Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 147
Redesigning Continuing Education in the Health Professions Appendix A Literature Review Tables Evidence on the effectiveness of continuing education (CE) and CE methods was identified through a literature review. Although nonexhaustive, the review included a comprehensive search of the Research and Development Resource Base (RDRB), a bibliographic database of more than 18,000 articles from fields including CE, knowledge translation, interprofessional literature, and faculty development. Articles in the RDRB are culled from Medline, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), Education Resources Information Center (ERIC), Sociological Abstracts, PsychoInfo, Library Information and Science Abstracts (LISA), and business databases, as well as automatic retrieval of articles from journals dedicated to medical education (e.g., Journal of Continuing Education in the Health Professions, Medical Education, Studies in Continuing Education). The RDRB was searched using keywords,1 and the results of the searches were culled by two independent reviewers using an iterative approach. Studies collected were from 1989 to April 2009. 1 Keywords used to search the RDRB included “patient participation,” “patient initiated,” “patient mediated,” “physician prompt,” “audit,” “feedback,” “checklist,” “checklists,” “protocol,” “protocols,” “reminder,” “reminders,” “academic detailing,” “simulation,” “simulations,” “lifelong learning,” “experiential,” “self-directed,” “reflection,” “problem based,” “model,” and “modeling.” These keywords were used alone or in combination.
OCR for page 148
Redesigning Continuing Education in the Health Professions Abstracts of search results were reviewed to eliminate articles that clearly did not pertain to CE methods, cost-effectiveness, or educational theory and to categorize the studies as informative, equivocal, or not informative of CE effectiveness. A wide range of designs were classified as informative, including randomized controlled trials, prospective cohort studies, observational studies, and studies with pre- and post-intervention assessment methodologies. Quantitative and qualitative approaches were included, and inclusion was not limited to studies with positive results. The most common reasons articles were classified as not informative were absence of a trial design, small sample size, and high likelihood of confounding factors in the design that could affect outcomes. The two reviewers independently classified abstracts and full texts of the articles and then compared their classification results. Interreviewer reliability was greater than 80 percent, and discrepancies were resolved by a consensus process. A third reviewer verified the results classified as informative or equivocal in a final round of detailed assessment of the study design, populations, intervention, type of outcome, and conclusions for each article. Systematic reviews and metaanalyses are included in Table A-1; studies and articles are included in Table A-2.
OCR for page 149
Redesigning Continuing Education in the Health Professions Table A-1 begins on the next page.
OCR for page 150
Redesigning Continuing Education in the Health Professions TABLE A-1 Summary of Systematic Reviews on Effectiveness of CE Methods Reference Purpose Number of Studies, Inclusion Criteria, and Databases Searched Reflection Ruth-Sahd, L. A. 2003. Reflective practice: A critical analysis of data-based studies and implications for nursing education. Journal of Nursing Education 42(11):488-497. * Identify common themes that emerge from data-based studies * Identify implications for reflective practice in the field of nursing education Sample: 20 articles, 12 doctoral dissertations, and 6 books Inclusion criteria: Delineated methodology section; emphasis on reflective practice in an education setting; publication between 1992 and 2002; English language Databases: CINAHL, Dissertation Abstracts International, ERIC, PsychInfo Simulation Issenberg, S. B., W. C. McGaghie, E. R. Petrusa, D. L. Gordon, and R. J. Scalese. 2005. Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Medical Teacher 27:10-28. Determine the features and uses of high-fidelity medical simulators that lead to the most effective learning (high-fidelity simulators are models, mannequins, or virtual packages that utilize realistic materials and equipment and incorporate feedback, computerized control, or other advanced technology) Sample: 109 articles Inclusion criteria: Empirical study; use of a simulator as an education assessment or intervention; learner outcomes measured quantitatively; experimental or quasi-experimental design Databases: ERIC, Medline, PsychInfo, Web of Science, Timelit
OCR for page 151
Redesigning Continuing Education in the Health Professions Main Results Limitations * Conditions necessary for reflection to be successful: Active motivation Safe learning environments Time availability * Students require guidance about how to practice reflection * No research on how unconscious knowledge is affected by reflective practice * Lack of hypothesis testing in reviewed studies High fidelity simulators facilitate learning under certain conditions: Repetitive practice Used in conjunction with multiple learning strategies Variety of clinical conditions captured Controlled environment where errors can be made and corrected Individualized learning where participants are actively involved Heterogeneity of research designs, educational interventions, outcome measures, and time frame precluded data synthesis using meta-analysis
