Physician Education on EHDI: A Method to the Madness

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Physician Education on EHDI A Method to the
Madness

• February 19, 2004
• 200 300 pm

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Presenters

• Michelle Esquivel, MPH
• EHDI Project Coordinator
• American Academy of Pediatrics
• Mary Pat Moeller, PhD
• Director, Center for Childhood Deafness
• Boys Town National Research Hospital

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Overview of Session

• History of Physician Knowledge and/or Education
  on EHDI Issues
• Background Related to Efforts to Assess Physician
  Level of Knowledge on EHDI Issues
• Models/Best Practices on Physician Education on
  EHDI

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Session Objective

• To share experiences, resources and models for
  education of primary care physicians and other
  pediatric health care professionals on early
  hearing detection and intervention issues.

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CME What Motivates Learning?

• Specific problem or issue (e.g., question about a
  patient)
• General problem (gaps in skills knowledge
  related to new technology)
• Cognitive dissonance (comparison with peers)
• Intrinsic factorsDr. B. Schuster (2002)

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Continuing Medical Education Most Successful
Methods

• Learning linked to clinical practice (including
  tests of knowledge evaluation of clinical
  practice needs)
• Educational meetings with interactive components
• Outreach events
• Use of multiple interventions (e.G., Outreach
  reminders Grand rounds with case study
  discussion reminders)

Davis, et al, 1995 Davis Maxmanian, 2002
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Meta Analysis of CME

• Less effective methods
• Audit
• Feedback
• Local consensus process
• Influence of opinion leaders

• LEAST Effective
• Formal CME conferences without interactive
  elements
• Unsolicited educational materials (including
  clinical guidelines)

Davis, et al, 1995
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Adult Learning Methods

• Diverse learning styles
• Prefer activities that are-Problem
  centered-Meaningful to life situation-Focused
  on immediacy of applicationBrookfield, 1986

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Project with Pediatricians
Formal Focus Group Work (N27)
Pilot Focus Groups (N 21)
Internet Based Survey (N263) Extend through
paper survey
Resource Development
Field test, revise disseminate
NIDCD supported
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Themes from Focus Groups Methods

• Consider time constraints in daily practice
  number of infants seen in practice life time
  action oriented, just in time resources
• Avoid dense content designed to make me an expert
• Need for common language across disciplines
• Low tech materials preferred by some

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Themes from Focus Groups Methods

• Attend to credible sources of information (like
  AAP)
• Avoid anecdotal in favor of evidence-based
  content
• Use familiar formats (e.g., Grand Rounds,
  algorithms, patient education materials)but
  consider how to challenge the comfort zone?

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Themes from Focus GroupsDesired Content Areas

• Guidance on protocols from AAP
• Test accuracy, training of testers, costs
• Evidence-based best practice guidelines
• Expectations related to intervention (teamwork)
• Linking systems with medical home
• Counseling parents
• Developmental indices
• Medical/genetic issues

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Themes from Focus GroupsPreferred Resources

• Grand Rounds materials
• Laminated cards with protocol steps
• Some requested web based materials
• Patient Education materials
• Journal articles AAP policies
• Efficacy research
• Multimedia CAN be effective.but.

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Not useful

• Dense information, time consuming to access
• Parent testimonial (depends on the approach)
• Anecdotal examples without detail
• Discipline specific terminology

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On-line Quantitative Survey

• Recruited through support from AAP (email blast,
  newsletters, Chapter Champion efforts)
• Included traditional survey questions and
  streaming audio from focus groups
• Effort to validate opinions of focus groups on
  larger scale

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Demographics of Group
Type N Rural Metro Male Female
Pediatrician 192 85 105 92 98
Neonatology 29 24 5 14 15
Family Practice 20 16 4 14 6
ENT 11 0 11 10 1
Other 11 5 6 6 5
Total 263 130 131 136 125
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Survey Examples (Knowledge)

• Q24. What is your best estimate of the time at
  whichd) A child can be definitively diagnosed
  as having a permanent hearing loss 
• e) A child requiring amplification can be
  fitted with hearing aids

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Survey Examples (Resources)

• How likely would you be to use the following
  types of materials in your practice? (Rank very
  to not helpful)-Downloadable Grand Rounds
  materials-Laminated cards with clear protocol
  steps-CDs or DVDs to use in patient
  education-Web sites with frequently updated
  info-CME courses online

