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continuing medical education and electronic decision support

Continuing medical education and electronic decision support to General Practitioners.

education and electronic support

Anders B. Mr Jensen, Professor

Background: Optimizing the basic palliative care has been shown beneficial to patients in end-of-life care, the general practitioner (GP) having a pivotal role in the health care system, providing comprehensive and continued medical care.

The aim of the study is to investigate the effect of a complex intervention in general practice on GPs' awareness of and confidence in providing end-of-life care.

Method: A follow-up study among 404 general practices in Central Denmark Region. The participating general practices will get the opportunity to receive education in palliative care and access to an electronic support, which provides advice on palliative care and an overview of the palliative population in each medical practice. The education and the support will focus on patients suffering from either metastatic cancer or chronic obstructive pulmonary disease (GOLD stage 4).

The end-of-life care delivered by the GPs to their deceased patients will be analysed, based on questionnaires to GPs and register data related to the deceased patients before and after the intervention, .

Primary outcomes: Place of death of deceased patients, time spent at home, and number of hospital admissions in the last three months of the patients' lives.

Secondary outcomes: Number and kinds of contacts between GPs and patients, use of relevant medicine and of the 'Safety Box'. Finally GPs' confidence concerning palliative care will be assessed in questionnaires.

Improving End-of-life Care by Continuing Medical Education and Electronic Decision Making Support for General Practitioners

Improving End-of-life Care by Continuing Medical Education and Electronic Decision Making Support for General Practitioners in Denmark - an Intervention Study

Looking at the proportion of General practitioners patients dying at home in the year following the continuing medical education meeting

Looking at all the deceased patients in one year following the continuing medical education meeting

assessed using questionnaire before and after the intervention

Danish Cancer Society

TrygFonden, Denmark

University of Aarhus

3-hour after work meeting. Multifaceted form. Content: Cancer symptoms positive predictive values, pit falls, reflections on barriers and attitudes towards early cancer diagnosis.

Continuing Medical Education

Peter Vedsted, PhD, Prof.

Flemming Bro, DrMed, Prof

Background Denmark has a lower survival of cancer compared to most European countries. Fast track pathways for organ specific cancers were established in the years 2008-2010. In 2011 further a fast track pathway for non-specific serious symptoms. Cancer in general practice is a low prevalence condition. Each general practitioner (GP) will see 8-10 new cancer patients per year. The investigators know that cancer patients have an increased use of general practice prior to diagnosis and that 25% of them wait for more than 20 days in general practice for referral according to the GPs. The latest Danish Cancer Plan therefore includes a CME as a key strategy to lower the GP threshold to refer patients to cancer fast track pathways.

The aim of this study was to investigate the effect of this CME in early cancer diagnosis. This is measured by changes in GP knowledge, attitude and risk assessment. GP referral behavior assessed by primary care interval and use of fast track referrals. GP´s cancer hit rate, cancer patients´ tumor stage at treatment and 1 year survival.

Methods/Design The study is conducted as a stepped wedge controlled design based on a quasi-cluster randomization.

In august 2012 an invitation to participate in the present study were sent to 859 general Practitioners (GPs) from the Central Denmark Region. GPs completed a form for each patient they referred to a fast-track diagnostic pathway for cancer within an 8-month period.

Every other week, we received data from a regional database. We reminded the referring GP-practice about non included patients. The collected data will be linked to registries.

The CME-intervention The CME-course was a 3-hour meeting after work. Guided by the available evidence from the literature following the investigators ensured a multifaceted interactive teaching method including case-based education. The content included by other topics positive predictive values, false reassurance from negative testing and other pit-false.

Statistical analyses The outcomes will be analyzed in a generalized linear random-effects model with random effect of GPs. Based on data it will be assessed whether further modeling of inter correlation within practices and within clusters is required, and whether the intervention effects are assumed equal for all GPs, or in random interaction with them. Analyses will be performed both in the full GP-population ("intention to intervening ") and in the 3 subgroups of GPs.

Denmark has a lower survival of cancer compared to most European countries. This could be explained by an inadequate organization of cancer investigation. In order to improve this, 34 fast track pathways for organ specific cancer diseases were established in the years 2008-2010. In 2011 further a fast track pathway for non-specific serious symptoms.

Another reason could be delay in general practice. Cancer in general practice is a low prevalence condition. Each general practitioner (GP) will see 8-10 new cancer patients per year. 50 % of cancer patients presented non-specific symptoms and even when they had organ specific alarm symptoms the positive predictive value for cancer was most often lower than 5%.

