Effectiveness Of A Virtual Patient Simulation At Improving Diagnosis And Treatment Of Cardiac Amyloidosis

Abstract

Background Many specialists are involved in the diagnosis and treatment of transthyretin cardiac amyloidosis (ATTR-CM) due to the variety of associated symptoms. Clinicians are therefore challenged to manage ATTR-CM as patient care progresses from diagnosis to treatment. We sought to determine if an online, virtual patient simulation (VPS)-based continuing medical education intervention could improve performance of cardiologists and primary care physicians (PCPs) related to individualized strategies to diagnose and treat ATTR-CM. Methods The intervention comprised two patients presenting in a VPS platform that allows learners to order lab tests, make diagnoses, and prescribe treatments in a manner matching the scope and depth of actual practice. Tailored clinical guidance (CG), based on current evidence and expert recommendation, was provided following each decision, followed by the opportunity for the learners to modify their decisions. Decisions were collected post-CG and compared with each user's baseline (pre-CG) decisions using a McNemar's test to determine significant levels of pre- to post-CG change in clinical decisions made with P values < .05 being considered as significant. Data were collected from December 22, 2020 through February 3, 2021. Results Significant absolute improvements were observed after CG for the following: Cardiologists (n= 91) Diagnose Wild-type ATTR-CM: 35% improvement (P<.001) Order/Initiate Urine immunofixation electrophoresis: 17% improvement (P<.001) Serum Kappa/Lambda Free Light Chain Ratio: 14% improvement (P<.001) Serum Immunofixation Electrophoresis: 20% improvement (P<.001) Bone scintigraphy: 17% improvement (P<.001) Gene sequencing: 21% improvement (P<.001) Tafamadis: 39% improvement (P<.001) Discontinue metroprolol: 57% improvement (P<.001) Patient education: 8% improvement (P<.01) Patient monitoring: 10% improvement (P<.01) Referral to amyloidosis treatment center: 6% improvement (P<.05) PCPs (n= 149) Diagnose Wild-type ATTR-CM: 25% improvement (P<.001) Order/Initiate ECG: 3% improvement (P<.05) Urine immunofixation electrophoresis: 12% improvement (P<.001) Serum Kappa/Lambda Free Light Chain Ratio: 14% improvement (P<.001) Serum Immunofixation Electrophoresis: 14% improvement (P<.001) Bone scintigraphy: 10% improvement (P<.001) Gene sequencing: 17% improvement (P<.001) Tafamadis: 27% improvement (6% pre-CG vs 33% post-CG; P<.001) Discontinue metroprolol: 62% improvement (P<.001) Patient education: 8% improvement (P<.01) Patient monitoring: 9% improvement (P<.01) Referral to amyloidosis treatment center: 9% improvement (P<.001) Conclusion VPS that immerses and engages specialists in an authentic, patient-based, practical learning environment can significantly improve evidence-based clinical decision making for diagnosis and treatment of ATTR-CM. Many specialists are involved in the diagnosis and treatment of transthyretin cardiac amyloidosis (ATTR-CM) due to the variety of associated symptoms. Clinicians are therefore challenged to manage ATTR-CM as patient care progresses from diagnosis to treatment. We sought to determine if an online, virtual patient simulation (VPS)-based continuing medical education intervention could improve performance of cardiologists and primary care physicians (PCPs) related to individualized strategies to diagnose and treat ATTR-CM. The intervention comprised two patients presenting in a VPS platform that allows learners to order lab tests, make diagnoses, and prescribe treatments in a manner matching the scope and depth of actual practice. Tailored clinical guidance (CG), based on current evidence and expert recommendation, was provided following each decision, followed by the opportunity for the learners to modify their decisions. Decisions were collected post-CG and compared with each user's baseline (pre-CG) decisions using a McNemar's test to determine significant levels of pre- to post-CG change in clinical decisions made with P values < .05 being considered as significant. Data were collected from December 22, 2020 through February 3, 2021. Significant absolute improvements were observed after CG for the following: Cardiologists (n= 91) Diagnose Wild-type ATTR-CM: 35% improvement (P<.001) Order/Initiate Urine immunofixation electrophoresis: 17% improvement (P<.001) Serum Kappa/Lambda Free Light Chain Ratio: 14% improvement (P<.001) Serum Immunofixation Electrophoresis: 20% improvement (P<.001) Bone scintigraphy: 17% improvement (P<.001) Gene sequencing: 21% improvement (P<.001) Tafamadis: 39% improvement (P<.001) Discontinue metroprolol: 57% improvement (P<.001) Patient education: 8% improvement (P<.01) Patient monitoring: 10% improvement (P<.01) Referral to amyloidosis treatment center: 6% improvement (P<.05) PCPs (n= 149) Diagnose Wild-type ATTR-CM: 25% improvement (P<.001) Order/Initiate ECG: 3% improvement (P<.05) Urine immunofixation electrophoresis: 12% improvement (P<.001) Serum Kappa/Lambda Free Light Chain Ratio: 14% improvement (P<.001) Serum Immunofixation Electrophoresis: 14% improvement (P<.001) Bone scintigraphy: 10% improvement (P<.001) Gene sequencing: 17% improvement (P<.001) Tafamadis: 27% improvement (6% pre-CG vs 33% post-CG; P<.001) Discontinue metroprolol: 62% improvement (P<.001) Patient education: 8% improvement (P<.01) Patient monitoring: 9% improvement (P<.01) Referral to amyloidosis treatment center: 9% improvement (P<.001) VPS that immerses and engages specialists in an authentic, patient-based, practical learning environment can significantly improve evidence-based clinical decision making for diagnosis and treatment of ATTR-CM.