OCR for page 152
Redesigning Continuing Education in the Health Professions Reference Purpose Number of Studies, Inclusion Criteria, and Databases Searched Sutherland, L. M., P. F. Middleton, A. Anthony, J. Hamdorf, P. Cregan, D. Scott, and G. J. Maddern. 2006. Surgical simulation: A systematic review. Annals of Surgery 243(3):291-300. Evaluate the effectiveness of surgical simulation compared with other methods of surgical training Sample: 30 trials with 760 participants Inclusion criteria: Randomized controlled trial; assessing surgical simulation; measures of surgical task performance Databases: Medline, EMBASE, Cochrane Library, PsycINFO, CINAHL, Science Citation Index Reminders Balas, E. A., S. M. Austin, J. A. Mitchell, B. G. Ewigman, K. D. Bopp, and G. D. Brown. 1996. The clinical value of computerized information services. A review of 98 randomized clinical trials. Archives of Family Medicine 5(5):271-278. Determine the clinical settings, types of interventions, and effects of studies in randomized clinical trials addressing the efficacy of clinical information systems Sample: 98 articles reporting on 100 trials Inclusion criteria: Randomized controlled trial (RCT); computerized information intervention in the experimental group; effect measured on the process or outcome of care Databases: Medline Shea, S., W. DuMouchel, and L. Bahamonde. 1996. A meta-analysis of 16 randomized controlled trials to evaluate computer-based clinical reminder systems for preventive care in the ambulatory setting. Journal of the American Medical Informatics Association 3(6):399-409. Assess the overall effectiveness of computer-based reminder systems in ambulatory settings directed at preventive care Sample: 16 trials Inclusion criteria: Randomized controlled trial; computer-based reminder; control group received no intervention Databases: Medline, Nursing and Allied Health database, Health Planning and Administration database
OCR for page 153
Redesigning Continuing Education in the Health Professions Main Results Limitations Computer simulation generally showed better results than no training at all but was not superior to standard training (e.g., surgical drills) or video simulation Insufficient evidence to evaluate types of simulation because outcomes were often not comparable across studies Patient and physician reminders, computerized treatment planners, and interactive patient education can make a significant difference in managing care (P < 0.05) Many trials evaluate the effect of information services on care processes as opposed to patient outcomes * Computer reminders improved preventive practices for vaccinations, breast cancer screening, colorectal cancer screening, and cardiovascular screening * Computerized reminders did not improve preventive practices for cervical cancer screening Heterogeneity in study designs and the ways in which results were presented
OCR for page 154
Redesigning Continuing Education in the Health Professions Reference Purpose Number of Studies, Inclusion Criteria, and Databases Searched Audit and Feedback Jamtvedt, G., J. M. Young, D. T. Kristoffersen, M. A. O’Brien, and A. D. Oxman. 2006. Does telling people what they have been doing change what they do? A systematic review of the effects of audit and feedback. Quality & Safety in Health Care 15(6):433-436. Review the effects of audit and feedback on improving professional practice Sample: 118 trials Inclusion criteria: Randomized controlled trials; utilized audit and feedback; objective measures of provider performance Databases: Cochrane Library Multifaceted Interventions and Reviews of Multiple Methods Cheraghi-Sohi, S., and P. Bower. 2008. Can the feedback of patient assessments, brief training, or their combination, improve the interpersonal skills of primary care physicians? A systematic review. BMC Health Services Research 8. * Review the efficacy of patient feedback on the interpersonal care skills of primary care physicians * Review the efficacy of brief training (up to one working week in length) focused on the improvement of interpersonal care Sample: 9 studies Inclusion criteria: Randomized controlled trials; published in English; based on primary care practitioners and their patients; utilized patient feedback or brief training or a combination of these methods; outcome measure was a patient-based assessment in change Databases: CENTRAL, Medline, EMBASE
OCR for page 155
Redesigning Continuing Education in the Health Professions Main Results Limitations * Effects of audit and feedback on improving professional practice are generally small to moderate * Effects of audit and feedback are likely to be larger when baseline adherence to recommended practice is low and audit and feedback are delivered more frequently and over longer periods of time * Lack of a process evaluation embedded in trials * Few studies compare audit and feedback to other interventions Brief training as currently delivered is not effective * Limited evidence on the effects of patient-based feedback for changes in primary care physician behavior * Evidence is not definitive due to the small number of trials * Variation in training methods and goals * Lack of theory linking feedback to behavior change