The investigators know that cancer patients have an increased use of general practice prior to diagnosis and that 25% of them wait for more than 20 days in general practice for referral. A study showed that 20 % of Danish GPs assumed a hypothetical cancer risk higher than 50% when they refer a 50 year old man to a cancer fast-track pathway. The latest Danish Cancer Plan included a CME as a key strategy to lower the GP threshold to refer patients to cancer fast track pathways.

The aim of this study is to investigate the effect of this CME in early cancer diagnosis. This is measured by changes in

* GP knowledge, attitude and risk assessment.
* GP referral behavior assessed by primary care interval and use of fast track referrals.
* GP´s cancer hit rate, cancer patients´ tumor stage at treatment and 1 year survival.

Methods/Design The study was conducted as a stepped wedge controlled design based on a quasi-cluster randomization. GPs from a cluster which had received CME were controlled by GPs from another cluster which had not yet received CME. GPs from each cluster were divided in an intervention group and a reference group depending on whether they participated in the CME or not.

In august 2012 an invitation to participate in the present study were sent to 859 general Practitioners (GPs) from the Central Denmark Region. GPs were asked to complete a form for each patient they referred to a fast-track diagnostic pathway for cancer within an 8-month period (September 2012 - May 2013). Data included presented symptoms, a GP-estimated cancer risk (predictive value) at referral time, date for referral and date for first presentation of a cancer related symptom to a general practitioner.

To increase the completeness of data, every other week, the investigators received data from a regional database on patients referred to a cancer diagnostic pathway. The referring GP-practice were reminded about non-included patients.

In order to link the collected data following registries were used:

* The Civil Registration Number (CRN), a unique 10-digit personal identification number assigned to every permanent and temporary Danish Residents
* The Hospital Discharge Registry that comprises The Patient Administrative System (PAS) which holds administrative information on hospital activities. Data includes dates of hospital admissions and type of admission.
* The Danish Cancer Registry (DCR) which holds information on all cancer diagnoses in Denmark.
* MedCom data from a web interface (referral hotel) that includes all electronic referral letters sent from general practice to hospital.
* Danish National Health Insurance Service Registry (NHSR) which holds information on all contacts to general practice and all services provided.

The CME-intervention The CME-course was a 3-hour meeting. Guided by the available evidence from the literature following issues were considered important.

* A multifaceted interactive teaching method.
* Knowledge transfer based on patient cases to create a close relation to every day practice.
* An emotional experience to facilitate change in attitude. An educational film was created for the occasion. The film illustrated a series of consultations between a GP and a patient.

Following topics were chosen:

* Faster investigation increases survival.
* Predictive positive values for cancer symptoms.
* False reassurance from a negative test and other pit falls.
* Delay in making an appropriate cancer referral.
* Difficulties in using fast track pathways for cancer.
* Difficulties in communicating cancer risk.

Statistical analyses The outcomes will be analyzed in a generalized linear random-effects model with random effect of GPs. Based on data it will be assessed whether further modeling of inter correlation within practices and within clusters is required, and whether the intervention effects are assumed equal for all GPs, or in random interaction with them. Analyses will be performed both in the full GP-population ("intention to intervening ") and in the 3 subgroups of GPs; GP participated in CME, Colleague participated, even GP neither colleagues participated in CME.

The Effect of CME on Early Cancer Diagnosis in General Practice

The Effect of Continuing Medical Education (CME) on Early Cancer Diagnosis in General Practice

GP knowledge and attitude are measured by ad hoc questions from an online questionaire. The answers will be dichotomized

Risk assessment is measured as a risk of cancer (0%-100%) each time a GP refers a patient to a fast track pathway

Patients use of general practice prior to diagnosis is measured as a ratio. The denominator is the amount of visits to general practice half year prior to diagnosis. The nominator is an average use of general practice over a half year based on the last years. The data is registered in health care registry.

GP Cancer hit rate per is measured as a proportion between patients referred to a fast track pathway diagnosed with cancer related to the total amount of referred patients. Civil registration numbers of all referred patients per GP from the MedCom data will be merge with National Registry of Cancer (NRC).

Cancer patients´ tumor stage at treatment is measured by TNM-stage from Danish Cancer Registry.

Cancer patients´ 1 year survival is measured by merging their Civil Registration Numbers with the Cause of Death Register.

Primary care interval is the amount of days from the date where the patient first presented a cancer relevant symptom to the GP to the date of referral to a fast track pathway for cancer.

