compendium of independent medical education...

1The author has reprinted this article for the sole purpose of educating the CME stakeholder in possession of this Compendium.

Demonstrating the Value of CME in Mainstream Peer-Reviewed Medical Journals and Conferences

Compendium of Independent Medical Education Publications

2017 Edition

1

Advancing the science of learning and behavioral

change in health care

© 2017 PRIME Education, LLC. All Rights Reserved. www.primece.com

For an electronic compendium please email Danielle Wright, Communications Lead Specialist at [email protected]

2

The educational philosophy of PRIME Education, LLC (PRIME®) embraces collaborative learning models that empower key stakeholders including clinicians, patients, healthcare teams, payers, and systems, to reflect on and react to effective processes of care practices that improve quality and patient outcomes. Through integration of validated models and frameworks, PRIME® leverages real-world data analytics and impactful learning interventions to achieve sustainable and scalable behavioral change across healthcare delivery systems.

PRIME®’s findings have been published in numerous peer-reviewed publications demonstrating positive impact on the healthcare ecosystem. For a full list of publications visit: www.primece.com/publications

As with all our outcomes compendiums, the purpose of this 2017 edition is to share the results of our learning models, research, and analytics, so that you can educate your internal stakeholders on the value of CME through demonstrating sustainability and scalability.

Each published reference in this Compendium is organized under one or more of the following domains:

• Data Analytics

• Systems- and Team-Based Care

• Quality Improvement

• Patient and Provider Collaboration

• Core Competencies

• Research

Forward

ScientificPoster

JournalArticle

Oral Presentation

2


Compendium Key

3


PRIME®’s Framework for Promoting and Evaluating the Sustainability and Scalability of CE Programs

The value of CE programs greatly depends on their sustainability and scalability. In accordance with leading healthcare organizations and other stakeholders, PRIME® has adapted the following definitions of these terms.1-3

• Sustainability: The ability to maintain CE program outcomes within the system of clinicians and/or patients in which the program was conducted

• Scalability: The ability to communicate and support the implementation of CE program outcomes in systems of clinicians and/or patients outside of the system in which the original program was conducted

Sustainability and scalability rely on effective transmission of innovative ideas, or diffusion,4 and incorporation of new practices into daily routine, through routinization and institutionalization.5,6 Based on innovation theory, and aligned with the literature on sustainability and scalability in quality improvement initiatives, PRIME® has adapted the following definitions of these terms.4-6

• Diffusion: Communication, over time, of knowledge, attitudes, and clinical practices through media or interpersonal channels among members of a social system

• Routinization: Development of organizational routine changes leading to improved healthcare practices• Institutionalization: Evolving adaptation of organizational processes and structures in response

to normalization of improved healthcare practices

Outcome Domains for Promoting Sustainability and Scalability

CE programs can be designed to promote sustainability and scalability of outcomes in various domains, examples of which include:

• Patient linkage to care and care retention• Patient and community health outcomes• Patient adherence to medications and care plans• Provider and team competence in reducing variations in evidence-based care• Provider and team performance on clinical practice guidelines and quality measures• Patient, provider, and team performance on patient-centered measures aligned with priorities

of the National Quality Strategy• Attitudes, perceptions, and values underlying positive behavior change

4


Educational Methods and Tools for Promoting Sustainability and Scalability

Effectively designed CE programs incorporate methods and tools for promoting sustainability and scalability over time.7,8

• Point-of-care checklists and guides for supporting decision-making • Support tools for shared decision-making • Patient engagement materials• Point-of-care guides for performing and documenting quality measures • Individual and team performance feedback from chart audits • Group learning for chart audit feedback• Feedback on patient-provider perceptions from tethered surveys• QI action plans developed through PDSA review cycles • Group action plan implementation and review cycles• Mentor-mentee programs: Reinforcing/sustaining achieved goals through teaching and scaling up

through new mentees• Published QI reports and tutorials

Methods for Evaluating Sustainability and Scalability of CE Outcomes

Effectively designed CE programs include targeted longitudinal methods for evaluating sustainability and scalability. In QI education projects, the methods are integrated into PDSA cycles, which include CE interventions and implementation of action plans. Examples of these longitudinal methods include:

• Chart audits for evaluating process-based quality measures • Chart audits for evaluating patient health outcomes • Qualitative analysis of chart notes and action plans, applying grounded theory and content analysis,

to assess practice change• Assessment of alignments and mismatches in patient-provider perceptions/experiences • Comparison of provider self-reports vs. chart data • Comparison of patient surveys vs. clinical outcomes data

1. Institute for Healthcare Improvement. Sustainability and spread how-to guide. www.ihi.org/resources/Pages/Tools/HowtoGuideSustainabilitySpread.aspx.

2. Healthcare Improvement Scotland. Guide on spread and sustainability. www.healthcareimprovementscotland.org.

3. Health Quality Ontario. Sustainability planner. www.hqontario.ca/Portals/0/documents/qi/qi-sustainability-planner-instruction-sheet-and-tool-en.pdf.

4. Rogers, E.M. (1995). Diffusion of innovations (4th edition). The Free Press. New York.

5. Slaghuis SS, et al. A framework and a measurement instrument for sustainability of work practices in long-term care. BMC Health Serv Res. 2011;11:314.

6. Slaghuis SS, et al. A measurement instrument for spread of quality improvement in healthcare. Int J Qual Health Care. 2013;25(2):125-131.

7. Geonnotti K, et al. Engaging primary care practices in quality improvement: Strategies for practice facilitators. Rockville, MD: Agency for Healthcare Research and Quality; March 2015.

8. National Quality Center. NQC action planning guide. Strategies for implementing your HIV quality improvement activities. April 2009. www.incarecampaign.org/files/quality-management-materials/strategies-for-implementing-your-quality-improvement-activities2

References

5

Table of Contents

Data Analytics, QI, Systems- and Team-Based Care, Patient and Provider Collaboration, Research

Data Analytics, Patient and Provider Collaboration,

QI, Research

Data Analytics, QI, Systems- and Team-Based Care, Patient

and Provider Collaboration, Research

Data Analytics, Systems- and Team-Based Care, Research

Data Analytics, QI, Patient and Provider Collaboration,

Research

Data Analytics, QI, Systems- and Team-Based Care, Patient

and Provider Collaboration

Data Analytics, Systems- and Team-Based

Care, Research

Data Analytics, QI, Patient and Provider

Collaboration

Data Analytics, Systems- and Team-Based Care,

QI, Research

Data Analytics, Systems- and Team-Based Care,

Research

Data Analytics, QI, Research

Core Competencies, Systems- and Team-Based Care, Research

Self-Reported Training Adequacy, Experience, and Comfort Level in Performing Schizophrenia-Related Clinical Skills Among Psychiatry Residents and Fellows

Comparing Patient and Provider Perceptions of Engagement and Care in Chronic Diseases

Applying Dose-Response Learning and Collaborative Partnerships to Impact Medication Management Outcomes

Comparing Patient and Clinician Perceptions of Engagement and Care in Chronic Diseases

Linking Patients and Clinicians to Improve the Quality of Care in Asthma Control

Outcomes of Continuing Professional Development (CPD) Programs for Managed Care Professionals

Quantifying and Closing Systems-Based and Interprofessional Collaborative Gaps in Oncology Care Through Tethered Patient and Provider Interventions

The Value of Dose-Response Learning to Maintain Continuing Professional Development in Managed Care and Specialty Pharmacy

Sustaining the Impact of Quality and Performance Improvement

Applying Quality Improvement into Systems-Based Learning to Improve Diabetes Outcomes in Primary Care

6

16

12

34

13

35

36

37

38

39

2016 Publications

CategoryReference Title Page

Acad Psychiatry, Oct 2016

JCEHP, July 2016

Dig Dis Sci, July 2016

BMJ Qual Improv Report, April 2016

ACEhp AIS, May 2016

ACEhp QIS, Sept 2016

World Congress, March 2016on CPD


Academy of Managed Care Pharmacy, Oct 2016

ACEhp AIS, May 2016

ACEhp AIS, May 2016


Improving Interprofessional and Coproductive Outcomes of Care for Patients with Chronic Obstructive Pulmonary Disease

26

Continuing Medical Education Improves Gastroenterologists’ Compliance with Inflammatory Bowel Disease Quality Measures 18



EMPIRICAL REPORT

Self-Reported Training Adequacy, Experience, and ComfortLevel in Performing Schizophrenia-Related Clinical Skillsamong Psychiatry Residents and Fellows

Laurence Greene1 & Kathleen Moreo1 & Henry Nasrallah2& Rajiv Tandon3

&

Tamar Sapir1

Received: 6 May 2016 /Accepted: 29 August 2016# Academic Psychiatry 2016

AbstractObjective In the context of an educational program on schizo-phrenia for psychiatry trainees, this survey study analyzedassociations between self-reported training adequacy, experi-ence in providing patient care, and comfort level inperforming schizophrenia-related clinical skills. The influenceof the education on comfort level was also assessed for eachskill.Methods Survey respondents were psychiatry residents andfellows who participated in a schizophrenia education pro-gram at an in-person workshop or through online videos re-corded at the workshop. In a pre-program survey, participantsreported their experience in providing schizophrenia patientcare and rated their training adequacy and comfort level forperforming seven clinical skills involved in diagnosing andtreating schizophrenia. The post-program survey includeditems for reassessing comfort level in performing the skills.Results Across the seven clinical skills, the proportion of re-spondents (n=79) who agreed or strongly agreed that theirtraining was adequate ranged from 29 to 88%. The proportionof high ratings for comfort level in skill performance rangedfrom 45 to 83 %. Comfort level was significantly associatedwith training adequacy for all seven clinical skills and withexperience in providing patient care for four skills. For allskills, comfort level ratings were significantly higher afterversus before the educational workshop. Commonly indicated

needs for further training included education on new thera-pies, exposure to a broader range of patients, and opportunitiesfor longitudinal patient management.Conclusions Psychiatry trainees’ self-reported, disease-specific training adequacy, experiences, and comfort levelhave unique applications for developing and evaluating grad-uate medical curriculum.

Keywords Evaluation . Curriculum development .

Educationalneedsassessment .Competencies .Schizophrenia

To guide curriculum development and evaluation, researchersin academic psychiatry have assessed educational experiencesand needs of psychiatry residents. Studies have reported resi-dents’ training needs in areas of telepsychiatry, professional-ism, treatment of vulnerable populations, and cultural sensi-tivities [1–4]. In the context of the Accreditation Council forGraduate Medical Education (ACGME) Milestones Project,questions have emerged regarding trainees’ educational expe-riences and needs involving specialty-specific competencies[5]. In 2015, the ACGME and the American Board ofPsychiatry and Neurology released the PsychiatryMilestones [6]. The publication provides a framework for cur-riculum development and evaluation in which outcomes arecategorized within subcompetencies and organized by devel-opmental levels [7–9].

Studies are lacking on competency-based educational ex-periences and needs among psychiatry trainees for specificdiseases. As part of a continuing medical education (CME)program on schizophrenia, we conducted a survey study inwhich psychiatry residents and fellows rated their trainingadequacy and comfort level, and reported their experience inproviding patient care, for a set of clinical skills involved inschizophrenia diagnosis and treatment. The skills are related

* Laurence [email protected]

1 PRIME Education, Inc., Tamarac, FL, USA2 St Louis University School of Medicine, St Louis, MO, USA3 University of Florida College of Medicine, Gainesville, FL, USA

Acad PsychiatryDOI 10.1007/s40596-016-0612-1

Author's personal copy


to Psychiatry Milestones subcompetencies. We designed thestudy to describe disease-specific educational experiences,needs, and outcomes of the psychiatrists in training who par-ticipated in the educational program. In addition, we analyzedassociations between the study variables—for example, therelationship between trainees’ experience in providing patientcare and comfort level in performing schizophrenia-relatedclinical skills. Our objective was to offer the academic psychi-atry community evidence and insights to support ongoing ef-forts to advance competency-based curriculum developmentand evaluation.

Methods

Setting and Participants

The survey was administered in the setting of an educationalprogram on schizophrenia that was offered to psychiatrytrainees by an accredited provider of GME and CME(PRIME Education, Inc.). The program comprised an 8-h in-person workshop, held in Chicago in September 2015, andfive online videos of presentations and discussions that wererecorded at the workshop. Three psychiatry academicians andschizophrenia experts, who serve as senior faculty in USmed-ical school residency programs, designed the content and ledthe workshop. Two of the presenters are co-authors of thisarticle (HN and RT). The educational format included interac-tive presentations, case-based discussions, and question-and-answer segments focusing on case-based clinical applications.The workshop was designed for participation of 25 psychiatryresidents and fellows who were selected by their programdirectors; each attendee represented a different US psychiatryprogram. Two months after the workshop, the five videocourses, averaging 60 min each, were posted online and madeavailable to 450 residents who were pre-enrolled by their pro-gram directors.

Pre- and post-workshop surveys were completed by all 25workshop attendees. Upon registering for the video courses,trainees representing different US psychiatry residency pro-grams who did not attend the workshop were invited to com-plete an online version of the same survey that was administeredon paper before the workshop. The invitation to complete theonline survey was extended to reach our goal of approximately50 respondents, each of whom received a USD$25 gift card forparticipation. The study methods were reviewed by an indepen-dent institutional review board (Sterling IRB, Atlanta, GA; IRBID# 5507), which granted exempt status.

Survey Items

The pre-program surveys included items for trainees to reporttheir extent of experience in providing schizophrenia patient

care and to rate their training adequacy and comfort level forthe following seven schizophrenia-related clinical skills: for-mulating a differential diagnosis; using validated scales toassess symptoms; treating acute psychotic relapses; selectingand initiating antipsychotic pharmacotherapy for first-episodepatients; evaluating and managing treatment adherence;adjusting or switching antipsychotic pharmacotherapies forpatients with lack of response, or safety or tolerability reasons;and managing side effects of antipsychotic pharmacotherapy.These skills aligned with the major topics of the educationalprogram and are related to selected ACGME PsychiatryMilestones in the domain of patient care [6].

Trainees reported their clinical experience by indicating thenumbers of patients with schizophrenia for whom they hadperformed each of the seven skills during their graduate med-ical training. Survey options were the following ranges ofpatient numbers: 0–5, 6–10, 11–15, 16–20, 21–40, or greaterthan 40. For each skill, trainees rated their training adequacyby indicating their level of agreement with the statement, “Myresidency training has provided me with adequate experiencein [the skill].” They rated their comfort level by indicatingtheir level of agreement with the statement, “I feel comfortableperforming [the skill].” Survey responses for training adequa-cy and comfort level were presented in Likert scales: stronglydisagree, disagree, neutral, agree, or strongly agree.

To assess continuing education and training needs, weasked an open-ended question: “In what areas of schizophre-nia care would you like to gain more experience during yourresidency or fellowship?” The survey also included an itemthat listed six training areas and asked respondents to choosethe top three areas that would most enhance theirschizophrenia-related clinical skills.

Immediately after the workshop, attendees completed asurvey with the same items for assessing comfort level inperforming the seven schizophrenia clinical skills. For logis-tical reasons, including the extended period over which theonline program was available, we did not evaluate the influ-ence of the video courses on comfort level.

Survey Data Analysis

For each schizophrenia-related clinical skill, we calculatedresponse frequencies for self-reported training adequacy,experience in providing patient care, and comfort level.We conducted chi-square tests or Fisher’s exact tests toevaluate associations among these variables, focusing onhow comfort level is related to training adequacy and ex-perience for each skill. Associations between these vari-ables and residency program year or fellowship status werealso evaluated. To assess the influence of the educationalworkshop on comfort level, we conducted Wilcoxonsigned rank tests for each clinical skill. For all analyses, ap value less than 0.05 was considered significant.

Acad Psychiatry



Results

Pre-program surveys were completed by 79 trainees (n=25workshop participants; n= 54 online video course partici-pants). Due to our planned restricted number of online surveyrespondents, the response rate for this group was 13 % of the450 pre-enrolled residents. Survey respondents were fellows(6.3 %) and postgraduate year (PGY) 1 (13.9 %), PGY 2(21.5 %), PGY 3 (35.5 %), and PGY 4 (22.8 %) residents;44 % were women. There were no significant associationsbetween the venue of survey completion (in-personworkshop or online) and the main study variables (trainingadequacy, experience, and comfort level). Thus, analyses arebased on combined survey responses from workshop at-tendees and video course registrants.

