Deepika Appana

Educating Resident Physicians Using Virtual Case-Based Simulation Improves Diabetes Management: A Randomized Controlled Trial

Purpose To test a virtual case-based Simulated Diabetes Education intervention (SimDE) developed to teach primary care residents how to manage diabetes. Method Nineteen primary care residency programs, with 341 volunteer residents in all postgraduate years (PGY), were randomly assigned to a SimDE intervention group or control group (CG). The Web-based interactive educational intervention used computerized virtual patients who responded to provider actions through programmed simulation models. Eighteen distinct learning cases (L-cases) were assigned to SimDE residents over six months from 2010 to 2011. Impact was assessed using performance on four virtual assessment cases (A-cases), an objective knowledge test, and pre–post changes in self-assessed diabetes knowledge and confidence. Group comparisons were analyzed using generalized linear mixed models, controlling for clustering of residents within residency programs and differences in baseline knowledge. Results The percentages of residents appropriately achieving A-case composite clinical goals for glucose, blood pressure, and lipids were as follows: A-case 1: SimDE = 21.2%, CG = 1.8%, P = .002; A-case 2: SimDE = 15.7%, CG = 4.7%, P = .02; A-case 3: SimDE = 48.0%, CG = 10.4%, P < .001; and A-case 4: SimDE = 42.1%, CG = 18.7%, P = .004. The mean knowledge score and pre–post changes in self-assessed knowledge and confidence were significantly better for SimDE group than CG participants. Conclusions A virtual case-based simulated diabetes education intervention improved diabetes management skills, knowledge, and confidence for primary care residents.

TeenBP: Development and Piloting of an EHR-linked Clinical Decision Support System to Improve Recognition of Hypertension in Adolescents

Context: Blood pressure (BP) is routinely measured in children and adolescents during primary care visits. However, elevated BP or hypertension is frequently not diagnosed or evaluated further by primary care providers. Barriers to recognition include lack of clinician buy-in, competing priorities, and complexity of the standard BP tables. Case Description: We have developed and piloted TeenBP— a web-based, electronic health record (EHR) linked system designed to improve recognition of prehypertension and hypertension in adolescents during primary care visits. Major Themes: Important steps in developing TeenBP included the following: review of national BP guidelines, consideration of clinic workflow, engagement of clinical leaders, and evaluation of the impact on clinical sites. Use of a web-based platform has facilitated updates to the TeenBP algorithm and to the message content. In addition, the web-based platform has allowed for development of a sophisticated display of patient-specific information at the point of care. In the TeenBP pilot, conducted at a single pediatric and family practice site with six clinicians, over a five-month period, more than half of BPs in the hypertensive range were clinically recognized. Furthermore, in this small pilot the TeenBP clinical decision support (CDS) was accepted by providers and clinical staff. Effectiveness of the TeenBP CDS will be determined in a two-year cluster-randomized clinical trial, currently underway at 20 primary care sites. Conclusion: Use of technology to extract and display clinically relevant data stored within the EHR may be a useful tool for improving recognition of adolescent hypertension during busy primary care visits. In the future, the methods developed specifically for TeenBP are likely to be translatable to a wide range of acute and chronic issues affecting children and adolescents.

Using Simulation Technology to Teach Diabetes Care Management Skills to Resident Physicians

Background: Simulation is widely used to teach medical procedures. Our goal was to develop and implement an innovative virtual model to teach resident physicians the cognitive skills of type 1 and type 2 diabetes management. Methods: A diabetes educational activity was developed consisting of (a) a curriculum using 18 explicit virtual cases, (b) a web-based interactive interface, (c) a simulation model to calculate physiologic outcomes of resident actions, and (d) a library of programmed feedback to critique and guide resident actions between virtual encounters. Primary care residents in 10 U.S. residency programs received the educational activity. Satisfaction and changes in knowledge and confidence in managing diabetes were analyzed with mixed quantitative and qualitative methods. Results: Pre- and post-education surveys were completed by 92/142 (65%) of residents. Likert scale (five-point) responses were favorably higher than neutral for general satisfaction (94%), recommending to colleagues (91%), training adequacy (91%), and navigation ease (92%). Finding time to complete cases was difficult for 50% of residents. Mean ratings of knowledge (on a five-point scale) posteducational activity improved by +0.5 (p < .01) for use of all available drug classes, +0.9 (p < .01) for how to start and adjust insulin, +0.8 (p < .01) for interpreting blood glucose values, +0.8 (p < .01) for individualizing treatment goals, and +0.7 (p < .01) for confidence in managing diabetes patients. Conclusions: A virtual diabetes educational activity to teach cognitive skills to manage diabetes to primary care residents was successfully developed, implemented, and well liked. It significantly improved self-assessed knowledge and confidence in diabetes management.