Use of fast track referrals is measured by counting the relevant electronic referral letters sent to a web interface called referral hotel (MedCom data) from each individual GP in Central Denmark Region.

Danish Committee for Health Education

Danish College of General Practitioners

Skin and Connective Tissue Diseases

Urinary Tract, Sexual Organs, and Pregnancy Conditions

Digestive System Diseases

Breast Neoplasms

Uterine Cervical Neoplasms

Colorectal Neoplasms

Intestinal Neoplasms

Gastrointestinal Neoplasms

Digestive System Neoplasms

Gastrointestinal Diseases

Colonic Diseases

Intestinal Diseases

Rectal Diseases

Uterine Neoplasms

Genital Neoplasms, Female

Urogenital Neoplasms

Uterine Cervical Diseases

Uterine Diseases

Genital Diseases, Female

Genital Diseases

Urogenital Diseases

Female Urogenital Diseases

Pregnancy Complications

Female Urogenital Diseases and Pregnancy Complications

Physicians enrolled in the control arm do not undergo training in health literacy, cancer screening and shared decision making

Physicians enrolled in the intervention arm undergo training in health literacy, cancer screening and shared decision making

Intervention physicians receive training in cancer risk communication and shared decision making (SDM). At the end of each visit with intervention physicians, standardized patients (SPs) reveal themselves as actors and give structured verbal feedback. After baseline SP visits, each intervention physician undergoes academic detailing with a communication expert. Intervention physicians are directed to a web-based communication skills tutorial where SP ratings are hyperlinked to key references for supplemental reading. Both study groups will receive annual reports detailing their patients' cancer screening status and aggregate ratings of their communication style.

Cancer risk communication skills training

Eboni Price-Haywood, MD, MPH

What's the purpose of this study? This 4-year study is designed: (1) to teach primary care physicians how to recognize low health literacy patients and effectively counsel them on cancer screening using risk communication and shared decision making and (2) to assess the impact of training on changes in physician communication behavior and changes in low health literacy patients' cancer screening behaviors. This study proposal is based on the hypothesis that physician training in cancer screening guidelines, health literacy, and communication skills will improve provider-patient interactions during encounters dealing with preventive health maintenance especially cancer screening.

How will the proposed study be implemented? Thirty-two physicians in the New Orleans metropolitan area will be recruited and randomly assigned to one of two groups. The unit of randomization will be the health care organization or clinic. The intervention group will receive training in health literacy, cancer screening, risk communication and shared decision-making. The control group will not receive communication training until the end of the study. Physicians in both groups will undergo three clinic visits with standardized patients (actors trained to portray real patients; mystery shoppers) but they will not be aware that they are conducting visits with actors. The visits will occur at study enrollment and at 6 and 12 months. At the end of each clinic visit, the standardized patients will rate the physicians' communication skills. Each physician assigned to the intervention group will receive verbal feedback on communication skills from the standardized patients and complete a web-based tutorial. Physicians in the control group will not have access to the web-based tutorial until the end of the study.

For each physician, 10-15 patients with limited health literacy will be recruited to the study. Each patient will rate his/her perceived involvement with care and global satisfaction with care at study enrollment and annually for three years. Age and gender-appropriate referral rates for breast, cervical and colorectal cancer screening and patients' receipt of such screening will be assessed annually for three years. All study physicians, regardless of group assignment, will receive performance feedback (report cards) on their cancer screening rates among low health literacy patients in their clinic.

Using Effective Provider-Patient Communication to Improve Cancer Screening Among Low Literacy Patients

Cervical/Breast/Colorectal cancer screening rates will be measured at baseline and annually for 2 years to assess whether screening rates improve over time

The mystery shoppers (standardized patients) will rate the physicians' shared decision making and counseling about cancer screening prior to the intervention at baseline and then again at 6-month and 12-month follow up evaluations to assess whether communication behaviors improve over time

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Improving End-of-life Care by Continuing Medical Education and Electronic Decision Making Support for General Practitioners	NCT02050256	Chronic Obstruc... Metastatic Canc...	continuing medi... education and e...	-	University of Aarhus
The Effect of CME on Early Cancer Diagnosis in General Practice	NCT02069470	Cancer	Continuing Medi...	-	University of Aarhus
Using Effective Provider-Patient Communication to Improve Cancer Screening Among Low Literacy Patients	NCT01361035	Cervical Cancer Breast Cancer Colorectal Canc...	Cancer risk com...	40 Years - 75 Years	Tulane University

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