Live Continuing Medical Education Research Articles

Preparing Clinicians to Provide Equitable Alzheimer’s Disease (AD) Care: What Continuing Medical Education (CME) Can Achieve (P12-2.003)

<h3>Objective:</h3> To assess the influence of live online CME on clinicians’ (HCPs) awareness of ethnic and racial differences in AD and ability to develop strategies to enhance care access for diverse patients. <h3>Background:</h3> Government agencies and advocacy groups have prioritized reduction of disparities in brain health. HCPs need to recognize the increased risks and burdens associated with AD in various ethno-racial groups and have outreach strategies for diverse underrepresented communities. <h3>Design/Methods:</h3> We partnered with advocacy groups and experts in community-based AD care to produce two 60-minute CME activities, launched 12/16/2021 and 3/2/2022. The activities were on-demand for one year. Experts recorded videos outlining their community-outreach strategy. In addition, HCPs could submit their outreach plans to be reviewed during the second CME activity. Responses to test questions before, immediately post, and 2 months after an activity, along with outreach plans, were analyzed for insights and identification of remaining gaps. Chi-square compared paired responses (pre/post and pre/2 mos, <i>P</i>&lt;0.05). <h3>Results:</h3> As of 10/4/22, 1,893 HCPs participated and 865 identified as treaters seeing 10 patients/week. Post activity, there were marked improvements in awareness of causes of AD care inequities (+37%, <i>P</i>&lt;0.05), genetic predisposition (+46%, <i>P</i>&lt;0.05), and ability to identify tools to evaluate cognitive status (+55%, <i>P</i>&lt;0.05). Reported practice changes included use of assessment tools and strategies to evaluate patients and account for genetic and cultural differences. Six outreach plans were reviewed (communities were rural, urban, and/or low-economic status). Outreach projects included providing culturally appropriate education to communities, hiring a socially sensitive workforce, connecting with churches, and enhancing research diversity. <h3>Conclusions:</h3> Data support the positive impact of live-online CME in preparing HCPs to provide equitable AD care through increased recognition of critical differences in risk among races and ethnic groups and development of outreach strategies to build trust and address barriers to access. <b>Disclosure:</b> Carole Drexel has nothing to disclose. Dr. Wilson has nothing to disclose. Ms. Bixler has nothing to disclose. Goldie S. Byrd has nothing to disclose. Dr. Zwerling has nothing to disclose. Dr. Allen has nothing to disclose. Ms. Lynn has nothing to disclose.

Abstract 11538: The Impacts of the Patient Voice in Continuing Medical Education (CME) to Enhance Homozygous Hypercholesterolemia (HoFH) Diagnosis and Management

Introduction: Early diagnosis and management of HoFH are key to achieving CV risk reduction. However, barriers to identifying probable cases, low awareness of current guidelines, and a lack of knowledge of treatment options continue to present challenges to HCPs. Hypothesis: CME with the patient voice can enhance HCP's competence in diagnosing and managing HoFH and adopting newest treatment options. Methods: A 60-minute CME activity that incorporated the patient voice was launched live-online 7/20/21 and was available on-demand for 1 year. Test questions were administered before and immediately after the activity. A follow-up survey on HCP behavior was sent to post-test respondents 2 months after activity completion. Responses were analyzed for engagement, lessons learned, and continuing gaps. Chi-square tests compared paired responses (P less than 0.05; pre/post). Results: As of 6/6/22, 1,806 HCPs had engaged (14% cardiologists and 57% PCPs managing an average of 50.2 patients per year with very high lipid levels). At entry, 68% of HCPs were at least “somewhat confident” in managing HoFH, while 48% did not know about newly approved agents for HoFH. Outcomes showed significant increases (pre vs post) in ability to recognize manifestations of HoFH (47% vs 87%), apply guidelines to reduce high LDL-C levels despite statin therapy (38% vs 92%), and recognize mechanism of action of evinacumab (43% vs 88%). On follow up, HCPs reported positive impacts on practice related to diagnosing HoFH, applying guideline-driven care to lower LDL-C, identifying high-risk patients, and referring appropriately. Conclusions: Live and on-demand CME including the voice of the patient successfully highlighted HoFH patient’s expectations of care and enhanced HCPs’ ability to adapt to the changing HoFH landscape. Additional education on this evolving landscape and associated guidelines can further enhance quality of care for HoFH patients.

