educational outcomes measurement: what we’ve learned, what’s ahead

1

Educational Outcomes Measurement:

What We’ve Learned, What’s Ahead

Derek T. Dietze, MAPresident

Presentation given at the 2006 Alliance for CME Annual Meeting as: Executive Director of CME Veritas Institute for Medical Education, Inc. Hasbrouck Heights, New Jersey

2

Session Objectives

1. Evaluate you organization’s educational outcomes measurement (EOM) in the context of others’ efforts

2. Identify opportunities to advance EOM3. Describe the potential impact of EOM

on the future of CME

You will be better able to:

3

Who Is in the Audience Today?

1. Medical education/communication company (MECC)

2. Hospital3. Medical school4. Medical specialty society5. Health system6. Commercial interest7. Other

1. What is your affiliation?

4

Who Is in the Audience Today?

2. I have been involved in CME for _____

1 = less than 1 year

2 = 1 to 3 years

3 = 3 to 5 years

4 = 5 to 10 years

5 = more than 10 years

5

Audience Opinion Poll

1 = Strongly disagree2 3456 = Strongly agree7 = Not applicable

3. To what extent do you agree with the following statement? Compared with other organizations, my organization is doing a great job of educational outcomes measurement.

6

Audience Opinion Poll

4. To what extent do you agree with the following statement?

Educational outcomes measurement is a fad that will pass with time.

1 = Strongly Disagree2345 6 = Strongly Agree

7

Audience Opinion Poll

1 = Strongly disagree2 3456 = Strongly agree7 = Not applicable

5. To what extent do you agree with the following statement? Implementing EOM is essential to the long-term success of my organization.

8

Audience Opinion Poll

1 = Strongly disagree2 3456 = Strongly agree7 = Not applicable

6. To what extent do you agree with the following statement? I need to learn a lot more about EOM.

9

CME should be a strategic asset for improving performance and enhancing patient care.

CME in the public interest.

10

From the CEO of the ACCME (Dec. 2005)

“On the research front, primary studies and syntheses no longer need to ask if CE, in general, improves practice or other outcomes because there is so much evidence that many kinds and combinations can do so.”

From Robertson, Umble and Cervero, Journal for Continuing Education in the Health Professions 23, 146, 2003

11

EOM: The Past

• Early-mid 1990s: discussion focused on the nature and definitions of “educational outcomes”

• Alliance for CME conference on educational outcomes

• Early-adopters and innovators• Since 2000: “we need to do EOM!”

12

The Value of CME

“A CME evaluation should focus on identifying, measuring, and describing the value provided by an intervention that leads to enhanced performance, improved healthcare quality, and reduced costs.”

Moore DE. A framework for outcomes evaluation in the continuing professional development of physicians. In: Davis D, Barnes BE, Fox R, eds. The Continuing Professional Development of Physicians: From Research to Practice. Chicago, Ill: American Medical Association; 2003.

13

Levels of Educational Outcomes

Learning Changes in self-reported knowledge of the participants; development of competence

PerformanceChanges in observed practice performance; the application of learning; the application of competence

Patient Health

Changes in the health status of patients due to changes in participant practice behavior

Population Health

Changes in the health status of a population of patients due to changes in widespread practice behavior

Participation The number of people who registered and/or participated

SatisfactionThe degree to which participants’ expectations about the setting and delivery of the CME activity were met

Adapted from: Moore DE. A framework for outcomes evaluation in the continuing professional development of physicians. In: Davis D, Barnes BE, Fox R, eds. The Continuing Professional Development of Physicians: From Research to Practice. Chicago, Ill: The American Medical Association; 2003.

14

Measurement: Alliance for CME Competencies Survey*

• Competency 2.12, “…offer educational consultation that emphasizes measurement in physician organizations to identify goals for education that are specific to the practice and measurable…,”

• Rated the lowest in terms of “responsibility” and “attainment” by CME leaders, managers, and coordinators (2.6/2.6).

*King R, North S. Alliance for CME Competency Areas Research Project Report. Alliance for CME; 2004.

