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Putting the Value in High-Value CPD
To build a business case for implementing high-value continuing professional development (CPD), it is critical to understand how CPD aligns with value-based purchasing as it takes hold in the United States and in other international markets as well. In the view of Paul Mazmanian, associate dean for assessment and evaluation studies at Virginia Commonwealth University, those responsible for managing professional development will likely face pressure to restructure the CPD enterprise to meet the demands of reorganizing health systems. Value would be based on how well the CPD meets the needs of the individual health care provider,
the profession, the public, and others investing in the results of CPD. Often, value is measured in financial terms, but there are also nonmonetized outcomes, such as interprofessional collaboration or patient satisfaction, that may be of equal or greater value than the financial implications of a CPD intervention.
WHAT IS THE VALUE PROPOSITION FOR HIGH-VALUE CPD?
Paul Mazmanian, Virginia Commonwealth University
To help the workshop participants better understand value when discussing high-value CPD, Mazmanian explored components of the value proposition [Value = (Outcomes + Quality)/Cost]. He first looked at outcomes and quality before delving into issues related to effectiveness and cost. Following his presentation, the audience used his ideas to grapple with defining the stakeholders for a business case that might benefit from a particular CPD intervention.
Outcomes and Quality
Mazmanian explained that outcomes can be measured at a number of different levels and with a variety of tools. The simplest outcome—and one that is often measured by traditional continuing education (CE)—is the number of people who participate in an activity. Outcomes can also be measured by participant satisfaction with the activity, knowledge gained through participation, intention to change practice as a result of the activity, and actual change in practice. Finally, an activity can be evaluated by its effect on changes in patient or population health. These would all be indications of quality. Tools ordinarily used to measure the effect of an educational activity include questionnaires, tests of knowledge, self-reported changes in knowledge or intention to change, observed changes in practice, and clinical or self-reported patient outcomes. Less frequently reported outcomes include immunization rates, mortality, morbidity, and other community health indicators. Box 3-1 outlines evaluation perspectives of Moore, Green, and Gallis with tools for achieving desired results and improved outcomes (Moore et al., 2009). Mazmanian uses the work of Moore because it offers increased sensitivity for measuring progress and success at levels 1 and 2, and, with more recent versions, at 3C.
Effectiveness
Next, Mazmanian explored the various forms that CE or CPD can take, and the evidence about the effectiveness of each form for affecting
changes in attitudes, learning, and behavior. The interventions and definitions noted in Table 3-1 are derived from the Cochrane Collaboration, Effective Practice and Organisation of Care Group, which recently updated its taxonomy to be more sensitive to accountability and organizational culture (EPOC, 2015).
As shown in Table 3-1, effects are inconsistent across interventions, settings, and behaviors. This analysis is derived largely from reviews of studies extending from 1995 to 2017 (Davey et al., 2017; Davis et al., 1995; IOM, 2010; Mazmanian, 2009; McGaghie, 2013; Neimeyer and Taylor, 2012; Rayburn et al., 2017). According to Mazmanian, the assembled evidence offers guidance about general principles for CE and CPD, but it provides limited specifics regarding the best ways to support learning and behavior change, in all cases. For the most part, there is evidence to support the overall effectiveness of CE and CPD in select instances, but too little evidence exists to make a compelling case for the effectiveness of CE or CPD in every circumstance (IOM, 2010). As a result, CPD providers cannot always determine the effectiveness of their instructional methods, and health professionals lack a dependable basis for choosing among CPD activities. However, this is not unique to CPD. There is visible concern throughout the behavioral sciences that study results too often are not replicable. Recent reports suggest that half or fewer of the published studies in psychology produce replicable results (Ioannidis et al., 2014; Van Bavel et al., 2016).
Mazmanian fears that the historic inability to draw definitive scientific conclusions about the effectiveness of CPD is clouding discussions about the value of CPD. He also noted the pivotal role of the learner in well-designed CPD: CPD participants must recognize a need for improvement, and be motivated to learn and actually implement changes, especially in the face of any resistance to change. Without these conditions, Mazmanian has difficulty seeing how CPD will be maximally effective.