Self-Reported Training Adequacy, Comfort Level,and Experience

Respondents gave moderate to high ratings for their trainingadequacy. For six of the seven schizophrenia-related skills,only 5 % or fewer respondents strongly disagreed or disagreedthat their training has been adequate; for the exception, whichwas the skill of using symptom rating scales, 35 % of respon-dents indicated these levels of disagreement. Across the othersix skills, the proportions of respondents who agreed orstrongly agreed that their training has been adequate were asfollows: evaluating and managing adherence (68 %),adjusting or switching antipsychotic pharmacotherapy(75 %), selecting and initiating antipsychotic pharmacothera-py (77 %), managing side effects (80 %), treating acute re-lapses (83 %), and formulating a differential diagnosis (88 %).For all of the skills, ratings of training adequacy were notsignificantly associated with residency program year or fel-lowship status.

Ratings of training adequacy generally corresponded toratings of comfort level. For five of the seven skills, the pro-portion of respondents who strongly disagreed or disagreedthat they are comfortable ranged from 3 to 6 %; slightly moretrainees reported these levels of disagreement for formulatinga differential diagnosis (17 %) and using symptom ratingscales (22 %). Comfort level was significantly related to yearof training for two skills: selecting and initiating antipsychoticpharmacotherapy for first-episode schizophrenia (p=0.006)and adjust ing or switching pharmacotherapy fornonresponding patients or those with safety or tolerability is-sues (p=0.009). For these two skills, respectively, 80 and91 % of PGY 1 residents agreed or strongly agreed that theywere comfortable. Corresponding values for PGY 2, 3, and 4residents were 59 and 53, 85 and 93, and 94 and 65 %. All ofthe fellows agreed or strongly agreed that they are comfortableperforming both skills.

The trainee’s reported experience in schizophrenia patientcare varied across the skills. Based on comparing the threelowest (≤15 patients) and three highest (>15 patients) responsecategories, the majority of trainees reported relatively lowlevels of experience in using symptom rating scales (82 %)and selecting and initiating pharmacotherapy (62 %). The ma-jority reported higher levels of experience in formulating adifferential diagnosis (67 %), evaluating and managing adher-ence (62 %), treating acute relapses (73 %), adjusting orswitching antipsychotic pharmacotherapy (56 %), and manag-ing side effects (57 %). Residency program year or fellowshipstatus was not significantly associated with reported experi-ence in providing patient care for any skill. Trends were evi-dent for formulating a differential diagnosis (p=0.058) andtreating acute relapses (p=0.077). In these analyses, the ma-jority of PGY 1–2 residents reported low levels of experience,and the majority of PGY 3–4 residents and fellows reportedhigh levels of experience.

Comfort level was significantly associated with self-reported training adequacy for all seven skills. The relation-ships between these variables are shown in Table 1, whichcompares percentages of trainees who responded in categoriesof low or high comfort and low or high training adequacy. Inthe table, “low” refers to Likert responses of strongly disagreeor disagree, and “high” refers to responses of agree or stronglyagree. The results generally indicate that the greatest percent-ages of trainees reported low comfort/low training adequacyor high comfort/high training adequacy. Across all skills,values for these two categories ranged from 25 to 100 and85 to 96 %, respectively. For most of the skills, markedlylower percentages of trainees reported high comfort/low train-ing adequacy or low comfort/high training adequacy.

Associations between comfort level and experience in pro-viding patient care were statistically significant for formulat-ing a differential diagnosis, using symptom rating scales, eval-uating and managing adherence, and managing side effects.For depicting this relationship in Table 1, “low” experiencerefers to 15 or fewer patients, and “high” experience refers tomore than 16 patients. Across the clinical skills, the propor-tions of trainees who reported high comfort/high experienceranged from 79 to 88%. In contrast to the findings for trainingadequacy and comfort level, relatively high proportions oftrainees reported high comfort/low experience; values in thiscategory ranged from 38 to 83 %.

Pre- to Post-Program Differences in Comfort Level

For all seven clinical skills, comfort level differed significant-ly between the pre- and post-workshop surveys, indicating apositive influence of the education. The main pre- to post-workshop differences were for responses of neutral, agree,or strongly agree to the statement “I feel comfortableperforming [the skill].” For the skills of formulating a

Acad Psychiatry



differential diagnosis and selecting and initiating antipsychot-ic pharmacotherapy, pre- to post-program differences werecharacterized by large reductions in the percentages of traineeswho selected agree in response to the statement (−53 and−32 %, respectively) and corresponding increases in re-sponses of strongly agree (52 and 28 %, respectively). Forthe other five skills, pre- to post-program reductions in thepercentages of trainees who chose neutral (range of −12 to−32 %) were offset by increases in the choices of agree and/or strongly agree (range of 20 to 40 %).

Education and Training Needs Assessment

For the survey item asking respondents to indicate the threeareas that would most enhance their schizophrenia training,the choices were (1) more education on the efficacy, safety,and utility of new antipsychotic therapies (71%); (2) exposureto a broader range of patients (56 %); (3) opportunities forlongitudinal management (49 %); (4) support for care

coordination and disease management (48 %); (5) opportuni-ties for schizophrenia research (35 %); and (6) training inMedicare and managed care (34 %). For the open-ended ques-tion regarding future schizophrenia training needs, the mostcommonly indicated topics were as follows: molecular, neu-rochemical, and genetic studies; approaches to preventing re-lapses; strategies for improving adherence; applications oflong-acting antipsychotic therapies; integration of cognitivebehavioral therapy or social services; and treatment and ongo-ing management of pregnant patients or patients with new-onset psychosis, comorbid substance abuse, or inadequate re-sponse to initial medications.

Discussion

This study, which adds to reports on educational experiencesand needs among psychiatrists in training [1–4], uniquely fo-cuses on skills involved in diagnosing and treating patients

Table 1 Comfort level in performing clinical skills for evaluating and treating people living with schizophrenia in relation to self-assessed trainingadequacy and experience in providing patient care

Low/low High/low Low/high High/high p valuec

% (N) % (N) % (N) % (N)

Formulating a differential diagnosis

Comfort level/training adequacya 100 (4/4) 0 (0/4) 13 (9/68) 85 (58/68) <0.0001

Comfort level/experienceb 23 (6/26) 65 (17/26) 13 (7/52) 85 (44/52) 0.0079

Using symptom rating scales

Comfort level/training adequacy 48 (13/27) 7 (2/27) 4 (1/23) 96 (22/23) <0.0001

Comfort level/experience 25 (16/64) 38 (24/64) 7 (1/14) 79 (11/14) 0.0423

Selecting/initiating therapy



Evaluating/managing adherence


Comfort level/experience 10 (3/30) 40 (12/30) 2 (1/48) 88 (42/48) <0.0001

Treating acute relapses



Adjusting/switching antipsychotic therapy



Managing side effects



Percentages have been roundeda For comfort level and training adequacy, “low” refers to Likert responses of strongly disagree or disagree, and “high” refers to responses of agree orstrongly agreeb For experience, “low” refers to 15 or fewer patients, and “high” refers to more than 16 patientsc p values are for chi-square or Fisher’s exact tests for overall associations between comfort level and training adequacy or comfort level and experience

Acad Psychiatry



with schizophrenia, which is arguably the most severe andpersistent psychiatric brain disorder. For six of the seven clin-ical skills, the majority of respondents agreed or stronglyagreed that their training has been adequate and that they arecomfortable performing the skills. The exception was usingvalidated scales for assessing symptoms. This finding is notsurprising, because many residency programs do not includeinstruction in using standardized rating scales to quantify ill-ness severity or severity of medication side effects. This gap intraining psychiatrists is serious because evidence-based clini-cal trials in psychopharmacology published in major journalsuse rating scales for inclusion and exclusion criteria as well asfor measuring efficacy and side effects. This gap will beremedied only if the ACGME and residency review commit-tees require that training programs include competency inmeasurement-based psychiatry using major rating scales.

In conceptualizing this project, we expected greater varia-tion in survey responses, corresponding to differences in theknowledge requirements and cognitive complexity forperforming the seven clinical skills. We also expected thatself-reported training adequacy and comfort level would beassociated with resident program year and fellowship status.However, respondents’ status was significantly associated on-ly with comfort level and for only two skills: selecting andinitiating pharmacotherapy and adjusting or switching phar-macotherapy. An unexpected finding was that compared withPGY 2, 3, and 4 residents and fellows, large percentages ofPGY 1 residents agreed or strongly agreed that they are com-fortable performing the skills. Many PGY 1 psychiatry resi-dents gain experience in providing care mainly in in-patientsettings, including many cases of acute schizophrenia. PGY 1residents may feel “comfortable” with schizophrenia-relatedskills because they do not realize the multiple complexities ofthe illness in the long-term setting. Thus, in some cases, PGY1 residents may rate their comfort as high because “they don’tknow what they don’t know.”

Medical education leaders recognize that trainee self-assessment is an essential element of the development andevaluation of knowledge, clinical skills, professionalism, andother competencies. However, studies have revealed discon-nects between residents’ self-assessments and the assessmentsof supervisors [10, 11]. The GME community has begun toaddress the implications of specialty-specific self-assessmentas a foundational skill and evaluation tool based on newACGME milestones. In a recent study, orthopedic surgeryresidents self-assessed their proficiency in achievingspecialty-specific milestones in different competency domains[12]. The residents successfully differentiated their proficien-cy for milestones in medical knowledge versus patient care. Inaddition, self-assessment scores were higher among PGY 5versus PGY 1 residents. Another recent study compared emer-gency medicine residents’ self-assessments of performance onspecialty-specific milestones with evaluations of attending

physicians in their institutions [13]. Among PGY 1–3 resi-dents, self-assessed ratings were consistently higher than su-pervisors’ ratings. In contrast, researchers have reported that,compared with ratings of attending surgeons, residents in gen-eral surgery underrate their laparoscopic skills and comfortlevel [14]. An earlier study involving psychiatry residents re-vealed a moderate but significant correlation (r=0.33) be-tween their self-rankings and performance on 11 subject areasof the Psychiatry Resident-in-Training Examination [15].

In addition to providing rationale for specialty-specific re-search on self-assessment among psychiatry trainees, an im-portant implication of this study is that self-assessment out-comes can be compared with feedback from faculty supervi-sors to identify educational gaps and, through a collaborativeprocess, develop and implement strategies for closing them.This approach aligns with the view that learners process andact on external feedback by interpreting it through the frame-work of self-assessment [13, 16, 17]. Skillful and valid self-assessment also can deepen the trainee’s insights into areas forimprovement in ways that motivate self-directed, lifelonglearning [11].

Whereas self-reported comfort level is not a surrogate forclinical competence, it is a fairly common measure in studiesassessing residents’ performance and training needs. Wefound that higher ratings of comfort level were significantlyassociated with self-reported experience in providing patientcare and training adequacy. Similar findings have been report-ed in the GME literature [18–20]. Our comparisons of pre-and post-workshop survey responses indicated significant in-creases in the percentages of trainees who agreed or stronglyagreed that they are comfortable performing the seven clinicalskills, although this finding is limited by the lack of a controlgroup.

Survey respondents from the in-person workshop and on-line video courses were selected by their program directorsand self-selected, respectively. Thus, inferences about thestudy findings may be limited to a unique group of psychiatrytrainees, who may be more confident and have higher experi-ence and comfort levels in performing schizophrenia-relatedclinical skills. Moreover, the survey study is limited by itssmall sample size. The workshop and video participants rep-resented different residency and fellowship programs; thus,heterogeneity in their trainingmay have influenced the results.For example, our finding that key variables, including experi-ence in providing patient care, were not significantly associ-ated with program year and fellowship status for most clinicalskills may have been due to differences in developmentalcurricula across the 25 programs. This observation is relevantto the design of future studies involving the ACGMEPsychiatry Milestones. As addressed by the working groupauthors, the ACGME does not expect residents to progressthrough the milestones in a linear pattern, and interindividualdifferences in progress are anticipated [6].

Acad Psychiatry



In addition to informing future research on the ACGMEPsychiatry Milestones, our findings may be useful for advanc-ing trainee and program evaluation. Program directors canconduct similar surveys of their residents at every year oftraining for every disease entity and then compare self-assessments with faculty ratings. Disconnects can providevaluable information for improving the clinical curriculumand mentoring residents about the accuracy of their self-as-sessment. This approach may contribute to refining evaluationmethods, to ultimately achieve the cherished goal of everyresidency training program: a genuinely competent group ofresidents before graduation.

Acknowledgments The authors acknowledge Jeffrey Carter for con-tributing to the analysis of the project data.

Compliance with Ethical Standards The study methods werereviewed by an independent institutional review board (Sterling IRB,Atlanta, GA; IRB ID# 5507), which granted exempt status.

Disclosures The authors are employees of, or academic educators/consultants to, PRIME Education, Inc., a health care education companythat received an independent continuing medical education (CME) grantfrom Otsuka America Pharmaceutical, Inc. and Lundbeck to conduct theeducational program described in this article. Otsuka AmericaPharmaceutical, Inc. and Lundbeck had no role in the study design orexecution, and the grant did not include support for conducting the sur-veys or writing this manuscript.

References

1. Crawford A, Sunderji N, López J, Soklaridis S. Defining compe-tencies for the practice of telepsychiatry through an assessment ofresident learning needs. BMC Med Educ. 2016;16:28.

2. Jain S, Lapid MI, Dunn LB, Roberts LW. Psychiatric residents’needs for education about informed consent, principles of ethicsand professionalism, and caring for vulnerable populations: resultsof a multisite survey. Acad Psychiatry. 2011;35:184–90.

3. Munshi A, Woods N, Hodges B. Psychiatry, war, and the learningneeds of residents. Acad Psychiatry. 2010;34:208–10.

4. Sockalingam S, Hawa R, Al-Battran M, Abbey SE, Zaretsky A.Preparing international medical graduates for psychiatry residency:a multi-site needs assessment. Acad Psychiatry. 2012;36:277–81.

5. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accred-itation system—rationale and benefits. N Engl J Med. 2012;366:1051–6.

6. Accreditation Council for Graduate Medical Education. ThePsychiatry Milestone Project. Available at: https://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/PsychiatryMilestones.pdf. Accessed April 19, 2015.

7. Thomas CR. Introduction and commentary on the psychiatry mile-stones. Acad Psychiatry. 2014;38:253–4.

8. Hunt J, Thomas CR. ACGME milestone development in generalpsychiatry: patient care and medical knowledge. Acad Psychiatry.2014;38:261–7.

9. Swing SR, Cowley DS, Bentman A. Assessing resident perfor-mance on the psychiatry milestones. Acad Psychiatry. 2014;38:294–302.

10. Davis DA, Mazmanian PE, Fordis M, et al. Accuracy of physicianself-assessment compared with observed measures of competence:a systematic review. JAMA. 2006;296:1094.

11. Anderson PA. Giving feedback on clinical skills: are we starvingour young? J Grad Med Educ. 2012;4:154–8.

12. Bradley KE, Andolsek KM. A pilot study of orthopaedic residentself-assessment using a milestones’ survey just prior to milestonesimplementation. Int J Med Educ. 2016;7:11–8.

13. Goldflam K, Bod J, Della-Giustina D, Tsyrulnik A. Emergencymedicine residents consistently rate themselves higher than attend-ing assessments on ACGME milestones. West J Emerg Med.2015;16:931–5.

14. Alameddine MB, Claflin J, Scally CP, et al. Resident surgeonsunderrate their laparoscopic skills and comfort level when com-pared with the rating by attending surgeons. J Surg Educ.2015;72:1240–6.

15. Lynn DJ, Holzer C, O’Neill P. Relationships between self-assessment skills, test performance, and demographic variables inpsychiatry residents. Adv Health Sci Educ Theory Pract. 2006;11:51–60.

16. Sargeant J, Armson H, Chesluk B, et al. The processes and dimen-sions of informed self-assessment. Acad Med. 2010;85:1212–20.

17. Bounds R, Bush C, Aghera A, et al. MERC at CORD FeedbackStudy Group. Emergency medicine residents’ self-assessments playa critical role when receiving feedback. Acad EmergMed. 2013;20:1055–61.

18. Suwanabol PA, McDonald R, Foley E, Weber SM. Is surgical res-ident comfort level associated with experience? J Surg Res.2009;156:240–4.

19. Marel GM, Lyon PM, Barnsley L, et al. Clinical skills in earlypostgraduate medical trainees: patterns of acquisition of confidenceand experience among junior doctors in a university teaching hos-pital. Med Educ. 2000;34:1013.

20. Hsieh E, Nunez-Smith M, Henrich JB. Needs and priorities inwomen’s health training: perspectives from an internal medicineresidency program. J Womens Health (Larchmt). 2013;22:667–72.

Acad Psychiatry



13

13

Meet the Winner of Excellence in Designand Outcomes SQUIRE Award, September 2016

Excerpt from Alliance Connect

Kathleen Moreo, RN-BC, BSN, BHSA, CCM, CDMS, president and CEO of PRIME® Education LLC, is the recent recipient of the Excellence in Design and Outcomes SQUIRE Award. Read about Kathleen's project, inspirations, roadblocks and more in our interview below.

