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Researching Education for Health Providers


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Title: Researching Education for Health Providers

Researching Education for Health Providers
  • Kathi J. Kemper, MD, MPH
  • Caryl J Guth Chair for Holistic and Integrative
  • Professor, Pediatrics, Public Health Sciences,

Disclosure Financial Support from Pharmaceutical
Companies - none
  • Specifically,
  • NO honoraria from companies for participation in
    advisory board, consultancies, provision of
    patient data, enrolling patients in a trial or
    giving a presentation at a company-sponsored
  • NO financial or other support of research
    activities for myself or my staff
  • NO travel, registration, accommodation or other
    support to attend conferences or meetings
  • NO attendance at company sponsored meetings
    launching new drugs
  • NO personal gifts, office gifts, meals or
    practice equipment from any companies
  • NOT a PI or investigator on any clinical trials
    supported by a company
  • No Receipt of free samples of any drugs or
    patient education materials from any company
  • NO visits welcomed by representatives from any
    pharmaceutical company
  • As per Lancet, 200636728

Support gratefully acknowledged from
  • NIH NCCAM 4/1/00 3/31/03 2003. R21
  • Curriculum for Pediatric Herbs/Dietary
  • NIH NCCAM 10/1/00 9/30/05. 25 (AT000538-01)
    Center for Pediatric Integrative Medical
  • National Library of Medicine 2/1/04 1/31/06
    (extended Based Curriculum About Herbs and
    Dietary Supplements
  • Fullerton Foundation. 11/1/04 10/31/05.
    Feasibility of Providing e-Curriculum on herbs
    and supplements for SC clinicians

Research Structure
Research Question - Subjects
  • Health care providers
  • Professionals
  • MD, PA, PharmD, RD, RN, Acupuncturists,
    Chiropractors, Massage therapists, Healing Touch,
  • Family and community
  • Parents, Teachers

Educational - Interventions
  • Publish research about efficacy/safety
  • Publish review articles
  • Develop curricula
  • Textbook chapters/Internet materials
  • Role model desired behavior
  • Write policy statements
  • Influence thought leaders
  • Create consumer demand (lay media)

Educational -Outcomes
  • Provider knowledge
  • Provider attitudes/confidence
  • Provider behavior
  • Communication practices
  • Medical record charting
  • Actual referrals and recommendations
  • Patient outcomes and satisfaction
  • Health care use
  • Cost of health care/ happiness/ productivity

Example 1 New Curriculum
  • Teaching pediatrics to family medicine residents
    using The Holistic Pediatrician as textbook
  • Compare 3rd year residents from I program to C
    programs in Puget Sound
  • Similar demographics, attitudes about CAM,
    referral to CAM (high in all groups)
  • Only difference felt better prepared to answer
    pt questions used more herbs personally
  • Problems sample size curricula is small in
    relation to learning experience large secular
  • Kemper KJ. J Alt Comp Med, 1999 5(3) 261

Example 2 Faculty Development
  • Curriculum for faculty leaders and teaching
    fellows at Boston Childrens
  • Seven 90 minute sessions very experiential, case
    based focus 4 topics HW QA final
    presentations that could serve to teach
  • Improved Knowledge (62 ?84 correct on herbs
    60 ?98 on acupuncture) Confidence (?1.8 on 5
    point scale) Improved communication about herbs
    (50 ?75)
  • Developed curriculum changed clinic forms
    changed standard lectures on asthma and ADHD
  • Kemper Alt Ther, 2002 8(6) 70-73

Example 3 Write Reviews and Texts
  • Since 1996, have written over 20 review articles
    and chapters for Contemporary Pediatrics,
    Pediatric Annals, Clinical Pulmonary Medicine,
    Office Emergency Medicine, Oski, Nelsons,
    Berde/Schechter, Pizzo/Poplack, Osborne/DeWitt
  • Lectures/Grand Rounds at more than 35
    institutions, AAP, Symposia Medicus,
  • Outcomes????? Control group? Secular changes?
  • Questions on Boards? Services covered by
    insurance? Physician confidence? AAP Section?