15

Forces Driving EOM

• Accountability for effectiveness, impact, and use of resources

• Desire for “exemplary” status• Performance improvement movement• MOC and MOL requirements/initiatives• Pay for performance movement• Increasingly a requirement of

commercial support• ACCME is “raising the bar” for providers• CME community’s desire for continuous

improvement

16

Performance Improvement Movement

October 6, 2004Performance Improvement Activities approved for creditStage A: Learning from current practice performance assessmentStage B: Learning from the application of PI to patient careStage C: Learning from the evaluation of the PI effort

May 23, 2005Internet Point of Care now eligible for credit> Review original clinical question(s).> Identify the relevant sources from among those consulted.> Describe the application of their findings to practice.

American Medical Association

17

Performance Improvement Movement (cont.)• American Academy of Family Physicians:

Performance Improvement in Practice

18

MOC and MOL Initiatives

• July 2003: ABFM introduced new MOC requirements for family physicians.

• Part IV requirement replaced the traditional clinical chart review. Focus on improving quality of care, rather than on record-keeping.

• Each FP must complete 1 QI project during his or her recertification cycle to comply with Part IV.

American Board of Medical Specialties: Part IV Maintenance of Certification

“Evidence of evaluation of performance in practice”

19

Board of Directors Action Plan Fiscal 2004

“Assure ACCME accreditation remains relevant by addressing the needs of medical boards to quantify learning and practice outcomes of individual physician learners.”

20

Pay for Performance Movement

Phase in of Medicare Pay for Performance

Q. Does the Academy (AAFP) have anything to help me see what P4P might be like?A. Yes. METRIC -- Measuring, Evaluating and Translating Research Into Care -- lets you earn 20 Prescribed CME credits in your office as you complete performance measurement and improvement projects.

21

Commercial Interests’ Expectations

Increasingly, commercial interests are requiring CME providers to:

• Include a sound outcomes measurement plan in grant requests

• Become more familiar with EOM methodologies and tools

• Report results for evaluation and future planning

22

Current Status of EOM

• Increasing understanding of EOM among some CME providers and MECCs

• Some measurement methodologies gaining acceptance and popularity

• Few standards or best practices• Some measurement beyond

“satisfaction” into “learning” and “performance”

• Lack of scientific rigor• Much talk• Limited experimentation• Fear

23

EOM Challenges• EOM competence, skills, and resources• Time• High level support & resources• Practical EOM methodologies/tools• Funding/support for EOM from

commercial interests• Actual/perceived lack of access to “the

data”• “Rigor mortis” and “perfection

paralysis”• Fear of the results

24

Current EOM Methodologies & Tools

• Follow-up surveys• Immediate pre- and post-activity

surveys/tests• Control group surveys• Focus groups• Clinical assertions• Clinical/case vignettes• Commitment to change• Pre- and post-activity prescription

measurement• Chart audits• QA data

25

Pre/Post Clinical Assertion with Control

“’Early aggressive therapy’ is treatment initiated within the first 6 months of RA onset.”

4.91

5.43

4.91

1 2 3 4 5 6

Pre-Activity

Post-Activity

Control

Strongly

Disagree

Strongly

Agree

n=117

n=129

n=33

Single-factor ANOVA:Significant at P < 0.01

Data courtesy of Veritas Institute for Medical Education, Inc.

26

Pre/Post Case Vignette: Patient With AS

• How would you treat a 28-year-old male patient exhibiting the following symptoms:– Morning stiffness– X-ray shows bilateral (sacroiliitis)– Swollen, painful knee– ESR 10– CBC normal

27

Case: AS PatientPercent of Pre-/Post-Discussion Responses

“How would you treat?”

35.8

22.5

58.8

4.8

5.2

8.7

10.6

12.4

21.1

20.2

Pre-discussion (n=111)Post-discussion (n=106)

Combination

Anti-TNF

MTX

SSZ

NSAIDs

Percent of ResponsesData courtesy of Veritas Institute for Medical Education, Inc.

28

Case: AS PatientPercent Change in Pre-/Post-Discussion Response

“How would you treat?”

Combination

Anti-TNF

MTX

SSZ

NSAIDs

-15.4

-5.3

-27.1

+10.2

+37.6

-40 -30 -20 -10 0 10 20 30 40 50Percent Change in Responses

Data courtesy of Veritas Institute for Medical Education, Inc.

29

Case Vignette: Post-activity with Control

Outcomes, Inc. CME Metrics Report, July 25, 2005. Challenging Cases in Gastroenterology—Then & Now, Jobson Education Group. Satellite symposium at Digestive Disease Week, May 15, 2005.