The Alliance: Can you briefly describe your project, "Applying Quality Improvement into Systems-Based Learning to Improve Diabetes Outcomes in Primary Care"?

Kathleen Moreo: We designed the quality improvement education program to support systems-based primary care teams in closing documented gaps in care quality and outcomes for patients with type 2 diabetes. The program's core component engaged 30 primary care physicians and their interprofessional clinical teams as a QI cohort. The clinicians practiced in accountable care organizations (ACOs) in Texas, Pennsylvania and Connecticut. After obtaining independent IRB approval for the QIE program and outcomes study, our research team audited 300 charts of patients with type 2 diabetes --- on average, 10 charts for each primary care physician in the QI cohort. Chart measures included patient demographics, medication adherence status, and changes in A1C and BMI between the first and last visits in the baseline period. We also audited the chart's ACO quality measures for patient experiences based upon the Centers for Medicare and Medicaid Services (CMS), patient-centered measures aligned with National Quality Strategy (NQS) priorities, and physicians' documented performance of national clinical quality measures for type 2 diabetes.

The QI project included CME/CE learning interventions that focused on strategies for closing gaps in the quality of type 2 diabetes care and patient outcomes. Continual improvement cycles were guided by analysis of the baseline chart audits, quantitative survey data and qualitative feedback offered by participants. During a period of time after the learning interventions concluded, we audited another 300 patient charts using the same methods applied for the baseline chart audits. This approach enabled us to assess the impact of the QI-focused education on the quality of the participating physicians' type 2 diabetes care processes and on patient outcomes. To extend the benefit of the education, we also offered the enduring learning interventions to clinicians throughout the U.S. who did not participate in the QI program.

14

This project was supported by Novo Nordisk Inc., one of ACEhp's QIE sponsors.

The Alliance: What was the inspiration behind your project?

KM: We were primarily motivated by published reports of significant gaps in clinicians' performance on diabetes-specific and patient-centered quality measures, specifically in the ACO setting. As established through the CMS Shared Savings Program, ACO-based providers must achieve benchmark levels of performance on quality measures in order to receive shares of associated cost savings. Seminal studies have indicated suboptimal rates of compliance with ACO quality measures for diabetes care and with patient-centered measures involving shared decision making. We designed our targeted educational interventions to support ACO-based primary care providers in aligning their practices with benchmark standards and helping patients achieve A1C goals, reduce body weight, and improve overall health and function.

The Alliance: What part of your project do you think stood out the most?

KM: As we reported in the journal article on this project, which was published in BMJ Quality Improvement Reports*, the outcomes of the program indicated a very positive impact of QI education on primary care physicians' performance of patient-centered quality measures and patient health outcomes. For example, there were significant education-associated improvements in assessment of medication side effects and counseling patients about medication risks/benefits, medication adherence and lifestyle modifications. The post-education chart audits also indicated patient adherence to diabetes medications and reductions in A1C and BMI. In addition to these objective measures of the program's success, we observed and recorded qualitative data that reflected positive attitudes and practices among interprofessional clinicians in the QI cohort that stemmed from their participation in the interventions. Many providers commented on the benefits of seeing and reflecting on their own performance and patient outcome data. Through gaining objective views on their practice patterns, providers acknowledged that they were more motivated and informed to improve their performance on type 2 diabetes quality measures.

The Alliance: What were some challenges you faced along the way? How did you overcome them?

KM: One of the greatest challenges we encountered involved supporting 30 physicians and their clinical teams in the continuous improvement cycles associated with the series of QI activities. To meet this challenge, we assigned our research coordinators to personally and consistently communicate with the practices throughout the engagement period. This included personal phone calls, emails, fax reminders and communications. Other main challenges involved logistics of the QI study methods. Our BMJ journal article details the techniques in research design that we used to overcome these challenges.

15

The Alliance: Will you be continuing this project?

KM: In order to sustain the value of this project, we recently obtained funding from Novo Nordisk Inc. to conduct a phase 2 project that takes a vertical dive into one large under-served system in the U.S. Through lessons learned from the initial diabetes project, we have incorporated patient encouragement through tethered surveys with their providers, and we have added patient coaching through Pack Health LLC. A key goal of our project is to measure patients' clinical outcomes tied to the performance improvement of providers.

*Moreo K, Sapir T, Greene L. Applying quality improvement into systems-based learning to improve diabetes outcomes in primary care. BMJ Qual. Improv. Report. 2015;4.


Short Communication

Comparing Patient and Provider Perceptions ofEngagement and Care in Chronic DiseasesKathleen Moreo, RN-BC, BSN, BHSA, CCM, Cm, CDMS; Tamar Sapir, PhD; Laurence Greene, PhD

The continuing professional development (CPD) commu-nity recognizes that optimal health care outcomes depend

on coproduction, defined by the partnerships that patients andproviders form in processes such as setting goals, makingtreatment decisions, and assessing care quality andoutcomes.1,2

To develop programs that effectively support provider andpatient coproduction, CPD professionals must first identify rele-vant gaps and needs.Generally, our approach to gap analysis andneeds assessment for coproduction involves conducting surveystudies to compare patients’ and providers’ disease-specifictreatment goals, relative knowledge and educational needs, per-ceptions, barriers, and behaviors. This approach addresses thecurrent lack of comprehensive patient-provider survey studies onvarious chronic diseases in the literature.

Through survey studies approved by independent institu-tional review boards, we sought to assess and compare patient–provider perceptions regarding hepatitis C and chronicobstructive pulmonary disease (COPD).

METHODS

A total of 80 primary care or specialty practices were recruitedfrom states with the highest prevalence of liver disease amongHispanic populations (n = 50) or from states with the highestCOPD prevalence (n = 30).

Providers in each practice invited three of their patients withhepatitis C or COPD to participate in a “tethered” patient–pro-vider survey study and educational activities. For the COPD pro-gram, in addition to the 90 patients in the tethered cohort,a separate comparatorgroupof125patients recruited fromCOPDadvocacy organizations across the U.S. completed the surveys.Provider surveys were completed by the physician treating thesurveyed patients in each practice.

In the surveys, patients and providers were asked to indicatetheir treatment goals, extent of agreement on treatment plans,perceptions about disease symptoms and their effects onquality of life, and attitudes and practices regarding shareddecision-making. In addition, patients were asked to indicate

their main barriers to optimal care and their needs foreducation and support; for these items, providers were askedto estimate patients’ responses.

Based on linked survey items, we compared percentages ofresponses for each provider, his/her patients (tethered group),and the advocacy patient group in the COPD study. Thismethod enabled identification of alignments and mismatchesin patients’ and providers’ responses. As an educationalapproach, survey feedback was presented to providersthrough a personalized online dashboard. In this medium,each provider viewed a series of graphs that depicted his/hersurvey responses related to de-identified patient responses.Based on identified gaps—for example,mismatches inpatients’and providers’ treatment goals or perceptions about the impactof disease symptoms on quality of life—providers identifiedan action plan for improving coproductive hepatitis C orCOPD care.

RESULTS

In surveys conducted for the hepatitis C program, 40% and54% of patients reported that they know their liver fibrosisstage and virus genotype, respectively; corresponding providerestimates of patients’ knowledge were 88% and 94%.Regarding perceived barriers to optimal treatment, 80% and63% of patients indicated “limited understanding of how toadhere to therapy” and “fear of stigma”; corresponding pro-vider estimates of patients’barrierswere 38%and26%.Thirty-eight percent of providers and 68% of patients reportedinvolvement in shared decision-making This discordance mayreflect a lack of a shared understanding among providers andpatients regarding the qualities that define shared decision-making.

Key findings from the COPD program surveys are summa-rized as follows:

• Acommonpattern occurred for ratings of the importance of3 treatment goals: managing symptoms, preventing exacer-bations, andpreventinghospitalizations.A ratingof“highlyimportant” was given by most providers (63%–77%) butby only 16%–25% and 31%–44% of patients in thetethered and advocacy groups, respectively.

• A total of 81% and 52% of patients in the tethered andadvocacy groups reported having agreedwith providers ona treatment plan, whereas 57% of providers indicatedagreement.

• Providers generally underestimated the impact of COPDon patients’ emotional health and quality of life.

Table 1 presents percentages for categories of action plansdeveloped by providers for the 2 disease areas.

Disclosures: The authors declare no conflict of interest. This project was supported

by educational grants from Gilead Sciences, Inc; AbbVie, Inc; and AstraZeneca LP.

The abstract on which this short communication is based was presented at the 2016

World Congress on Continuing Professional Development under the same title.

Ms. Moreo: President and CEO, PRIME Education, Inc, Tamarac, FL. Dr. Sapir:Chief Scientific Officer, PRIME Education, Inc, Tamarac, FL. Dr. Greene: ScientificEducation Manager, PRIME Education, Inc, Tamarac, FL.

Correspondence: Tamar Sapir, PhD, PRIME Education, Inc, 8201 West McNab

Road, Tamarac, FL 33321; e-mail: [email protected].

Copyright ª 2016 The Alliance for Continuing Education in the Health Professions,

the Association for Hospital Medical Education, and the Society for Academic

Continuing Medical Education

DOI: 10.1097/CEH.0000000000000102

S44 JCEHP n Summer 2016 n Volume 36 n Supplement 1 www.jcehp.org

Copyright ª 2016 The Alliance for Continuing Education in the Health Professions, the Association for Hospital Medical Education,and the Society for Academic Continuing Medical Education. Unauthorized reproduction of this article is prohibited.


DISCUSSION

Our findings suggest discordance of patient–provider goals andperceptions that may have important implications for developingCPD programs to support coproduction. To complement con-ventional methods in audit and feedback education, patient–provider survey results can be presented as instructional contentto prompt reflection and identification of targeted action plansfor closinggaps.Discordance ingoals andperceptions can informCPDeducational design, aswell as research, to support providersand patients in reconciliation and negotiation to achieve thehighest goals of coproduction. For example, the identification ofmismatches in patients’ and providers’ treatment goals mayinform the design of coproductive CPD programs in which the 2groups are supported in developing shared understandings andnegotiation skills. Successful outcomes of this type of programwould demonstrate narrowed gaps in patients’ and providers’treatment goals.

REFERENCES

1. Batalden M, Batalden P, Margolis P, et al. Coproduction of healthcareservice. BMJ Qual Saf. 2016;25:509–517.

2. Cramm JM, Nieboer AP. The changing nature of chronic care andcoproduction of care between primary care professionals and patients withCOPD and their informal caregivers. Int J Chron Obstruct Pulmon Dis.2016;11:175–182.

TABLE 1.

Providers’ Action Plans for Improvement After Review ofSurvey Results

Action Plan CategoryFrequency ofResponse, %

Hepatitis C

Addressing issues in patient health literacy 33

Using educational tools or translators 23

Engaging patients in shared decision-making 19

Aligning screenings with guidance recommendations 13

Improving interdisciplinary team communication 8

Educating patients about therapies 4

Chronic obstructive pulmonary disease

Counseling patients in smoking cessation 25

Engaging patients in shared decision-making 24

Addressing issues in patient health literacy 15

Aligning follow-up with guidance recommendations 10

Understanding influence of patients’ financial limitations 9

Educating patients about therapies 6

Improving care coordination 6

Addressing patients’ emotional issues 5

Patient-Clinician Perceptions in Chronic Diseases Moreo et al. S45

Copyright ª 2016 The Alliance for Continuing Education in the Health Professions, the Association for Hospital Medical Education,and the Society for Academic Continuing Medical Education. Unauthorized reproduction of this article is prohibited.


ORIGINAL ARTICLE

Continuing Medical Education Improves Gastroenterologists’Compliance with Inflammatory Bowel Disease Quality Measures

Tamar Sapir1 • Kathleen Moreo1 • Jeffrey D. Carter1 • Laurence Greene1 •

Barry Patel2 • Peter D. R. Higgins3

Received: 27 September 2015 / Accepted: 26 January 2016

� Springer Science+Business Media New York 2016

Abstract

Background Low rates of compliance with quality mea-

sures for inflammatory bowel disease (IBD) have been

reported for US gastroenterologists.

Aims We assessed the influence of quality improvement

(QI) education on compliance with physician quality

reporting system (PQRS) measures for IBD and measures

related to National Quality Strategy (NQS) priorities.

Methods Forty community-based gastroenterologists

participated in the QI study; 20 were assigned to educa-

tional intervention and control groups, respectively. At

baseline, randomly selected charts of patients with mod-

erate-to-severe ulcerative colitis were retrospectively

reviewed for the gastroenterologists’ performance of 8

PQRS IBD measures and 4 NQS-related measures. The

intervention group participated in a series of accredited

continuing medical education (CME) activities focusing on

QI. Follow-up chart reviews were conducted 6 months

after the CME activities. Independent t tests were con-

ducted to compare between-group differences in baseline-

to-follow-up rates of documented compliance with each

measure.

Results The analysis included 299 baseline charts and

300 follow-up charts. The intervention group had signifi-

cantly greater magnitudes of improvement than the control

group for the following measures: assessment of IBD type,

location, and activity (?14 %, p = 0.009); influenza vac-

cination (?13 %, p = 0.025); pneumococcal vaccination

(?20 %, p = 0.003); testing for latent tuberculosis before

anti-TNF-a therapy (?10 %, p = 0.028); assessment of

hepatitis B virus status before anti-TNF-a therapy (?9 %,

p = 0.010); assessment of side effects (?17 %,

p = 0.048), and counseling patients about cancer risks

(?13 %, p = 0.013).

Conclusions QI-focused CME improves community-

based gastroenterologists’ compliance with IBD quality

measures and measures aligned with NQS priorities.

Keywords Inflammatory bowel disease � Qualityimprovement � Physician quality reporting system �Continuing medical education

Introduction

To achieve the goals of quality-driven health care, clini-

cians must demonstrate benchmark performance on

national quality measures. In 2011, through collaboration

with the Crohn’s and Colitis Foundation of America

& Tamar Sapir

[email protected]

Kathleen Moreo

[email protected]

Jeffrey D. Carter

[email protected]

Laurence Greene

[email protected]

Barry Patel

[email protected]

Peter D. R. Higgins

[email protected]

1 PRIME Education, Inc., 8201 West McNab Road, Tamarac,

FL 33321, USA

2 Indegene Total Therapeutic Management, 300 Townpark Dr

#100, Kennesaw, GA 30144, USA

3 Department of Gastroenterology, University of Michigan

Health System, 1500 E Medical Center Dr # 391, Ann Arbor,

MI 48109, USA

123

Dig Dis Sci

DOI 10.1007/s10620-016-4061-1



(CCFA), the American Gastroenterological Association

(AGA) published a set of 10 process-based quality mea-

sures for the care of adults with inflammatory bowel dis-

ease (IBD) [1]. Eight of these measures were adopted by

the Centers for Medicare & Medicaid Services (CMS) for

the Physician Quality Reporting System (PQRS) program

in 2013 and 2014 [2]. The PQRS program originally pro-

vided incentive payments for eligible health care profes-

sionals who met criteria for reporting quality measures. As

of 2015, the program imposes annual increasing reim-

bursement penalties for failing to report quality measure

data according to CMS requirements [3]. In health care

systems such as accountable care organizations, quality

assessment is partly determined by compliance with

patient-centered measures that align with the six priorities

of the National Quality Strategy (NQS) [4]. These priorities

entail improving patient safety, engaging patients in their

care, enhancing care coordination and communication,

using the most effective prevention and treatment methods,

promoting community health initiatives, and making health

care more affordable.

The first studies on US gastroenterologists’ compliance

with PQRS quality measures for IBD have recently been

published [5–8]. Feuerstein and coinvestigators reviewed

the charts of IBD patients who received care from gas-

troenterologists at a tertiary medical center. Performance

on all 8 PQRS quality measures for IBD was documented

for only 6.5 % of patients [5]. We previously conducted 2

quality improvement (QI) programs in which charts of IBD

patients who received care from community-based gas-

troenterologists were reviewed before and after the physi-

cians participated in accredited continuing medical

education (CME) activities. The programs focused on the

care of patients with Crohn’s disease [6] or ulcerative

colitis [7, 8]. Baseline chart reviews revealed low and

variable rates of compliance with PQRS measures for IBD

and NQS-related measures [6–8].

Leaders in the US gastroenterology community have

called for incorporating national IBD quality measures in

QI programs that engage clinicians in rigorous documen-

tation, along with performance analysis and feedback [9–

12]. The educational interventions in our previously

reported IBD QI studies included individualized feedback

on chart reviews. The education was associated with sig-

nificant improvements in documented performance of

some IBD and NQS-related quality measures, especially

among gastroenterologists whose baseline compliance rates

were low [7, 8]. However, due to the pragmatic nature of

these programs and studies, the findings are somewhat

limited by methodological issues such as a lack of nonin-

tervention control groups.

