Case Study

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Better evidence? Better resources? Better
education? Better outcomes?
Dave Davis, MD, FCFP, Senior Director,
Continuing Health Care Education Performance
Improvement, Association of American Medical
Colleges, Washington DC Adjunct Professor,
University of Toronto, Toronto, ON
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An outline

• What is the Clinical Care gap? an overview,
  its causes
• What's the fuss? where do guidelines and evidence
  fit in this picture?
• What do we know about developing and implementing
  guidelines and best evidence?
• So what? Can we make it better? Whats the role
  for faculty? For CME providers
• Be careful what you wish for implications for
  Medical Schools, the Academic Medical Center,
  comparative effectiveness research and for CME

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Question 1 What is the clinical care
gap? (and what causes it?)
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Some US data on underuse Goldman and McGlynn,
National Report Card on US Health Care, Rand
Health, 2005

• 12 metropolitan areas, roughly 30 conditions
  studied, gt6,000 patient records examined
• Substandard care noted in 45 of clinical areas
  (of this, 46 underuse 11 overuse) Little
  variation by region or by type of condition
  (chronic, acute), socioeconomic status
• Notable gaps in care in depression, alcohol
  abuse, diabetes care (about 45), pneumonia
  (39)
• Better care (gt50 compliance with
  recommendations) noted in hypertension, cardiac
  care, but just
• NOTE and pretty stunning evidence about
  overuse and misuse too

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Where does all the knowledge go?
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What causes the gap?
?
Best available evidence/practice
Actual Practice
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No time
No, Thursdays out. How about never-is never good
for you?
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Daves top 10 reasons for not buying into CPGs

• 10) There are SO many of them!
• 9) Guidelines, what guidelines?
• I am too busy to adopt this new stuff
• 7) Patient problems are complex they dont fit
  neatly into those little boxes
• 6) They were made in Washington (Ottawa,
  Saskatchewan), wouldnt apply here OR there
  were no blue-eyed family docs on the panel

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Daves top 10, contd

• 5) I dont trust all this EBM stuff
• 4) You ever tried reading one of those things?
  Its like 200 pages of dense text. Man.
• 3) MY patients expect ME to make decisions!
• 2) I already DO abide by the guidelines, yup,
  yessirree, 100, all the time thats me - Mr.
  Guidelines.....and
• 1) MY patients are different!!

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What causes the gap?
Clinician CME system Health Care
system Evidence/ CPGs Patient, family
Best available evidence/practice
Actual Practice
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Question 2 Where do evidence and guidelines
fit into this picture?
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Old views of knowledge use
The faculty member
The outcome knowledge retention, regurgitation,
application
Lecture, print material
Knowledge/evidence
Curriculum planning
The learner/clinician
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Problems with the old model 1 the level of
evidence
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Problems with the old model 2- the shape and
size of the evidence

• compatibility
• complexity
• cost
• relative advantage
• accessibility
• format
• patency of evidence, process of development
• opportunity trial-ability
• Note the AGREE instrument

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Problem 3 volume
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Problem 4 how we implement the evidence
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Problem 5 no tools
Adapted from Straus et al, 2005
guidelines
systematic reviews
studies
self/patient experiences
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Question 3 how can we make it better?
Question 3 How can we make it better?
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Forces for change
QI, comparative effectiveness strategies
Research about effective CME, QI
Accreditation reqts
The new CME
Knowledge explosion
Accountability performance measurement
CME
Regulatory focus on outcomes
Competency assessment, recertification
Content issues new diseases, prevention,
screening
Evidence, Bias, comparative effectiveness
Governmental cost containment issues
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(Maybe) a better view of knowledge creation,
adaptation, use
The faculty member
The outcome knowledge management skills better
delivery methods better care
Evidence creation, adaptation
Assessment strategies
Learner engagement
The learner/clinician
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Possible Solution 1 engage faculty more
effectively in evidence development
Clinical practice guidelines are consensus and/or
evidence-based statements of care intended to
provide direction and assist decision-making in
clinical care for both patients and
clinicians.. Adapted from the Institute of
Medicine, 1990
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PS 2 Fostering the creation and shaping the
evidence and tools
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Making knowledge out of information
Adapted from Straus et al, 2005
practice aids
guidelines
systematic reviews
studies
self/patient experiences
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PS 3 Reconsider educational boundaries

• Faculty Development
• Enhance assessment skills
• Learn and enhance critical appraisal, knowledge
  management teaching skills
• Broaden familiarity with educational
  interventions, health systems

• UME, GME
• Enhance assess self-directed learning,
  critical appraisal, knowledge mgmt. skills,
  portfolios
• Enhance attention to CQI concepts and tools
• Adopt new competencies PBLI, SBP - performance
  assessment (peers, supervisors, nurses, other
  360 degree formats, etc)
• Use and appraise learning resources of practice

Implications for CME providers, faculty
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In CME - Changing the teaching paradigm

• FROM formal lectures, courses, educational
  materials
• TO learner facilitation
• increased interactivity, sequencing (e.g., RSS)
• small group learning, research transfer networks,
  communities of practice
• ICT web-, video-conferencing, on-line, PDAs,
  text, IM, IT
• simulations
• patient-mediated strategies
• audit/feedback reminders
• comprehensive, QI- or practice-based
  interventions

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PS 4 helping faculty understand the special
case of the clinician-learner

• The Pathman Model
• awareness of a guideline, practice innovation,
  change
• agreement with the innovation or guideline
• adoption trying out the new practice,
  irregularly
• adherence abiding by the new practice on all
  appropriate occasions
• Pathman, 1996

The clinician-learner

• age, motivation
• (dis)incentives
• experience
• time
• environment
• training
• Emphasis on knowledge
• Inability to detect needs, evaluate performance
• ?self-directed learning
• ?critical appraisal

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  Stratege the delivery of CME possible methods
for changing provider performance by Pathman
stages
Davis et al, BMJ, 2003
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Findings from the CME literature

• Didactic, mono-method, one-time-only CME
  not so effective
• Needs Assessment important the more the better
  (subjective needs, objective, gaps and barrier
  analysis)
• Effective CME may have predisposing, enabling
  and reinforcing strategies
• Knowledge necessary but not sufficient for
  change Quantitative methodology necessary but
  not sufficient to understand change
• consider the message/size and complexity of
  change and consider the setting
• NOTE ACCP guidelines on CME (March, 2009 not
  all guidelines are clinical)

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.and, PS 2,851 The AAMC and its role in
moving evidence into action
Changing the CME paradigm
Helping train the CME, improvement workforce
Collaborations and partnerships
Supporting KT-like research
GOALS
Promoting better-evidence lifelong learning
Logistics
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Are we there yet?

• Of course not we need -
• Increased focus on Knowledge Translation (T2,
  T3) - training, education, studies
• Clearer UME, GME, CME standards about lifelong
  learning, knowledge management, critical
  appraisal
• Increased, non-commercial support for
  CME/Improvement better CME methods and
  integration
• more professional development for faculty,
  CME/CQI/implementation professionals
• More tools (see www.aamc.org/cme for starters)
• Transfiguration is one of the most complex and
• dangerous subjects you will learn at Hogwarts
• Professor McGonagal, 1997, Harry Potter and the
  Philosophers Stone

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One step at a time
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Daves contact info
ddavis_at_aamc.org 202-862-6275 www.aamc.org/cme