An Introduction to Pulmonary Arterial Hypertension (PAH): Diagnosis, Referral, and TreatmentInterim Outcomes Report (as of May 11, 2020)

Actelion Grant ID: 54654195Bayer Grant ID: 23249

Series Description: Dr. Beverly Jordan and Dr. Dan Schuller reviewed primary care implications of emerging PAH treatments and recent changes to clinical practice guidelines during the Alabama state chapter of the American Academy of Family Physicians 2019 annual meeting. The discussion introduced strategies for improved assessment, diagnostics, referral practices, and overall patient care.

Release/Expiration: February 4, 2020 – February 4, 2021

Credit: 1.0 AMA PRA Category 1 Credit™ and 1.0 AAFP prescribed credit

Sponsors: Academy for Continued Healthcare Learning (ACHL) and the New Jersey Academy of Family Physicians (NJAFP).

Supporters: Actelion and Bayer

Intended Audience: Primary care physicians and other community-based practitioners who may encounter at-risk patients who should be assessed for PAH and/or referred to specialty PAH care.

Activity Availability: • myCME: https://www.mycme.com/an-introduction-to-pah-diagnosis-referral-and-treatment/activity/6436/• ACHLcme: https://www.achlcme.org/Detail/4118/An-Introduction-to-PAH-Diagnosis-Referral-and-Treatment

Direct Video Access: https://www.achlcme.org/digital/PAH-regional/index.html

Overview

Interim Participation (as of May 11, 2020)812 Clinical Participants; 304 Certificates Issued (1500 Learners Guaranteed)

Practicing Type26% Physicians, 29% Physician Assistants, 11% Nurse Practitioners, 7% Nurses, 3% PharmDs and 24% Other HCPs

Objectivity & BalanceObjectivity and balance rated as good/excellent by 98% of learners

Learning Objectives

99% of learners strongly agree or agree that all learning objectives were met, with an average rating of 3.51

Faculty

Drs. Jordan and Schuller were rated as excellent or good by 98% of learners

Executive Summary

Executive SummaryAn effect size of 0.89 indicates that learners are now ~51.18% more knowledgeable of the content assessed than prior to participating in this education.

88% of learners will change their practice! Most notably, 56% will improve screening processes for patients at high-risk for PAH and 46% will start the steps to make a diagnosis of exclusion.

96% indicated participation in this activity will improve their patient outcomes.

Changes will impact 666 to more than 2,488 PAH patients each month.

Insurance/reimbursement issues, lack of equipment or necessary resources, and patient adherence issues were reported as the most common barriers to implementing changes in practice

Following the activity learners demonstrated increased knowledge surrounding the diagnosis of PAH including recognition, differential diagnosis and associated causes, as well as therapy selection.

Future Education Opportunities

Reinforcement on value of early identification, referral, and management of patients outside of a specialist

Competency in applying and interpreting echocardiography for a differential diagnosis

Review of treatment guidelines, including new and emerging therapies

Outcomes Reporting Methodology• First-attempt posttest scores are reported throughout:

• Initial answer choices for the posttest provide insight into the learners’ ability to immediately recall and apply the education.

• For post-activity questions administered as part of the evaluation (versus the online survey), only first-attempt was collected.

• Pre- and posttest responses have been paired/matched. Non-completer data has been omitted from the analysis to ensure comparison groups are equivalent.

• Participant: term used to describe an HCP who reviewed CME front matter and took action to begin the education.

Cohen’s d Effect Size

An effect size of 0.89 indicates that learners are now ~51.18% more knowledgeable of the content assessed than prior to participating in this education.

Pretest Posttest

44%Mean

0.217Standard Deviation

310Sample Size

67%Mean

0.294Standard Deviation

310Sample Size

Cohen’s d Effect Size = 0.89

This Effect Size calculation includes all learner completers and encompasses all pre/post-test questions. Paired data was used to calculate means and standard deviations.

Cohen (1988): .2 = small, .5 = medium, .8 = largeWolf (1986): .25 = educationally significant, .50 = clinically significant

Participation

29%

26%11%

7%

3%

24%

Participation by Clinician Type

Physician AssistantPhysicianNurse PractitionerNursePharmacistOther HCP

Participants Certificates 812 304

29%

11%

8%7%4%

4%3%

3%

31%

Participation by Specialty

CardiologyFamily Medicine/Primary CareInternal MedicineEmergency MedicinePulmonologySurgeryAllergy/ImmunologyOrthopedicsOther

Learning Objectives

99% of learners strongly agree or agree that all learning objectives were met, with an average rating of 3.51.

