Continuing Medical Education Advances Confidence of Clinicians Treating Myocardial Infarction
A recent study published in Critical Pathways in Cardiology analyzed the results of a continuing medical education (CME) program that addressed patients with cardiovascular problems, including myocardial infarction (MI). The study concluded, among other things, that the CME activities were effective in improving knowledge of clinician’s long term and enhancing confidence of clinicians long term. The study was supported by an educational grant from Daiichi Sankyo, Inc. and Lilly USA, LLC who provided no role in the preparation of the manuscript.
Background, Need for CME
An estimated 610,000 new cases of myocardial infarction (MI) and 325,000 recurrent MIs will occur this year in the United States; this translates to 1 MI every 34 seconds. Recurrent events and the mortality associated with acute coronary syndromes (ACSs) are also high; as many as 36% of men and 47% of women 45 years of age will die within 5 years after a first MI.
Despite the publication of clinical practice guidelines for managing ACS by the American College of Cardiology (ACC), the American Heart Association (AHA), and the Society for Cardiovascular Angiography and Interventions (SCAI), one study found that 25% of opportunities to provide guideline-recommended care were missed. Poor guideline adherence was associated with significant mortality; with every 10% decrease in guideline adherence, there was a 10% increase in mortality.
Primary care clinicians play a central role in the prevention and management of coronary heart disease (CHD). According to ACC/AHA guidelines, primary care providers should
1) evaluate the presence and status of control of major risk factors for CHD for all patients at regular intervals,
2) calculate 10-year risk of developing symptomatic CHD for all patients who have 2 or more major risk factors to assess need for primary prevention strategies, and
3) implement secondary prevention strategies in patients with established CHD or CHD-risk equivalent (eg, diabetes, chronic kidney disease, high risk according to stratification).
However, only 17% of physicians were found to use a CHD risk calculator usually or always in their practice. A recent study also showed that 52% of clinicians surveyed stated that risk assessments took too much of their time, whereas 21% felt that they did not believe that risk assessments added any more value to their clinical evaluation. Another study showed that although clinicians were fully aware of the need to base risk assessments on the combination of all risk factors, the majority of them were found to be using subjective methods to assess risk. Moreover, results from 2 studies indicated that treatment decisions were influenced by patient wishes, local health policy, and healthcare systems rather than the recommended guidelines. It was also found that clinicians estimated cardiovascular disease (CVD) risk as being less severe when they used their subjective methods to assess risk as compared with the risk predicted with the use of the guideline-recommended methods.
The ACC/AHA guidelines also emphasize that for optimum secondary prevention, it is critical that clinicians effectively manage long-term treatment with dual antiplatelet and adjuvant therapies in addition to managing other risk factors. However, recent data show that 23% and 18% of patients have not filled their discharge cardiac medications by day 7 and day 120, respectively, despite the fact that concurrent use of antiplatelet agents, beta-blockers, angiostensin-converting enzyme inhibitor (ACEI), and lipid-lowering therapies have been shown to lower mortality.
Results from a survey of clinicians indicated that 63% of participants were not aware of the ACC/AHA guideline recommended delay between stent placement and subsequent surgical procedure, and approximately 30% of survey participants were found to recommend no delay or a delay of 1 to 2 weeks only. This lack of awareness of the guideline recommendations in addition to poor or absent communication with patients’ cardiologists while managing patients who may need to undergo a planned or an unplanned surgery increases the risk of cardiovascular or bleeding event rates in patients with ACS.
Additionally, increased bleeding in patients, potentially because of inappropriate use of proton pump inhibitors (PPIs), has been shown to lead to premature discontinuation of antiplatelet therapy. Availability of conflicting data from clinical trials, a registry analysis, ex vivo platelet inhibition studies, and an Food and Drug Administration (FDA) warning advising clinicians to use caution in prescribing PPI concurrently with clopidogrel have led to a great deal of confusion and inconsistent practice among primary care clinicians.
As primary care clinicians are the clinical professional who most routinely interact with patient’s post-MI, these facts clearly highlight the existence of knowledge, competence, and performance gaps in managing long-term treatment of patients with ACS leading to poor patient outcomes. Thus, educational activities highlighting the current evidence-based data and guidelines, and their clinical relevance to manage patients effectively and appropriately, are expected to minimize bleeding risk and risk of future cardiovascular events.