TABLE 3-1 Educational Interventions and Their Effectiveness
| Intervention | Definition | Effectiveness for Behavior Change |
|---|---|---|
| Educational material | Printed/published and distributed recommendations for clinical care | Little or no effect |
| Conferences | Conferences, workshops, lectures outside practice setting | Mixed effectiveness |
| Intervention | Definition | Effectiveness for Behavior Change |
|---|---|---|
| Outreach visits | Trained person meets with providers in practice setting to improve performance | Mixed effectiveness |
| Local opinion leaders | Practitioners defined by their colleagues as influential, often using sociometric techniques to make the determination | Mixed effectiveness |
| Patient-mediated interventions | Physicians get information from patients who receive it from other sources | Mixed effectiveness |
| Audit and feedback | Summary of clinical performance of health care over a specified period, with or without recommendations for clinical action; information obtained from medical records, databases, patients, or observation | Mixed effectiveness |
| Reminders | Intervention (manual or computerized) prompting physicians to perform a clinical action (e.g., reminders about screening/preventive services, enhanced laboratory reports, and administrative support, such as follow-up appointment systems or stickers on charts) | More consistent effectiveness |
| Multifaceted interventions | Select combinations of the previous seven interventions, such as outreach visits, clinical information from patients, or computer reminders to counsel patients about specific disorders | More consistent effectiveness |
| Interprofessional education | Two or more health and social care professionals learning interactively in educational sessions | Mixed effectiveness |
| Interprofessional collaboration | Interventions in health care settings to improve care provided by two or more health professionals | Mixed effectiveness |
SOURCE: Presented by Paul Mazmanian, April 6, 2017.
Costs
Mazmanian explained that there are many ways to analyze the costs and benefits of a CPD program, and gave three examples. First was a simple calculation of the per-participant cost; for example, the total costs of the venue, materials, staffing, and food divided by the number of participants. Second was an analysis that included nonmonetary benefits; for example, if a specific CPD program costs more than another option, but it is more time efficient, the extra money may be worth the time savings. Third was a cost analysis that takes into account future revenue gains that are due to the program; for example, a physician that is trained in a procedure through CPD will be able to generate future revenue by performing the procedure, and this revenue may justify the initial expense of CPD. Mazmanian closed by saying that those who provide and study education and patient care must articulate sound explanations and realistic expectations for the value of their work; yet, the science to explain outcomes is incomplete with uncertain causal linkages.
Table Discussions
In an attempt to bring the presentations of Karahanna and Mazmanian to life, Cervero asked the workshop participants to talk to the other people at their small tables to identify examples of high-value CPD activities. The examples could be theoretical or based on an actual activity drawn from personal experiences. Each table had a designated facilitator encouraging dialogue on examples of high-value CPD activities, who benefits from a particular CPD design and how they benefit, and what the associated costs might be with an identified activity. After 10 minutes of discussion, one participant from each table reported back to the larger group with his or her identified CPD activity and its associated costs and benefits. These comments, shown in Table 3-2, are those of the individual respondent and should not be considered a group consensus.
PATIENT PERSPECTIVE AND NONECONOMIC VALUES
Andrew Spiegel, International Alliance of Patient Organizations
Spiegel, director of the International Alliance of Patient Organizations, told workshop participants that although much of the attention is focused on the economic benefits of CPD, CPD can also contribute to important noneconomic benefits for the patient. Spiegel has been a leader in the patient advocacy community for more than 20 years, after his parents died 2 days apart from two different cancers. Over these 20 years, Spiegel has worked to improve the patient experience by identifying and addressing
TABLE 3-2 Exploring Costs and Benefits to High-Value CPD Activities
| CPD Activity | Costs | Benefits |
|---|---|---|
| Table 1 respondent: Based on an actual example of an interactive, longitudinal workplace minicourse at USUHS that teaches epidemiologists how to use geographic information system (GIS) mapping | Expenses include the teacher who was from the USUHS and paid for by taxpayers, the epidemiologists’ time, and purchase of the software. |
|
| Table 2 respondent: A theoretical CPD activity for learning leadership and management skills | The main cost would be the delivery of the training and the opportunity costs (i.e., what has to shift in order to accommodate the training). |
|
| Table 3 respondent: A theoretical CPD activity for training health care workers to combat the opioid epidemic | While the costs for the program are uncertain, there were theorized financial gains through reduced public health costs and improved public safety. |
|
| CPD Activity | Costs | Benefits |
|---|---|---|
| Table 4 respondent: Based on an actual example of a team-based simulation activity for health care workers in a high-risk OB section to practice very specific high-risk interventions |
A potential perverse disincentive is that C-sections actually have a higher bundle rate. So if there is a decrease in the number of C-sections, this may change the revenue stream. |
|
| Table 5 respondent: A theoretical CPD activity using TeamSTEPPS as applied to palliative care in the home | Costs involve a simple metric of calculating the cost of care in the hospital versus the cost of care in the home. |
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| CPD Activity | Costs | Benefits |
|---|---|---|
| Table 6 respondent: Based on an actual example where a national association with thousands of clinics around the United States wanted to improve the competencies of administrators at each of the clinics | Costs include an expert consultant, the platform for delivery of the education, and the time of the administrators. |
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| Table 7 respondent: A theoretical interprofessional CPD activity looking at ventilator-acquired pneumonia in a practice setting | While the costs for the program are uncertain, it was theorized that health care expenditures would be reduced in terms of implementing this bundle. |
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NOTE: OB = obstetrics; TeamSTEPPS = Team Strategies & Tools to Enhance Performance & Patient Safety; USUHS = Uniformed Services University of the Health Sciences.