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Preliminary Survey Results (N263)

• Strong support for screening (90)
• Concern about test accuracy (53) and false
  positive rates (74)
• Most (69) do not believe screening causes undue
  anxiety for parents
• Most (70.2) refer immediately, but almost 30
  wait 4 weeks to 3 months
• 23 do not regularly receive screening results
• Only 33 felt trained to address this need

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How Confident Are You That You Know What to Do If
an Infant in Your Practice Does Not Pass a
Newborn Hearing Test?
Response Category
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When can an infant be fit with hearing aids?
Response Category (months)
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Thinking About Physicians You Know and Work
With, How InformedAre They About the Following
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Content Needs Identified in Quantitative Survey

• Protocols for follow up (81 great need)
• Guidelines for informing families (63)
• Impact of varying degrees of hearing loss on
  child language (74) (unilateral, mild, late
  onset gt severe to profound)
• Screening for late onset SNHL (73)
• Useful contacts patient education (75)

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Content Needs Identified in Quantitative Survey

• Desire on-line CME course (66)
• Medical interventions for SNHL (83)
• Educational and audiological interventions for
  hearing loss (84)
• Genetics of HL (11)

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Trends by Professional Category
5
8
9
2
6
11
10
7
12
3
1
4
Otolaryngologist
Family Physician
Pediatrician
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CME and Resource Creation

• Based on effective assessment of learning needs
  removal of barriers
• Should encourage self-assessment
• Address gaps and extend educational resources in
  a strategic manner

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AAP EHDI Program

• Began in August 2001
• Establishment of network of pediatricians in
  states to champion this issue
• Phase I Education of Champions
• Phase II Education of General Membership

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Education of Champions

• Monthly EHDI E-Mail Express
• Participation in National EHDI Conferences
• Mentoring by National Experts/Task Force members
• Mini-Grant Opportunities

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Education of Champions

• Visiting Professorship/Lectureship Opportunities
• Participation in medical home training
  conferences
• Participation in CDC EHDI Ad Hoc Conference Calls

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Education of General AAP Membership

• Articles in AAP news
• Dissemination and promotion of resource materials
  and information
• Articles in chapter newsletters
• Sessions at AAP national conference and
  exhibition
• Sessions/materials at AAP practical pediatrics
  courses
• CME teleconference series
• Visiting professorship/lectureship opportunities

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Practical Pediatrics Courses

• Include information in sessions on developmental
  and behavioral pediatrics
• Distribution of flow chart, Universal Newborn
  Hearing Screening Diagnosis and Intervention
  Guidelines
• Distribution of patient chart companion piece
  when available

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CME Teleconference Series

• AudiencePrimary care pediatricians, family
  physicians
• FacultyNationally renowned Betty Vohr, MD
  Judy Gravel, PhD Albert Mehl, MD and Mary Pat
  Moeller, PhD

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CME Teleconference Series Content Areas

• Definitions of types of congenital hearing loss
• Major genetic and environmental causes of
  congenital hearing loss
• Newest technologies used in hearing screening
• Importance of diagnostic confirmation of hearing
  loss
• Physicians medical work-up
• Amplification choices

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CME Teleconference Series Content Areas (cont)

• Cochlear implantation
• Parental concern about delayed language
  development
• Case studies
• Parenting issues
• AAP Universal Newborn Hearing Screening,
  Diagnosis, and Intervention Guidelines for
  Pediatric Medical Home Providers and how to
  implement

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CME Teleconference SeriesContent Areas (cont)

• Costs and reimbursement issues related to
  amplification devices
• Empowering families to advocate effectively for
  their child for the appropriate resources
• Roles of early intervention and why intervention
  services are recommended
• Important referrals needed for children with
  permanent hearing loss
• National resources

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CME Teleconference Series

• CME credit for participants
• Noontime sessions to accommodate those in
  practice
• Toll-free call in
• Presentation slides and resource materials in
  advance
• Free for participants!

