Robert E. Kristofco

Physician internet medical information seeking and on‐line continuing education use patterns

Introduction: Although physician Internet use patterns have been studied, little attention has been paid to how current physician learning and change theories relate to physician Internet information seeking and on‐line learning behaviors. The purpose of this study was to examine physician medical information–seeking behaviors and their relevance to continuing education (CE) providers who design and develop on‐line CE activities. Methods: A survey concerning Internet use and learning was administered by facsimile transmission to a random sample of 2,200 U.S. office‐based physicians of all specialties. Results: Nearly all physicians have access to the Internet, know how to use it, and access it for medical information; the Internets professional importance to physicians currently is in the area of professional development and information seeking to provide better care rather than for patient‐physician communication. A particular patient problem was the most common reason for seeking information. The credibility of the source, quick and 24‐hour access to information, and ease of searching were most important to physicians. Barriers to use included too much information to scan and too little specific information to respond to a defined question. Discussion: The importance of the Internet to physician professional development is growing rapidly. Access to on‐line continuing medical education must be immediate, relevant, credible, and easy to use. A sense of high utility demands content that is focused and well indexed. The roles of the CE provider must be reshaped to include helping physicians seek and construct the kind of knowledge they need to improve patient care.

Standardizing evaluation of on-line continuing medical education: physician knowledge, attitudes, and reflection on practice.

Introduction: Physicians increasingly earn continuing medical education (CME) credits through on‐line courses, but there have been few rigorous evaluations to determine their effects. The present study explores the feasibility of implementing standardized evaluation templates and tests them to evaluate 30 on‐line CME courses. Methods: A time series design was used to compare the knowledge, attitudes, and reported changes in practice of physician participants who completed any of 30 on‐line CME courses that were hosted on an academic CME Web site and a CME Web portal during the period from August 1, 2002, through March 31, 2003. Data were collected at baseline, at course completion, and 4 weeks later. Paired t tests were used to compare the means of responses across time. Results: U.S. physicians completed 720 post‐tests. Quality of content was the characteristic of most importance to participants; too little interaction was the largest source of dissatis‐faction. Overall mean knowledge scores increased from 58.1% to 75.6% at post‐test and then decreased to 68.2% at 4 weeks following the course. Effect sizes of increased knowledge immediately following the course were larger for case‐based than for text‐based courses. Nearly all physicians reported making changes in practice following course completion, although reported changes differed from expected changes. Conclusions: Increases in physician knowledge and knowledge retention were demonstrated following participation in on‐line CME courses. The implementation of standardized evaluation tests proved to be feasible and allowed longitudinal evaluation analyses across CME providers and content areas.

Quantitative Pediatric Vision Screening in Primary Care Settings in Alabama

Purpose. Alabama Medicaid reimburses “objective” vision screening (VS), i.e., by acuity or similar quantitative method, and well child checks (WCCs) separately. We analyzed the frequency of each service obtained. Methods. Claims for WCC and VS provided between October 1, 2002 and September 30, 2003 for children aged 3 to 18 years, and summary data for all enrolled children, were obtained from Alabama Medicaid. We used univariate analysis followed by logistic regression to explore the potential influence of factors (patient age, provider type, and provider’s volume of WCCs) on the receipt of VS at pre-school ages. Results. Children receiving WCCs were 55% black, 40% white, and 5% other. Percentages of children with WCC claims were highest at 4 years (57%) and thereafter declined to 30% at 6 to 14 years and to <10% at 18 years. Nearly all VS (>98% at each age) occurred the same day as the WCC. Pediatricians provided 68% of all WCCs. Multivariate analysis, after adjusting for nesting of pre-school patients within provider, showed the odds ratios (ORs) of VS were increased by patient age (5 years vs. 3 years, OR = 3.57, p < 0.0001), nonphysician provider type (nonphysician vs. pediatrician, OR = 1.80, p = 0.0004) and high WCC volume (at or above vs. below the median number (n = 8) of WCC per provider per year (OR = 7.11, p < 0.0001)). Because VS rates were high when attendance to WCC visits was low, few enrolled children received VS at any age (6% at the age of 3, 13% at the age of 4, and a maximum of 20% at the age of 5). Conclusions. National efforts to reduce preventable vision loss from amblyopia are hampered because children are not available for screening and because providers miss many opportunities to screen vision at pre-school age. Efforts to improve VS should target pediatrician-led practices, because these serve greater numbers of children.

How quality improvement interventions can address disparities in depression

&NA; The quality of depression care, especially care received by minorities, needs improvement. Several interventions have been developed for the purpose of improving the quality of depression management in primary care, including quality improvement strategies employing disease management approaches, the chronic care model, and the Breakthrough Collaborative Series developed by the Institute for Healthcare Improvement. This article reviews these interventions and examines their potential to contribute to the improvement of depression care.