VP.39 A new era for gMG management: Impact of continuing education on improving diagnosis and classification of gMG patients

The management of gMG is changing with the advent of targeted therapeutics and an expanding pipeline. HCPs need to know how to use biomarkers and antibody testing to better individualize therapeutic decisions. We assessed the impact of online continuing medical education (CME) for clinicians (HCPs) on competence related to generalized myasthenia gravis (gMG) diagnosis and knowledge of current and new and emerging treatment options. One 60-min CME activity was launched live-online on 3/9/21 and remained on-demand for 1 year. Test questions were administered pre-, immediately post-, and 2 months post-activity. Responses from learner polling and follow-up surveys were analyzed for engagement, lessons learned, and continuing gaps. Chi-square compared paired responses (pre/post & pre/2 mos, p<.05). When the activity expired, 906 HCPs engaged with the activity, 223 of them reporting 9.4 patient visits for MG every month. Results showed statistically significant immediate increases in knowledge related to treatment-resistant gMG disease burden (76% post vs 30% pre), therapeutic predictive value of gMG associated antibodies (84% post vs 39% pre), and mechanisms of action of new immunoglobulin G (IgG) and emerging neonatal Fc receptor (FcRn) targeted agents (87% post vs 39% pre). During the follow-up survey, 88% of HCPs reported the education to benefit their clinical practice, with write-in examples of changes related to implementation of EMG and antibody testing for diagnosis, increased awareness of new treatments options, and enhanced ability to provide patient counseling regarding management options. These data support the positive impact of live and on-demand online CME education on awareness of gMG burden, diagnosis, prognosis based on biomarkers, and its evolving management. The education also revealed areas in need for continuous education regarding the impact on gMG burden on treament selection, and strategies to individualize therapy.

Commitment to Change Statements and Actual Practice Change After a Continuing Medical Education Intervention.

Continuing medical education (CME) interventions often evaluate participant commitment to change (CTC) clinical practice. Evidence linking CTC to actual practice change is limited. In an intervention that combined live CME with changes to the electronic health record to promote judicious antibiotic use for children with urinary tract infections (UTIs), we evaluated CTC and subsequent prescribing behavior in Kaiser Permanente Colorado, an integrated health care system. CTC was assessed immediately after the session using closed-ended questions about session learning objectives and open-ended questions to elicit specific practice changes. Perceived barriers to implementing recommended changes were also assessed. Among 179 participants, 80 (45%) completed postsession evaluations and treated one or more child with a UTI in the subsequent 17 months (856 UTIs in total). In closed-ended responses about session learning objectives, 45 clinicians (56%) committed to changing practice for antibiotic choice and duration, whereas 37 (46%) committed to implementing new practice guidelines. When asked open-ended questions to identify specific practice changes, 32 (40%) committed to antibiotic choice change and 29 (36%) committed to treatment duration change. Participants who made specific CTC statements had greater improvement in antibiotic choice (relative rate ratio 1.56, 95% CI 1.16-2.09) and duration (relative rate ratio 1.59, 95% CI 1.05-2.41) than participants who did not make specific commitments. Few perceived barriers affected subsequent prescribing. Commitments to changing specific clinical behaviors were associated with sustained changes in prescribing for children with UTIs. Linking self-evaluations with clinical data in integrated health care systems is an important tool for CME evaluators.

What Influences Choice of Continuing Medical Education Modalities and Providers? A National Survey of U.S. Physicians, Nurse Practitioners, and Physician Assistants.

To explore what influences clinicians in selecting continuing medical education (CME) activities in the United States. In August 2018, the authors conducted an Internet-based national survey, sampling 100 respondents from each of 5 groups: family medicine physicians, internal medicine and hospitalist physicians, medicine specialist physicians, nurse practitioners, and physician assistants. In total, 1,895 clinicians were invited and 500 (26%) responded. Questions addressed the selection and anticipated use of CME delivery modalities and perceived characteristics of specific CME providers. Response formats used best-worst scaling or 5-point ordinal response options. The factors identified as most important in selecting CME activities were topic (best-worst scaling net positivity 0.54), quality of content (0.51), availability of CME credit (0.43), and clinical practice focus (0.41), while referral frequency (-0.57) ranked lowest. The activities that the respondents anticipated using most in the future were live (mean 3.8 [1 = not likely, 5 = very likely]), online (mean 3.5), point-of-care (mean 3.5), and print-based (mean 3.5) activities. For online CME, the features of greatest appeal were that learning could be done when clinicians had time (mean 4.4), at their own pace (mean 4.2), and at lower cost (mean 4.2). For live CME, the features of greatest appeal were that the subject was best taught using this modality (mean 4.0), or the activity was located in a destination spot (mean 4.0) or a regional location (mean 3.9). When rating specific CME providers, most academic institutions received relatively high ratings for research focus and clinical practice focus, whereas commercial providers had slightly higher ratings for ease of access. Responses were generally similar across clinician types and age groups. Physicians, nurse practitioners, and physician assistants are interested in using a variety of CME delivery modalities. Appealing features of online and live CME were different.