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CME Teleconference Series

• Logistics/Coordination
• - Staff/time intensive
• - Volunteer/faculty intensive
  development of content outline and
  information, slides, practice session,
  unfamiliar presentation scenario
• - Phone Company Preparation (Call taped)
• - Registration Coordination, documentation
• - Promotion/Marketing

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CME Teleconference Series
Successes

• Comprehensive curriculum
• Resources useful and valuable
• Approximately 50-70 participants per call
  despite somewhat limited promotion
• More than individuals registered participated
  (practice-wide participation)
• Faculty well prepared and knowledgeable
• Informative question-and-answer period

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CME Teleconference Series
Successes

• Extremely positive evaluation results
• Content provided information useful to practice
• Changes will be made in practice as a result of
  participation
• Very likely to share information learned with
  colleagues
• Teleconference format was convenient and
  effective
• Relatively easy model to replicate

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CME Teleconference Series

• Challenges
• -Last minute registrations
• -No shows
• -Resource material dissemination in advance
• -Technology (downloading slides,
  connecting to the call)
• -Time zone(s)

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CME Teleconference Series

• Costs
• Graphic Design and Printing for Program
  Brochure/Marketing Materials
• CME Application Fee
• Express Mail and Postage (for marketing/promotion
  and registration packets and CME follow up)
• Telephone Conferencing Service for planning calls
  and the teleconference series calls
• Indirect Costs (staff time, volunteer time)

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Visiting Professorship/Lectureship Opportunities

• Available to Chapter Champions
• Criteria Grand rounds presentation as well as
  other smaller, more focused meetings and
  presentations
• Funds available for speaker travel, expenses and
  honorarium
• Held in Delaware, Louisiana, Ohio, California,
  Hawaii (March 2004)

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Visiting Professorship/Lectureship Opportunities

• Faculty Betty Vohr, MD Christine
  Yoshinaga-Itano, PhD Karl White, PhD Mary Pat
  Moeller, PhD Noel Matkin, PhD
• Topics Dependent on the needs identified by the
  Chapter Champion who applied
• Examples Early Intervention Cost/reimbursement
  issues related to hearing aids state
  requirements for education for children
  identified with hearing loss physician
  contributions to EHDI programs resident
  education on screening issues EHDI challenges
  and opportunities EHDI guidelines on UNHS
  evaluation and management of children with
  hearing loss outcomes and genetics of hearing
  loss.

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Visiting Professorship/Lectureship Opportunities

• Successes
• - Opportunity for national experts to present
  locally
• - Several presentations coordinated and held in
  various locations in each state/hospital
• - Multidisciplinary approach
• - Cost effective, i.e., funds expended compared
  to number of individuals educated

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Visiting Professorship/Lectureship Opportunities

• Challenges
• - Time intensive to coordinate
• - Availability of experts to coincide with
  availability of time slots for presentations
• - Incredible amount of detail orientation
• - No staff available on-site to handle
  logistics rely on Chapter Champion and others
• - Difficult to collect and truly analyze overall
  summary and evaluation instruments

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Additional Resource Development (NIDCD Grant)

• Grand Rounds materials on CD (currently in field
  testing stage)
• Support for development of AAP Pedialink module
  on newborn hearing screening and follow up
• Patient education materials (downloadable)
• Web site development expansion

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24,000 children are born each year in the U.S.
with some degree of hearing loss. Most of these
children are born to parents with normal hearing,
who have had no experience with deafness or
hearing loss of any kind. It is natural to feel
overwhelmed and unprepared to deal with the
situation. It is important to remember that you
are not alone. This website will give you
information, answer questions and provide
support. We will introduce you to other parents
who have walked in your footsteps. Lets begin by
exploring some next steps in your communication
journey with your baby.
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Future Directions Nurses Knowledge about EHDI

• Few studies have been conducted
• Pilot data collected at BTNRH (N 20) showed the
  following informational needs-medical and
  educational interventions-screening/testing
  methods-impact of HL of varying degree on
  language-surveillance, useful contacts-patient
  education materials-50 not confident, but
  doctors are
• Foresee a major role in patient education

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Preferred Resources Nursing

• Frequently updated web site
• On-line CME courses
• Written protocol guides
• Handouts for parents
• Clear, understandable, brief teaching pieces

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Summary

• Effective CME design related to EHDI should
  include-physician self-assessment-just in time
  resources-variety of strategies multiple
  interventions-techniques relevant to practice
  -evaluation of impact from varied
  sources-sensitivity to practice constraints
• Use what is already in existence!

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Physician Education and EHDI

• Contact information
• Michelle Esquivel
• 847/608-6550
• mzesquivel1_at_yahoo.com
• Mary Pat Moeller
• 402/498-6521
• moeller_at_boystown.org