This article reports a QI program and study in which

compliance with IBD and NQS-related quality measures

was assessed in a group of community-based gastroen-

terologists before and after they participated in a series of

QI-focused CME activities. Performance on the measures

was evaluated through baseline and follow-up (post-edu-

cation) chart reviews of patients with ulcerative colitis. To

evaluate the influence of the education, we also reviewed

baseline and follow-up charts of patients who received care

from a nonintervention control group of community-based

gastroenterologists.

Methods

The QI study received independent institutional review

board approval (Sterling IRB, Atlanta, GA; IRB ID #4613).

Physician Recruitment and Baseline Review

Randomly identified community-based gastroenterology

practices across the US were contacted to provide infor-

mation about the QI project and to inquire about interests in

participating. Recruitment phone calls were made until 40

gastroenterologists in different practices were enrolled. In

order of their agreement to participate, 20 gastroenterolo-

gists were assigned to the educational intervention group,

and then 20 were assigned to the nonintervention control

group. All of the physicians signed consent forms for their

participation in the educational program and study.

The study was designed to retrospectively review 300

charts at baseline, for the 1-year period of January 1, 2013

to December 31, 2013. We planned to review 10 charts and

5 charts, respectively, for each gastroenterologist in the

intervention and control groups. Administrative staff in

each practice randomly selected charts of patients who met

the following inclusion criteria: age C18 years; diagnosis

of moderate-to-severe ulcerative colitis confirmed by ICD-

9 codes and the Montreal classification system [13]; and at

least 1 visit with the physician during the 1-year baseline

review period. In each practice, a list of eligible patients

was alphabetized and numbered. Random sampling

tables were used to select an oversample of up to 25 eli-

gible charts. An administrative fee of $500 was offered to

each practice to reimburse costs for identifying patient

charts and providing chart access to the reviewers.

Charts were abstracted for patient demographics and the

gastroenterologists’ documented performance of (1) the 8

IBD quality measures included in the 2013 and 2014 PQRS

programs and (2) patient-centered measures aligned with

NQS priorities, including assessment of side effects and

provision of patient counseling about IBD-related topics

(Table 1). For each PQRS measure, denominators were

adjusted and exclusions were applied. We chose the

patient-centered measures based on their alignment with

Dig Dis Sci

123



NQS priorities for ensuring that patients are engaged in

their health care, improving communication, promoting

effective prevention and treatment practices, or making

care safer. Documentation of performance on each measure

was recorded for analysis in Statistical Package for the

Social Sciences (SPSS), version 22.

Educational Interventions

The educational interventions comprised a series of

accredited CME activities. After their baseline charts

were reviewed, gastroenterologists in the intervention

group participated in the first activity, a private audit

feedback session. Administered through web conference

software, the individualized sessions were led by a clin-

ician trained in interpreting and presenting quality mea-

sures abstracted from patient charts. Each session was

organized by the presentation of slides with graphs

showing the participating gastroenterologist’s rates of

compliance with the PQRS quality measures for IBD and

the NQS-related measures. Presented as mean percentages

of charts documented for each measure, the graphs also

included de-identified, aggregated compliance rates for

the other gastroenterologists in the intervention group.

The audit feedback sessions were designed to guide par-

ticipants in identifying measures for which baseline per-

formance was suboptimal. For these measures, the

presenter asked the participating gastroenterologist to

reflect and comment on barriers to performance and

documentation. In addition, the presenter and participant

discussed an individualized action plan for improving

performance and documentation. During the audit feed-

back sessions, a facilitator took notes to record key dis-

cussion points, including participants’ barriers to

compliance with IBD quality measures and strategies for

addressing them.

Table 1 Measures assessed through patient chart audits

2013–2014 Physician Quality Reporting System (PQRS)

Quality measures for inflammatory bowel disease (IBD)a

Measure 226: Tobacco use screening and cessation intervention

Percentage of patients who were screened for tobacco use one or more times within 24 months AND who received cessation counseling

intervention if identified as a tobacco user

Measure 269: Type, anatomic location and activity all documentedb

Percentage of patients who have documented the disease type, anatomic location and activity, at least once during the reporting period

Measure 270: Corticosteroid-sparing therapy

Percentage of patients who have been managed by corticosteroids C10 mg/day for C60 consecutive days that have been prescribed

corticosteroid-sparing therapy in the last reporting year

Measure 271: Corticosteroid-related iatrogenic injury—bone loss assessment

Percentage of patients who have received dose of corticosteroids C10 mg/day for C60 consecutive days and were assessed for risk of bone

loss once per the reporting year

Measure 272: Influenza immunization

Percentage of patients for whom influenza immunization was recommended, administered or previously received during the reporting year

Measure 273: Pneumococcal immunization

Percentage of patients that had pneumococcal vaccination administered or previously received

Measure 274: Testing for latent tuberculosis (TB) before initiating anti-TNF (tumor necrosis factor) therapy

Percentage of patients for whom a TB screening was performed and results interpreted within 6 months prior to receiving a first course of

anti-TNF therapy

Measure 275: Assessment of Hepatitis B virus (HBV) status before initiating anti-TNF therapy

Percentage of patients who had HBV status assessed and results interpreted within 1 year prior to receiving a first course of anti-TNF therapy

Measures aligned with NQS priorities

Assessment of side effects

Counseling about medication risks/benefits and adherence

Counseling about colorectal surgery

Counseling about cancer risks

a All PQRS measures apply to patients aged 18 years and older with a diagnosis of IBDb Type defined as Crohn’s disease, ulcerative colitis, or IBD-unclassified; location determined based on current or historic endoscopic and/or

radiologic data; and activity defined in terms of luminal disease status (quiescent, mild, moderate, severe) and presence of extraintestinal

manifestations

Dig Dis Sci

123



Within 4 weeks after his/her audit feedback session,

each gastroenterologist in the intervention group partici-

pated in an accredited small-group webinar. A total of 5

webinars were offered on different dates to accommodate

scheduling and promote interaction. The webinars were led

by expert gastroenterologists who were selected based on

their involvement in national QI programs and their

established records of IBD research. One of the co-authors

of this article (PDRH) served as a presenter for 3 of the

webinars. The expert gastroenterologists led the study

participants in discussions about the evidence-based ratio-

nale for applying IBD quality measures in practice and

effective methods for performing and documenting the

measures.

To reinforce the education provided in the audit feed-

back sessions and small-group webinars, we developed an

online/mobile toolkit that included accredited CME activ-

ities on improving the quality of IBD care and nonac-

credited resources for supporting the gastroenterologists in

performing, documenting, and reporting PQRS quality

measures for IBD. The accredited activities included four

30- to 60-min interactive videos that addressed applications

of quality measures to various aspects of ulcerative colitis

and Crohn’s disease care, including diagnosis, treatment

decision-making, and ensuring patient safety. The toolkit

also included a 20-page monograph that presented the

evidence-based rationale for applying quality measures in

IBD practice.

Follow-up Chart Review and Analysis

Six months after the intervention group completed the

CME activities, follow-up chart reviews were conducted.

According to the same methods used for the baseline per-

iod, we planned to review 10 charts and 5 charts, respec-

tively, for each gastroenterologist in the intervention and

control groups. Charts were randomly identified for

patients with ulcerative colitis who met the previously

listed inclusion criteria and had at least 1 visit with the

gastroenterologist in the 6-month period after the educa-

tional activities. The period for follow-up chart review was

6 months, from December 1, 2014 to May 31, 2015.

Statistical Analysis

Chi-square tests or t tests were conducted to compare

demographic characteristics of physicians in the interven-

tion and control groups and to determine whether patient

demographics differed in the chart samples selected for

baseline and follow-up reviews, as well as between the

intervention and control groups. To assess the influence of

the CME activities, we calculated the percentage of patient

charts with documented performance of each PQRS and

NQS-related measure at baseline and follow-up for each

gastroenterologist. Overall mean percentages were then

calculated for the 2 periods in the intervention and control

groups. Independent t tests were performed to compare the

differences in mean provider-level compliance rates from

baseline to follow-up between the 2 groups. For all anal-

yses, p values less than 0.05 were considered significant.

Results

The 40 gastroenterologists practiced in Alabama, Florida,

New York, Texas, New Jersey, Arizona, Illinois, Indiana,

Massachusetts, Missouri, Tennessee, Virginia, or Wash-

ington. The control group had significantly more clinical

experience than the intervention group based on mean

years in gastroenterology practice (25 vs. 18 years,

p = 0.04; Table 2). There were nonsignificant differences

in geographic distribution and percentages of males and

females between the intervention and control groups.

However, post hoc multiple regression analysis indicated

that none of these demographic variables was significantly

associated with changes in rates of compliance with the

IBD quality measures or NQS-related measures. Before the

follow-up chart reviews, one of the gastroenterologists in

the intervention group dropped out of the study.

The baseline analysis included 199 charts for the inter-

vention group (mean = 10.5 charts per physician,

range = 5–25 charts) and 100 charts for the control group

(mean = 5.0 charts per physician, range = 4–10 charts).

The follow-up analysis included 200 charts for the inter-

vention group (mean = 10.5 charts per physician,

range = 5–25 charts) and 100 charts for the control group

(mean = 5 charts per physician, range = 2–10 charts).

Several of the gastroenterology practices provided fewer

eligible charts than were targeted. Because these practices

were enrolled in the QI program, their charts were included

in the analysis. All but 1 of the 40 gastroenterologists used

electronic health records.

Within-group analyses indicated no significant differ-

ences between the baseline and follow-up chart samples for

patients’ ages, body mass index (BMI), proportion of

females and males, and disease duration. In addition, there

were no significant differences between patient demo-

graphics in the intervention and control group charts,

respectively, for age (45.5 and 48.5 years), proportion of

females (48.5 and 49 %), BMI (27.5 and 27.4), and disease

duration (10.0 and 7.5 years).

Baseline and follow-up rates of documented compliance

with the PQRS quality measures for IBD are presented in

Table 3. Across the 2 periods, the difference in the per-

centage of documented charts was significantly greater in

the intervention versus control group for 5 of the 8 PQRS

Dig Dis Sci

123



measures. The differences in changes for the 5 measures,

reflecting greater magnitudes of improvement in the

intervention group, were as follows: assessment of IBD

type, anatomic location, and activity (?14 %, p = 0.009);

influenza vaccination (?13 %, p = 0.025); pneumococcal

vaccination (?20 %, p = 0.003); testing for latent tuber-

culosis before initiating anti-TNF-a therapy (?10 %,

p = 0.028); and assessment of hepatitis B virus status

before initiating anti-TNF-a therapy (?9 %, p = 0.010).

The differences in baseline to follow-up compliance rates

did not differ significantly between groups for smoking

cessation intervention in current smokers and bone loss

assessment and corticosteroid-sparing therapy in patients

using corticosteroids over prolonged periods.

Table 4 presents the percentages of charts that were

documented for measures aligned with NQS priorities.

Compared with the control group, the intervention group

had significantly greater magnitudes of improvement for 2

of the 4 measures: assessment of medication side effects

(?17 %, p = 0.048) and counseling patients about cancer

risks (?13 %, p = 0.013). The differences in baseline to

follow-up compliance rates did not differ significantly

between groups for counseling patients about colorectal

surgery or medication risks/benefits and adherence.

Table 5, which reflects notes taken during the audit

feedback sessions, summarizes participants’ most com-

monly discussed barriers to compliance with IBD quality

measures and the education strategies that we employed to

address the barriers.

Discussion

Recent studies have indicated low and variable rates of

compliance with IBD quality measures among gastroen-

terologists practicing in tertiary care and community-based

settings [5–8]. In the present study, the mean baseline

percentages of patient charts with documented

Table 2 Demographic

characteristics of intervention

and control groups

Intervention group

(n = 20)

Control group

(n = 20)

p value

Males/females (%) 70/30 90/10 0.24

Years in gastroenterology practice 18 25 0.04

US geographic region (%) 0.44

Northeast 30 15

South 35 50

Midwest 20 10

West 15 25

Table 3 Baseline and follow-up rates of compliance with PQRS quality measures for IBD

Intervention Control p value

Baseline (%) Follow-up (%) D (%) Baseline (%) Follow-up (%) D (%)

Smoking cessation interventiona 64 53 -11 50 14 -36 0.151

Assessment of disease type, location, and activity 77 92 15 83 84 1 0.009

Corticosteroid-sparing therapyb 89 95 6 55 75 20 0.860

Bone loss assessmentb 7 23 16 0 15 15 0.978

Influenza immunization 28 43 15 4 6 2 0.025

Pneumococcal immunization 8 28 20 1 1 0 0.003

TB testing before anti-TNF-a therapyc 74 89 15 70 75 5 0.028

HBV testing before anti-TNF-a therapyc 58 83 25 45 61 16 0.010

PQRS physician quality reporting system, TB tuberculosis, TNF tumor necrosis factor, HBV hepatitis B virus

Unless otherwise noted, compliance rates were based on physician-level analysis of 199 baseline charts and 200 post-education charts for the

intervention group (n = 19 physicians), and 100 baseline charts and 100 follow-up charts for the control group (n = 20 physicians)a Eligibility based on current tobacco smoking status: 14 baseline charts (n = 10 physicians) and 19 follow-up charts (n = 12 physicians) for the

intervention group; 6 baseline charts (n = 6 physicians) and 7 follow-up charts (n = 7 physicians) for the control groupb Eligibility based on prolonged corticosteroid use: 27 baseline charts (n = 14 physicians) and 40 follow-up charts (n = 13 physicians) for the

intervention group; 11 baseline charts (n = 8 physicians) and 20 follow-up charts (n = 8 physicians) for the control groupc Eligibility based on anti-TNF-a use: 62 baseline charts (n = 16 physicians) and 87 follow-up charts (n = 16 physicians) for the intervention

group; 20 baseline charts (n = 14 physicians) and 28 follow-up charts (n = 15 physicians) for the control group

Dig Dis Sci

123



performance on the 2013–2014 PQRS measures ranged

from 5 % for bone loss assessment in patients using cor-

ticosteroids to 81 % for assessment of disease type, loca-

tion, and activity. For the NQS-related measures, mean

baseline compliance rates ranged from 18 to 85 %. In a

previous QI education study, we reviewed charts of adults

with Crohn’s disease who received care from 20 commu-

nity-based gastroenterologists who did not participate in

the present study [6]. Baseline rates of compliance with the

PQRS measures for IBD ranged from 3 % for pneumo-

coccal immunization to 98 % for corticosteroid-sparing

therapy. Feuerstein and coinvestigators reviewed the

electronic health records of 367 patients with Crohn’s

disease or ulcerative colitis who received care from general

gastroenterologists or IBD specialists at a large tertiary

medical center [5]. Rates of compliance with the PQRS

measures ranged from 21 % for pneumococcal immu-

nization to 96 % for smoking cessation intervention. In our

previous studies, rates of documented testing for latent

tuberculosis and hepatitis B virus before initiating anti-

TNF-a therapy did not exceed 29 % [6, 8]. The mean

baseline rates reported here (72 and 52 %, respectively)

and by Feuerstein and coinvestigators (67 and 74 %,

respectively) [5] are considerably higher, reflecting

Table 4 Baseline and follow-up rates of compliance with NQS-related measures

Intervention Control p values

Baseline

(%)

Follow-up

(%)

D(%)

Baseline

(%)

Follow-up

(%)

D(%)

Assessment of medication side effects 59 70 11 56 50 -6 0.048

Counseling about medication risks/benefits and

adherence

80 92 12 89 89 0 0.174

Counseling about colorectal surgery 28 25 -3 7 6 -1 0.819

Counseling about cancer risks 29 51 22 13 22 9 0.013

For all measures, compliance rates were based on physician-level analysis of 199 baseline charts and 200 follow-up charts for the intervention

group (n = 19 physicians), and 100 baseline charts and 100 follow-up charts for the control group (n = 20 physicians)

Table 5 Quality improvement (QI) education strategies for addressing barriers to compliance with IBD quality measures

Barriers to compliance Quality Improvement Education Strategies

Attitudinal barriers

Skeptical attitudes about relationships between process-based quality

measures and patient outcomes

Presentation of evidence and expert consensus views supporting

positive relationships between IBD process-based quality measures

and patient outcomes

Workflow and care coordination barriers

Indeterminate roles of clinical staff in performing and documenting

different quality measures

Guidance for clinical staff training in QI roles and responsibilities

Gaps in interprofessional understanding, collaboration, and

communication between physicians in community practice and

providers in managed care organizations

Provision of educational resources on managed care from professional

organizations such as the Academy of Managed Care Pharmacy

Lack of time for performing quality measures and providing patient

education and counseling

Guidance for adjusting clinical workflow and staff responsibilities for

better time efficiency

View that other providers should be responsible for performing

selected measures (e.g., influenza and pneumococcal vaccinations

provided by primary care physicians)

Guidance and staff assignments for effective care coordination

practices to ensure that patients receive care aligned with quality

measures and that the measures are appropriately documented

Documentation barriers

Lack of structured fields in electronic health records for documenting

certain measures

Instruction on adding fields or templates to electronic health records, or

to assist documenting performance in chart notes, and building

queries to automatically pull documentation fields into chart notes

Uncertainty about specific documentation processes and requirements Provision of QI ‘‘toolkit’’ checklists and step-by-step instructions for

performing and documenting quality measures; guidance on using

online registries and other systems for reporting quality measures

Dig Dis Sci

123



progress in the gastroenterology community for these 2

measures. However, the initial reports indicate that per-

formance of IBD quality measures is suboptimal and

variable across measures and physicians.