664-P: The Case for Targeted Diabetes Medication and Device CME for PCPs

Objective: This study aimed to evaluate primary care physicians’ (PCPs) perceptions of and desired improvements to diabetes continuing medical education (CME). Methods: In March-April 2019, 306 U.S.-based PCPs who treat people with diabetes and earn diabetes CME credits completed an online survey. Results: On average, respondents regularly see 391 people with diabetes (38% on insulin) for checkups and allot 16% of annual CME credit hours to diabetes. More than 75% of PCPs believe that improved PCP education could enhance care for people with diabetes and 82% believe that new diabetes technologies and therapies will change their practice significantly over the next five years. Respondents commonly reported that CME does not adequately cover diabetes drugs/devices, cost/insurance, or behavioral health. More than 80% of surveyed PCPs currently initiate and manage diabetes medications, though &amp;gt;55% would prefer to outsource to a diabetes specialist. The trend is reversed for diabetes devices: 34% of PCPs in this study currently initiate and manage CGM, whereas 54% would like to, and 24% currently initiate and manage insulin pumps, whereas 53% would like to. Respondents most commonly used journal articles and online courses—used by 79% and 65%, respectively—to obtain diabetes CME credits, though academic/medical conferences were regarded as the most useful. Nearly all PCPs also believe improved patient education would improve diabetes care. Discussion: PCPs in this study believe both online and live CME, alongside improved patient education, can help them adapt to the rapidly evolving diabetes management landscape. More PCPs would prefer to outsource diabetes medication management than do currently, suggesting discomfort with managing these medications. Conversely, PCPs would like to take a more active role in diabetes device management. CME could help close both gaps in order to enhance PCPs’ comfort and efficacy in managing diabetes. CGM should be emphasized given its dual applications in diagnostics and therapy. Disclosure B.J. Levine: Employee; Self; Onduo. J.M. McDermott: Other Relationship; Self; Various. J.B. Lackner: None. E. Shoger: None. K.C. Stoner: Other Relationship; Self; Various companies and organizations. R.S. Beaser: None. K.L. Close: Other Relationship; Self; Abbott, Air Liquide, American Diabetes Association, AstraZeneca, Dexcom, Inc., Janssen Pharmaceuticals, Inc., JDRF, Leona M. and Harry B. Helmsley Charitable Trust, Lilly Diabetes, Merck &amp; Co., Inc. Funding The Leona M. and Harry B. Helmsley Charitable Trust

MON-006 Effect of Live CME at Improving Knowledge of Internal Medicine Physicians Related to Cardiovascular Outcomes with Antihyperglycemic Therapies

Introduction: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in people with diabetes globally. Based on recent cardiovascular outcomes trial (CVOT) data, antihyperglycemic therapies have the potential to reduce cardiovascular (CV) risk in patients with type 2 diabetes (T2D). We sought to assess the baseline knowledge and the effect of a live continuing medical education (CME) on internal medicine physicians regarding knowledge of recent CVOT data. Method: A live, interactive satellite symposium was held at the American College of Physicians (ACP) annual meeting. We assessed the effects of the symposium education using a pre-/post-assessment study design. During the symposium, participants were given iPads to answer pre/post questions and the post-activity evaluation. The pre-/post-assessment instrument included knowledge- based questions. Pearson’s chi-squared test assessed whether the post‐assessment score differed from the pre‐assessment score. P values are shown as a measure of significance; P values <.05 are considered statistically significant. Results: A total of 182 physicians attended the symposium, of which 135 (74%) participated in the interactive questions via iPad. Significant overall improvements were seen in all but one area. • There was a 22% positive difference from pre- to post-assessment in the percentage of participants who correctly identified the >10% reduction in fatal/nonfatal MI/stroke that a 1% reduction in A1c would correlate with (25%, n=105 pre; 47%, n=91 post; P=.001). • There was a 6% positive difference from pre- to post-assessment in the percentage of participants who recognized the 14% reduction in 3-point MACE demonstrated in the EMPA-REG CVOT trial (36%, n=98 pre; 45%, n=105 post-assessment; P=.242). • Finally, there was a 41% positive difference from pre- to post-assessment in the percentage of participants who recognized that both canagliflozin and empagliflozin had demonstrated a >30% reduction related to hospitalizations with heart failure line (25%, n=89 pre; 66%,n=100 post; (P<.001). Ongoing educational gaps identified by low post-assessment knowledge levels include: 53% of participants still failed to recognize the correlation between reduction in A1c and reduction of CV events, 55% of participants still failed to identify 3-point MACE reductions from a specific CVOT, and 34% still failed to identify similarities in CVOT related to HHF. Conclusion: This study demonstrates the success of a case-based, interactive live satellite symposium on improving knowledge of internal medicine physicians related to CVOT data. The ongoing educational gaps identified in this activity demonstrate a need for additional education focused on improving knowledge of data from CVOT. Further, internal medicine physicians could also benefit from deeper case-based education focusing on application of CVOT data.

