Clinical practice gaps and challenges in non-alcoholic steatohepatitis care: An international physician needs assessment.

BACKGROUND AND AIMS: Even as several pharmacological treatments for non-alcoholic steatohepatitis (NASH) are in development, the incidence of NASH is increasing on an international scale. We aim to assess clinical practice gaps and challenges of hepatologists and endocrinologists when managing patients with NASH in four countries (Germany/Italy/United Kingdom/United States) to inform educational interventions. METHODS: A sequential mixed-method design was used: qualitative semi-structured interviews followed by quantitative online surveys. Participants were hepatologists and endocrinologists practising in one of the targeted countries. Interview data underwent thematic analysis and survey data were analysed with chi-square and Kruskal-Wallis tests. RESULTS: Most interviewees (n = 24) and surveyed participants (89% of n = 224) agreed that primary care must be involved in screening for NASH, yet many faced challenges involving and collaborating with them. Endocrinologists reported low knowledge of which blood markers to use when suspecting NASH (56%), when to order an MRI (65%) or ultrasound/FibroScan® (46%), and reported sub-optimal skills interpreting alanine aminotransferase (ALT, 37%) and aspartate aminotransferase (AST, 38%) blood marker test results, causing difficulty during diagnosis. Participants believed that more evidence is needed for upcoming therapeutic agents; yet, they reported sub-optimal knowledge of eligibility criteria for clinical trials. Knowledge and skill gaps when managing comorbidities, as well as skill gaps facilitating patient lifestyle changes were reported. CONCLUSIONS: Educational interventions are needed to address the knowledge and skill gaps identified and to develop strategies to optimize patient care, which include implementing relevant care pathways, encouraging referrals and testing, and multidisciplinary collaboration, as suggested by the recent Global Consensus statement on NAFLD.

Barriers to shared decision-making with women of reproductive age affected by a chronic inflammatory disease: a mixed-methods needs assessment of dermatologists and rheumatologists.

OBJECTIVES: The main study objective was to identify challenges and barriers experienced by dermatologists and rheumatologists when engaging women of reproductive age in shared decision-making (SDM) related to treatment and management of chronic inflammatory disease (CID) before, during and after pregnancy. DESIGN: A mixed-methods study was conducted, employing (1) semistructured interviews, (2) an online survey and (3) triangulation of findings. PARTICIPANTS: 524 dermatologists and rheumatologists entered the study; 495 completed it; 388 met inclusion criteria for analysis. Participants were included if actively practising in Germany (GER), the UK or the USA; had a minimum 5% caseload of female patients of reproductive age with either axial spondyloarthritis, psoriasis, psoriatic arthritis or rheumatoid arthritis; and had experience prescribing biologics. RESULTS: 48 interviews and 340 surveys were analysed. Interviews underscored dermatologists and rheumatologists' suboptimal integration of SDM in clinical practice. In the survey, 90% (n=305) did not know about SDM models. A perceived lack of competency counselling patients on pregnancy and family planning was also identified during interviews. Among the survey sample, 44% (n=150) of specialists agreed they preferred leaving pregnancy-related discussions to obstetricians and/or gynaecologists and 57% (n=189) reported having suboptimal skills discussing contraceptive methods with patients. Another finding that emerged from interviews was the perception that all biologics are strictly contraindicated during pregnancy. Suboptimal knowledge was noted among 57% (n=95) of dermatologists and 48% (n=83) of rheumatologists surveyed in that regard, with a statistically significant difference by country among dermatologists (GER: 42% vs UK: 71% vs USA: 57%, p=0.015). CONCLUSIONS: This study identified low levels of knowledge, skill and confidence, as well as attitudinal issues, that explain why SDM is not fully integrated in dermatology and rheumatology clinical practice. Blended-learning interventions are recommended to assist CID specialists in developing effective communication and patient engagement competencies.

National Trends in Prescription Opioid Risk Mitigation Practices: Implications for Prescriber Education.

OBJECTIVES: To assess national trends in selected prescription opioid risk mitigation practices and associations with prescriber type, state-specific opioid overdose severity, and required pain education. METHODS: Analysis of the national SCOPE of Pain registrants' baseline self-report of five safer opioid prescribing practices over three years (March 2013-Februrary 2016). RESULTS: Of 6,889 registrants for SCOPE of Pain, 70-94% reported performing each of five opioid risk mitigation practices for "most or all" patients, with 49% doing so for all five practices. Only 28% performed all five practices for "all" patients prescribed opioids. There were few differences among three yearly cohorts. Advanced practice nurses reported performing practices for "all" patients more often than physicians or physician assistants. Clinicians from states with high opioid overdose rates reported significantly higher implementation of most practices, compared with clinicians from states with low rates. CONCLUSIONS: Prescribers report low levels of employing five opioid risk mitigation practices for all patients prescribed opioids before attending a safer opioid prescribing training. POLICY IMPLICATIONS: Safer opioid prescribing education should transition from knowledge acquisition toward universal implementation of opioid risk mitigation practices.

