negative (r = -0.31).
Discussion:
The meta-analysis suggests that the effect size of CME on physician knowledge is a medium one; however, the effect size is small for physician performance and patient outcome. The examination of moderator variables shows there is a larger effect size when the interventions are interactive, use multiple methods, and are designed for a small group of physicians from a single discipline.
Critical appraisal might be the most important skill to acquire in medical school. Despite its importance, this issue has received little attention in obstetrics and gynecology training. This article describes the approach used at San Francisco General Hospital. We teach critical appraisal in several ways. We provide a series of student seminars that foster critical reading of the literature. Topics range from technology assessment to contraception to sexually transmitted diseases. Evidence-based ward rounds complement the experience. During the rotation, each student formally reviews one topic in women's health using the US Preventive Services Task Force rating system. Although we lack a quantitative assessment of this approach, student feedback has been enthusiastic. Critical appraisal skills enable students to continue their medical education after completion of their formal training.
Outreach visits have been identified as an intervention that may improve the practice of health care professionals, in particular prescribing. This type of 'face to face' visit has been referred to as university-based educational detailing, public interest detailing, and academic detailing.
To assess the effects of outreach visits on improving health professional practice or patient outcomes.
We searched MEDLINE up to March 1997, the Research and Development Resource Base in Continuing Medical Education, and reference lists of related systematic reviews and articles.
Randomised trials of outreach visits (defined as a personal visit by a trained person to a health care provider in his or her own setting). The participants were health care professionals.
Two reviewers independently extracted data and assessed study quality.
Eighteen studies were included involving more than 1896 physicians. All of the outreach visit interventions consisted of several components, including written materials and conferences. Reminders or audit and feedback complemented some visits. In 13 studies, the targeted behaviours were prescribing practices. In three studies, the behaviours were preventive services, including counselling for smoking cessation. In two studies, the outreach visits were directed toward improving the general management of common problems encountered in general practice, including asthma, diabetes, otitis media, hypertension, anxiety, and acute bronchitis. All studies examined physician behaviour and in three studies other health professionals such as nurses, nursing home attendants or health care workers were targeted. Positive effects on practice were observed in all studies. Only one study measured a patient outcome. Few studies examined the cost effectiveness of outreach.
Educational outreach visits, particularly when combined with social marketing, appear to be a promising approach to modifying health professional behaviour, especially prescribing. Further research is needed to assess the effects of outreach visits for other aspects of practice and to identify key characteristics of outreach visits that are important to its success. The cost-effectiveness of outreach visits is not well evaluated.
Both the theory of diffusion of innovations and the social influences model of behaviour change suggest that using local opinion leaders to transmit norms and model appropriate behaviour may improve health professional practice.
To assess the effects using local opinion leaders on the practice of health professionals or patient outcomes.
We searched MEDLINE to May 1998, the Research and Development Resource Base in Continuing Medical Education, and reference lists of related systematic reviews and articles.
Randomised trials of the use of local opinion leaders (defined as health professionals nominated by their colleagues as being educationally influential). The participants were health care professionals responsible for patient care.
Two reviewers independently extracted data and assessed study quality.
Eight studies were included involving more than 296 health professionals. A variety of patient problems were targeted, including acute myocardial infarction, cancer pain, osteoarthritis, rheumatoid arthritis, chronic lung disease, vaginal birth after caesarean section, labour and delivery, and urinary catheter care. Six of seven trials that measured health professional practice demonstrated some improvement for at least one outcome variable, and in two trials, the results were statistically significant and clinically important. In three trials that measured patient outcomes, only one achieved an impact upon practice that was of practical importance: local opinion leaders were effective in improving the rate of vaginal birth after previous caesarean section.
Using local opinion leaders results in mixed effects on professional practice. However, it is not always clear what local opinion leaders do and replicable descriptions are needed. Further research is required to determine if opinion leaders can be identified and in which circumstances they are likely to influence the practice of their peers.