FDA Expands REMS Requirements for Opioids

Back to table of contents Previous article Next article Professional NewsFull AccessFDA Expands REMS Requirements for OpioidsNick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:29 Oct 2018https://doi.org/10.1176/appi.pn.2018.11a14AbstractChanges to the Risk Evaluation and Mitigation Strategy (REMS) include several measures to help better communicate the serious risks about the use of opioids to patients and health care professionals.In September, the Food and Drug Administration (FDA) broadened its Risk Evaluation and Mitigation Strategy (REMS) program for opioids to include immediate-release opioid painkillers, in addition to extended-release and long-acting products. The opioid REMS now covers 347 painkillers, including the medications most commonly prescribed in outpatient settings.iStock/Moussa81In addition to expanding the painkiller list, the updated opioid REMS requires that the training be made available to all health care professionals who are involved in the management of patients with pain, and not only to those who prescribe the medication.A REMS is a drug safety program that the FDA can require for certain medications that have known safety concerns. The exact strategy varies with each drug, but often includes components such as requiring prescribers to have special certifications or requiring patients to be monitored regularly to support the safe use of that medication.The primary component of the opioid REMS is a requirement that all manufacturers of approved opioid analgesics provide unrestricted grants to accredited continuing education providers for the development of continuing medical education (CME) related to safe opioid prescribing.There is currently no mandatory federal requirement that prescribers or other health care personnel take these CME modules. However, the agency noted that its Opioid Policy Steering Committee is continuing to assess the landscape of opioid prescribing to see if there are circumstances when the FDA should require some form of mandatory education.The updated REMS will require that opioid-related CME materials now be made accessible to nurses, pharmacists, and others who are involved in the management of patients in pain. Given the larger audience, the FDA has also broadened the range of information that needs to be included in an opioid REMS. This includes more information on both acute and long-term pain management, including adding sections on pharmacological and non-pharmacological alternatives to opioid analgesics.“Providers have a critical role to play in making sure these products are appropriately prescribed to patients,” said FDA Commissioner Scott Gottlieb, M.D., in the agency’s press release. “Our new effort is aimed at arming providers with the most current and comprehensive information on the appropriate management of pain. This includes ensuring that prescriptions are written for only appropriate purposes and durations of use. Appropriate prescribing practices and education are important steps that we’re prioritizing to help address the human and financial toll of this crisis.”The agency also stated that it will require opioid analgesic manufacturers to include information about the availability of REMS-compliant education on the labels of all drugs intended for outpatient settings. The educational information will be listed in the “Boxed Warning” and “Warnings and Precautions” sections of the labels.The revised CME training materials for opioid painkillers are expected to be available to health care providers in the Spring of 2019. ■More information on the Opioid Analgesic Risk Evaluation and Mitigation Strategy can be accessed here. A listing of live and online CME courses is available on the Collaborative on REMS (CO*RE) website. ISSUES NewArchived

Implementation of a Flipped Classroom for Nuclear Medicine Physician CME.

