Dave Davis

DOES CME WORK? AN ANALYSIS OF THE EFFECT OF EDUCATIONAL ACTIVITIES ON PHYSICIAN PERFORMANCE OR HEALTH CARE OUTCOMES*

Objective: To answer the question, “does CME work?” by reviewing the effectiveness of continuing medical education (CME) and other related educational methods on objectively-determined physician performance and/or health care outcomes. These interventions include educational materials, formal, planned CME activities or programs, outreach visits such as academic detailing, opinion leaders, patient-mediated strategies, audit and feedback, reminders, or a combination of these strategies. Methods: MEDLINE, ERIC, NTIS, the Research and Development Resource Base in CME and other relevant data sources including review articles were searched for relevant terms, from 1975 to 1994. Of those articles retrieved, randomized controlled trials of educational strategies or interventions which objectively assessed physician performance and/or health care outcomes were selected for review. Data were extracted from each article about the specialty of the physician targeted, the clinical subject of the intervention, the setting and the nature of the educational method, and the presence or degree of needs assessment or barriers to change. Results: More than two-thirds of the studies (70%) displayed a change in physician performance, while almost half (48%) of interventions produced a change in health care outcomes. Community-based strategies such as academic detailing (and to a lesser extent, opinion leaders), practice-based methods such as reminders and patient-mediated strategies, and multiple interventions appeared to be most effective activities. Mixed results and weaker outcomes were demonstrated by audit and educational materials, while formal CME conferences without enabling or practice-reinforcing strategies, had relatively little impact. Conclusion: Strategies which enable and/or reinforce appear to “work” in changing physician performance or health care outcomes, a finding which has significant impact on the delivery of CME, and the need for further research into physician learning and change.

Practitioner and Organizational Barriers to Evidence-based Practice of Physical Therapists for People With Stroke

Background and Purpose: The purpose of this study was to identify practitioner barriers (education, attitudes and beliefs, interest and perceived role, and self-efficacy) and organizational barriers (perceived support and resources) to physical therapists’ implementation of evidence-based practice (EBP) for people with stroke. Subjects: The participants were 270 physical therapists providing services to people with stroke in Ontario, Canada. Methods: A cross-sectional mail survey was conducted. Results: Only half of respondents had learned the foundations of EBP in their academic preparation or received training in searching or appraising research literature. Although 78% agreed that research findings are useful, 55% agreed that a divide exists between research and practice. Almost all respondents were interested in learning EBP skills; however, 50% indicated that physical therapists should not be responsible for conducting literature reviews. Average self-efficacy ratings were between 50% and 80% for searching and appraising the literature and below 50% for critically appraising psychometric properties and understanding statistical analyses. Despite Internet access at work for 80% of respondents, only 8% were given protected work time to search and appraise the literature. Discussion and Conclusion: Lack of education, negative perceptions about research and physical therapists’ role in EBP, and low self-efficacy to perform EBP activities represent barriers to implementing EBP for people with stroke that can be addressed through continuing education. Organizational provision of access to Web-based resources is likely insufficient to enhance research use by clinicians.

Continuing Medical Education: A New Vision of the Professional Development of Physicians.

The authors describe their vision of what continuing medical education (CME) should become in the changing health care environment. They first discuss six types of literature (e.g., concerning learning and adult development principles, problem-based/practice-based learning, and other topics) that contribute to ways of thinking about and understanding CME. They then state their view that the Association of American Medical Colleges (AAMC) has made a commitment to helping CME be more effective in the professional development of physicians. In presenting their new vision of CME, the authors describe their interpretation of the nature and values of CME (e.g., optimal CME is highly self-directed; the selection and design of the most relevant CME is based on data from each physicians responsibilities and performance; etc.). They then present seven action steps, suggestions to begin them, and the institutions and organizations they believe should carry them out, and recommend that the AAMC play a major role in supporting activities to carry out these steps. (For example, one action step is the generation and application of new knowledge about how and why physicians learn, select best practices, and change their behaviors). Six core competencies for CME educators are defined. The authors conclude by stating that collaboration among the appropriate academic groups, professional associations, and health care institutions, with leadership from the AAMC, is essential to create the best learning systems for the professional development of physicians.

Evaluating the teaching of evidence based medicine: conceptual framework

Although evidence for the effectiveness of evidence based medicine has accumulated, there is still little evidence on what are the most effective methods of teaching it.

Continuing Medical Education Effect on Practice Performance

BACKGROUND There has been sizable debate and widespread skepticism about the effect of continuing medical education (CME) on the performance of physicians in the practice setting. This portion of the review was undertaken to examine that effect. METHODS The guideline panel used data from a comprehensive review of the effectiveness of CME developed by The Johns Hopkins Evidence-based Practice Center, focusing on the effect of CME on clinical performance. RESULTS The review found 105 studies, which evaluated the impact of CME on short- and long-term physician practice performance. Nearly 60% met objectives relative to changing clinical performance in prescribing; screening; counseling about smoking cessation, diet, and sexual practices; guideline adherence; and other topics. Single live and multiple media appeared to be generally positive in their effect, print media much less so. Multiple educational techniques were more successful at changing provider performance than single techniques. The amount or frequency of exposure to CME activities appeared to have little effect on behavior change. CONCLUSIONS Overall, CME, especially using live or multiple media and multiple educational techniques, is generally effective in changing physician performance. More research, however, is needed that focuses on the specific types of media and educational techniques that lead to the greatest improvements in performance.