Please rate the following objectives to indicate if you are better able to: Analysis of RespondentsRating scale:

4=Strongly Agree; 1=Strongly Disagree

Evaluate recent changes to PAH clinical practice guidelines and their impact on primary care assessment, diagnostics, and referrals. 3.56

Describe primary care strategies for assessing/referring potential PAH cases to specialty care at earlier disease stages. 3.51

List effective community-based clinical support strategies of PAH cases in the primary care setting. 3.51

Discuss primary care impact of updates to PAH disease classifications/risk stratifications and related therapeutics. 3.51

Review emerging clinical research initiatives in PAH/novel therapies and their potential impact on patient care plans in the primary care setting. 3.48

Objectivity & Balance

Activity was perceived as objective, balanced and non-biased.

99%

1%

The education was free of commercial bias

Yes No

66%

32%

2%0%

10%

20%

30%

40%

50%

60%

70%

Excellent Good Fair Poor

Rating of objectivity & balance

N=304

Faculty Evaluation

The faculty were rated good or excellent across all areas by 98% of learners, with an average rating of 3.67.

Please rate the faculty on the criteria listed

Rating scale: 4=Excellent; 1=PoorAbility to effectively convey

the subject matter

Ability to present scientifically rigorous

information

Dan Schuller, MD 3.69 3.64

Beverly Jordan, MD 3.70 3.64

N=304

Beverly Jordan, MDProfessional Medical AssociateEnterprise, Alabama

Dan Schuller, MDProfessor and ChairDepartment of Internal Medicine: TransmountainTexas Tech University Health Sciences CenterPaul L. Foster School of MedicineEl Paso, Texas

Pretest vs. Posttest Summary

Participants demonstrated improved knowledge and competence on five of five pre/posttest questions.

45%

59%

44%

32%39%

68%76%

72%

57%61%

0%

20%

40%

60%

80%

100%

Topic 1 Topic 2 Topic 3 Topic 4 Topic 5

Pre 1st Attempt Post

Topic % Change

1 Hemodynamic definition 51%

2 Differential diagnosis 29%

3 Diagnosis 64%

4 Therapy selection 78%

5 Guidelines 61%

Overview of Correct Responses57% Average

Increase

15%

45%

16%24%

13%

68%

7%12%

A B C D0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre (n=310) 1st Attempt Post (n=310)

Knowledge Acquisition: Definition

Following participation in this activity, learner's knowledge of the hemodynamic definition of PH increased by 51%. Given the recent

update to the definition of PH and emphasis of education in this activity, clinicians may consider PAH in more patients that were previously

considered borderline.

1. Which of the following best describes the updated definition of pulmonary hypertension (PH) in terms of mean pulmonary arterial pressure (mPAP)?

A. mPAP > 15 mm Hg

B. mPAP > 20 mm Hg

C. mPAP > 22 mm Hg

D. mPAP > 25 mm Hg

Hemodynamic Definition of PH

59%

13%20%

8%

76%

7%13%

4%

A B C D0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre (n=310) 1st Attempt Post (n=310)

Knowledge Acquisition: Differential Diagnosis

Post activity 76% of learners were able to identify the first step in making a differential diagnosis of PAH .

Future education should build upon this strong knowledge base and focus on competency in applying and interpreting echocardiography.

Notably, 44% of learners indicated an interest in more education on the diagnosis of exclusion.

2. In patients with symptoms, signs, and history suggestive of PAH, the guidelines recommended which first step for making a differential diagnosis?

A. Echocardiography

B. Cardiac catheterization

C. Ventilation/perfusion lung scan

D. High-resolution computed tomography

Differential Diagnosis

44%

35%

13%8%

72%

17%

6% 5%

A B C D0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre (n=310) 1st Attempt Post (n=310)

Clinical Competence: Diagnosis

Baseline competence surrounding PAH diagnosis was 44% and showed an increase of 64% post activity; this improvement in diagnostic

competence among healthcare professionals can improve PAH patient outcomes through early diagnosis and referral.

3. Which of the following clinical scenarios may describe a patient in early-stage PAH (eg, WHO Functional Class I or II) that should be referred to a PAH specialist for further clinical evaluation? A. A 32-year-old female with persistent fatigue and dyspnea on exertion

that has not responded to 3+ months of conventional asthma treatments, and has a negative methacholine bronchoprovocation test

B. A 64-year-old male, current smoker, with obesity-related COPD, chronic cough, and daytime fatigue that has not improved after use of a CPAP

C. 54-year-old female with frequent dyspnea, history of poorly controlled asthma, recurrent bronchitis, and seasonal allergies

D. 19-year-old male with a recent history of pneumothorax and syncope during athletic exertion

Diagnosis of PAH

18%

31% 32%

19%13%

17%

57%

13%

A B C D0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre (n=310) 1st Attempt Post (n=310)

Knowledge Acquisition: Therapy Selection

Post activity 57% of learners were able to immediately recall the clinical implications from the AMBITION trial.