N=46 for both groups P=0.05

30

Only patients with severe and/or refractory cases of urticaria should be managed with steroids.

Pre/Post/Follow-up Clinical Assertions with Control

4.66 4.81

5.64 5.725.33

5.75

4.74

1

2

3

4

5

6

Baseline Live Pre Live Post Live + EMPost

Live OnlyFU

Live + EMFU

BaselineFU

Strongly agree

Strongly disagree

*ANOVA P <

0.001

n=390 n=1,753 n=1,374n=335 n=229 n=67 n=372FU = Follow-up survey

EM = Enduring material

Mean RatingLive only

participants do not maintain learning

Live + EM participants maintain better learning

through follow up

Dietze DT, Magazine HI. Enhancing and Sustaining Learning: Report of a Comprehensive CME Initiative and Educational Outcomes Measurement Plan (forum). Alliance for CME 31st Annual Conference; January 24, 2006; San Francisco, California.

31

Performance Improvement ProjectPurpose:

Decrease the risk of recurrent vascular events in patients with AMI and CAD by initiating therapy with lipid-lowering agents during hospitalization.

Measurement Point:Percentage of defined AMI and CAD patients who received a lipid lowering agent charge during stay.

Multidisciplinary Team on PI Project:Cardiology Physicians, Telemetry Nursing Staff, Quality Services, CME Department, Pharmacy Decision Support (data specialist)Information courtesy of Susan G. McAlexander, MPA, CHES, CME Coordinator,

Providence St. Peter Hospital, Olympia, WA, February 2006.

32

Measurement, Data Collection & Analysis• Lipid use rates compared monthly and

quarterly for changes after interventions.• Education – CME and other• Forms adjustments• In-services• Monthly project task force meetings to project

planning, discuss interventions and results.

• Aggregate and specific rate collection performed in the Quality Department utilizing charge data and chart review.

• Assessment of knowledge post CME single activity intervention performed by CME department.

• Monthly tends reported on graphs.

33

Results and Application to Future CME• Goal percentage attained in 3rd quarter for AMI

patients and 4th quarter for ICS patients.• Greatest change noted in the cardiology and

internal medicine sections. Family medicine N too low to have statistical significance.

• Final report to CIC included a recommendation to tie CME into future PI projects for maximal impact.

• CME was seen to have a positive and reinforcing effect on physician learning and practice change.

34

Measurement Is in Your Future!

35

From the CEO of the ACCME (Dec. 2005)“The Board wants to make it clear that the ACCME values an accreditation system that rewards providersa) for establishing a mission that identifies improvements in physician performance and/or patient or population health as organizational goals, and b) for having a process in place to measure and increase its effectiveness in meeting this mission.”

36

From the CEO of the ACCME (Dec. 2005)“Over the next few months…presentation of draft new compliance criteria and policy through which ACCME will reward providers for having processes in place:• To facilitate changes in knowledge, strategy, performance-in-practice, healthcare delivery or patient health.• To facilitate life-long learning based on individualized needs assessment where effectiveness is measured by the learning or improvements that occur.• To deliver education in support of the ACGME/ABMS Core Competencies, around specialty-specific curricula and in the context of the IOM Competencies.”

37

Audience Opinion Poll

1 = Strongly disagree2 3456 = Strongly agree

7. To what extent do you agree with the following statement? New ACCME compliance criteria for measurement of CME effectiveness would be a positive step forward for the CME community.

38

Audience Opinion Poll

1 = Strongly disagree2 3456 = Strongly agree7 = Not applicable

8. To what extent do you agree with the following statement? Compared to other organizations, my organization is doing a great job of EOM.

39

Audience Opinion Poll

1 = Strongly disagree2 3456 = Strongly agree7 = Not applicable

9. To what extent do you agree with the following statement? Implementing EOM is essential to the long-term success of my organization.

40

Vision for EOM

• EOM standards and benchmarks

• EOM best practices• Proven methodologies and

tools• More efficient and effective

CME• Improved patient care• Improved patient outcomes• Improved population health

41

Thank You for Your Participation!

Derek T. Dietze, MAPresident

derek.dietze@improvecme.com

Queen Creek, Arizona