Policy makers and continuing educators often face difficult decisions about which educational and quality assurance interventions to provide. Where possible, such decisions are best informed by rigorous evidence, such as that provided by systematic reviews. The Cochrane Collaboration is an international organization that aims to help people make well-informed decisions about health care by preparing, maintaining, and ensuring the accessibility of systematic reviews of the benefits and risks of health care interventions. International collaborative review groups prepare Cochrane reviews for publication in The Cochrane Library, a collection of databases available on CD-ROM and the World Wide Web and updated quarterly. The Cochrane Effective Practice and Organization of Care Group (EPOC) aims to prepare and maintain systematic reviews of professional, financial, organizational, and regulatory interventions that are designed to improve professional practice and the delivery of effective health services. EPOC has 17 reviews and 20 protocols published in Issue 3, 2000, of the Cochrane Library, with further protocols in development. We also have undertaken an overview of previously published systematic reviews of professional behavior change strategies. Our specialized register contains details of over 1,800 studies that fall within the group's scope. Systematic reviews provide a valuable source of information for policy makers and educators involved in planning continuing education and quality assurance initiatives and organizational change. EPOC will attempt to keep the Journal of Continuing Education in the Health Professions informed on an ongoing basis about new systematic reviews that it produces in the area of continuing medical education and quality assurance.
Educational meetings and printed educational materials are the two most common types of continuing education for health professionals. An important aim of continuing education is to improve professional practice so that patients can receive improved health care.
To assess the effects of educational meetings on professional practice and health care outcomes.
We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE (from 1966), the Research and Development Resource Base in Continuing Medical Education in January 1999 and reference lists of articles.
Randomised trials or well designed quasi-experimental studies examining the effect of continuing education meetings (including lectures, workshops, and courses) on the clinical practice of health professionals or health care outcomes.
Two reviewers independently applied inclusion criteria, assessed the quality of each study, and extracted study data. We attempted to collect missing data from investigators. We conducted both qualitative and quantitative analyses.
Thirty-two studies were included with a total of 36 comparisons. The studies involved from 13 to 411 health professionals (total N= 2995) and were judged to be of moderate or high quality, although methods were generally poorly reported. There was substantial variation in the complexity of the targeted behaviours, baseline compliance, the characteristics of the interventions and the results. The heterogeneity of the results was best explained by differences in the interventions. For 10 comparisons of interactive workshops, there were moderate or moderately large effects in six (all of which were statistically significant) and small effects in four (one of which was statistically significant). For interventions that combined workshops and didactic presentations, there were moderate or moderately large effects in 12 comparisons (eleven of which were statistically significant) and small effects in seven comparisons (one of which was statistically significant). In seven comparisons of didactic presentations, there were no statistically significant effects, with the exception of one out of four outcome measures in one study.
Interactive workshops can result in moderately large changes in professional practice. Didactic sessions alone are unlikely to change professional practice.
Science is supposed to be cumulative, but scientists only rarely cumulate evidence scientifically. This means that users of research evidence have to cope with a plethora of reports of individual studies with no systematic attempt made to present new results in the context of similar studies. Although the need to synthesize research evidence has been recognized for well over two centuries, explicit methods for this form of research were not developed until the 20th century. The development of methods to reduce statistical imprecision using quantitative synthesis (meta-analysis) preceded the development of methods to reduce biases, the latter only beginning to receive proper attention during the last quarter of the 20th century. In this article, the authors identify some of the trends and highlights in this history, to which researchers in the physical, natural, and social sciences have all contributed, and speculate briefly about the "future history" of research synthesis.
Health services research consistently demonstrates a gap between research-based best clinical practice and what doctors actually do. Traditionally, the profession of medicine has behaved as if dissemination of research findings in peer-reviewed journals will eliminate this gap, even though professionals typically have less than 1 hour per week to read. This problem is complicated by the fact that physicians have not been trained generally to appraise published research, which is of variable quality in any event. Physicians interested in changing their practices also encounter organizational, peer group, and individual barriers at the same time as they face information overload and patient expectations. In a word, physicians' abilities to manage information is overwhelmed. This article both summarizes initiatives to improve physicians' information management through efforts to synthesize available evidence and describes the current evidence base of effectiveness and efficiency of dissemination and implementation strategies. We conclude that there is an imperfect evidence base to support decisions regarding strategies that are likely to be appropriate and effective under varying circumstances. Since this problem is compounded by the lack of a theoretical base for conceptualizing physician behavior change, we suggest exploring the applicability of behavioral theories to the understanding of professional behavior change. We also suggest exploring the use of theory-based process evaluations alongside randomized trials of dissemination and implementation strategies to further test theories and to explore causal mechanisms. Further research is required to explore determinants of provider behavior to better identify modifiable and non-modifiable effect modifiers, to develop methods of identifying barriers and facilitators to change, and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.