This 78% shift in knowledge on the use of combination therapy across clinicians supports specialty care recommendations as HCPs are more

aware of the benefits of initial combination therapy, which offers opportunity to play a greater role in community-based PAH patient

monitoring.

4. Results from the AMBITION trial support which clinical practice?

A. Preferential use of tadalafil over ambrisentan

B. Incorporation of sequential add on therapy when clinical response inadequate

C. Initial combination therapy with ambrisentan and tadalafil

D. Initial therapy with ambrisentan

Therapy Selection

39%

18%

31%

12%

61%

10%

20%

9%

A B C D0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre (n=310) 1st Attempt Post (n=310)

Knowledge Acquisition: Guidelines

Following participation, learners’ knowledge of the 2019 CHEST guidelines increased by 56%.

Given that these guidelines recommend incorporation of community-based clinical support strategies, this knowledge increase should persuade clinicians to offer more support for their PAH patients.

5. The 2019 CHEST guidelines recommend incorporation of which community-based clinical support strategies into the management of PAH?

A. Supervised exercise and palliative care

B. Spiritual support

C. Social support

D. Rehabilitation and spiritual support

2019 Chest Guidelines

11%

49%

40%

29%

65%

6%

A B C0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre (n=310) Post (n=310)

Clinical Confidence: PAH Diagnoses

Prior to participation, 60% of learners were “very” or “somewhat” confident in their ability to diagnose PAH early in the disease course.

This percentage increased to 94% after participation.

How confident are you in making a diagnosis of PAH early in the disease course?

A. Very confident

B. Somewhat confident

C. Not at all confident

PAH Diagnoses

Behavioral Assessments

59%28%

14%

If you suspect your patient has PAH, which will you do first?

Initiate tests to make a differential diagnosisRefer patient to expert centerSeek support for treatment for an internal care team/specialist

60%37%

3%

How likely are you to refer your patients with suspected PAH earlier to a PAH specialty center or PAH specialist?

Very likely Somewhat likely Not at all likely

The majority of learners understand that PAH is a diagnosis of exclusion and are comfortable initiating this process and referring out to a specialist when alternative diagnoses are ruled out. Importantly, sixty percent of learners will

refer their patients earlier, which may translate into better outcomes.

Practice Change

88% of learners will change their practice! Most notably, 56% will improve screening processes for patients at high-risk for PAH and 46% will start the steps to make a diagnosis of exclusion.

12%

7%

20%

33%

46%

56%

0% 10% 20% 30% 40% 50% 60%

This activity validated my current practice; no changes will bemade

Other changes

Review and update treatment plans for my PAH patients basedon change to guideline recommendations

Provide supportive care for PAH patients in partnership withspecialists

Start the steps to make a diagnosis of exclusion

Improve screening processes for patients at high-risk for PAH

N=304 Multiple responses allowed

Patient Care Impact

31%

54%

12%3%

Number of patients with PAH seen per month:

01-1011-2021-50

Changes will impact 666 to more than 2,488 PAH patients each month. This assumes data in chart above is representative of all HCP completers (304), who indicated they would change their practice as a result of their

participation in this activity (88%).

N=304

Barriers to Planned Change

21%

2%

3%

4%

9%

11%

16%

16%

18%

18%

22%

0% 5% 10% 15% 20% 25%

No barriers

Lack of supporting evidence in the literature

Lack of consensus or professional guidelines

Other

Organizational/institutional culture

Do not have an implementation strategey

Cost

Lack of staff time to implement change

Patient adherence/compliance issues

Lack of equipment or necessary resources

Insurance/reimbursement issues

Participants indicated insurance/reimbursement issues (22%) as most common barrier to implementing changes in their practice, followed by lack of equipment or necessary resources (18%) and patient adherence issues (18%). Of those who identified barriers, 92% will attempt to address these barriers in order to improve their

performance.N=304; multiple responses allowed

Topics of Interest

23%

37%

38%

44%

0% 20% 40% 60% 80% 100%

Post-diagnosis risk-stratification

PAH supportive care

Evaluating PAH treatment

Diagnosis of exclusion criteria for PAH

Diagnosis of exclusion criteria and evaluation PAH treatment were rated with highest interest for future education.