OCR for page 156
Redesigning Continuing Education in the Health Professions Reference Purpose Number of Studies, Inclusion Criteria, and Databases Searched Davis, D., M. A. O’Brien, N. Freemantle, F. M. Wolf, P. Mazmanian, and A. Taylor-Vaisey. 1999. Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 282(9):867-874. Review, collate, and interpret the effect of formal continuing medical education (CME) interventions on physician performance and health care outcomes Sample: 14 studies Inclusion criteria: Randomized controlled trial of formal didactic and/or interactive CME; >50% physicians Databases: RDRB, Cochrane Library, Medline Forsetlund, L., A. Bjørndal, A. Rashidian, G. Jamtvedt, M. A. O’Brien, F. Wolf, D. Davis, J. Odgaard-Jensen, and A. D. Oxman. 2009. Continuing education meetings and workshops: Effects on professional practice and health care outcomes. Cochrane Database Systematic Reviews (2):CD003030. To assess the effects of educational meetings on professional practice and health care outcomes Sample: 81 trials involving more than 11,000 health professionals Inclusion criteria: Randomized controlled trial of educational meetings that reported an objective measure of professional practice or health care outcomes Databases: Cochrane Library Grimshaw, J., L. Shirran, R. Thomas, G. Mowatt, C. Fraser, L. Bero, R. Grilli, E. Harvey, A. Oxman, and M. A. O’Brien. 2001. Changing provider behavior: An overview of systematic reviews of interventions. Medical Care 39(8 Suppl 2):II2-II45. Identify, appraise, and synthesize systematic reviews of professional education or quality assurance interventions to improve quality of care Sample: 41 reviews Inclusion criteria: Interventions targeted at health professionals; reported measures of professional performance and/or patient outcomes; study design included explicit selection criteria Databases: Medline, Healthstar, Cochrane Library
OCR for page 157
Redesigning Continuing Education in the Health Professions Main Results Limitations * Interactive CME sessions that enhance participant activity and provide the opportunity to practice skills can effect change in professional practice and, on occasion, health outcomes * Didactic sessions did not appear to be effective in changing physician performance * Limited number of randomized controlled trials and settings limits generalizability of findings * The comparability of CME interventions is debatable due to the lack of comparability of reviewed interventions * Educational meetings alone are not likely to be effective for changing behaviors * The effect of educational meetings combined with other interventions is most likely to be small and similar to other types of CE, such as audit and feedback, and educational outreach visits * Heterogeneity in study designs and the ways in which results were presented * Observed differences in changing behaviors cannot be explained with confidence * Passive approaches generally ineffective * Active approaches effective under some circumstances * Multifaceted interventions more likely to be effective than interventions with one method Lack of agreement within the research community on a theoretical or empirical framework for classifying interventions
OCR for page 216
Redesigning Continuing Education in the Health Professions Reference Study Purpose Sample, Method, Outcome Measures, and Duration Martin, C. M., G. S. Doig, D. K. Heyland, T. Morrison, and W. J. Sibbald. 2004. Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). Canadian Medical Association Journal 170(2):197-204. Test the hypothesis that evidence-based algorithms to improve nutritional support in the intensive care unit (ICU) would improve patient outcomes Sample: 499 patients in 14 ICUs over an 11-month period Method: Cluster randomized controlled trial Experimental group: introduction of evidence-based recommendations Control group: no intervention Outcome measures: Days of enteral nutrition, length of stay in hospital, mortality rates, length of stay in ICU Duration: 11 months Monaghan, M. S., P. D. Turner, M. Z. Skrabal, and R. M. Jones. 2000. Evaluating the format and effectiveness of a disease state management training program for diabetes. American Journal of Pharmaceutical Education 64(2):181-184. Determine whether a CE approach to disease management training in diabetes mellitus is an effective means of improving both cognitive knowledge and confidence levels of participants Sample: 25 pharmacists participating in a training program Method: Cohort study with pre- and post-intervention design Outcome measures: Scores on a pre- and post-test examination; scores on a 15-item attitudinal questionnaire Duration: 14 months
OCR for page 217
Redesigning Continuing Education in the Health Professions Description of Educational Method Findings Evidence-based recommendations were introduced via in-service education sessions, reminders by a local dietitian, posters, and academic detailing * Patients in intervention ICUs received significantly more days of enteral nutrition (6.7 vs. 5.4 per 10 patient-days; p = 0.042), had a significantly shorter mean stay in hospital (25 vs. 35 days; p = 0.003), and showed a trend toward reduced mortality (27% vs. 37%; p = 0.058) than patients in control ICUs * Mean stay in the ICU did not differ between control and experimental groups Traditional lectures and small-group exercises in which participants obtained “hands-on” information related to the pharmacist’s role * Cognitive post-test scores (68.8%) improved significantly (p < 0.001) over the pre-test scores (49.6%) * Post-test scores on all 15 attitudinal items significantly improved over pre-test scores (p < 0.012)