CME and Cardiovascular
A number of continuing medical education (CME) programs are implemented as stand-alone educational opportunities with no follow- up and are based on the assumption that a certain percentage of participants will change their behavior based on the content presented. Activities that apply adult learning principles by facilitating participant reflection on current practices, relating current practice to established guidelines, and recommending evidence based strategies to overcome identified practice gaps have been shown to be very effective. Additionally, activities that allow time for participants to practice what they have learned and provide opportunities for the participants to observe improvement in outcomes or identify barriers to implementation of what they have learned have been shown to result in clinician behavior change.
The development and implementation of such educational activities with the clear goal of improving performance among primary care clinicians who manage patients with ACS showed that the activities were effective in enhancing the knowledge and confidence of participants. More importantly, the activities also improved the competence and self-reported performance of clinicians. Additionally, the participant feedback indicated that implementation of the guideline recommendations, evidence-based data, and clinical practice strategies resulted in observed improvement in patient outcomes.
To elucidate evidence-based data, clinical practice strategies, specific guideline recommendations, and the real life application of guideline recommendations in the management of patients with ACS, specifically with respect to antiplatelet therapy, the authors designed CME activities as a case presentation interlaced with didactic lecture. To keep the participants engaged, an audience response system was used, and on presentation of a case scenario, the participants were asked to choose the appropriate next steps. The presenting faculty commented on the polling results, either reinforcing the participant decision or providing evidence that pointed to the contrary.
Pre-, post-, and 8-week follow- up surveys were used to assess and quantify changes in knowledge and confidence from baseline (asked using pre- and post-surveys), as well as the differences between participants’ current (baseline) versus planned (asked immediately post-activity) frequency of use of the recommended evidence-based clinical practice strategies that were reinforced in the curriculum.
Survey Questions and Data Collection
Ten Pri-Med Update meetings, 3 American Academy of Family Practice state chapter meetings, 1 American Academy of Family Practice national symposium, and an enduring activity hosted on Medscape were used to reach a broad audience of primary care clinicians. All of the live activities took place between August 2009 and December 2009, and the enduring activity was hosted on Medscape from February 2010 to February 2011. Combined aggregate data were available for a range of 1204 to 1487 respondents for the presurvey, a range of 635 to 1488 respondents for the postsurvey, and a range of 142 to 200 for the follow-up survey. Based on self-reported demographic data, the respondents who answered the current and planned frequency-of-use questions saw a combined total of approximately 5971 to 8647 patients with ACS each month. The respondents who answered the frequency-of-use questions in the follow-up survey saw a combined total of approximately 579 to 910 patients with ACS each month.
Effectiveness of Educational Activities in Improving Knowledge
The aggregate pre-activity responses showed that approximately 36% were not aware that the strongest predictor of stent thrombosis is antiplatelet medication discontinuation, thus confirming the identified gap in clinical management. Results obtained post-activity showed that the education was significantly effective in imparting this knowledge. Data obtained at 8 weeks after the activity showed that the educational activities were effective over time in addressing this gap among clinicians. Data confirmed that there was a gap in knowledge regarding drug–drug interactions between clopidogrel and PPIs and statins, which significantly improved post-activity. The educational activities were effective in enhancing participants’ knowledge, and this knowledge was retained over time.
Effectiveness of Educational Activities in Enhancing Confidence
Results from the preactivity survey confirmed that primary care clinicians who participated in the activities were not confident in their ability to ensure that patients adhere to the guideline recommended duration of dual antiplatelet therapy. Comparison of aggregate data obtained pre- and postactivity showed that the content specifically covering adherence to guideline-recommended duration of antiplatelet therapy achieved its goal, with a large effect size. Comparison of the 8-week follow-up results with preactivity results showed that there was a statistically significant improvement in clinicians. Comparison of the 8-week follow-up survey results with those obtained postactivity revealed that the increased confidence that primary care clinicians gained as a result of the activity was sustained even after 8 weeks.
With respect to primary care clinicians’ confidence in collaborating effectively with their patients’ cardiologists to provide long-term follow-up care, comparison of aggregate responses obtained post activity with those obtained pre-activity indicated that the activities had a large and significant effect on increasing confidence. Comparison of the 8-week follow-up results with the results obtained immediately post activity showed that the increased confidence observed immediately after the activity was sustained even after 8 weeks.
Increase in Monitoring Adherence to Guideline recommended Duration of Antiplatelet Therapy
The study showed that the education was effective in improving the intention of clinicians to use this clinical practice strategy compared with their baseline use. The content discussed in the activities was effective in nudging primary care clinicians to monitor their patients’ adherence to guideline-recommended duration of antiplatelet therapy.