Increasingly, emerging technologies are expanding instructional possibilities, with new methods being adopted to improve knowledge acquisition and retention. Within medical education, many new techniques have been employed in the undergraduate setting, with less utilization thus far in the continuing medical education (CME) sphere. This paper discusses the use of a new method for CME-the "flipped classroom," widely used in undergraduate medical education. This method engages learners by providing content before the live ("in class") session that aids in preparation and fosters in-class engagement. A flipped classroom method was employed using an online image-rich case-based module and quiz prior to a live CME session at a national nuclear medicine meeting. The preparatory material provided a springboard for in-depth discussion at the live session-a case-based activity utilizing audience response technology. Study participants completed a survey regarding their initial experience with this new instructional method. In addition, focus group interviews were conducted with session attendees who had or had not completed the presession material; transcripts were qualitatively analyzed. Quantitative survey data (completed by two-thirds of the session attendees) suggested that the flipped method was highly valuable and met attendee educational objectives. Analysis of focus group data yielded six themes broadly related to two categories-benefits of the flipped method for CME and programmatic considerations for successfully implementing the flipped method in CME. Data from this study have proven encouraging and support further investigations around the incorporation of this innovative teaching method into CME for nuclear imaging specialists.

Improving the diagnostic workup of hyponatremia in the setting of kidney disease: a continuing medical education (CME) initiative.

Hyponatremia is a common electrolyte disorder and is associated with mortality. We examined the frequency of appropriate testing in response to an episode of inpatient hyponatremia in a large urban hospital to better inform our educational intervention. We then evaluated the impact of a live CME activity with a focus on CKD- and ESRD-associated hyponatremia physiology, on diagnostic practices of audience hospitalist attendings. We performed a retrospective database analysis of all patients admitted to Montefiore Medical Center in 2014 to examine the performance of hospital staff in response to hyponatremia across all CKD stages. We then did a comparative analysis of diagnostic workup orders for hyponatremic patients admitted to audience members of a live CME activity in the 4months prior as compared to the 4months after the activity. The prevalence of hyponatremia was 27% in a cohort of hospitalized patients: 41% of these hyponatremia inpatients had CKD, and 11.4% had ESRD. Overall less than 10% of patients had orders written for serum and urine osmolality without adifferential pattern based on CKD or ESRD diagnosis. Among the patients admitted to the CME audience hospitalists, urine/serum osmolality and urine sodium orders occurred infrequently overall and did not differ after vs. before the lecture. The frequency of appropriate diagnostic orders written in response to an episode of hyponatremia was very low and did not vary based on degree of CKD. A CME activity with an emphasis on the role of CKD/ESRD in diagnostic accuracy did not improve the order quality in a group of audience hospitalists. Efforts to improve the diagnostic workup of hyponatremia with concomitant kidney disease are crucial to proper management of these patients.

Improving immunization (imm) rates among oncology patients and health care providers (HCP) through a partnership of continuing medical education (CME) and quality improvement (QI) in an NCI-designated comprehensive cancer center.

43 Background: Onc pts are at increased risk of vaccine (vac)-preventable diseases and suffer worse sequelae. Regulatory requirements demand imm of patients and HCP. There is a large practice gap among clinicians in awareness of imm guidelines, of pt imm status, and of the high risk of transmission from HCP to immunocompromised pt. Methods: From May 2012 to June 2013 the City of Hope CME coordinated a team of MDs, QI specialists, infection control, IT, nursing, and pharmacy in a QI CME initiative to increase the imm rates of pt and HCP by education (ed) to clinicians, pt and families. Multiple ed platforms were used (live CME meetings, web-based content, point of care applications, visual cues, clinician longitudinal self-assessment surveys, systems-based support tools, patient handouts) with emphasis on MD-friendly platforms. Results: &gt;350 HCP participated in CME events (59% MDs, 18% RN). Analysis of ed and clinical outcomes is from 4 areas. (1) Change in HCP attitudes through self-assessment surveys shows an increase in clinician knowledge of types and timing of imm, in use of system-based tools (standard orders, vac computerized manager), and in involvement of pts in imm history and ed. (2) There was an increase of doses of influenza vaccines in pts (Sept-March, 2010-11/ 2011-12/ 2012-13: 1129/1480(31% increase)/1838(24% increase). (3) Respiratory viral testing of pts was done to assess number of confirmed infections. (4) Influenza vac rates of hospital workers improved with the largest increase in the medical staff (65 to 76%). Conclusions: This interdisciplinary CME initiative to improve imm rates among onc pts involved ed activities and system-based changes. Improvements were seen in areas of HCP attitude, performance, and acceptance of their own vac. 24% of the medical staff remain unvaccinated, raising both ethical and compliance challenges to reach the 2020 90% goal of Joint Commission. A gap remains in HCP attitudes regarding their own vac which may not be amenable to analytical-based CME. Use of other decision-making/learning styles is necessary for further progress. CA62505 and Pfizer.