Example 4 Policies
  • Pharmacy guidelines on use of home supply at
    Boston Childrens
  • Pharmacy and Clinical guidelines to ask patients
    about use of CAM at WFUSM
  • No discernable impact
  • Need prospective study

Example 5 Role model
  • Role model inclusion of CAM at Boston Childrens
  • Referrals to acupuncturist, massage, TT,
    hypnosis, MD (most for Ca and CF) (Kemper and
    Wornham. APAM, 2001 155 449-454)
  • Charting in medical record review articles on
  • 2100 consults in 5 years
  • Outcome CPG for CF includes acupuncture and CF
    Family Services pays for RN time to do
    TT/HT/Reiki (Highfield et al. J Alt Comp Med,
    200511(2) 373)

Traditional research Randomized Controlled Trials
Many patients use herbs and supplements (HDS)
  • 2nd most common CAM tx following prayer
  • 40 - 60 of adults use multivitamins
  • Women calcium, folate
  • Infants, Children vitamin D, vit K
  • 10 - 20 of kids use other HDS, especially kids
    with chronic or recurrent illnesses, e.g.,
    asthma, ADHD, autism, special health needs,
    chronic abdominal pain, cancer, allergies
  • NOT routinely taught in health professions

Health professionals want to know more about
herbs and supplements (HDS)
  • Top rated topic among pediatricians in AAP
    survey 90 desire additional info.
  • Popular in Family Medicine and Internal Medicine
    as well CME programs by UCSF/Harvard, Scripps
  • Increasing numbers of review articles in many
    mainstream journals
  • Kemper K, OConnor K. Amb Pediatr, 20044482-87
  • http//

How to educate clinicians?
  • Review articles (e.g. Contemporary Pediatrics)
  • Meta-analyses
  • Web sites (LHTF, ConsumerLabs, NMCD)
  • Case reports
  • Conference, lectures (Herbal Jeopardy, Grand
  • Detailing and bribes (think big Pharma)
  • General media Time, Newsweek, 60 minutes

Barriers to CE/ CME
  • Time
  • Money
  • Credibility/Trust

Pilot Study Boston
  • BCH, MCPHS, LHTF collaboration
  • 20 modules with links focus on herb per module
  • Moderated Listserv 1-2 weekly
  • 2 modules weekly X 10 weeks, sent by email
  • Randomized cross-over
  • Solicitations by email to Longwood area
    institutions (about 2000 emails sent) widely

Baseline characteristics Boston study
  • 537 enrolled (111 MD 30 RN 46 PharmD 350 RD)
    84 fac/practice 16 trainees
  • Age 40 years 86 women 86 Caucasian
  • 24 from Longwood area 76 out of area
  • 66 had training about herbs in past year 7
    hours median
  • 77 used H/DS themselves 4 or more days a week
    (MV, Ca, Vit E, Vit C, Vit B, echinacea,
    chamomile, soy, Mg all greater than 10)

Baseline K, A, P Boston Pilot
  • Knowledge 50 correct on 10 TF 10 MC (better
    for RD faculty/practice all less than 60 avg)
  • Confidence average 4/10 possible
  • Communication 1.4 / 4 possible, e.g., median
    percentage of patient encounters in last month
    talk about H/DS was 10
  • Low scores on side effects and interactions

Improvements AFTER Intervention Pilot Study
  • Knowledge 3 points with Intervention vs. 1.4 for
    wait group, Plt0.01
  • Confidence 2.6 vs. 0.6, Plt0.01
  • Communication 0.21 vs -0.1, Plt0.01
  • Similar improvements in wait list group when they
    got e-curriculum improvements sustained in
    initial Intervention group
  • Questions will it work for MORE modules (40)?
    Can we do it by BOLUS vs. DRIP PUSH vs. PULL CE
  • Need more questions, especially on

Factorial Design for Curriculum Delivery
  • MD/PA
  • Pharm D, pharmacists
  • RD, nutritionists
  • Faculty, in-practice, in training
  • Access email at least twice a week
  • Agree to complete baseline and outcome
  • CME/CE credit 35 for 10 hours

  • Northwest Area Health Educ. Center e-mail
  • NW AHEC mail brochures (Spring only)
  • Medical schools, alumni offices, nursing schools,
    pharmacy schools, RD programs, SC AHEC (Spring
  • Personal contacts, APA Listserv, Flyers at
    Scripps herb conference, CAHCIM (Spring only)

  • 40 modules, sorted by diagnosis, problem in 10
    groups, e.g. oncology, cardiology, pulmonary,
    womens, pediatrics
  • Over 300 links to evidence-based sources
  • Moderated listserv
  • Offered through NW AHEC CME/ CE offered for 10
    12 hours credit
  • Same program offered in each of two semesters,
    Fall, 2004 and Spring, 2005 (RN CE)

Primary Outcomes
  • Drop-out rate (non-completion of outcome
  • Changes in Knowledge, Confidence, Practice
  • Feedback about course