Cost‐benefit analysis: Review of an evaluation methodology for measuring return on investment in continuing education

&NA; There is little evidence of measurement of return on investment for continuing medical education (CME) demonstrated in the current literature. The purpose of this review is to provide examples of cost‐benefit analysis and evaluation methodology used to measure return on investment, and to encourage exchange on this issue among CME professionals. The information in this article was gathered from reports of learning outcome evaluations and cost‐effectiveness measurements in continuing education for health care professionals, as well as cost‐benefit analyses from other settings. Evaluation methods are briefly reviewed from typical evaluation of program objectives, quality of educators, and overall participant satisfaction, to the current need for evaluating the effectiveness of educational programs, to the ultimate outcome of these effects on patient health. The need for cost‐benefit analysis in CME is becoming more evident in working with supporters of such medical educational activities. Presenting the actual measurement of benefits and costs of educational alternatives provides the funding decision maker and others with a comparison for the return on investment.

Addressing disparities in diagnosing and treating depression: A promising role for continuing medical education

&NA; Depression is a very common reason that individuals seek treatment in the primary care setting. However, advances in depression management are often not integrated into care for ethnic and racial minorities. This supplement summarizes evidence in six key areas—current practices in diagnosis and treatment, disparities, treatment in managed care settings, quality improvement, physician learning, and community‐based participatory research—used to develop an intervention concept described in the concluding article. Evidence of gaps in the care for minorities, while discouraging, presents unique opportunities for medical educators to develop interventions with the potential to change physician behavior and thereby reduce disparities and enhance patient outcomes.

Improving depression care for ethnic and racial minorities: a concept for an intervention that integrates CME planning with improvement strategies.

&NA; Depression is one of the most common reasons that individuals seek treatment in the primary care setting. Research in the past 15 years has shown that dramatic improvement in the management of patients with depression is possible. Advances in pharmacotherapy and delivery of depression care have been reported, but few currently benefit members of ethnic and racial minorities. Educating physicians and other health professionals has been suggested as one approach to address the issues related to disparities in depression care. There is little evidence, however, that education alone is effective. The authors of this article believe that incorporating physician learning activities that are planned using approaches that have been shown to be effective in interventions currently demonstrating some success in improving depression care provided to ethnic and racial minorities will enhance the impact and sustainability of these interventions. This article—the conclusion of this supplement—will describe an intervention concept that integrates a quality improvement model (the Institute for Health Improvements Breakthrough Series Collaborative model) with an evidence‐based approach to planning CME and supports the integration by using action inquiry technologies and community‐based participatory research methods. Relevant approaches from implementation research are discussed, and suggestions for testing the intervention concept are provided.

Evaluation of the effectiveness of an international diploma course in tropical medicine

Background: Numerous impediments to conducting continuing education (CE) courses in remote sites, particularly those courses that take place in developing countries, can include challenges associated with planning, infrastructure, and financial risk. This study reports the effectiveness of a course planned in the United States and executed in Peru, the Gorgas Course in clinical tropical medicine. Methods: A survey was conducted of participants who had completed the Gorgas Course as recently as 6 months and as long as 3 years earlier. The questionnaire sought to determine each participants reason for participation, whether the course was instrumental in the participants reaching the personal goal associated with participation, and whether the participant considered the course to be worth the time and money spent to enable participation. Results: Forty‐nine participants responded to the questionnaire, all of whom indicated that the Gorgas Course enabled achievement of the personal goal associated with participation. Fully 100% of course participants stated that participation was worth the time and monetary expenditure, most often citing their having access to patients with tropical diseases and the personal enrichment of living overseas as reasons the course was worth its high cost. Findings: It is logistically and financially feasible to conduct CE courses in developing countries, provided that the organization in the planning country has strong, pre‐established relationships with the host institution(s). Continued collaboration between planning partners and frequent, rigorous course evaluations are necessary to enable an international CE course to become a stable, continuous academic offering.

Design of a randomized clinical trial to improve rates of amblyopia detection in preschool aged children in primary care settings

PURPOSE To present the design of a cluster randomized controlled trial (cRCT) to evaluate the effectiveness of a web-based intervention for improving provider knowledge about strabismus and amblyopia (S/A) and preschool vision screening (PVS), increase PVS rates, and improve rates of S/A diagnoses made by eye specialists. This is the first cRCT targeting amblyopia prevention. METHODS Participants were Medicaid providers in AL, SC, or IL who had Internet access and had filed at least 8 claims for well child visits (WCV) for children ages 3 or 4 years old during a 12-month period before enrollment. Randomization to the Intervention (vision) or Control (blood pressure) arm occurred at the cluster level, defined as the provider (or group of providers) and his/her patients seen for WCVs. RESULTS 65 Intervention providers (IPs) with 3547 children aged 3 or 4 years, and 71 Control providers (CPs) with 5053 children enrolled. The study will report measures of knowledge and self-reported vision screening behaviors from web-based data. The primary outcomes will be rates of PVS among PCPs, and rates of diagnosis of S/A by eye specialists among the children belonging to Control and Intervention practices. CONCLUSIONS We had the same difficulty recruiting PCPs as reported by others. Baseline rates of PVS were low (14.1%), as were rates that S/A were diagnosed by eye providers (1.4%). Our data show a need to improve both primary outcome measures.