The QI-focused educational activities in this study were

associated with significantly greater improvements in the

intervention versus control group for 5 of the 8 PQRS

quality measures for IBD. In the intervention group,

compliance rates either decreased or did not increase sig-

nificantly for smoking cessation intervention, bone loss

assessment, and corticosteroid-sparing therapy. These 3

measures depend on eligibility criteria of current smoking

status or prolonged use of corticosteroids. As noted in

Table 2, a small proportion of patient charts met these

criteria; thus, the data for these measures are limited.

This study adds to a series of QI programs and outcome

studies in which we reviewed charts of patients with IBD

before and after their gastroenterologists participated in

accredited CME activities [6, 8]. This study is unique in its

inclusion of a nonintervention control group and its focus

on assessing and improving the quality of care for patients

with ulcerative colitis. In our previous study involving 20

different community-based gastroenterologists and reviews

of 400 charts of Crohn’s disease patients, education was

associated with improved documentation of PQRS IBD

measures only in ‘‘low-performing’’ physicians, designated

by compliance rates in the lowest quartile [6]. The edu-

cational interventions included individualized audit feed-

back sessions; however, there were no follow-up small-

group webinars.

Given its context in a pragmatic QI program, this study

was not designed to determine the extent to which each

educational activity influenced the outcomes. The audit

feedback sessions and small-group webinars were designed

to flexibly address the performance gaps and educational

needs of individual participants. More time was devoted to

discussing barriers and solutions to performing quality

measures for which the individual’s baseline compliance

rates were low compared with absolute standards and mean

rates for the other participants. Systematic reviews indicate

that audit and feedback education generally elicits small-

to-moderate, but meaningful improvements in clinical

performance [14, 15]. Many of the gastroenterologists in

the intervention group reported a lack of standardized

processes in their clinics for accomplishing the PQRS

quality measures, which led to discussion about ways to

establish reliable processes to identify gaps, act on these

gaps, and document completion of the quality measures for

each patient, often by leveraging new capabilities of their

electronic health record systems.

The study outcomes were process-based quality mea-

sures rather than patient outcomes. Thus, we assessed the

performance of the same physicians, based on randomly

selected patient charts, across the baseline and follow-up

periods. This design was intended to control for partici-

pant-related extraneous variables. In addition, the inclusion

of chart reviews for a nonintervention group was intended

to control for the Hawthorne effect and secular factors that

may have influenced compliance with the quality measures.

The gastroenterologists were not blinded to the study goals

or to their group assignments; thus, bias related to this

factor may have influenced the study outcomes. The study

may also have been limited by its short follow-up period,

which was 6 months. Although all patients had at least 1

visit with their gastroenterologist in the follow-up period,

the relatively short duration may have precluded perform-

ing some of the quality measures. It is also possible that,

without continual reinforcement, performance on quality

measures may revert to baseline levels.

The IBD quality measures on which the study was based

were included in the 2013–2014 PQRS program. In 2015,

changes to the measures set were enacted through collab-

oration between the AGA, the National Committee for

Quality Assurance, and the American Medical Association

Physician Consortium for Performance Improvement. A

major revision was retirement of the measure for assess-

ment of IBD type, anatomic location, and activity [16].

Other recent developments include a new AGA system for

reporting IBD quality measures and alternative methods for

meeting CMS reporting requirements [17]. Future revisions

may include the addition of outcomes-based IBD quality

measures [12]. Given the early stage and evolving nature of

value-based IBD care, to address issues of sustainability

and clinical relevance, future QI programs and studies

should be designed to account for ongoing and anticipated

revisions to quality measures as well as reporting systems

and requirements. Moreover, bias in the appropriateness of

the quality measure may influence compliance. For

example, many gastroenterologists may consider surgical

counseling as not applicable or inappropriate for the

majority of their ulcerative colitis patients.

This study demonstrates that QI-focused CME can

improve community-based gastroenterologists’ compliance

with quality measures for IBD and measures aligned with

NQS priorities. Our findings suggest that the QI education

interventions positively influenced performance on some

quality measures to a greater degree than others. Future

studies are thus needed to identify factors that explain the

potential for QI interventions to promote positive practice

changes, especially for IBD quality measures deemed to be

most clinically important. New studies are also needed to

identify the most effective types of educational interven-

tions for QI programs and to develop strategies for scaling

interventions so that greater numbers of gastroenterology

clinicians can become involved in national efforts to

improve the quality of care for patients with IBD.

Dig Dis Sci

123



Acknowledgments AbbVie, Inc. and Takeda Pharmaceuticals

U.S.A., Inc. for providing funding of the study on which the article is

based.

Author contribution Tamar Sapir, Jeffrey D. Carter, Kathleen

Moreo, Laurence Greene, Barry Patel, and Peter D.R. Higgins were

involved in Study and educational design. Barry Patel, Jeffrey Carter,

Tamar Sapir, and Laurence Greene were associated with Chart review

and analysis. Tamar Sapir, Kathleen Moreo, Jeffrey D. Carter, and

Peter D.R. Higgins did Development and presentation of educational

activities. Jeffrey D. Carter, Laurence Greene, Barry Patel, Tamar

Sapir, Kathleen Moreo, and Peter D.R. Higgins were involved in Data

interpretation and statistical analysis. Laurence Greene, Tamar Sapir,

Kathleen Moreo, Jeffrey D. Carter, and Barry Patel contributed to

Manuscript drafting. Peter D.R. Higgins, Laurence Greene, Tamar

Sapir, Kathleen Moreo, Jeffrey D. Carter, and Barry Patel were

involved in Manuscript review and revision.

Compliance with ethical standards

Conflict of interest Tamar Sapir, Kathleen Moreo, Jeffrey Carter,

and Laurence Greene represent PRIME Education, Inc., a healthcare

education company that received independent educational grants from

AbbVie, Inc. and Takeda Pharmaceuticals U.S.A., Inc. to conduct the

quality improvement project described in this article. The funders had

no role in the study design or execution, and the grants did not include

support for writing this manuscript. Barry Patel represents Indegene

Total Therapeutic Management, a research company contracted by

PRIME Education to perform the reviews of patient charts for this

study. Peter D.R. Higgins, MD, has received honoraria from PRIME

Education, Inc. for participation as faculty in the educational activities

described in this article. Dr. Higgins was a prior consultant for

AbbVie, Inc.

References

1. American Gastroenterological Association. Adult Inflammatory

Bowel Disease Physician Performance Measures Set. https://

www.gastro.org/practice/quality-initiatives/IBD_Measures.pdf.

Accessed 18.01.2016.

2. Centers for Medicare & Medicaid Services. Measures Codes.

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assess

ment-Instruments/PQRS/MeasuresCodes.html. Accessed 18.01.2016.

3. Centers for Medicare & Medicaid Services. Payment Adjustment

Information. https://www.cms.gov/Medicare/Quality-Initiatives-

Patient-Assessment-Instruments/PQRS/Payment-Adjustment-

Information.html. Accessed 18.01.2016.

4. Agency for Healthcare Research and Quality. About the National

Quality Strategy (NQS). http://www.ahrq.gov/workingforquality/

about.htm. Accessed 18.01.2016.

5. Feuerstein JD, Lewandowski JJ, Martinez-Vazquez M, et al.

Documented compliance with inflammatory bowel disease qual-

ity measures is poor. Dig Dis Sci. 2015;60:339–344.

6. Greene L, Sapir T, Moreo K, et al. Impact of quality improve-

ment educational interventions on adherence to quality measures

for adults with Crohn’s disease. Inflamm Bowel Dis. 2015;21:

2165–2171.

7. Greene L, Moreo K, Sapir T, et al. Use of chart audit and private

feedback to improve physician quality and performance measures

in ulcerative colitis: preliminary results. J Contin Educ Health

Prof. 2014;34:S39–S40.

8. Greene L, Moreo K. Quality improvement education to improve

performance on ulcerative colitis quality measures and care

processes aligned with National Quality Strategy priorities. BMJ

Qual Improv Report. 2015;4. doi:10.1136/bmjquality.u208829.

w3554.

9. Siegel CA, Allen JI, Melmed GY. Translating improved quality

of care into an improved quality of life for patients with

inflammatory bowel disease. Clin Gastroenterol Hepatol.

2013;11:908–912.

10. Melmed GY, Siegel CA. Quality improvement in inflammatory

bowel disease. Gastroenterol Hepatol (NY). 2013;9:286–292.

11. Siegel CA. Creating quality measures in IBD. Gastroenterol

Hepatol. 2010;6:218–220.

12. Melmed GY, Siegel CA, Spiegel BM, et al. Quality indicators for

inflammatory bowel disease: development of process and out-

come measures. Inflamm Bowel Dis. 2013;19:662–668.

13. Satsangi J, Silverberg MS, Vermeire S, et al. The Montreal

classification of inflammatory bowel disease: controversies,

consensus, and implications. Gut. 2006;55:749–753.

14. Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects

on professional practice and healthcare outcomes. Cochrane

Database Syst Rev. 2012;6:CD000259.

15. Jamtvedt G, Young JM, Kristoffersen DT, et al. Audit and

feedback: effects on professional practice and health care out-

comes. Cochrane Database Syst Rev. 2006;2:CD000259.

16. American Gastroenterological Association. Physician Quality

Reporting System (PQRS) and the Value-Based Payment Modi-

fier. http://www.gastro.org/practice/quality-initiatives/performance-

measures/400-1708901-MHC-AGA_PQRS-IBD-Flashcard.pdf.

Accessed 18.01.2016.

17. American Gastroenterological Association. Digestive Health

Recognition ProgramTM. http://www.gastro.org/practice-manage

ment/quality/quality-reportng/digestive-health-recognition-pro-

gram-dhrp. Accessed 18.01.2016.

Dig Dis Sci

123



Improving Interprofessional andCoproductive Outcomes of Care forPatients with Chronic ObstructivePulmonary Disease

Kathleen Moreo, Laurence Greene, Tamar Sapir

To cite: Moreo K, Greene L,Sapir T. ImprovingInterprofessional andCoproductive Outcomes ofCare for Patients with ChronicObstructive PulmonaryDisease. BMJ QualityImprovement Reports2016;5:u210329.w4679.doi:10.1136/bmjquality.u210329.w4679

Received 8 March 2016Revised 1 April 2016

PRIME Education, Inc.(PRIME)

Correspondence toLaurence [email protected]

ABSTRACTIn the U.S., suboptimal care quality for patients withchronic obstructive pulmonary disease (COPD) isreflected by high rates of emergency department visitsand hospital readmissions, as well as excessive costs.Moreover, a substantial proportion of COPD patients donot receive guideline-directed therapies. In qualityimprovement (QI) programs, these types of health careproblems are commonly addressed throughinterventions that primarily or exclusively supportphysicians in aligning their practices with guidelinesand clinical quality measures. However, the root causesof many deficits in health care quality are notnecessarily “physician centric.” Instead, they ofteninvolve suboptimal collaboration among members ofinterprofessional health care teams and gaps incoproductive relationships among patients andproviders.We conducted a QI project to identify

interprofessional and coproductive correlates of COPDcare quality in the context of a continuing educationprogram designed to advance knowledge and skillamong patients, providers, and the interprofessionalCOPD team regarding coproductive COPD care.Participants in the program included providers in 30primary care practices across the U.S. who, along withtheir own COPD patients and a separate cohort ofpatients from COPD advocacy groups, completed apatient-provider survey study designed to identifyalignments and mismatches in coproductiveperceptions and behaviors, a private surveyfeedback session for each practice’s team,and online/mobile educational activities on COPD.In addition, more than 1,000 additional providers and200 patients participated in just the online/mobileeducation.From the patient perspective, baseline measures

indicated a high rate of dissatisfaction with COPDtreatment plans and suboptimal coproductiveinteraction with members of the interprofessionalhealth care team. Across providers, there were gapsand variation in provision of patient education,attitudes and practices regarding shared decision-making, and care coordination with pulmonaryspecialists. In addition, relatively low proportions ofproviders reported high levels of skill in variouscoproductive processes.

The project outcomes indicated mismatches betweenCOPD patients and providers in perceived ability torecognize COPD exacerbations, shared treatment goals,barriers to medication adherence, perceived impact ofCOPD on quality of life, and other aspects of COPDcare. Providers demonstrated improvements inknowledge and attitudes regarding coproductive andcoordinated COPD care.

PROBLEMIn the U.S., chronic obstructive pulmonarydisease (COPD) affects an estimated 24million adults and accounts for more than1.5 million emergency department visits and725,000 hospitalizations per year. The 30-dayreadmission rate for people hospitalized withacute COPD exacerbations is nearly 25%.1 2

The total annual cost estimates for COPDexceed $35 billion.3 Up to 40% of patientswith COPD exacerbations do not receiveguideline-directed therapies, and up to 50%receive at least one medication that isdeemed potentially harmful.4 5 In qualityimprovement (QI) programs, these types ofhealth care problems are commonlyaddressed through interventions, includingcontinuing education, that primarily orexclusively support physicians in aligningtheir practices with evidence-based guide-lines and clinical quality measures. However,the root causes of many deficits in healthcare quality are not necessarily “physiciancentric.” Instead, they often involve subopti-mal collaboration among members of inter-professional healthcare teams and gaps incoproduction, which is defined by the extentto which patients and providers form part-nerships in services such as shared treatmentgoal-setting and decision-making, and assess-ment of care quality and outcomes.6 7

This article reports a phase 1 projectdesigned to identify interprofessional and

Moreo K, et al. BMJ Quality Improvement Reports 2016;5:u210329.w4679. doi:10.1136/bmjquality.u210329.w4679 1

Open Access BMJ Quality Improvement Programme

group.bmj.com on July 6, 2016 - Published by http://qir.bmj.com/Downloaded from


coproductive correlates of COPD care quality in thecontext of a continuing education program. Conductedby PRIME Education, Inc. (PRIME©), a multi-accreditedprovider of interprofessional continuing education(IPCE) for health care teams, the project was motivatedpartly by new models of value-based health care thatemphasize aligning practice with patient-centered prior-ities of the National Quality Strategy (NQS). These pri-orities include engaging patients and caregivers aspartners, promoting effective communication betweenpatients and providers, and enhancing care coordinationamong members of interprofessional health care teams.The project involved a patient-provider survey study

and educational activities for primary care clinicians—including physicians, nurse practitioners, and physicianassistants—as well as patients with COPD, and othermembers of the COPD care team. Our QI team com-prised PRIME’s trained QI education staff, includingspecialists in designing patient-provider surveys and ana-lyzing the results and in developing, implementing, andevaluating measurable outcomes of educational inter-ventions that target gaps in care quality. Here wedescribe how the methods and outcomes of this projecthave informed the development of an ongoing compre-hensive QI education program on COPD.

BACKGROUNDIn addition to high rates of emergency department visitsand hospital readmissions, many patients with COPDhave long delays in diagnosis and treatment initiationafter initial symptoms, underutilization of effective ser-vices such as pulmonary rehabilitation, and inadequateself-management behaviors.8 9 Commonly reported con-sequences include compromised functional capacity,disease-related psychosocial disorders, and poor qualityof life.10 These markers of suboptimal COPD carequality can be partly attributed to gaps in interprofes-sional collaborative practice and patient-providercoproduction. For example, delayed diagnosis and treat-ment initiation can result from oversights in referralpractices and care coordination between primary careproviders and pulmonary specialists. Inadequate self-management behaviors are frequently associated withdeficient patient education and counseling, as well asineffective patient-provider communication.11

The hallmarks of coproduction among patients andproviders include shared treatment goal-setting anddecision-making, mutual understanding of the patient’sdisease-related knowledge and needs for education, andcommitments to respectful and productive communica-tion.11 12 Evidence is mounting to support the view thatpatients who are engaged as partners in their healthcare experience better outcomes at lower costs.13

Moreover, patients’ perceptions of the quality of theirCOPD care are correlated with the strength of coproduc-tive relationships with their providers.11 12 To be effect-ive in promoting coproduction, however, QI initiatives

must be informed by evidence and insights into theextent to which relationships between COPD patientsand providers, as well as among members of interprofes-sional care teams, are indeed coproductive.Comprehensive studies are lacking in the literature on

coproduction in COPD. Findings from two recent studiesindicated disconnects between patient and provider per-ceptions of patients’ knowledge needs and preferredmethods of education, as well as beliefs about the effectsof smoking on disease etiology and progression.14 15

Through the QI interprofessional continuing education(IPCE) program reported in this article, we sought toidentify alignments and mismatches in patients’ and pro-viders’ goals, perceptions, attitudes, and behaviorsregarding various aspects of COPD care quality.