OCR for page 218
Redesigning Continuing Education in the Health Professions Reference Study Purpose Sample, Method, Outcome Measures, and Duration Naunton, M., G. M. Peterson, G. Jones, G. M. Griffin, and M. D. Bleasel. 2004. Multifaceted educational program increases prescribing of preventive medication for corticosteroid induced osteoporosis. Journal of Rheumatology 31(3):550-556. Assess a comprehensive educational program aimed at increasing the use of osteoporosis preventive therapy in patients prescribed long-term oral corticosteroids Sample: All patients admitted to the Royal Hobart Hospital, Australia; all physicians and pharmacists in 2 regions in Australia Method: Controlled trial Experimental group: geographic region received multifaceted educational program Control group: geographic region received no intervention Outcome measures: Evaluation feedback from GPs and pharmacists; drug utilization data Duration: 17 months Pronovost, P. J., S. M. Berenholtz, C. Goeschel, I. Thom, S. R. Watson, C. G. Holzmueller, J. S. Lyon, L. H. Lubomski, D. A. Thompson, D. Needham, R. Hyzy, R. Welsh, G. Roth, J. Bander, L. Morlock, and J. B. Sexton. 2008. Improving patient safety in intensive care units in Michigan. Journal of Critical Care 23(2):207-221. Describe the design and lessons learned from implementing a large-scale patient safety collaborative and the impact of an intervention on teamwork climate in intensive care units Sample: 99 ICUs across the state of Michigan over 24 months Method: Cohort study of ICU teams Outcome measures: Improvements in safety culture scores using a teamwork questionnaire; adherence to evidence-based interventions for ventilated patients Duration: 17 months
OCR for page 219
Redesigning Continuing Education in the Health Professions Description of Educational Method Findings All GPs and pharmacies in the study area were sent educational materials and guidelines; received academic detailing visits and reminders; and were provided educational magnets for their patients * Use of preventive therapy increased from 31% of admitted hospital patients taking corticosteroids to 57% post-intervention (p < 0.0001) * Significant increase in the use of preventive therapy in the intervention region over the control region (p < 0.01) * Collaborative project included group meetings and conference calls to share best practices and evaluate performance * Partnership between hospital leadership, ICU improvement teams, and ICU staff to identify and resolve barriers * Daily goals communication toolkits for staff education, redesign of work processes, and support of local opinion leaders * Teamwork climate improved from baseline to post-intervention (t(71) = −2.921, p < 0.005) * Post-intervention: 46% had >60% consensus of good teamwork; pre-intervention: 17% of ICUs had >60% consensus of good teamwork
OCR for page 220
Redesigning Continuing Education in the Health Professions Reference Study Purpose Sample, Method, Outcome Measures, and Duration Rashotte, J., M. Thomas, D. Grégoire, and S. Ledoux. 2008. Implementation of a two-part unit-based multiple intervention: Moving evidence-based practice into action. Canadian Journal of Nursing Research 40(2):94-114. Examine the impact and sustained change of a 2-part, unit-based multiple intervention on the use by pediatric critical care nurses of guidelines for pressure-ulcer prevention Sample: 23 pediatric critical care nurses in a Canadian pediatric ICU Method: Cohort study Outcome measures: Before-and-after measures of frequency of use of interventions as documented in patient records and by observation Duration: 6 months Richards, D., L. Toop, and P. Graham. 2003. Do clinical practice education groups result in sustained change in GP prescribing? Family Practice 20(2):199-206. Determine whether a peer-led small-group educational program is an effective tool in changing practice when added to audit and feedback, academic detailing, and educational bulletins Sample: 230 GPs in urban New Zealand Method: Retrospective analysis of a controlled trial Experimental group: audit and feedback, individual academic detailing, educational bulletins, and peer-led group academic detailing sessions Control group: audit and feedback, academic detailing, and educational bulletins Outcome measure: Targeted prescribing for 12 months before and 24 months after education sessions Duration: 36 months
OCR for page 221
Redesigning Continuing Education in the Health Professions Description of Educational Method Findings * Part I targeted individuals with independent and group learning activities: laminated pocket guides, bedside decision-making algorithm * Part II incorporated local and organizational strategies: unit champions, bedside coaching, development of standards Significant change in implementation of 2 of 11 recommended practices following both interventions (p < 0.001) * Clinical practice education groups met monthly * GP-led discussion of evidence-based topics * Individual prescribing data provided to each GP * Peer-led small-group discussions had a sustained, positive effect on prescribing behavior that was in addition to any effect of the other educational methods (mean effect size = 1.20) * Mean duration of significant effect was 14.5 months (CI: 95%)