unmet patient needs. He noted that in the patient advocacy community the issue of CPD is not “ever discussed or published” despite the self-evident link between health care provider skills and knowledge and the patient experience. Spiegel said:
There is little debate that CPD can improve the health care provider’s knowledge base and skill level, can change behaviors and attitudes, and can improve clinical outcomes. All of this can (and should) benefit the patient.
Based on Spiegel’s personal and professional experiences, he identified 12 patient-focused goals for CPD:
- CPD can increase patients’ knowledge about their disease and treatment options. Spiegel said that, despite efforts by the patient advocacy community to educate patients outside the clinic setting, patients still tend to get most of their information from their doctors and follow their doctors’ recommendations. For this reason, it is essential that CPD helps providers effectively convey and translate information about disease management to their patients.
- CPD can promote patient comfort. Patient comfort can take many forms, including comfort in understanding the disease, comfort with the treatment of the disease, and comfort with medication management.
- CPD can ensure that health care providers are reliable sources of information. Spiegel said that “Dr. Google” has changed the traditional patient–provider relationship. Patients now come into a provider’s office armed with information gleaned from the Internet. To work within this new paradigm, providers must stay up to date not just on the latest scientific information about a disease but also on what patients and others are talking about on the Internet.
- CPD can consider patient preferences. Sometimes what a patient prefers is inconsistent with other stakeholders’ goals, said Spiegel. For example, when Spiegel’s mother was battling cancer, her preference was to be in the hospital where she could get access to care and pain management. However, her wishes were in contrast to the goals of stakeholders like payers and providers, whose goal is generally to keep patients out of the hospital to reduce costs and minimize the risk of hospital-acquired infections. CPD could educate health care providers to better understand and acknowledge these differing priorities.
- CPD can recognize the informed patient and encourage dialogue. Spiegel observed that some providers are annoyed with patients who gather their own information and want to be active participants in understanding and managing their disease. CPD could help providers understand how to work with these patients and encourage dialogue.
- CPD can teach providers to value patients’ time. Spiegel suggested that CPD could help providers understand that patients have lives and activities outside of disease management, and that the timing of clinic appointments and treatments should acknowledge this reality.
- CPD can encourage clinical trials where appropriate. Most patients receive information about clinical trials from their health care providers, but the majority of health care providers do not even discuss clinical trials with patients, said Spiegel.
- CPD can recognize that illness affects more than the patient. When a patient is diagnosed with a disease, there is an entire community of people who are affected, including the patient, the family, the caretaker, and the employer. CPD could help providers recognize this fact, and recognize the value and importance of all community members’ time and perspectives.
- CPD can consider the effect of treatment on nonmedical issues. Spiegel said that while medical guidelines may tell a provider the “best” treatment for a patient, this does not take into account the patient’s perspective and the effect that a treatment may have on the patient’s family or ability to work. CPD could encourage better dialogue between providers and patients to make these types of decisions.
- CPD can consider the caregiver. A patient’s caregiver can be a key player in a patient’s treatment plan. The provider can learn to take the time to acknowledge the caregiver’s role and offer assistance and information to that caregiver when indicated or requested.