BASELINE MEASUREMENTAfter obtaining independent institutional review board(IRB) approval, we identified regions of the U.S. with ahigh prevalence of people with COPD and a highdensity of primary care practices treating COPD patients.To identify these regions, we used the 2010 U.S. Census,surveillance data from the Centers for Disease Controland Prevention, and the American Medical AssociationPhysician Masterfile. Crossover data from these sourceswere used to calculate a composite score for ranking the48 contiguous states by population, COPD prevalence,and density of primary care practices. We identified thetop 10 states by highest-ranking composite scores and,from these states, selected 1,257 primary care practicesthrough ICD-9 codes for COPD. We used electronic andtelephonic communications to recruit a final cohort of30 primary care practices with interprofessional clinicalstaff. From each practice, a physician, nurse practitioner,or physician assistant was enrolled as the primary partici-pant in the program, and each provider was encouragedto engage his/her entire treatment team in the project.The enrolled providers reported having office visits withan average of 18 patients with COPD per week.Each of the 30 primary care providers invited three of

their patients with COPD to participate in a “tethered”patient-provider survey study. (Throughout this article,the tethered group refers to patients who receivedprimary care from the 30 providers in the QI cohort.)The surveys included items that prompted patients andproviders to indicate their respective COPD treatmentgoals, perceptions about the disease symptoms and itseffects on quality of life, assessment of patients’ abilitiesto recognize and respond to COPD exacerbations, viewson patient barriers to medication adherence, attitudesand practices regarding shared decision-making, andother aspects of COPD care quality. In addition to the90 patients in the tethered cohort, a separate externalgroup of 125 patients, who were recruited from COPDadvocacy groups across the U.S., completed the patientsurveys (Patient advocacy groups are organizations thatprovide services to patients with specific diseases or

2 Moreo K, et al. BMJ Quality Improvement Reports 2016;5:u210329.w4679. doi:10.1136/bmjquality.u210329.w4679

Open Access



disorders; the services may include awareness-buildingactivities, educational programs, and various forms ofsupport for individuals affected and their caregivers).The surveys were designed to identify alignments and

mismatches in patients’ and providers’ responses tolinked items. Our systematic approach to tethered surveydevelopment begins with a literature review of validatedsurvey instruments and studies on patient-provider per-ceptions, and incorporates their findings to createsurveys that are easily understood by patients and mean-ingful to providers. We develop survey items at theFlesch-Kincaid 5th - 6th grade level based on the FleschReading Ease score, which evaluates readability based onsyllables, numbers of words per sentence, and other ele-ments for patients. Survey instruments are included inour IRB protocol. Patients and providers completesurveys online or through a mobile application. Ourrigorous review process includes multiple internal andexternal reviews, conducted by patients, interventionalmapping consultants, expert faculty in the disease state,practicing clinicians, and research professionals. Notonly are our surveys tailored to the population andsetting, their implementation is managed by our QI spe-cialists who are dedicated to guiding participantsthrough the project from beginning to end.As described in the following section, the patient-

provider survey findings were individually presented tothe 30 primary care practices as an educational interven-tion during a private feedback session conducted witheach practice. In addition, providers in the 30 practicesparticipated in a series of QI-focused online/mobileeducational activities on COPD, which were also dissemi-nated to a national audience of more than 1,000 clini-cians including physicians, nurse practitioners, physicianassistants, nurses, pharmacists, and case managers.Key baseline findings from the patient surveys are

summarized as follows:▸ The majority of patients (69%) indicated that they

are not completely satisfied with their COPD treat-ment plan.

▸ Despite reporting that cigarette smoking is the mostlikely cause for their COPD, 87% of patients indi-cated that they currently smoke at least 1 cigaretteper week.

▸ In response to a question about the sufficiency ofinformation received from their COPD health careteam (1 = none; 3 = the right amount; 5 = too much),patients’ mean rating for information and assistanceon smoking cessation was 2.3.

▸ Although a large proportion of the patients reportedfeeling confident in discussing questions about COPDwith their physicians (80%), relatively few patientsexpressed confidence in such discussions with othermembers of their COPD care teams, including nurses(32%) and other health care professionals (24%).

▸ Patients gave low to moderate ratings (4.0-7.6 on a10-point scale) to different members of interprofes-sional care teams for their understanding of the

impact of COPD on emotional health and quality oflife.The surveys included an open-ended item asking

patients for the main messages they would like to giveproviders about how to improve COPD care quality. Thegeneral themes of these messages are summarized asfollows:▸ Improve listening and communication skills▸ Demonstrate greater understanding and compassion

about the effects of COPD▸ Provide education on lifestyle modification, new treat-

ments, self-care, and other important aspects ofCOPD care

▸ Work cooperatively with the patient’s other healthcare providers

▸ Involve patients in treatment and care decisions▸ Direct patients to community education and support

resourcesSupplementary Table 1 presents examples of patients’

open-ended comments categorized by these themes.Baseline assessments for the 30 providers were qualita-

tive, derived through reviewing transcript notes takenduring the survey feedback sessions. Key themes andobservations derived from discussions during the ses-sions are summarized as follows:▸ Across providers, there was considerable variation in

provision of patient education on essential self-caretopics such as recognizing exacerbations and takingappropriate action to ensure timely treatment.

▸ Many providers reported that they educated patientsabout COPD causes, risks, symptoms, and treatment;however, few providers offered education and coun-seling on patient-centered interests and outcomessuch as strategies for emotional coping and improvingquality of life.

▸ Many providers acknowledged a lack of training andexperience in counseling to address issues of emo-tional health and quality of life for patients withCOPD.

▸ There was considerable variation in attitudes andpractices regarding shared decision-making. Someproviders commented that they take full responsibilityfor treatment decision-making because they “knowwhat is best” for their patients. At the other end ofthe spectrum, providers expressed the view that theyare patient advocates who regularly encourage shareddecision-making. Reported barriers to effectiveshared decision-making included a lack of trainingand experience in cultural competence.

▸ Several of the primary care providers cited subopti-mal communication with pulmonology specialists as abarrier to optimal COPD care quality.Our qualitative analysis indicated that the different

perspectives among providers were not systematicallyassociated with their ages, gender, geographic location,or other demographic factors.For the series of online/mobile educational activities

on COPD, we developed a pre- and post-program survey


Open Access



to assess providers’ attitudes and barriers to patient-centered COPD care and self-assessed ability to performkey skills in coproductive relationships with patients.These activities were to designed to improve providers’confidence and competence in COPD assessment aswell as in patient counseling and shared decision-making. At the time this article was published, baselinesurveys for the ongoing program had been completedby more than 1,000 interprofessional providers in add-ition to the 30 QI cohort providers. The pre- and post-program surveys included items for self-assessing abilitiesto perform various patient-centered and coproductiveskills. On the pre-program survey, relatively low propor-tions of providers in the QI cohort reported strongagreement with statements indicating high levels of con-fidence in assessing COPD prognosis and in counselingpatients about topics of COPD treatment (30%) andquality of life through referrals to case management,skilled nursing, and palliative care (10%). (SeeSupplementary Table 2.) Respondents reported thattheir greatest barriers to providing optimal COPD carewere patients’ continued smoking (72%), non-adherence to treatment plans (69%), and lack of under-standing about COPD progression (43%).

DESIGNThe main educational components in this program were(1) 30 live and Internet-based performance improve-ment courses in which the 30 primary care practicesreceived feedback on patient-provider survey findings;(2) an Internet-based (online/mobile) simulationcourse on patient-centered and interprofessional COPDcare; (3) a set of 3 nonaccredited checklists for aligningCOPD care with evidence-based guidelines and nationalquality measures; and (4) 2 educational tools specificallydesigned for patients.

__________________During the private feedback courses, graphs were pre-sented that compared de-identified and aggregatedsurvey responses for (1) the participating physician,nurse practitioner, or physician assistant; (2) the provi-der’s patients in the tethered cohort; (3) all patients inthe tethered cohort, which enabled benchmark compar-isons with peer providers; and (4) and patients in theCOPD advocacy groups. In presenting the survey find-ings, the clinician-educator pointed out alignments andmismatches between the provider’s responses and thoseof the different patient groups. The clinician-educatorengaged the provider and participating clinical teammembers in reflection and discussion of targeted actionplans for resolving identified mismatches. A moderatortook notes on the discussions. Providers were also ableto view the survey findings on a personalized onlinedashboard. At the conclusion of each course, providerswere prompted to identify a personalized action plan forimprovement in coproductive COPD care.

The rationale for the private feedback session wasbased on principles and evidence for audit and feedbackas an intervention in continuing education programs forhealth care professionals. In a meta-analysis of 140studies on the effects of audit and feedback education,significant improvements in clinical practice wereobserved.16 Our adaptation and implementation of thismethod were also informed by supporting rationalefrom a white paper developed by the Agency forHealthcare Research and Quality17 and our applicationof feedback in previous successful QIE programs.18–22

The essential premise of this method is that, throughreviewing quantitative and qualitative data that directlyreflect their clinical performance, health care profes-sionals can reinforce strengths and develop targetedstrategies for overcoming weaknesses. Data indicatingalignments and mismatches in aspects of patient-provider coproduction enable opportunities to effect-ively negotiate treatment goals and align practices withpatient-centered measures of care quality.The Internet simulation course was designed as a

follow-up intervention to reinforce lessons learned andprovide evidence-based information to support actionplans developed in the feedback sessions. It was alsodesigned to engage and educate the interprofessionaltreatment team in unified learning. This course was accre-dited for 1.5 hours for physicians and physician assistantsby the Accreditation Council for Continuing MedicalEducation (ACCME); for nurse practitioners by theAmerican Association of Nurse Practitioners (AANP); forpharmacists by the Accreditation Council for PharmacyEducation (ACPE); for nurses by the American NursesCredentialing Center (ANCC); and for case managers bythe Commission for Case Manager Certification (CCMC).The simulation demonstrated case-based approaches

to effective interprofessional collaborative practice inCOPD and coproductive strategies for overcoming bar-riers to optimal COPD care and treatment outcomes.Reinforcement of the interprofessional team was estab-lished through the IPCE design of the simulation andmulti-accreditation. Additional reinforcement of theseskills and strategies was afforded by the series of COPDcare checklists and patient education tools. The check-lists contained items for (1) guideline-directed COPDdiagnosis and assessment; (2) educating patients aboutCOPD, lifestyle modifications, medication use, exacerba-tion prevention strategies, and follow-up visits with provi-ders; and (3) performing NQS-related measures forclinical care, patient safety, and community/populationhealth. The patient tools comprised a self-assessmentquestionnaire and a self-management tool.The simulation course and the COPD care checklists

were packaged in an online/mobile toolkit that facili-tated access to the 30 primary care providers, interpro-fessional members of their practices’ clinical teams and,as of the publication date for this article, a national audi-ence of more than 1,000 primary care and specialtyproviders.


Open Access



_____________In analyzing the patient-provider survey data, we com-pared percentages of responses to linked items for theparticipating provider and the tethered and advocacypatient groups. This method enabled identification ofalignments and mismatches in COPD-related goals, per-ceptions, attitudes, and behaviors. The design facilitatedinvestigation of potential influences of patient participa-tion in advocacy group activities that might improvecoproductive skills. The analysis was guided by our teth-ered patient-provider model of learning, which is basedon a framework of coproductive aims for patient andprovider education,23 adopted from the HIMSSFoundation and National eHealth Collaborative’s patientengagement model.24 Outcome domains were identifiedby the framework of Moore et al., such that pre- to post-activity improvements self-reported competence and per-formance were categorized at levels 4 and 5.25

STRATEGYThe project’s three sets of educational components—theprivate feedback courses, the case-based simulation activ-ity, and the COPD care toolkit—instantiate our strategyfor supporting the participating providers in improvingcompetencies in essential interprofessional and copro-ductive aspects of COPD care. In addition, the series ofinterventions facilitated outcomes to inform our devel-opment of a phase 2 QI education project that we beganin early 2016. As described in this article, the feedbackcourse was designed to guide providers in developing apersonalized action plan to close identified gaps incoproductive aspects of COPD care. In the successiveeducational activities, this action plan served as input toorient participants to targeted, individual learning objec-tives and as impetus toward program completion.During the online/mobile activities, providers com-pleted course evaluations intended to measure improve-ment in knowledge, attitudes, beliefs, and competencerelated to evidence-based treatment and coproductiveCOPD care. Data used as input for the improvementcycles are presented in Supplementary Table 2.

RESULTSDemographicsFor the patients in the tethered (n = 90) and advocacygroups (n = 125), mean ages were 64 and 67 years,respectively; mean ages at COPD diagnosis were 54 and56 years; and mean durations since diagnosis were 9 and11 years. A substantial proportion of patients in the teth-ered group (39%) and advocacy group (50%) reportedhaving had respiratory symptoms for more than twoyears before they were diagnosed with COPD. A largepercentage of patients in the tethered and advocacygroups reported that they were in advanced stages ofCOPD, either Stage 3 (30% and 36%, respectively) orStage 4 (16% or 42%, respectively).

As derived from the patient-provider surveys, key mis-matches and alignments in coproductive aspects ofCOPD care are summarized as follows.

COPD Testing FrequencyPatients and providers were asked to indicate how oftenspirometry or lung function testing was performed.Whereas 36% and 34% of patients in the tethered andadvocacy groups, respectively, reported that they neveror rarely receive these tests, 83% of the providersreported that they perform the tests regularly.

Shared Treatment GoalsA survey question asked patients and providers to indi-cate their most important goals for COPD treatment.Participants were instructed to select all goals that theydeemed important from a list of five goals. The surveyresults indicated a common pattern for three of thetreatment goals: managing symptoms, preventing exacer-bations, and preventing hospitalizations. As shown inSupplementary Table 2, the majority of providers ratedall three of these goals as highly important; however,relatively low percentages of patients in the tethered andadvocacy groups gave high ratings.

Agreement on Treatment PlanAmong patients in the tethered and advocacy groups,respectively, 81% and 52% reported having agreed withtheir providers on a COPD treatment plan, whereas 57%of providers indicated this agreement. Across the teth-ered and patient advocacy groups, 86% and 61% ofpatients reported that they did not miss a prescribeddose during this period. However, only 59% of providersestimated that their patients were fully adherent.

Perceived Barriers to Medication AdherenceCompared with patients in the tethered and advocacygroups, a smaller proportion of providers attributedmedication non-adherence to patients’ having troubleremembering to take their medications (seeSupplementary Table 2). Relatively fewer patients thanproviders indicated that a main barrier to adherence ispatient beliefs that COPD treatment plans are not effect-ive in achieving goals. A similar pattern was observed forattributing non-adherence to lack of patient insurancecoverage.

Perceived Impact of COPD on Quality of LifeIn response to a survey item addressing the impact ofCOPD on emotional aspects of quality of life, a largeproportion of patients in the tethered and advocacygroups associated their disease with experiences offatigue (61% and 64%), frustration (46% and 59%),and feelings of being overwhelmed (38% and 50%).Providers estimated, on average, that only 33% of theirpatients are emotionally affected by COPD. During theprivate feedback sessions, a number of providersacknowledged the importance of addressing patients’


Open Access



emotional needs, but they admitted a lack of trainingand competence in the assessment, communication, andmanagement skills necessary to adequately supportpatients.

Most Important Topics for COPD EducationPatients and providers gave similar high ratings for theimportance of various topics for COPD education,including topics of treatment options, side effects,importance of adherence, and symptom management.However, a greater proportion of providers (79%) thanpatients in the tethered and advocacy groups (45% and17%) rated smoking cessation assistance as a highlyimportant topic. For most of the topics, with the excep-tion of smoking cessation assistance, the advocacypatient group’s ratings were higher than those of thetethered patient group and closer to those of theproviders.