Clinical decision support for recognition and management of hypertension: A randomized trial

In this cluster-randomized trial conducted in a large health system, an EHR-linked CDS improved the recognition and guideline-adherent management of hypertension. OBJECTIVES: Although blood pressure (BP) is routinely measured in outpatient visits, elevated BP and hypertension are often not recognized. We evaluated whether an electronic health record–linked clinical decision support (CDS) tool could improve the recognition and management of hypertension in adolescents. METHODS: We randomly assigned 20 primary care clinics within an integrated care system to CDS or usual care. At intervention sites, the CDS displayed BPs and percentiles, identified incident hypertension on the basis of current or previous BPs, and offered tailored order sets. The recognition of hypertension was identified by an automated review of diagnoses and problem lists and a manual review of clinical notes, antihypertensive medication prescriptions, and diagnostic testing. Generalized linear mixed models were used to test the effect of the intervention. RESULTS: Among 31u2009579 patients 10 to 17 years old with a clinic visit over a 2-year period, 522 (1.7%) had incident hypertension. Within 6 months of meeting criteria, providers recognized hypertension in 54.9% of patients in CDS clinics and 21.3% of patients in usual care (P ≤ .001). Clinical recognition was most often achieved through visit diagnoses or documentation in the clinical note. Within 6 months of developing incident hypertension, 17.1% of CDS subjects were referred to dieticians or weight loss or exercise programs, and 9.4% had additional hypertension workup versus 3.9% and 4.2%, respectively (P = .001 and .046, respectively). Only 1% of patients were prescribed an antihypertensive medication within 6 months of developing hypertension. CONCLUSIONS: The CDS had a significant, beneficial effect on the recognition of hypertension, with a moderate increase in guideline-adherent management.

CC1-01: A Simulated Diabetes Learning Intervention Improves Provider Knowledge and Confidence in Managing Diabetes

Background/Aims Provider performance on diabetes measures is variable, and is at least partially due to differences in provider knowledge and confidence in managing patients with diabetes and multiple co-morbidities. Objective To evaluate whether a simulated learning program can improve provider knowledge and self-confidence in diabetes management. Methods 19 primary care residency programs and 341 consented residents were randomized to (a) intervention (177 residents) or (b) control (164 residents) conditions. Intervention subjects were assigned 18 learning cases using SimCare Diabetes, a web-based immersive simulation program that challenges providers to achieve blood sugar, blood pressure, and lipid goals in 6 months of simulated time, as well as to address other issues such as severe obesity and insulin resistance, hypoglycemia, depression, obstructive sleep apnea, and non-adherence. Between simulated encounters with a patient, providers receive personalized feedback on progress to goals and treatment actions taken or omitted. 92 intervention and 128 control subjects completed a post-intervention follow-up online survey with 10 multiple choice knowledge and 5 self-confidence assessment questions using a 5-point Likert scale (1=not at all confident, 5=very confident). Mean (95% CI) knowledge test and self- confidence measures, adjusting for residency program clustering, were compared by group. Results On knowledge testing, 46% of the intervention group answered more than half the answers correctly compared to 16% of the control group. The mean knowledge score (95% CI) was 5.31 (4.87–5.75) for intervention and 4.1 (3.69–4.50) for control subjects (p<.001). Self-confidence measures were higher for intervention compared to control subjects for: use of all available drug classes to manage diabetes (3.64 vs. 3.09, p<.001), insulin use (4.12 vs. 3.36, p<.001), interpretation of blood sugars (4.21 vs. 3.58, p< .001), setting individualized treatment goals (4.06 vs. 3.42, p< .001), and overall confidence in managing diabetes (3.97 vs. 3.28, p< .001). Discussion An immersive online simulated diabetes learning program was effective at improving knowledge and self-confidence for diabetes management in primary care residents. Support and partnerships to maintain and spread the technology are desirable.