  • Eligible and enrolled 1268
  • Age 40 years (younger in Spring, more students)
  • Female 75
  • Race 84 Caucasian 8 Asian 5 African
  • No demographic differences in 4 randomized groups

Practice Characteristics,
  • Profession
  • Students/Trainees 31
  • MD/PA 30
  • RN 23
  • RD 12
  • PharmD 5
  • Faculty/practice 57
  • Seen pts in past 30 days 67
  • Live in NC 47
  • Use herbs 85 (MV, Ca, B Vits Vit C Vit E
    fish oil green tea flax seed Vit D folate
    glucosamine Mg CoQ10 iron) AVG 5.5
  • NSD in 4 randomized groups

Patient Epidemiology
  • What percentage of your patients do you estimate
    currently use herbs or other dietary supplements?
  • Range 0,100
  • Mode 30
  • Median 35

Baseline Knowledge
  • True/False 74
  • Multiple choice 59
  • Overall 66 correct at baseline

Note to help participants meet CE/CME
requirements of 70 correct at outcome, we made
questions easier than in Boston pilot study
Confidence - baseline
  • 19 questions
  • Cronbachs alpha 0.91
  • Score (Strongly Disagree 1 Strongly Agree
    5) Possible range 19, 95
  • Average baseline score 52.5 18.2

Fall, 2004 Baseline Practice Questions In last
30 days, in what percentage of your clinical
encounters have you
  • Discussed with a pt or family, the use of H/DS?
  • Median and mode 10
  • Did you initiate discussion about HDS?
  • Mode 0 median 30
  • Ask about dose /frequency?
  • Mode 0 median 10
  • Ask about side effects?
  • Median and mode 0
  • Record use in medical record?
  • Mode 0 median 20

Practice / Communication (only for participants
who saw a patient in prior 30 days)
  • 11 questions Score range 0, 10
  • Cronbachs alpha, 0.84
  • Baseline 2.20 1.92

Completion rates for Fall, 2004
Didnt sign up for credit, N260 Completed 145
1st FU Immediately after course Completers (780)
vs. Non-completers (487)
  • No significant differences by
  • Delivery strategy, or baseline communication

Completers (780) vs. non-Completers (487)
Significantly Differ
  • Age (42 vs 37 yrs)
  • Gender (77 vs 71 women)
  • Profession highest completion for Pharmacists
    and nutritionists (gt70) lowest for students
  • Clinically active (saw pts in last 30 days) (70
    vs 62)
  • Paid CE fee (58 vs 27)
  • Number of HDS used as baseline 5.7 vs 5.2
  • Completers had higher knowledge and confidence at

Web Use PUSH vs PULL
Most popular links
LHTF Echinacea Example
Improvements from Baseline to First, Immediate FU
  • Knowledge, 22 increase to 89 correct
  • Confidence, 10.5 points to 64.3
  • Communication practices, 0.33, from 1.67 to 2.0
  • All Plt0.01 significance

Improvement with curriculum Knowledge Correct ?
from baseline to immediate follow-up
Improvements with curriculum Confidence (N735)
Improvements with Curriculum Communication
Practices (N440)
If delivery strategy didnt affect improvement,
what did?
  • NOT gender
  • YES, Knowledge affected by
  • Paying CE fee (most important in regression
  • Age lt30 or greater than 50
  • Profession students, nutritionists, and nurses
    had bigger gains than MDs or PharmDs
  • Using herbs. Those who used fewest at baseline
    improved the most

Confidence most improved for
  • Being a trainee (vs being in practice)
  • Paying CE fee
  • Being under 30 or over 50 years old
  • Profession being a nurse or student vs being a
    nutritionist, or pharmacist

Communication most improved for
  • NOT affected by any predictor variable

Positive Feedback from Participants
  • "I enjoyed the course (and learned a lot)."
  • Dr. Richard Theuer - Raleigh, NC
  • I'd just like to say how much I enjoyed having
    access to this great information through such an
    easy-to-use format as e-mail.  I not only learned
    a lot as I went along, but now I have a wonderful
    printable resource as well.  I've utilized some
    of the information already with my staff here in
    our practice.  Thank you for making this
  • Elizabeth Richards, RN, MS - Asheville, NC
  • I have enjoyed this experience very much. I wish
    I had more time to spend with it. This has been
    most useful information.
  • Russell Knop, MS, CSAC - Hillsborough, NC