Improvement in Knowledge, Attitudes, Beliefs Related toCoordinating COPD CareAs indicated in self-assessment evaluations following theon-demand online and mobile educational activities, the30 primary care providers in the cohort significantlyimproved their knowledge, attitudes, and beliefs relatedto coproductive COPD care. All cohort providersexpressed confidence in being able to achieve their per-sonal action plans over the next six months to improvethe quality of their COPD patients’ care. From pre- topost-program, there was a 55% increase in providers’self-reported ability to discuss referrals for case manage-ment, skilled nursing, and palliative care with COPDpatients; a 32% increase in recognizing benefits of pul-monary rehabilitation; and a 36% increase in providers’self-rated ability to discuss COPD prognosis/progressionand available pharmacologic options with their patients.Additional pre- and post-activity survey data indicatingpositive effects of the education are presented inSupplementary Table 2.Improvements were also seen among the more than

1,000 interprofessional learners nationwide whoaccessed the online activities (43% primary care; 12%physician specialists; 34% nurse case managers; 7%pharmacists; 4% physician assistants). There was a 43%increase in learners’ self-reported ability to discuss refer-rals for case management, skilled nursing, and palliativecare with COPD patients; a 25% increase in recognizingbenefits of pulmonary rehabilitation; and a 47%increase in self-rated ability to discuss COPD prognosis/progression and available pharmacologic options withCOPD patients.

LESSONS AND LIMITATIONSPrimary objectives of this project were to assess gaps incoproductive COPD care and raise awareness and knowl-edge among patients, providers, and the interprofes-sional COPD team, as well as to inform the development

of a comprehensive phase 2 QI education project onCOPD. The following lessons learned and interpreta-tions of the results address these objectives.▸ The baseline data for primary care providers who par-

ticipated in the online/mobile educational activitiesrevealed needs for QI-focused continuing educationon coproductive skills including communicating withpatients about COPD progression and prognosis,treatment options, and referrals to specialists.

▸ The patient-provider survey data indicated key mis-matches in perceptions of patients’ receipt of import-ant COPD assessment tests, patients’ abilities torecognize exacerbations, patients’ barriers to medica-tion adherence, and the impact of COPD on quality oflife. In addition, disconnects were identified in copro-ductive goal-setting and agreement on treatmentplans. These disconnects reflect needs and opportun-ities for collaborative patient-provider educationdesigned to promote accurate and timely recognitionof symptoms, prompt implementation of action plansto avoid exacerbations, and shared understanding oftreatment goals and barriers to achieving them.

▸ Alignments between patient-provider survey responseswere observed for the importance of many, but not all,topics of patient education. In addition, assessment ofoverall quality of COPD care, there was agreementbetween patients’ overall ratings of “good” or “verygood” and providers’ estimates of patients’ ratings.

▸ For many survey items, responses were more closelyaligned for patients in the advocacy group and provi-ders compared with patients in the tethered groupand providers. This observation supports inclusion ofadvocacy initiatives in QI education programs forCOPD.

_______________Given the project’s focus on primary care providers, theoutcomes are not generalizable to pulmonology specia-lists. However, a large proportion of patients with COPDin the U.S. are treated and managed in primary care set-tings. The project’s outcomes are especially relevant inaddressing interprofessional aspects of COPD care,including needs for appropriate and timely referrals tospecialists and effective care coordination and transi-tions. As planned, the primary care providers who parti-cipated in the patient-provider survey study andfeedback sessions practiced in areas of the U.S. with ahigh prevalence of COPD and high practice density.Thus, generalizability to primary care providers in lesspopulated areas with fewer COPD patients, includingsome rural communities, is also limited.This project was designed to identify interprofessional

and coproductive correlates of COPD care quality in thecontext of a continuing education program, which pro-vides standardized educational methods and measuresunder regulated accreditation criteria to engage clini-cians in continuing professional development. Thus, the


Open Access



project was not intended to implement formal improve-ment methods such as PDSA. Moreover, it would havebeen ideal to collect more data points and extend theproject over a longer period of time in order to assess itssustainability. However, as intended, the project hasinformed the design and development of a larger-scalephase 2 project in which chart data on providers’ adher-ence to quality measures for COPD and patient-centeredcare will be collected in multiple improvement cyclesover an extended period. The phase 2 program beganin early 2016 and will end in 2017. Results are intendedfor future publication.This pragmatic QI education project was not designed

to determine the extent to which the three interventionswere individually responsible for the improvementsobserved in the survey conducted for Internet-based(online/mobile) simulation course.

CONCLUSIONThrough patient-provider surveys and assessments con-ducted in association with continuing education activities,we have identified key alignments and mismatches inpatients’ and primary care providers’ goals, perceptions,attitudes, and behaviors regarding interprofessional andcoproductive aspects of COPD care. The project outcomesare applicable to designing QI education interventions tosupport providers and patients in reinforcing coproductivealignments and in developing skills for communication,negotiation, and reconciliation to appropriately resolvemismatches that undermine high-quality care.

Acknowledgements The authors acknowledge James Mateka and MelanyVidret for coordinating the cohorts for this QI project; Laura Simone forcontributing to the development of the patient-provider survey and educationalcontent; and Jeffrey Carter and Matthew Weeks for contributing to theanalysis of the project data.

Declaration of interests The authors represent PRIME Education, Inc., ahealth care education company that received an independent educational grantfrom AstraZeneca LP to conduct the quality improvement project described inthis article. AstraZeneca LP had no role in the study design or execution, andthe grant did not include support for writing this manuscript.

Ethical approval Independent institutional review board approval was grantedbefore participants were recruited and enrolled in this program (Sterling IRB,Atlanta, GA, USA; IRB ID #4991).

Open Access This is an open-access article distributed under the terms ofthe Creative Commons Attribution Non-commercial License, which permitsuse, distribution, and reproduction in any medium, provided the original workis properly cited, the use is non commercial and is otherwise in compliancewith the license. See:• http://creativecommons.org/licenses/by-nc/2.0/• http://creativecommons.org/licenses/by-nc/2.0/legalcode

REFERENCES1. Mannino DM, Braman S. The epidemiology and economics of

chronic obstructive pulmonary disease. Proc Am Thorac Soc2007;4:502–6.

2. Mannino DM, Homa DM, Akinbami LJ, Ford ES, Redd SC. Chronicobstructive pulmonary disease surveillance—United States, 1971-2000. Respir Care 2002;47:1184–99.

3. Ford ES, Murphy LB, Khavjou O, Giles WH, Holt JB, Croft JB. Totaland state-specific medical and absenteeism costs of COPD among

adults aged = 18 years in the United States for 2010 and projectionsthrough 2020. Chest 2015;147:31–45.

4. Lindenauer PK, Pekow P, Gao S, Crawford AS, Gutierrez B,Benjamin EM. Quality of care for patients hospitalized for acuteexacerbations of chronic obstructive pulmonary disease. Ann InternMed 2006;144:894–903.

5. Mularski RA, Asch SM, Shrank WH, Kerr EA, Setodji CM, AdamsJL, Keesey J, McGlynn EA. The quality of obstructive lung diseasecare for adults in the United States as measured by adherence torecommended processes. Chest. 2006;130:1844–50.

6. Batalden M, Batalden P, Margolis P, et al. Coproduction of healthcareservice. BMJ Qual Saf 2015 Sep 16. [Epub ahead of print]

7. Cramm JM, Nieboer AP. The changing nature of chronic care andcoproduction of care between primary care professionals andpatients with COPD and their informal caregivers. Int J ChronObstruct Pulmon Dis 2016;11:175–82.

8. Make B, Dutro M, Ryne P-R, et al. Undertreatment of COPD: aretrospective analysis of US managed care and Medicare patients.Int J Chron Obstruct Pulmon Dis 2012;7:1–9.

9. Ingebrigtsen TS, Marott JL, Vestbo J, et al. Characteristics ofundertreatment in COPD in the general population. Chest2013;144:1811–18.

10. Weldam SW, Lammers JW, Heijmans MJ, Schuurmans MJ.Perceived quality of life in chronic obstructive pulmonary diseasepatients: a cross-sectional study in primary care on the role of illnessperceptions. BMC Fam Pract 2014;15:140.

11. Cramm JM, Nieboer AP. A longitudinal study to identify the influenceof quality of chronic care delivery on productive interactions betweenpatients and (teams of) healthcare professionals within diseasemanagement programs. BMJ Open 2014;4:e005914.

12. Cramm JM, Nieboer AP. Productive patient-professional interactionimproves the well-being of chronically ill patients. Qual Life Res2015;24:897–903.

13. Greene J, Hibbard JH, Sacks R, Overton V, Parrotta CD. Whenpatient activation levels change, health outcomes and costs change,too. Health Aff (Millwood) 2015;34:431–7.

14. Hernandez P, Balter MS, Bourbeau J, et al. Canadian practiceassessment in chronic obstructive pulmonary disease: respiratoryspecialist physician perception versus patient reality. Can Respir J2013;20:97–105.

15. Menezes AM, Landis SH, Han MK, et al. Continuing to confrontCOPD International Surveys: comparison of patient and physicianperceptions about COPD risk and management. Int J ChronObstruct Pulmon Dis 2015;10:159–72.

16. Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects onprofessional practice and healthcare outcomes. Cochrane DatabaseSyst Rev 2012;6:CD000259.

17. Agency for Healthcare Quality and Research. Private PerformanceFeedback Reporting for Physicians http://www.ahrq.gov/professionals/clinicians-providers/resources/privfeedbackgdrpt/index.html.

18. Sapir T, Moreo K, Carter J, Greene L, Patel B, Higgins PDR.Continuing medical education improves gastroenterologists'compliance with inflammatory bowel disease quality measures. DigDis Sci 2016 Feb 12. [Epub ahead of print]

19. Sapir T, Rusie E, Greene L, Yazdany J, Robbins ML, RudermanEM, Carter J, Patel B, Moreo K. Influence of continuing medicaleducation on rheumatologists’ performance on national qualitymeasures for rheumatoid arthritis. Rheumatol Ther 2015;doi:10.1007/s40744-015-0018-7.

20. Moreo K, Sapir T, Greene L. Applying quality improvement intosystems-based learning to improve diabetes outcomes in primarycare. BMJ Qual Improv Report 2015;4.

21. Greene L, Moreo K. Quality improvement education to improveperformance on ulcerative colitis quality measures and careprocesses aligned with National Quality Strategy priorities. BMJ QualImprov Report 2015;4.

22. Greene L, Sapir T, Moreo K, Carter J, Higgins PD. Impact of qualityimprovement education on documented adherence to qualitymeasures for adults with Crohn's disease. Inflamm Bowel Dis2015;21:2165–71.

23. Moreo K, Goldenberg L. New patient-centered models of continuingeducation in the quest for quality. Available at: http://www.primece.com/downloads/new-patient-centered-models-2014.pdf.

24. Healthcare Information and Management Systems Society (HIMSS)Foundation and National eHealth Collaborative. Patient engagementframework. Available at: http://www.himss.org.

25. Moore DE, Green JS, Gallis HA. Achieving desired results andimproved outcomes: integrating planning and assessmentthroughout learning activities. J Contin Educ Health Prof2009;29:1–15.


Open Access



with Chronic Obstructive Pulmonary DiseaseCoproductive Outcomes of Care for Patients Improving Interprofessional and

Kathleen Moreo, Laurence Greene and Tamar Sapir

doi: 10.1136/bmjquality.u210329.w46792016 5: BMJ Qual Improv Report

http://qir.bmj.com/content/5/1/u210329.w4679Updated information and services can be found at:

These include:

MaterialSupplementary

79.DC1.htmlhttp://qir.bmj.com/content/suppl/2016/06/17/bmjquality.u210329.w46Supplementary material can be found at:

References#BIBLhttp://qir.bmj.com/content/5/1/u210329.w4679

This article cites 17 articles, 2 of which you can access for free at:

Open Access

http://creativecommons.org/licenses/by-nc/2.0/legalcodehttp://creativecommons.org/licenses/by-nc/2.0/with the license. See:

properly cited, the use is non commercial and is otherwise in compliance distribution, and reproduction in any medium, provided the original work isCommons Attribution Non-commercial License, which permits use, This is an open-access article distributed under the terms of the Creative

serviceEmail alerting

box at the top right corner of the online article. Receive free email alerts when new articles cite this article. Sign up in the

CollectionsTopic Articles on similar topics can be found in the following collections

(8)Respiratory medicine / Pulmonology (38)Open access

Notes

http://group.bmj.com/group/rights-licensing/permissionsTo request permissions go to:

http://journals.bmj.com/cgi/reprintformTo order reprints go to:

http://group.bmj.com/subscribe/To subscribe to BMJ go to:


34

Sustaining the Impact of Quality and Performance Improvement

Alliance AIS, May 2016Best in Class Outcomes Podium Presentation

Abstract Sustainability is the cornerstone of any education designed to impact performance and quality. Our project innovatively tackled sustainability as well as addressed unmet needs related to a real-world data analytics and quality improvement project in rheumatoid arthritis (RA) that we concluded in early 2015. The results of this RA CME project recently reached thousands of rheumatology clinicians across the US through Rheumatology and Therapy, a Springer peer-reviewed medical journal.1 However, sustainability of the RA program was not likely without a follow-on strategy to assist practitioners in applying the published evidence to practice.

To achieve sustainability in the impactful changes we had witnessed through our QI project, we developed a follow-on live program in 2015 through which we presented benchmarked quality and performance data to 456 rheumatology clinicians across the US via 2 live webinars. The intent was to bring the data to RA practitioners and clinicians in a way that was relevant and impactful. This was followed by an endured streaming webcast, which continues to be supported on our website to impact a larger audience. All activities were multi-accredited for the interprofessional RA treatment team. To infuse the new education with relevant data missing from the original project, we added survey responses from RA patients which were paired with systems-based barriers found through our project analyses that were not able to be addressed through the former educational strategy. We utilized the TELMS Model2 to design patient and provider surveys, and we presented the results of these data during the live webinars. Through this data, rheumatologists and the rheumatology treatment team gained new perspectives in how RA patients describe their experiences with their care in their rheumatologists’ practices and across value-based healthcare systems, and whether and to what extent they wish to be involved in current and ongoing care. We also used the webinars as a virtual learning lab to provide learners with leave-behind tools to improve benchmarked outcomes of care.

References:1. Sapir et al. Influence of continuing medical education on rheumatologists’ performance on national quality measures for rheumatoid

arthritis. Rheumatol Ther. 2015; doi:10.1007/s40744-015-0018-7.

2. Ruggerio JE, Robinson CO, Paynter NL. Coordinated learning to improve evidenced-based care: A model for continuing education for the new healthcare environment. Abstract presented at the 2015 ACEhp Quality Symposium; September 28-30, 2015; Chicago, IL

Kathleen Moreo, RN, BSN, CCM, CDMS

President, PRIME Education, LLC


37


38

37

Background The quality of patient experiences and education predicts key healthcare outcomes such as adherence and achievement of treatment goals. However, comprehensive mechanisms are lacking for patients to share their healthcare experiences, perspectives, and educational needs with their clinicians toward the goals of quality improvement and continuing professional development (CPD). To address this gap, we developed a tethered patient-provider model of education based on principles of collaborative learning and coproduction.

Purpose Through tethered surveys administered to providers and patients in 2 chronic disease areas—hepatitis C (HCV) and chronic obstructive pulmonary disease (COPD)—we compared patient-reported experiences, barriers, and educational needs with estimated patient responses and self-assessed skills reported by physicians.

Interventions In the context of continuing medical education (CME/CE) programs, surveys were administered to patients (n = 300) and their clinicians (n = 70) in HCV and COPD. Patients self-reported their symptoms, quality of life, medication use and adherence patterns, barriers to adherence and self-care, perceptions of their clinicians’ communication and shared decision-making skills, educational needs, and other experiences and outcomes. Clinicians were asked to estimate their patients’ responses to the same survey items, to rate their own communication and shared decision-making skills in coproductive health, and to assess patients’ educational needs.

Results/Applications Among other key results, comparisons of the tethered patient and clinician survey responses indicated that physicians often underestimate their patients’ desire to be actively involved in shared decision-making. In addition, mismatches were identified in patients’ ratings and physicians’ self-assessment of skills in patient monitoring, education, shared decision-making, and addressing quality of life issues.

Future Directions In the context of collaborative learning and coproduction models, our presentation will address future applications of tethered patient-provider survey responses to designing initiatives for quality improvement and CPD.

Authors: Jeffrey Carter, PhD, Laurence Greene, PhD, Tamar Sapir, PhD, and Kathleen Moreo, RN-BC, BSN, BHSA, CCM, CDMS

Comparing Patient and Clinician Perceptions of Engagementand Care in Chronic Diseases

World Congress on CPD, March 2016Podium Presentation, San Deigo, CA

38

Linking Patients and Clinicians to Improve the Quality of Care in Asthma Control

Background Poor asthma control is associated with gaps in patients’ understanding of their disease, its treatments, and self-care skills. To address limitations in conventional clinician and patient asthma education, we developed a tethered patient-clinician model of education based on principles of coproductive health.