OCR for page 222
Redesigning Continuing Education in the Health Professions Reference Study Purpose Sample, Method, Outcome Measures, and Duration Saini, B., L. Smith, C. Armour, and I. Krass. 2006. An educational intervention to train community pharmacists in providing specialized asthma care. American Journal of Pharmaceutical Education 70(5):118-126. Test the effect of an educational intervention on pharmacist satisfaction and practice behavior as well as patient outcomes Sample: 27 pharmacists providing asthma care to 102 patients in Australia Method: Controlled trial Experimental group: educational intervention Control group: no intervention Outcome measures: Participant reactions gauged using a questionnaire; asthma severity; peak flow indices; medication costs per patient Duration: 6 months Schneeweiss, S., and S. Ratnapalan. 2007. Impact of a multifaceted pediatric sedation course: Self-directed learning versus a formal continuing medical education course to improve knowledge of sedation guidelines. Canadian Journal of Emergency Medical Care 9(2):93-100. Evaluate the effectiveness of a sedation course in improving physicians’ knowledge of pediatric procedural sedation guidelines, relative to self-directed learning Sample: 48 emergency staff physicians, fellows, and residents in a pediatric emergency department Method: Randomized controlled trial Experimental group: self-directed learning Control group: formal, 4-hour course Outcome measures: Scores on multiple choice pre- and post-intervention exam Duration: 2 weeks
OCR for page 223
Redesigning Continuing Education in the Health Professions Description of Educational Method Findings Self-directed learning, small-group learning, and workshops with case studies in addition to asthma care training provided in a lecture * Significant reduction in asthma severity in the experimental group (p < 0.001) vs. the control group * In the experimental group, peak flow indices improved from 82.7% at baseline to 87.4% (p < 0.0010) at the final visit * Significant reduction in defined daily dose of albuterol used by patients (p < 0.015) * The 4-hour course consisted of small-group and didactic instruction with case studies * The self-directed group received a package with learning objectives, guidelines, a pocket card, and reading materials Control group’s median exam score (83.3%; range: 75.8-96.5%) was significantly higher (p < 0.0001) than median exam score of the experimental group (73.3%; range: 43.5-86.6%)
OCR for page 224
Redesigning Continuing Education in the Health Professions Reference Study Purpose Sample, Method, Outcome Measures, and Duration Scholes, D., L. Grothaus, J. McClure, R. Reid, P. Fishman, C. Sisk, J. E. Lindenbaum, B. Green, J. Grafton, and R. S. Thompson. 2006. A randomized trial of strategies to increase Chlamydia screening in young women. Preventive Medicine 43(4):343-350. Evaluate an intervention to increase guideline-recommended Chlamydia screening Sample: 23 primary care clinics; 3,509 sexually active females ages 14-25 Method: Randomized controlled trial Experimental group: enhanced guideline intervention Control group: standard guideline implementation instructions Outcome measures: Post-intervention Chlamydia testing rates Duration: 27 months Young, J. M., C. D’Este, and J. E. Ward. 2002. Improving family physicians’ use of evidence-based smoking cessation strategies: A cluster randomization trial. Preventive Medicine 35(6):572-583. Evaluate a multifaceted, practice-based intervention involving audit, feedback, and academic detailing to improve family physician smoking cessation advice Sample: 60 family physicians in Australia Method: Cluster randomized controlled trial Experimental group: multifaceted intervention Control group: no intervention Outcome measures: Delivery of smoking cessation advice determined by patient recall, physician report, and medical record audit; utilization of nicotine replacement therapies Duration: 6 months NOTE: NA = Not applicable.
OCR for page 225
Redesigning Continuing Education in the Health Professions Description of Educational Method Findings The enhanced guideline group used clinic-based opinion leaders, individual measurement and feedback, exam room reminders, and chart prompts * Enhanced intervention did not significantly affect Chlamydia testing (OR = 1.08; 95% CI: 0.92-1.26; p = 0.31) * Testing rates increased among women making preventive care visits in intervention vs. control clinics * Audit and feedback conducted by a medical peer * Medical record prompt in the form of Post-it notes on medical records * Provision of additional resources for physicians and patients * Significant increase in the experimental group over the control group in the use of nicotine replacement gum (p = 0.0002) and patches (p = 0.0056) * No significant differences between groups in smokers’ recall or documentation in medical record of specific cessation advice
OCR for page 226
Redesigning Continuing Education in the Health Professions This page intentionally left blank.