The impact of lifestyle medicine continuing education on provider knowledge, attitudes, and counseling behaviors

Background: There is a need for effective continuing medical education (CME) programs to increase healthcare providers’ knowledge and skills in lifestyle medicine so that healthcare providers are better equipped to assist patients in adopting and maintaining healthier lifestyle behaviors.Aims: To evaluate the impact of five live face-to-face CME programs in lifestyle medicine on providers’ barriers, knowledge, confidence, and professional counseling behaviors.Methods: 200 participants completed researcher-generated surveys before and 90 days after each CME program. Paired t-tests measured significant changes for all outcome variables, and regression analyses assessed predictors of these changes.Results: Barriers that were targeted during the programs, i.e. lack of knowledge/skills, lack of materials, and perceived poor patient compliance showed highly significant improvement. Participants also reported significant changes in knowledge, confidence, and counseling behaviors in the areas of exercise and stress management. Some improvements occurred in areas that the CME programs did not target as much, i.e. nutrition, smoking, and weight management. The greatest predictor of change was the baseline level of scores. Those participants who could most benefit from change did show the largest improvements.Conclusions: Live CME programs can be effective in educating healthcare providers about topics within the rapidly expanding field of lifestyle medicine.

Criteria for awarding CME credits to health physicians.

Credits have traditionally served as an incentive for physicians to participate in the continuing medical education (CME), which is the means for life-long learning. The public at large has granted special rights to the profession of medicine giving them their most precious commodity; their lives. The providers of CME have a responsibility to maintain and update physicians' knowledge and competency. 1 United States and Canada have been using continuing medical education credit to measure physician's participation in education for more than 50 years. It has been proven that engaging in lifelong learning would lead to a change in physician’s practice and improved patient care and outcomes.2 In this perspective, we have specifically defined the criteria for awarding CME credits to encourage practicing physicians in Pakistan and particularly within our University setting; as no system has yet been developed to measure and certify physician's participation in educational events. However, this could be replicated to award credits to other continuing professional development (CPD) activities. American Medical Association Physician's Recognition Award (AMA PRA), was emerged in 1968, in which live educational activities i.e. Category I was designated by accredited providers, whereas the rest five categories included various types of self-directed activities. In 1985, the AMA (PRA) was defined into categories 1 and 2 that made physicians fixed to attain 150 credit hours every 3 years with a minimum of 60 credit hours participation in Category I, i.e. live CME activities. The AMA and the Accreditation Council for Continuing Medical Education (ACCME) describes CME as 'educational activities that serve to maintain, develop, or enhance the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public or the profession'.3 Ever since its beginning, credit for CME has been calculated by units of time and awarded in hourly increments, as traditionally CME is mainly lecture-based and could most easily be measured in hours. CME activities in and outside US are still based on one credit per 60 minutes academic activity and are a source to career advancement and salary differentials in some cases.4

Clinician Attitudes About Commercial Support of Continuing Medical Education

Pharmaceutical and medical device company funding supports up to 60% of accredited continuing medical education (CME) costs in the United States. Some have proposed measures to limit the size, scope, and potential influence of commercial support for CME activities. We sought to determine whether participants at CME activities perceive that commercial support introduces bias, whether this is affected by the amount or type of support, and whether they would be willing to accept higher fees or fewer amenities to decrease the need for such funding. We delivered a structured questionnaire to 1347 participants at a series of 5 live CME activities about the impact of commercial support on bias and their willingness to pay additional amounts to eliminate the need for commercial support. Of the 770 respondents (a 57% response rate), most (88%) believed that commercial support introduces bias, with greater amounts of support introducing greater risk of bias. Only 15%, however, supported elimination of commercial support from CME activities, and less than half (42%) were willing to pay increased registration fees to decrease or eliminate commercial support. Participants who perceived bias from commercial support more frequently agreed to increase registration fees to decrease such support (2- to 3-fold odds ratio). Participants greatly underestimated the costs of ancillary activities, such as food, as well as the degree of support actually provided by commercial funding. Although the medical professionals responding to this survey were concerned about bias introduced from commercial funding of CME, many were not willing to pay higher fees to offset or eliminate such funding sources.