Purpose Applying the model, we conducted a patient-clinician educational program to improve the quality of care for adults with asthma. In 40 asthma specialty practices across the U.S., pre- and post-program surveys were administered to patients (n=160) and their clinicians (n=40) to assess the program’s impact on each group’s knowledge, attitudes, practice patterns (clinicians), and self-care skills (patients). Self-reported patient outcomes were also assessed over 12 weeks.

Interventions The interventions comprised live clinician-patient teaching and learning sessions, led by the 40 asthma specialists and their clinical teams, and attended by 5-8 of each practice’s patients; a train-the-trainer asthma curriculum with educational resources for guiding the sessions and teaching clinicians how to continue conducting these patient education programs in the future; a follow-on asthma quality toolkit disseminated to the 40 asthma clinical teams and expanded to a national audience of clinicians; and patient enrollment in a 12-week asthma coaching program.

Results/Applications Survey findings indicated that clinicians often underestimate their patients’ needs for asthma education and overlook opportunities for coproductive consultation. The educational program was associated with significant increases in clinicians’ competence and confidence in skills, including using validated tools to assess asthma control, evaluating adherence, and making shared treatment decisions with patients. Survey data from the patients offered insights into their reasons for nonadherence; barriers to asthma control; and needs for education. Among patients, the educational program was associated with better understanding of clinicians’ reasons for assessing asthma triggers, symptoms, and medication adherence; and greater insights into self-care goals and practices.

Future Directions To advance sustainability of the learning, we will engage attendees and clinicians in exploring additional approaches to coproductive health to improve patient outcomes.

Authors: Tamar Sapir, PhD, Jeffrey Carter, PhD, Kathleen Moreo, RN-BC, BSN, BHSA, CCM, CDMS

World Congress on CPD, March 2016Podium Presentation, San Deigo, CA


41

BA

CK

GR

OU

ND

AN

D P

UR

PO

SE

Prov

ision

s of U

.S. h

ealth

car

e re

form

are

exp

andi

ng th

e ro

les o

f man

aged

car

e ph

arm

acy p

rofe

ssio

nals,

ther

eby c

reat

ing

oppo

rtuni

ties f

or th

e CP

D co

mm

unity

in

mee

ting

educ

atio

n an

d tra

inin

g ne

eds.1,

2 (See

“Maj

or R

oles

of M

anag

ed C

are

Phar

mac

y Pro

fess

iona

ls”) I

n co

nduc

ting

CPD

prog

ram

s on

vario

us c

hron

ic di

seas

es,

we a

sses

sed

educ

atio

nal n

eeds

and

out

com

es a

mon

g 5,

266

man

aged

car

e ph

arm

acist

s. Th

roug

h re

trosp

ectiv

e an

alys

es, w

e so

ught

to id

entif

y key

them

es to

in

form

the

desig

n an

d ev

alua

tion

of e

ffect

ive C

PD p

rogr

ams t

hat s

uppo

rt m

anag

ed

care

pha

rmac

ists i

n ac

hiev

ing

the

goal

s of v

alue

-bas

ed a

nd q

ualit

y-driv

en h

ealth

car

e.

ME

THO

DS

Prog

ram

s an

d Ed

ucat

iona

l For

mat

sCE

pro

gram

s wer

e con

ducte

d in

April

2014

to Ju

ly 20

15 fo

r U.S

.-bas

ed m

anag

ed ca

re

profe

ssion

als o

n co

stly c

hron

ic dis

ease

are

as im

pacti

ng m

anag

ed ca

re: in

fectio

us d

iseas

e (h

epat

itis C

and

HIV)

, car

diova

scula

r dise

ase (

angin

a an

d hy

perch

oleste

rolem

ia),

and

imm

unolo

gic d

iseas

e (rh

eum

atoid

arth

ritis)

. The

educ

ation

al for

mat

s wer

e live

nat

ional

sym

posia

, live

web

inars,

and

endu

ring w

eb a

ctivit

ies.

Part

icip

ants

Parti

cipan

ts in

the

CE p

rogr

ams i

nclud

ed 5

,266

man

aged

care

pha

rmac

ists w

ho

com

plet

ed p

re- a

nd p

ost-p

rogr

am su

rveys

in th

e fo

llowi

ng ty

pes o

f CE

activ

ities

: he

patit

is C

(n =

1,5

68 p

harm

acist

s [21

0 in

live

CE; 1

,358

in o

nline

CE]

), HI

V (n

= 1

,218

pha

rmac

ists [

253

in liv

e CE

; 965

in o

nline

CE]

), hy

perc

holes

tero

lemia

(n

= 1

,020

pha

rmac

ists [

573

in liv

e CE

; 447

in o

nline

CE]

), an

gina

(n =

756

pha

rmac

ists

[197

in liv

e CE

; 559

in o

nline

CE]

), an

d rh

eum

atoid

arth

ritis

(n =

704

pha

rmac

ists

[65

in liv

e CE

; 639

in o

nline

CE]

). Ph

arm

acist

s wor

ked

in m

ajor U

.S. h

ealth

plan

s, sp

ecial

ty ph

arm

acies

, and

clos

ed sy

stem

orga

nizat

ions s

uch

as th

e Vet

eran

s Adm

inistr

ation

.

CPD

Asse

ssm

ents

Pre-

post

prog

ram

surve

ys w

ere a

dmini

stere

d an

d dis

cuss

ion tr

ansc

ripts

were

colle

cted

from

CE

pro

gram

s to

asse

ss C

PD n

eeds

and

educ

ation

al im

pact

on:

�

Decla

rativ

e and

pro

cedu

ral k

nowl

edge

abo

ut d

iseas

e and

med

icatio

n

man

agem

ent t

opics

�

Attit

udes

and

bar

riers

rega

rding

issu

es su

ch a

s the

rapy

acc

ess,

inter

profe

ssion

al

colla

bora

tion,

and

optim

al m

anag

emen

t int

erve

ntion

s

�

Com

pete

nce i

n va

lue-b

ased

and

qua

lity-d

riven

man

aged

care

skills

Data

Ana

lysis

Acro

ss C

E pr

ogra

ms a

nd d

iseas

e ar

eas,

perc

enta

ge m

eans

wer

e ca

lcula

ted

for:

�

Frequ

ency

of p

artic

ipant

-repo

rted

attit

udes

and

bar

riers

base

d on

sim

ilar s

urve

y ite

ms

�

Abso

lute a

nd re

lative

pre

-pos

t diffe

renc

es in

evid

ence

-bas

ed ch

oices

to kn

owled

ge

an

d co

mpe

tenc

e que

stion

s gro

uped

by s

imila

r top

ics

Iden

tifica

tion

of K

ey Th

emes

Retro

spec

tive

analy

ses o

f sur

veys

and

tran

scrip

ts we

re co

nduc

ted

to id

entif

y key

th

emes

in C

PD n

eeds

and

edu

catio

nal o

utco

mes

. The

mes

wer

e id

entif

ied b

y (1)

rank

ing

parti

cipan

ts’ m

ost c

omm

on re

spon

ses t

o su

rvey i

tem

s tha

t add

ress

ed C

PD n

eeds

and

(2

) ass

essin

g the

mag

nitud

e of

pre

-pos

t pro

gram

chan

ges i

n kn

owled

ge, a

ttitu

des a

nd

barri

ers,

and

decis

ion-m

aking

.

R

ES

ULT

S

1. M

ain B

arrie

rs to

Pro

vidin

g Op

timal

Man

aged

Car

e

Outco

mes o

f Cont

inuing

Profe

ssiona

l Deve

lopme

nt (CP

D) Pro

grams

for M

anaged

Care

Pharm

acy Pr

ofessi

onals

2. M

ain Fa

ctor

s Con

sider

ed in

Ther

apy A

cces

s/Se

lectio

n

3. M

ain P

riorit

y Are

as fo

r Man

aged

Car

e Int

erve

ntion

s

4. Im

pact

of C

E on

Kno

wled

ge, A

ttitu

des,

and D

ecisi

on-M

akin

g

5. Qu

alita

tive D

ata:

Repr

esen

tativ

e Com

men

ts

CO

NC

LUS

ION

S &

FU

TUR

E D

IRE

CTI

ON

S

The

outc

omes

of t

arge

ted

CPD

prog

ram

s for

man

aged

car

e ph

arm

acy p

rofe

ssio

nals

inclu

de si

gnifi

cant

gai

ns in

:

�

Know

ledge

abo

ut d

iseas

e scre

ening

and

det

ectio

n m

etho

ds, th

erap

y effic

acy a

nd

sa

fety,

and

evide

nce-

base

d gu

idelin

es �

Attit

udes

towa

rd p

roac

tive d

iagno

sis a

nd tr

eatm

ent t

o cu

rb fu

ture

costs

�

Com

pete

nce i

n m

aking

pat

ient-s

pecif

ic m

anag

emen

t dec

ision

s

In th

e co

ntex

t of e

volvi

ng m

odels

of q

ualit

y-driv

en a

nd va

lue-

base

d he

alth

car

e, ne

w CP

D pr

ogra

ms a

re n

eede

d to

supp

ort m

anag

ed c

are

prof

essio

nals

in:

�

Imple

men

ting d

iseas

e pre

vent

ion st

rate

gies

�

Prom

oting

scre

ening

and

early

dise

ase d

etec

tion

�

Incre

asing

pat

ient c

are a

cces

s, lin

kage

, and

rete

ntion

�

Critic

ally e

valua

ting e

viden

ce fo

r the

rapy

effic

acy,

safet

y, an

d ut

ility

�

Apply

ing co

mpa

rativ

e effe

ctive

ness

rese

arch

and

guide

lines

�

Cont

aining

costs

thro

ugh

enha

nced

pat

ient s

afety

and

adhe

renc

e �

Impr

oving

inte

rpro

fessio

nal c

ollab

orat

ion sk

ills

Ackn

owle

dgem

ents

Data

for t

his p

oste

r was

retro

spec

tively

ana

lyzed

from

pro

jects

by P

RIM

E Ed

ucat

ion, In

c. (

) sup

porte

d by

inde

pend

ent m

edica

l edu

catio

n gr

ants

from

:

Refe

renc

es

1.

Acad

emy o

f Man

aged

Car

e Ph

arm

acy.

Top

10 E

mer

ging

Heal

th C

are T

rend

s: Im

plica

tions

for P

atien

ts, P

rovid

ers,

Paye

rs

and

Phar

mac

eutic

als.

http

://w

ww.a

mcp

.org

/am

cp-fo

unda

tion/

Reso

urce

s/tre

nds.

2.

Natio

nal G

over

nors

Asso

ciatio

n. Th

e Ex

pand

ing

Role

of P

harm

acist

s in

a Tra

nsfo

rmed

Hea

lth C

are

Syste

m. h

ttp:/

/www

.

© 1

997-

2016

PRI

ME

Educ

atio

n, In

c.

Kath

leen

Mor

eo, R

N-BC

, BSN

, BH

SA, C

CM, C

DMS,

Lau

renc

e G

reen

e, P

hD, M

azi R

asul

nia,

PhD

60

%

58

%

52

%

49

%

37%

28

%

Poor

inte

rpro

fess

iona

l co

mm

unica

tion

Chall

enge

s in

mon

itorin

g m

edica

tion

adhe

renc

e

Lack

of l

ong-

term

eff

icacy

and

safet

y dat

a

Nona

dher

ence

Side

effe

cts

Ther

apy c

ompl

exity

Know

ledge

: Tre

atm

ent G

uide

lines

Know

ledge

: Dise

ase

Scre

enin

g M

etho

ds

Know

ledge

: Evid

ence

for

Ther

apy E

ffica

cy a

nd S

afet

y

Attit

udes

: Im

porta

nce

of E

arly

Dete

ctio

n an

d Sc

reen

ing

Attit

udes

: Agr

eem

ent w

ith

Early

Aggr

essiv

e Tre

atm

ent

Case

-Bas

ed C

ompe

tenc

y: Tre

atm

ent D

ecisi

on-M

akin

g

30

%

29

% 35

%

18%

22

%30

%

80

%

95

%

129

%

67%

86

%67%

P va

lues

wer

e ≤

0.01

for a

nalys

es o

f pre

-pos

t di

ffere

nces

in k

nowl

edge

and

com

pete

ncy.

Abso

lute

Pre

-to-P

ost I

ncre

ase

Rela

tive

Pre-

to-P

ost I

ncre

ase

The

deci

sion

s of

trea

tmen

t

elig

ibilit

y an

d th

e ap

prop

riatio

n

of l

imite

d re

sour

ces

mus

t be

m

ade

inde

pend

ent o

f e

ach

othe

r.—

Pha

rmac

ist a

tten

ding

p

rogr

am o

n H

CV

“

”

The

re a

re o

ppor

tuni

ties

for t

he h

ealth

car

e te

am

to w

ork

mor

e co

llabo

rativ

ely

t

o en

hanc

e pa

tient

qua

lity

a

nd s

ave

mon

ey.

— P

harm

acis

t att

endi

ng

pro

gram

on

HIV

“

”

Pro

vide

rs re

cogn

ize

asse

ssm

ent t

ools

—ni

ce

t

o fo

cus

on Q

I mea

sure

s

and

thei

r im

plic

atio

ns

fo

r pro

vide

rs.

— P

harm

acis

t att

endi

ng

pro

gram

on

angi

na

“

”

I ho

pe th

is a

nd o

ther

man

aged

ca

re p

rogr

ams

are

com

plet

ed

b

y in

tern

ists

, car

diol

ogis

ts, a

nd

P

CP

s ac

ross

the

boar

d. T

here

is to

o m

uch

disp

arity

in p

ract

ice.

— P

harm

acis

t att

endi

ng

prog

ram

on

hype

rcho

lest

erol

emia

“

”

The

big

gest

impr

essi

on m

ade

on m

e w

as h

ow in

tere

sted

the

phar

mac

y

d

irect

ors

are

in e

nsur

ing

qual

ity c

are

for t

he p

atie

nts.

.. In

an id

eal

wor

ld, t

here

wou

ld b

e a

way

to g

et p

harm

acis

ts a

nd d

octo

rs to

geth

er

o

n a

larg

e sc

ale

so w

e co

uld

unde

rsta

nd e

ach

othe

r and

wor

k as

a te

am

fo

r the

pat

ient

s, ra

ther

than

hav

ing

anon

ymou

s, a

nd b

y de

faul

t, a

dver

saria

l rel

atio

nshi

ps.

— R

heum

atol

ogis

t att

endi

ng

pro

gram

on

RA

“

”

65

%

57%

51%

48

%

41%

37%

30

%

22

%

Evid

ence

-bas

ed

guid

eline

s

Ther

apy s

afety

Dise

ase

seve

rity

Adhe

renc

e

Ther

apy e

ffica

cy

Ther

apy

cont

rain

dica

tions

Cost

issue

s

Treat

men

t com

plex

ity

71%

51%

50

%

40

%

39

%

27%

Interp

ret an

d app

ly qu

ality

mea

sures

for

healt

h poli

cy

decis

ions

Impr

ove p

atien

t ad

here

nce

Man

age

healt

h ca

re co

sts

Expa

nd th

erap

y co

vera

ge

Asse

ss in

divid

ual

patie

nt th

erap

y nee

ds

Educ

ate

heal

th c

are

prov

ider

s in

netw

orks

Maj

or R

oles

of M

anag

ed C

are

Phar

mac

y Pro

fess

iona

ls • A

naly

sis

of c

ost-

bene

fit p

rofil

es fo

r pol

icy

sett

ing

or re

tros

pect

ive

clai

ms

revi

ew• M

edic

atio

n se

lect

ion

and

disp

ensi

ng• M

edic

atio

n th

erap

y m

anag

emen

t• P

atie

nt e

duca

tion,

cou

nsel

ing,

and

coo

rdin

atio

n

• Pro

mot

ing

adhe

renc

e to

ther

apie

s di

spen

sed

• Ide

ntifi

catio

n an

d pr

even

tion

of d

rug-

drug

inte

ract

ions

• Avo

idan

ce o

f med

icat

ion

wast

e an

d ab

use


ACEhp William Campbell Felch Award for Outstanding Research in CE

ACEhp Grand Leadership Award

ACEhp Distinguished Leadership Award

ACEhp Alliance Industry Summit Overall Best in Class QIE Outcomes

ACEhp Best in Class QIE Outcomes

ACEhp SQUIRE Excellence in Outcomes and Design

ACEhp SQUIRE Excellence in Multidisciplinary Approach

Excellence Awards

JAN 2016

JAN 2016

JAN 2016

MAY 2016

MAY 2016

SEP 2016

SEP 2016


© 1997-2017 PRIME Education, LLC8201 W McNab Rd, Tamarac, FL 33321

Phone: (954) 718-6055 • Fax: (954) 718-6013

www.primece.com

compendium of independent medical education...

Documents