- CPD can encourage recognition that a patient is a unique individual. Spiegel noted that regulators and policy makers are often looking for a “one-size-fits-all” approach to patient care in order to save costs and simplify the system. However, providers need to remember that patients have unique bodies and unique needs, and these standard guidelines may not be appropriate for every patient.
- CPD can remind providers that patients come before economics. When providers are making decisions about disease management, they should keep in mind that patients are more important than the bottom line. CPD can help providers take patient preferences into account and to think creatively in order to “find a way to pay!”
Spiegel concluded that when CPD is being developed and implemented, “the patient must always be the central focus.” He reminded workshop participants that “at some point, we will all be patients.” In response to a call for questions and comments, many workshop participants responded.
Marilyn De Luca of the New York University School of Nursing and Medicine shared that she and her colleagues often forget that the provider does not “own the illness or . . . birthing experience,” and asked Spiegel how CPD can help providers understand and acknowledge the centrality of the patient in making informed decisions about disease management. Spiegel responded that the patient’s perspective and involvement in care depend in large part on cultural expectations. He said that in Europe, patients who are diagnosed with colon cancer generally accept the testing and treatment that the government is willing to pay for; whereas in the United States, patients fight for the best medical care available, even when it is just an incre-
mental advance in treatment. CPD that is geared toward helping providers understand and acknowledge the patient’s perspective can be adapted for the culture and health care environment of the patient’s country.
Michelle Troseth, president of the National Academies of Practice, asked Spiegel to elaborate further on his point about encouraging informed dialogue between patients and providers. Spiegel said that in his experience, the traditional relationship between patients and providers—in which the provider makes the decisions and the patient follows orders—is falling away as the generations shift. He noted that younger patients are more likely to come to the doctor’s office armed with information, and likewise, younger providers are more likely to recognize and understand that patients want to be informed and active decision makers in their care.
Sandeep Kishore of the Young Professionals Chronic Disease Network brought up the tension between the rights and needs of the individual patient versus the realities of tight budgets and the needs of the population as a whole. He asked Spiegel for his perspective on how to balance this tension. Spiegel responded that there is no easy answer. He noted that as medical advances are made, there are new and very expensive treatments or cures becoming available, but it is financially unfeasible to pay for every patient’s treatment. The National Institute for Health and Care Excellence in the United Kingdom attempts to address this tension by conducting an assessment that compares the cost of the treatment to the value of the life that would be extended or saved. This kind of assessment inevitably denies treatment to some patients, he remarked, before wondering aloud, “Should every patient have access to every therapy no matter where they are in the world?” The International Alliance of Patient Organizations advocates for universal quality health care in every country in the world, but Spiegel admits that achieving this goal is enormously difficult and not getting any easier.
Brenda Zierler of the American Academy of Nursing said that chronic disease management, and cancer care in particular, requires a team approach. She noted that patients often spend a relatively small amount of time with their doctors, and much more time with other team members who meet patient needs for comfort, information, therapy, and social work. Zierler and Spiegel agreed that the design and implementation of CPD could reflect this team approach to care, rather than further entrenching the silos within health care.
Joanna Cain of the American Board and College of Obstetrics and Gynecology described her experience. Some of the best advice about how to train physicians, she said, has come from her cancer patients. However, these patients are not always comfortable sharing their opinions in such formal venues as large meetings or committees. Noting that the patient perspective is invaluable in building a business case for CPD, she asked Spiegel
how patients can be encouraged to share their ideas and provide input. Spiegel agreed that patients are often intimidated about getting involved in academic or policy discussions, and said that as a consequence, many important conversations have traditionally lacked the patient perspective. He said that patient advocacy organizations are changing this unfortunate dynamic, and that these groups are participating in discussions about many aspects of health care. Patient advocacy groups have not yet been included in the discussions about CPD, Spiegel said, but they are eager to participate and can provide this critical patient perspective.
Referring to Spiegel’s conclusion that “we will all be patients,” Laura Magaña Valladares of the Association of Schools and Programs of Public Health said that preferably, we would all be “really healthy citizens.” She asked Spiegel for his perspective on prevention and health promotion. He responded that cancer screening as a preventive measure has been an enormous success in recent years. An increase in screenings such as colonoscopies has saved “literally tens of thousands of lives in the last 10 to 15 years.” He noted that the increase in screenings was attributable “primarily” to CPD, and that a great opportunity exists for health care providers to continue to make strides in preventive care.
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