One of the most common findings from health services research is a failure to routinely translate research findings into daily practice. Previous systematic reviews of strategies to promote the uptake of research findings suffered from a range of methodologic problems that have been addressed in a more recent systematic review of guideline dissemination and implementation strategies. Changes in practitioner behavior; in the desired direction, were reported in 86% of the comparisons made. The median effect size overall was approximately 10% improvement in absolute terms. The review suggests that interventions that were previously thought to be ineffective (e.g., dissemination of educational materials) may have modest but worthwhile benefits. Also, multifaceted interventions, previously thought to be more effective than single interventions, were found to be no more effective than single interventions. Overall, there is an imperfect evidence base for decision makers to work from. Many studies had methodologic weaknesses, and reporting of this kind of research is generally poor, making the generalizability of study findings frequently uncertain. A better theoretical underpinning of studies would make this body of research more useful.
Surrogate end points in clinical research pose real danger. A surrogate end point is an outcome measure, commonly a laboratory test, that substitutes for a clinical event of true importance. Resistance to activated protein C, for example, has been used as a surrogate for venous thrombosis in women using oral contraceptives. Other examples of inappropriate surrogate end points in contraception include the postcoital test instead of pregnancy to evaluate new spermicides, breakage and slippage instead of pregnancy to evaluate condoms, and bone mineral density instead of fracture to assess the safety of depo-medroxyprogesterone acetate. None of these markers captures the effect of the treatment on the true outcome. A valid surrogate end point must both correlate with and accurately predict the outcome of interest. Although many surrogate markers correlate with an outcome, few have been shown to capture the effect of a treatment (for example, oral contraceptives) on the outcome (venous thrombosis). As a result, thousands of useless and misleading reports on surrogate end points litter the medical literature. New drugs have been shown to benefit a surrogate marker, but, paradoxically, triple the risk of death. Thousands of patients have died needlessly because of reliance on invalid surrogate markers. Researchers should avoid surrogate end points unless they have been validated; that requires at least one well done trial using both the surrogate and true outcome. The clinical maxim that "a difference to be a difference must make a difference" applies to research as well. Clinical research should focus on outcomes that matter.
Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not consistently been found to be effective.
To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes.
We searched the Cochrane Effective Practice and Organisation of Care Group's register and pending file up to January 2004.
Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes.
Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. For each comparison we calculated the risk difference (RD) and risk ratio (RR), adjusted for baseline compliance when possible, for dichotomous outcomes and the percentage and the percent change relative to the control group average after the intervention, adjusted for baseline performance when possible, for continuous outcomes. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: the type of intervention (audit and feedback alone, audit and feedback with educational meetings, or multifaceted interventions that included audit and feedback), the intensity of the audit and feedback, the complexity of the targeted behaviour, the seriousness of the outcome, baseline compliance and study quality.
Thirty new studies were added to this update, and a total of 118 studies are included. In the primary analysis 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback is a component compared to no intervention. For dichotomous outcomes the adjusted risk difference of compliance with desired practice varied from - 0.16 (a 16 % absolute decrease in compliance) to 0.70 (a 70% increase in compliance) (median = 0.05, inter-quartile range = 0.03 to 0.11) and the adjusted risk ratio varied from 0.71 to 18.3 (median = 1.08, inter-quartile range = 0.99 to 1.30). For continuous outcomes the adjusted percent change relative to control varied from -0.10 (a 10 % absolute decrease in compliance) to 0.68 (a 68% increase in compliance) (median = 0.16, inter-quartile range = 0.05 to 0.37). Low baseline compliance with recommended practice and higher intensity of audit and feedback were associated with larger adjusted risk ratios (greater effectiveness) across studies.
Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.
Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not been found to be consistently effective.
To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes.
We searched the Cochrane Effective Practice and Organisation of Care Group's register up to January 2001. This was supplemented with searches of MEDLINE and reference lists, which did not yield additional relevant studies.
Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes.
Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken.
We included 85 studies, 48 of which have been added to the previous version of this review. There were 52 comparisons of dichotomous outcomes from 47 trials with over 3500 health professionals that compared audit and feedback to no intervention. The adjusted RDs of non-compliance with desired practice varied from 0.09 (a 9% absolute increase in non-compliance) to 0.71 (a 71% decrease in non-compliance) (median = 0.07, inter-quartile range = 0.02 to 0.11). The one factor that appeared to predict the effectiveness of audit and feedback across studies was baseline non-compliance with recommended practice.
Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The absolute effects of audit and feedback are more likely to be larger when baseline adherence to recommended practice is low.