Can We Alter Physician Behavior by Educational Methods? Lessons Learned from Studies of the Management and Follow-up of Hypertension.

Introduction: As expectations for effective continuing medical education (CME) grow, so, too, does the need to identify relationships among educational methods, physician performance, and patient outcomes associated with specific disease entities. Thus, we set out to review the literature on the effectiveness of physician educational interventions in the management and follow‐up of hypertension. Method: We searched PubMed and the Research and Development Resource Base in Continuing Medical Education for randomized controlled trials of physician educational interventions. We included only those studies that (a) used replicable educational interventions with > 50% physician involvement and that employed objective methods to measure physician behavior change or patient outcomes, (b) indicated a physician or patient dropout rate of < 30%, and (c) followed outcome measurement for > 30 days. Studies were designated “positive” if one or more of the primary outcome measures demonstrated a statistically significant change in physician performance or health care outcome. Results: We found 12 studies in which 7 different physician educational interventions were employed, alone or in combination, including reminders (computer or chart), formal CME, computerized decision support systems/risk stratification, printed educational materials, academic detailing, continuous quality improvement projects, and disease management aids in patient charts. Of the 12, 7 were positive and 4 were negative. One had mixed results. Discussion: Although physician educational interventions, especially reminders, improved the follow‐up of hypertension, they were ineffective in changing blood pressure levels. However, they may have some utility in improving compliance with guideline recommendations.

Continuing Education, Guideline Implementation, and the Emerging Transdisciplinary Field of Knowledge Translation.

&NA; This article discusses continuing education and the implementation of clinical practice guidelines or best evidence, quality improvement, and patient safety. Continuing education focuses on the perspective of the adult learner and is guided by well‐established educational principles. In contrast, guideline implementation and related concepts borrow from the fields of quality improvement and patient safety and from health services research. Relative to the question of improved clinical outcomes, both to some extent afford only partial understanding of a complex issue. Knowledge translation (KT) is a transformative concept that links the best elements of both broad fields and, in particular, adds educational elements to the work of health services researchers and others. Interdisciplinary in the extreme, KT is explored in some detail: its major elements (information, facilitation, context, the clinician‐learner, among others) considered as variables in an equation leading to knowledge uptake and improved health care outcomes and an improved functioning health care system.

The contingencies of organizational learning in long-term care: factors that affect innovation adoption.

We apply the theoretical frameworks of knowledge transfer and organizational learning, and findings from studies of clinical practice guideline (CPG) implementation in health care, to develop a contingency model of innovation adoption in long-term care (LTC) facilities. Our focus is on a particular type of innovation, CPGs designed to improve the quality of LTC. Our interest in this area is founded on the premise that the ability of LTC organizations to adopt and sustain the use of innovations like CPGs is contingent on the initial capacity these institutions have to learn about them, and on the presence of factors that contribute to capacity building at each stage of innovation adoption. Based on our review of relevant theory, we develop a set of fifteen testable propositions that relate factors operating at the guideline, individual, organizational, and environmental levels in LTC institutions to stages of guideline adoption/transfer. Our model offers insights into the complexities of adopting and sustaining innovations in LTC facilities particularly, in health care organizations specifically, and in service organizations generally.

Continuing medical education. Global health, global learning.

CME—continuing medical education—has become an international discipline. Defined as any and all ways by which doctors learn after the formal completion of their training,1 CME is being shaped by several forces. Foremost among these are the globalisation of health2; cross disciplinary movements such as evidence based medicine; common trends in medical education and the assessment of professional competence; and the impact on health care and professional education of the identification of the determinants of health.3 4 Add to these electronic mail and the internet allowing instant global communication and virtually unlimited access to medical information and it is not hard to see why CME has become an international concern.5 This paper reviews the main published work on CME, identifies major themes in its development, and points to ways that may help standardise and support the provision of CME internationally. To gather information for this article, I searched the Research and Development Resource Base in CME extensively for articles (published 1986-96) that describe CME activities worldwide, excluding North America and the United Kingdom.6 At the time this article was written, it contained references to over 7000 articles and monographs devoted to continuing health professional education. I also searched Medline, eric, embase, and other databases for articles (published 1986-96), using terms and phrases such as world health, global health, international cooperation, and international educational exchange and continuing medical education terms combined with geographical names. Then I circulated the results of the literature searches and a brief questionnaire to key informants in the field, to identify other articles and to add their opinions about forces for and trends in continuing medical education. #### Summary points Health is a global issue; hence continuing medical education is an integral phenomenon International CME is more than conferences and courses—it includes projects in needs …

Selecting educational interventions for knowledge translation

The term “education” has many meanings, although its gestalt shows little effect on the performance of clinicians or the outcomes of health care. This lack of effect is especially true in continuing medical education (CME), where education often implies a large, group-based session held in a