A recent study published in the American Journal of Managed Care (AJMC) sought to determine whether changes in physician behavior associated with a continuing medical education (CME) activity on atrial fibrillation (AF) can be measured using an administrative claims database.
The authors found that analysis of administrative claims data from Humana providers who participated in an AF CME activity and their patients demonstrated a significant reduction in AF-related healthcare costs and utilization, including decreased length of stay. Humana providers, in addition to the other CME activity participants, demonstrated significant gains in knowledge of evidence-based care strategies when presented with real-world scenarios of patients with AF. As a result, the authors concluded that, “use of administrative claims data is an innovative way of measuring the effectiveness of CME.”
Executive Summary/Take-Away Points
Participation in a certified CME webcast activity on management of patients with AF was associated with a significant decrease in AF-related healthcare utilization and costs:
- CME can improve physician confidence and knowledge.
- Improved physician competence may translate into healthcare savings through better patient care
- CME can help physicians provide quality care, which may affect reimbursements in the new pay-for-performance era of healthcare.
Study Design
A retrospective, analytical review of physician practice changes and AF patient– related healthcare utilization and costs derived from an administrative claims database was performed on a cohort of Humana health system physicians.
The Humana physicians participated in a specified CME activity on the management of patients with AF. A quantitative analysis of the CME-certified AF webcast was performed to assess changes in participant confidence and knowledge. Participants responded to 1 confidence question on a 4-point Likert scale as well as 5 knowledge questions with only 1 correct answer.
Treatment patterns of these providers and clinical outcomes of a cohort of established AF patients were compared 6 months before and 6 months after physician participation in the AF CME activity. Administrative claims data corresponding to the predetermined study measures were collected and evaluated on the same group of eligible patients in both the pre-CME and post-CME activity periods of the study.
Results
Provider Characteristics. In an effort to explore possible changes in physician practice patterns and AF patient outcomes after heightened awareness of guideline measures and current evidence, 395 physicians were identified who completed both the presurvey and postsurvey of the AF CME activity. Of these physicians, 204 were excluded due to incomplete name information, missing activity completion date, foreign residence, or completion of the activity after June 1, 2010. The remaining 191 providers were merged with the Humana electronic data warehouse. A total of 114 providers encountered Humana member patients during the study period. Of those providers, a total of 84 encountered 932 Humana member patients with a diagnosis of AF in the pre-CME period.
All study participants were physicians, and the majority specialized in cardiology. Of the study participants who provided practice information, more than one-half practiced in community or private practice, and nearly one-fourth were associated with hospital practices. Sixteen percent of study physicians did not provide practice details.
Patient Characteristics. The majority of patients included in the study were male (57%) and patients had a mean age of 74 years. Overall, 24% of patients were in their 60s, 39% of patients were in their 70s, and 32% were in their 80s. The most common comorbidities were hypertension (88%), heart failure (53%), cardiovascular disease (42%), and diabetes (14%).
Prescription Patterns. Evaluation of prescriptions for rhythm and rate control therapies revealed that 83% of patients were being treated with at least 1 of these approaches; 78% were treated with rate control agents, and 28% were treated with rhythm control agents. A significant increase in the use of dronedarone was observed during the study period, with nearly a 3-fold increase in new users in the post-CME activity period (7 vs 20, P = .0004). A trend toward decreased use of flecainide was also observed after the CME intervention, although these results were not statistically significant.
One fourth of patients were hospitalized for AF over the course of the study period. Significant decreases in the number and duration of AF-related hospitalizations were observed in the post-CME period. Additionally, declines in the absolute number of AF-related 30-day readmission rates during the study period were observed, as well as decreases in hospitalizations for common AF-related complications (stroke and gastrointestinal bleeding).
A significant decline in AF-related healthcare spending was observed in the post-CME activity period, primarily driven by significant savings in medical costs (inpatient, outpatient, and emergency department). Healthcare utilization also decreased significantly; the number of inpatient and outpatient visits dropped.