Constructive Feedback
  • It was just too much for me to keep up
    overwhelming decrease number of modules and
    links smaller doses
  • A little slower pace would have been helpful
    more time Too much information in a short
    period from a BOLUS participant
  • better as an online instead of email program.
    I got only part of the emails. from someone who
    received PUSH

More Feedback
  • .. internet links were very helpful. Ability
    to go into any amount of depth on any topic.
  • I learned about several resources of which I
    was not aware.
  • The modules were a fast read I could choose to
    access or not access links. I can go at my
    own pace.
  • Excellent format thorough coverage. I really
    liked the case study approach
  • affordable way to get CE
  • Sharing and talking to colleagues about what I
    was learning Reading questions from other

  • More courses like this
  • Ongoing updates on the same topic
  • Printed reference materials to accompany the
  • Patient handouts
  • Searchable index for topics
  • Clinical tools for recording patients use of HDS
  • Provide course and references in Spanish

Initial impact study citation
  • Kemper KJ, Gardiner P, Gobble J, Mitra A, Woods
    C.Randomized Controlled Trial Comparing Four
    Strategies for Delivering e-Curriculum to Health
    Care Professionals ISRCTN88148532. BMC Med
    Educ. 2006 Jan 116(1)2

Long-term Follow-Up
  • October November, 2006
  • Approximately 6 10 months after completing the
    Spring or Fall curriculum, we emailed the same
    follow-up questions to all enrollees
  • Four reminders
  • Free enrollment in another on-line class on herbs
  • Of 780 who completed the first follow-up, 385
    (49) completed long-term followup

Long term completers (N385) versus
Non-completers (N395)
  • Non-Completers and completers did not differ in
    average age (42 years), gender, race, self-rated
    computer expertise (4.3 on 7 point scale),
    knowledge, confidence, herb use or communication
    practices at baseline, being a trainee (vs in
    practice), intervention group, spring (vs fall)
    enrollment or professional group or having paid

Changes from baseline and first follow-up
  • Knowledge (N385)
  • From baseline 67.7 to 78.8 (10.1 pts, Plt0.001)
  • Initial FU 89.8 to 78.8 (-12.1, Plt0.001)
  • Confidence (N385)
  • From baseline 53.7 to 66.9 (13.2, Plt0.001)
  • From initial FU 64.5 to 66.9 (2.3, P0.009)
  • Communication (N182)
  • From baseline 2.6 to 3.6 (1.0, Plt0.001)
  • From initial FU 3.3 to 3.6 (0.3, P0.007)

Long term completers (N385)
Plt0.001 by Wilcoxon
Confidence Among Long-term Completers (N385)
Plt0.001 by Wilcoxon
Communication Practices in Long-term Completers
Plt 0.001 by Wilcoxon
Changes over time
  • NOT affected by delivery strategy
  • Initial bivariate analyses suggest differences
  • Knowledge by profession, age, herb use, seeing
    patients, paying for CE/CME
  • Confidence by profession, practice, age, herb
    use, seeing patients, paying for CE/CME
  • Communication - NSD

Conclusions so Far
  • More web use with push
  • More drop outs if no-pay
  • Link usage declines over time
  • LHTF favored want handouts want indexing and
    hard copies booklets?
  • Randomization worked curriculum works
    regardless of delivery strategy,
  • Confidence and communication continue to increase
    after course, but little meaningful improvement
    in communication

Next Steps?
  • Currently, we are providing 12 on-line classes,
    each one hour long, free for medical students
    here, fees for everyone else
  • Market comparison of KNOWLEDGE-oriented versus
    BEHAVIOR oriented classes
  • Preliminary view of impact on Confidence and
  • Over 500 enrolled since 12/05

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Next study questions (grant submitted 10/05 for
7/06 start)
  • Impact of B versus K curriculum
  • Impact of one versus higher doses of classes
  • Impact at 1 and 6 months
  • Impact of required versus elective
  • Impact on self-reported versus chart review of
  • Two parts
  • Pt 1 RCT of 1600 clinicians (K vs B 1 and 6
  • Pt 2 RCT of 75 RNs at NCBH (required vs
    elective chart review)

  • CAM education for multidisciplinary professionals
    is feasible high interest by women
  • Role modeling is effective
  • Few technical problems with web-based data entry
    or content delivery harder to do email delivery
  • Few problems with SPAM Listserv works well even
    for very LARGE numbers of enrollees
  • Coordinating teamwork over different campuses and
  • Impact of review articles, chapters, talks is
    harder to measure
  • Need cost-benefit analyses!
  • Need to look at patient outcomes.
  • Educational research is fun, challenging
  • And fundable.!

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