N=304 multiple responses allowed

Activity ImpactSelf-reported change in practice• 6 MWT, refer to center of excellence • Assist our facility with implementing these changes and keep staff

current with treatment options for patients• Be more aware of PAH early symptoms.• Be more aware of potential PAH as a diagnosis in patients with SOB

and refer earlier for evaluation of potential PAH.• Be more aware of RT and its sided pressures on echo, also add

walking test more frequently in office• Be more proactive in diagnosis PAH and refer patients to PAH centers

for evaluation and treatment.• Better assessment and workup• Better communication with PAH centers• Close monitoring of patients with exercise intolerance• Consider PAH as part of my differential, and feel comfortable initiating

the workup• Consider PAH in the differential of more patients and start work up

earlier• Consider PAH more often in differential diagnosis• Critically think about the sign and symptoms of the patient to find the

right diagnosis• Earlier referral and higher level of suspicion• Earlier referral to PAH specialists • Earlier referral, initially dual therapy.• Earlier referral. Quicker echo.• Echo then refer to Special ctr.

• Evaluate in pts charts possibility of PH diagnosis• Evaluate patients better and know what types of imaging they need• formally diagnose, more aggressive referral• Get together with specialist on treatment plans• Have a higher clinical index of suspicion for PAH in patients with no

identified dx for DOE and refer sooner after initial testing• Have higher index of suspicion for diagnosis, initiate quicker workup

and treatment execution.• High level of clinical suspicion in patients with unexplained dyspnea

and diagnosis of exclusion• higher index of suspicion for pulmonary hypertension (all classes)• History of patient and echo.• I refer a lot to our pulmonary hypertension specialist • I will be able to better identify PAH in my patient population and know

when to refer• Improve analysis of pt. w suspected PAH and improve selective care• Improve screening for diagnosis of patients at high risk for PAH which

improves steps to make diagnosis of exclusion• Improve screening process and provide supportive care• Improve screening processes for patients at high-risk for PAH and start

the steps to make a diagnosis of exclusion• Increase awareness about this diagnosis and use diagnostic tools to

help to identify this patients at an earlier stage.• Initiate referral and initiate PAH work up• Initiate tests to make a differential diagnosis and use combination

rather than single drug therapy

Activity Impact (cont)Self-reported change in practice• Instruct echo techs to focus in on clear TR Doppler envelopes and

instruct echo techs to evaluate IVC and hepatic veins• Keep diagnosis of PAH in forefront and take the steps to rule-out other

diseases.• Keep high index of suspicion and remember it is a diagnosis of

exclusion and refer to specialist as soon as suspicion is present.• Keep PAH in differential, refer suspected cases early to specialty • Keep PAH on my differential with dyspnea on exertion, refer when PAH

is suspected following ECG• Look for signs and symptoms sooner and continue to learn about PAH

and the S&S• More aggressive management/referral and implementing diagnostic

assessment earlier on in symptom course. • More aggressive with diagnostic test and refer earlier• more aware of survival enhancing therapies and risk stratification• More diagnostic testing, PFT's and Echocardiograms. • More supportive care for my patient's with PAH. Patient education

regarding PAH• Order echocardiogram in suspected PAH patient and encourage

exercise for these patients• Ordering tests to come with Dx of the right class, do 6MWT more often• PAH has to be part of my Differential Diagnosis with patients that

present with PAH type symptoms. Also, initiate prompt testing/workup to rule out other causes of a possible PAH case, so as a result a diagnosis can be made promptly.

• PAH supportive care, risk stratification

• Pay attention to echo results of patients with unexplained dyspnea and follow up on additional testing

• Refer to a specialist, consult specialist when I need, understanding new diagnostic criteria for PAH

• Review RVSP on echos and understand pt's with heart disease and PH better

• Screen for PH & PAH with more proficiency. I identify PH often in chronic resp and CHF patients, and now I will seek out Physicians capable of helping them

• Screen more, refer for Echo and specialist• Screen patients more effectively and make sure the proper steps are

taken to get correct diagnosis• Select appropriate PAH management strategies based on patient

characteristic • Starting initial workup, referring to specialist• Teaching pathophysiology; planning for function testing.• Think of P.H. in the differential diagnosis of my patients with S.O.B.

and order the appropriate tests to make the initial diagnosis• Treat more people with Pulm HTN and research more• Watch patient for continue s/s and ask how long this as been going on.• Will attempt to address these barriers in order to implement changes in

competence, performance, and/or patients' outcomes• Will continue to have a high index of clinical suspicion to make PAH

diagnosis and manage accordingly.• Will look at echos more closely, have a lower threshold for testing and

referral.

Contact InformationBrittany PusterVP, Education DevelopmentAcademy for Continued Healthcare Learning (ACHL)

E: bpuster@achlcme.orgP: 773-714-0705 ext. 134C: 303-829-2562