CME Activity Outcomes
Of the overall webcast participants (Humana and non-Humana providers) who redeemed CME credit, 285 participants completed the pretest, and 280 completed the posttest. The majority of webcast participants were medical doctors who specialized in cardiology and/or electrophysiology, and most practiced in community hospitals or private practices. In addition, 4% of participants were nurse practitioners and physician assistants.
Humana webcast participants demonstrated notable gains in knowledge, with the average percentage of correct responses to knowledge-based questions increasing from 63% to 81%. Similarly, all 283 webcast participants were found to have increased knowledge after completing the webcast. Significant gains in confidence were also observed in both groups, particularly with those who felt “extremely” confident in selecting an individualized, evidence-based treatment regimen after completing the activity. Although more Humana participants reported high levels of confidence before and after the webcast, both groups had significant gains in confidence after completing the webcast.
Discussion
This pilot study, which involved a relatively new approach to establishing a partnership between a CME provider and a health services research center to perform a retrospective cohort analysis of physician practices and corresponding patient outcomes in the treatment of AF, represented an effort to move beyond traditional CME outcomes assessments to determine the real-world patient impact of an educational activity.
From this partnership, the authors reported that participation in the CME-certified intervention was associated with a 33% reduction in AF-related healthcare costs accrued by the 932 eligible patients with established AF who were treated by the 84 participating physicians. Furthermore, patients treated by these physicians had a 40% reduction in the number of inpatient days in the 6 months following the activity.
A strength of this study is the demographic characteristics of the patient population. The AF patients included in the study were fairly representative of the AF population as a whole. In the overall population of AF patients, the median age is approximately 75 years, and the distribution of men and women is roughly equal. Furthermore, comorbidities are common in this patient population.
The authors hypothesized that participation in the AF CME activity was associated with heightened awareness and better implementation of evidence-based AF care, which may have translated into the selection of more appropriate rate and/or rhythm control therapies for individual patients and, in turn, improved overall disease management and patient outcomes.
Those patients who were hospitalized due to either AF or other cardiovascular-related conditions also had significantly shorter stays. The increased use of dronedarone and shorter hospital stays were associated with healthcare cost savings in select patients with AF, and indicates that the observed positive association between the CME intervention and true improvements in patient outcomes is valid.
Initial analysis of outcomes from all CME-certified webcast activity participants demonstrated significant gains in confidence and knowledge. When activity outcomes were limited to only Humana participants, similar findings for gains in knowledge were found. This finding was validated in the comparison of knowledge data between the Humana cohort and the non- Humana webcast participants. Humana participants were more likely to have a high degree of confidence in their abilities to individualize treatment regimens for their patients with AF.
Previous research used administrative claims data as a method of analysis of physician performance improvement. Walden and colleagues demonstrated a reduced time to diagnosis of myelodysplastic syndromes after physicians participated in a traditional medical educational forum compared with nonparticipating physicians. This study was retrospective in nature, using a sliding scale window to examine physician behavior 6 months prior to and 6 months after CME activity participation. In contrast, the current analysis tracked performance changes and outcomes within the same group of physicians and their patients, and provides a more global assessment of physician behaviors and healthcare system changes after a CME activity.
Several limitations are associated with this study that may restrict the generalizability of the results. Physicians within the Humana cohort may have participated in additional CME activities on the topic of AF patient management during the study period, thereby influencing their practice patterns. Additionally, the time frame of the study was limited to 12 months, and changes in practice behavior may have occurred more gradually, over a longer period of time. Limitations common to administrative claims data include the nonrandomization of subjects, the potential for selection bias, and errors in claims coding.
Conclusion
As healthcare costs continue to increase, focus is shifting away from fee-for-service reimbursements and is moving toward a performance-based, quality care platform. Physicians are being assessed on the quality of care they provide and the outcomes of their patients in an effort to reduce patient complications and, in turn, healthcare costs. With greater knowledge comes a greater ability to make treatment decisions that can optimize patient health. “CME is a valuable tool in enhancing physician knowledge, competence, and performance and is influential in driving effective changes in healthcare utilization and costs.”