Impact on Clinical Behavior of Face-to-Face Continuing Medical Education Blended with Online Spaced Education: A Randomized Controlled Trial

Spaced education (SE) is a novel, evidence-based form of online learning. We investigated whether an SE program following a face-to-face continuing medical education (CME) course could enhance the course's impact on providers' clinical behaviors. This randomized controlled trial was conducted from March 2009 to April 2010, immediately following the Current Clinical Issues in Primary Care (Pri-Med) CME conference in Houston, Texas. Enrolled providers were randomized to receive the SE program immediately after the live CME event or 18 weeks later (wait-list controls). The SE program consisted of 40 validated questions and explanations covering 4 clinical topics. The repetition intervals were adapted to each provider based on his or her performance (8- and 16-day intervals for incorrect and correct answers, respectively). Questions were retired when answered correctly twice in a row. At week 18, a behavior change survey instrument was administered simultaneously to providers in both cohorts. Seventy-four percent of participants (181/246) completed the SE program. Of these, 97% (176/181) submitted the behavior change survey. Across all 4 clinical topics, providers who received SE reported significantly greater change in their global clinical behaviors as a result of the CME program (p-values .013 to < .001; effect size 0.7). Ninety-seven percent (175/179) requested to participate in future SE supplements to live CME courses. Eighty-six percent (156/179) agreed or strongly agreed that the SE program enhanced the impact of the live CME conference. Online spaced education following a live CME course can significantly increase the impact of a face-to-face course on providers' self-reported global clinical behaviors.

Online spaced education to supplement live courses

Spaced education is a novel, evidence-based form of online learning. E-mails containing clinically relevant case scenarios and multiple-choice questions are sent to participants at regular intervals. The participant submits an answer, the response is recorded in a central server, and the learner receives immediate feedback. Questions are repeated to participants based on an adaptive algorithm that customises the spacing and content of subsequent questions in order to maximise knowledge acquisition and retention for each learner. As a stand-alone educational intervention, spaced education has been shown in randomised trials to increase knowledge acquisition, boost learning retention and improve clinical behaviour. A recent report by the US Department of Education found that online education which is blended with live courses is more effective than online educational interventions alone. It is not clear how spaced education can best be ‘blended’ with traditional forms of medical education to improve its efficacy and acceptability. We conducted a pilot study to determine whether spaced education can be an effective supplement to a live lecture-based continuing medical education (CME) course. Attendees of the Harvard Medical School Update in Internal Medicine course, held in Boston, MA in December 2008, were recruited via e-mail. The spaced education programme began at the close of the programme in December 2008 and ran to May 2009. The programme consisted of 12 questions on hepatitis C, which was the topic of a featured lecture during the course. The 12-item adaptive spaced education course was structured so that learners were sent two questions every 2 days. If a question was answered incorrectly, it was repeated 12 days later. If a question was answered correctly, it was repeated 24 days later. Once a question had been answered correctly twice in a row, it was retired and not repeated again. Participants completed the programme by retiring 80% of the questions and, upon doing so, were asked to complete an end-of-programme evaluation using 5-point Likert scales. A total of 86 attendees enrolled in the trial, 15 of whom (17%) did not answer any questions. Of the remaining 71 participants, 47 (66%) completed the programme and 42 of these (89%) submitted the end-of-programme evaluation. Respondents reported that: (i) the programme enhanced the impact of the live CME course (90% strongly agree/agree); (ii) they would recommend the spaced education programme to a colleague (85%); (iii) the programme reinforced their knowledge of hepatitis C (91%), and (iv) the programme increased their confidence in managing patients with hepatitis C (81%). Forty-one of 42 respondents (98%) requested to participate in further spaced education programmes offered as supplements to live CME courses. In summary, our study demonstrates that online spaced education is an effective and well-accepted supplement to a live CME course. Further research is needed to determine if spaced education can boost the ability of live CME courses to improve clinical practice patterns.