Clinical decision support directed to primary care patients and providers reduces cardiovascular risk: a randomized trial

ObjectivenTo test the hypothesis that use of a clinical decision support (CDS) system in a primary care setting can reduce cardiovascular (CV) risk in patients.nnnMaterials and MethodsnTwenty primary care clinics were randomly assigned to usual care (UC) or CDS. For CDS clinic patients identified algorithmically with high CV risk, rooming staff were prompted by the electronic health record (EHR) to print CDS that identified evidence-based treatment options for lipid, blood pressure, weight, tobacco, or aspirin management and prioritized them based on potential benefit to the patient. The intention-to-treat analysis included 7914 adults who met high CV risk criteria at an index clinic visit and had at least one post-index visit, accounted for clustering, and assessed impact on predicted annual rate of change in 10-year CV risk over a 14-month period.nnnResultsnThe CDS was printed at 75% of targeted visits, and providers reported 85% to 98% satisfaction with various aspects of the intervention. Predicted annual rate of change in absolute 10-year CV risk was significantly better in CDS clinics than in UC clinics (-0.59% vs. +1.66%, -2.24%; Pu2009<u2009.001), with difference in 10-year CV risk at 12 months post-index favoring the CDS group (UC 24.4%, CDS 22.5%, Pu2009<u2009.03).nnnDiscussionnDeploying to both patients and providers within primary care visit workflow and limiting CDS display and print burden to two mouse clicks by rooming staff contributed to high CDS use rates and high provider satisfaction.nnnConclusionnThis EHR-integrated, web-based outpatient CDS system significantly improved 10-year CV risk trajectory in targeted adults.

Potential Misclassification of Blood Pressure Status in Children and Adolescents With Short or Tall Stature

Blood pressure (BP) is measured in percentiles that are adjusted for sex, age, and height percentile in children and adolescents. Standard tables for the conversion of BP percentiles do not present exact BP percentile cutoffs for extremes in stature, either short (<5th percentile) or tall (>95th percentile). An algorithm can be used to calculate exact BP percentiles across a range of height z scores. We compared values from standard BP tables with exact calculations of BP percentiles to see which were better at identifying hypertension in more than 5,000 children with either short or tall stature. Study subjects were 3-17-year-old patients within HealthPartners Medical Group, an integrated health care delivery system in Minnesota, at any time between 2007 and 2012. Approximately half of the subjects who met the criteria for hypertension using exact calculation would be misclassified as normal using available thresholds in the published BP tables instead of the recommended algorithm, which was not included in the tables.

PS1-47: Primary Care Residents Highly Rate Simulated Diabetes Training

Purpose Simulation training is prevalent in aviation and engineering industries, but acceptance by medical providers is unknown. Our objective was to design and evaluate resident physician satisfaction with simulated diabetes training. Methods This web-based learning program integrated these components: 18 unique diabetes learning cases, an interactive care management interface, a physiologic model to simulate outcomes of actions across a series of patient encounters, and a library of feedback messages to critique and guide provider actions. A total of 341 consented primary care residents in 19 U.S. residency programs were randomized to receive (n=177) or not receive (n=164) the learning intervention. A satisfaction survey evaluating program features was completed by 94 (53%) of intervention subjects. Responses to open-ended questions about features considered valuable and areas needing improvement were assessed using qualitative methods. Results Likert-scale responses were favorably higher than neutral for general satisfaction (93%), recommending to colleagues (91%), training adequacy (90%), navigation ease (95%), blood sugar displays (86%), drug info and help links (76%), goal progress graphs (49%), and feedback received (81%). Difficulty finding time to do cases was an issue for (51%) of responders. Open-ended responses (n=87) indicated that the most valuable learning pertained to insulin management (n=35), general management (n=23), and goal- achievement (n=10). Suggested improvements included software enhancements (n=34) and nothing bad to report (n=27). Discussion Learning through case simulations in a web-based dynamic environment is rated highly for satisfaction and ease of use by resident physicians. Most would recommend it to colleagues.