The educational activities were very effective in improving competence. A change in competence was evident when comparing the aggregate baseline (current) mean with the planned mean data. The study suggested that clinicians were able to implement this clinical practice strategy as they had intended.
DISCUSSION
Clear gaps in the knowledge, competence, and performance of primary care clinicians who provide long-term management for patients with ACS exist, potentially accounting for the high rates of mortality and poor overall outcomes. Educational activities directed
toward primary care clinicians were developed and implemented and the change in knowledge, competence, and performance measured.
Premature antiplatelet discontinuation has been shown to be the single most significant contributor to stent thrombosis, a devastating complication that can result in mortality. Hence, retention of this knowledge among primary care clinicians who manage long term therapy in patients with ACS is critical for improving lasting adherence to recommended antiplatelet therapy. The aggregate data supported that there was a knowledge gap, and this gap was significantly improved by the content discussed in the educational activities.
The newly gained knowledge was retained even after 8 weeks and is expected to improve overall outcomes in patients, as clinicians will be more vigilant with respect to their patients’ adherence to antiplatelet therapy. This is corroborated by the comments made by the participants who stated that they observed improved outcomes in their patients, and that they were efficiently monitoring their patients’ adherence to the recommended antiplatelet therapy. The observed attrition of knowledge seen at 8 weeks in some participants clearly validates the need for ongoing education, repeated reminders, or other interventions to increase knowledge retention.
Preactivity, the majority of participants wrongly chose the option that indicated that PPIs inhibit the efficacy of clopidogrel thus validating a knowledge gap. The responses also indicate that the participants who see patients with ACS were either unaware of these new data or at the very least confused regarding the current data. The content discussed in the activities clarified the differences between the various conflicting data and was effective in enhancing the knowledge of these clinicians. However, some of the clinicians indicated that they substituted a PPI with an H2 blocker or substituted omeprazole with pantoprazole in patients post-MI because of their effects in reducing antiplatelet efficacy, clearly highlighting the need for further education on this ongoing controversy.
Impact of Enhanced Confidence on Patient Outcomes
The educational activities were effective not only in improving clinicians’ confidence in their ability to ensure patient adherence to guideline-recommended duration of dual antiplatelet therapy immediately postactivity, but also at 8 weeks after the activity. This increased confidence is expected to result in a decrease in the incidence of secondary coronary events because of stent thrombosis.
Similarly, results show that the activities were very effective in improving primary care clinicians’ confidence in their ability to collaborate effectively with their patients’ cardiologists, and this gained confidence was sustained even after 8 weeks. This increased collaboration will result in better management of patients post-ACS and will also enable primary care clinicians to determine what type of procedures need antiplatelet therapy discontinuation and which ones do not. In summary, increased collaboration will result in improved quality of life for patients as well as improved overall patient outcomes.
Performance Changes Among Clinicians in Frequency of Use of Various Clinical Practice Strategies
For assessing risk and stratifying patients, aggregate results from clinicians who see patients with ACS showed that the content discussed in the activity resulted in improved competence. Some of the comments made by participants indicate that they are now better able to assess and stratify their patients, and they are better serving their patients because of this knowledge, clearly highlighting the effectiveness of these activities in changing competence and performance.
With respect to monitoring patient adherence to guideline recommended duration of antiplatelet therapy, baseline and planned frequency comparisons show that the knowledge that the participants gained through the activity led to a change in their competence. This resulted in a positive performance change and in improving patient outcomes overall. Some clinicians indicated that the knowledge gained through the activity has urged them to monitor more regularly resulting in increased compliance and adherence to the guideline-recommended medications.
The comments from participants also showed improvement in the performance of at least some clinicians. Self-reported performance for the frequency of prescribing concomitant omeprazole and clopidogrel with caution shows that the participating clinicians who see patients with ACS clearly adhered to their plan to increase use of this strategy, indicating that the activities were effective in changing their competence and performance.
Conclusion
In summary, analyses of results from the pre-, post-, and 8-week follow-up surveys indicate that the content developed and discussed in the educational activities was effective in enhancing the knowledge, confidence, competence, and performance of participating clinicians who see patients with ACS, at least with respect to
most of the strategies discussed. Preliminary evidence from a series of educational activities in 2010 also supports the effectiveness of activities similar to the ones described here. Results from some survey questions discussed here indicate that in some cases the self-reported performance was lower than what the clinicians
planned for immediately after the activities because of the presence of various barriers. Thus, future educational activities should be directed to highlight strategies to overcome at least some of the barriers such that the performance of all participants is improved.