Development of an undergraduate curriculum in obstetrical simulation

algorithm that customises the spacing and content of subsequent questions in order to maximise knowledge acquisition and retention for each learner. As a stand-alone educational intervention, spaced education has been shown in randomised trials to increase knowledge acquisition, boost learning retention and improve clinical behaviour. Why the idea was necessary A recent report by the US Department of Education found that online education which is blended with live courses is more effective than online educational interventions alone. It is not clear how spaced education can best be ‘blended’ with traditional forms of medical education to improve its efficacy and acceptability. We conducted a pilot study to determine whether spaced education can be an effective supplement to a live lecture-based continuing medical education (CME) course. What was done Attendees of the Harvard Medical School Update in Internal Medicine course, held in Boston, MA in December 2008, were recruited via e-mail. The spaced education programme began at the close of the programme in December 2008 and ran to May 2009. The programme consisted of 12 questions on hepatitis C, which was the topic of a featured lecture during the course. The 12-item adaptive spaced education course was structured so that learners were sent two questions every 2 days. If a question was answered incorrectly, it was repeated 12 days later. If a question was answered correctly, it was repeated 24 days later. Once a question had been answered correctly twice in a row, it was retired and not repeated again. Participants completed the programme by retiring 80% of the questions and, upon doing so, were asked to complete an endof-programme evaluation using 5-point Likert scales. Evaluation of results and impact A total of 86 attendees enrolled in the trial, 15 of whom (17%) did not answer any questions. Of the remaining 71 participants, 47 (66%) completed the programme and 42 of these (89%) submitted the endof-programme evaluation. Respondents reported that: (i) the programme enhanced the impact of the live CME course (90% strongly agree ⁄ agree); (ii) they would recommend the spaced education programme to a colleague (85%); (iii) the programme reinforced their knowledge of hepatitis C (91%), and (iv) the programme increased their confidence in managing patients with hepatitis C (81%). Forty-one of 42 respondents (98%) requested to participate in further spaced education programmes offered as supplements to live CME courses. In summary, our study demonstrates that online spaced education is an effective and well-accepted supplement to a live CME course. Further research is needed to determine if spaced education can boost the ability of live CME courses to improve clinical practice patterns.

Assessment of barriers to changing practice as CME outcomes *

Continuing medical education (CME) is meant to drive and support improvements in practice. To achieve this goal, CME activities must move beyond simply purveying knowledge, instead helping attendees to contextualize information and to develop strategies for implementing new learning. CME attendees face different barriers to implementing learning, depending on both personal and practice specific contexts. We sought to develop a framework, applicable across multiple CME activities, for categorizing barriers that learners anticipated encountering after CME activities. Building on previous work, qualitative research methods were used to develop an enhanced framework classifying attendee-perceived barriers to implementing CME learnings in practice. Three thousand one hundred thirty (3130) narrative responses on attendee-perceived barriers to implementing learnings were collected from 75 Kaiser Permanente Colorado live CME activities for family medicine, internal medicine, pediatric, and OB/GYN clinicians in 2008 and 2009. Our CME Learning Transfer Barrier Framework contains 27 discrete barriers in 12 barrier categories (including "none"). The barrier framework was applicable across two years of live CME activities for different clinician target audiences. Assessing, characterizing, and summarizing barriers to implementing learning during CME activities can provide valuable information to inform subsequent CME interventions, and provide feedback to organizational leaders to inform performance improvement efforts. The framework may be applicable to other CME formats and to CME activities for audiences in different practice settings.

Meeting the Need for Continuing Education

Meeting the Need for Continuing Education

Advances and Controversies in Clinical Nutrition: The Education Outcome of a Live Continuing Medical Education Course

The aim of this study was to assess participants' nutrition knowledge and practice behavior before and after completing a live continuing medical education (CME) nutrition course designed for practicing nutrition clinicians. Electronic surveys were sent to the first 100 registered participants before and after attending the course. The curriculum consisted of 16.75 hours of live education. The curriculum was revised when the precourse surveys identified a gap in medical knowledge or practice behavior. Knowledge change was assessed by a 15-question survey given before and 1 week after the course. Change in practice behavior was accessed by a 10-question survey administered 2 months after the course. Dietitians were the predominant discipline group attending the course. Sixty-three percent of those surveyed practiced hospital nutrition, 19% outpatient nutrition, and 18% an equal mix. Forty-eight percent indicated that they write parenteral nutrition (PN) orders and 51% write enteral nutrition (EN) orders; of these, 62% indicated they are comfortable writing PN orders and 81% are comfortable writing EN orders. Twenty-three percent indicated that they manage home PN and EN patients. Twenty-six percent stated they were certified in nutrition support. Seventy-eight percent of the participants responded to survey 2; the median correct response rates were 51% pre- and 76% postcourse. Seventy percent responded to survey 3; the median positive clinical practice behavior change was 69%. This live CME course improved knowledge, and a majority of attendants reported changing their nutrition practice after this course.