A multi-stakeholder perspective on asthma care in Canada: findings from a mixed methods needs assessment in the treatment and management of asthma in adults.

BACKGROUND: Although several aspects of asthma care have been identified as being sub-optimal in Canada, such as patient education, practice guideline adoption, and access to care, there remains a need to determine the extent to which these gaps remain, so as to investigate their underlying causes, and potential solutions. METHODS: An ethics-approved mixed methods educational needs assessment was conducted in four Canadian provinces (Alberta, British Columbia, Ontario, and Quebec), combining a qualitative phase (45-min semi-structured interviews with community-based healthcare providers and key stakeholders) and a quantitative phase (15-min survey, healthcare providers only). RESULTS: A total of 234 participants were included in the study, 44 in semi-structured interviews and 190 in the online survey. Five clinical areas were reported to be suboptimal by multiple categories of participants, and specific causes were identified for each. These areas included: Integration of guidelines into clinical practice, use of spirometry, individualisation of asthma devices to patient needs, emphasis on patient adherence and self-management, and clarity regarding roles and responsibilities of different members of the asthma healthcare team. Common causes for gaps in all these areas included suboptimal knowledge amongst healthcare providers, differing perceptions on the importance of certain interventions, and inadequate communication between healthcare providers. CONCLUSIONS: This study provides a better understanding of the specific causes underlying common gaps and challenges in asthma care in Canada. This information can inform future continuing medical education, and help providers in community settings obtain access to adequate materials, resources, and training to support optimal care of adult patients with asthma.

Identifying the educational needs of physicians in pediatric epilepsy in order to improve care: results from a needs assessment in Germany, Spain, and the United States.

The objective of this study was to gather evidence-based data on the educational needs of neuropediatricians. A needs assessment was conducted to identify the clinical challenges of physicians when diagnosing, medically treating, and managing pediatric patients with epilepsy; which could be addressed through educational interventions. A two-phase mixed-methods approach was used to conduct the needs assessment in Germany, Spain, and the US. Phase 1 consisted of qualitative data collection through multiple sources: a literature review, semi-structured interviews with clinicians and nurses working in pediatric epilepsy, and interpretation and input from faculty experts. Qualitative data were coded (NVivo) and analyzed using a thematic analysis, and findings were then used to design the second phase. Phase 2 consisted of quantitative data collection through an online survey that aimed to validate the identified challenges and underlying causes using a larger sample than in Phase 1. Data from the survey were analyzed using frequency tabulations and chi-square tests (SPSS). A total of 267 participants were included in the study. Phase 1 included 88 participants (neurologists, pediatricians, neuropediatricians, and nurses). Phase 2 included 179 participants (neurologists, pediatricians, and neuropediatricians). The main areas of challenge which emerged from the triangulated data included: the integration of guidelines into practice, identification of epilepsy and epilepsy events, integration of genetic testing into practice, integration of non-pharmacological treatments, transition from pediatric to adult care, and involvement and engagement with caregivers. Underlying causes of these challenges are reported, along with supporting qualitative findings. This study identified the educational needs of physicians working in pediatric epilepsy in Germany, Spain and the USA. Increasingly, educational interventions are required to be evidence-based. The results of this study could be used to design such interventions to support neuropediatricians who wish to specialize in pediatric epileptology, in order to manage the identified challenges.

Major knowledge gaps and system barriers to guideline implementation among European physicians treating patients with atrial fibrillation: a European Society of Cardiology international educational needs assessment.

Aims: Guideline-adherent treatment is associated with improved prognosis in atrial fibrillation (AF) patients but is insufficiently implemented in clinical practice. The European Society of Cardiology (ESC) performed a multinational educational needs assessment study among cardiologists, general practitioners/family physicians (GPs/FPs), and neurologists in order to evaluate knowledge and skills of physicians and system factors related to AF care delivery. Methods and results: A total of 561 physicians (294 cardiologists, 131 neurologists, and 136 GPs/FPs) from six European countries participated. This mixed-methods study included exploratory semi-structured qualitative interviews (n = 30) and a quantitative survey that included two clinical cases (n = 531). We identified eight key knowledge gaps and system barriers across all domains of AF care. A majority across all specialties reported skills needing improvement to classify AF pathophysiologically, rather than based on duration of episodes, and reported lack of availability of long-term electrocardiogram recording. Skills interpreting the CHA2DS2-VASc and the HAS-BLED scores were reported as needing improvement by the majority of neurologists (52% and 60%, respectively) and GPs/FPs (65% and 74%). Cardiologists calculated the CHA2DS2-VASc and HAS-BLED scores in 94%/70% in a presented case patient, but only 60%/49% of neurologists and 58%/42% of GPs/FPs did. There was much uncertainty on how to deal with anticoagulant therapy in complex patients. There was also a high disparity in using rate or rhythm control strategies, and indications for ablation. Information delivery to patients and communication between different specialties was often considered suboptimal, while national regulations and restrictions often hamper international guideline implementation. Conclusion: We identified major gaps in physicians' knowledge and skills across all domains of AF care, as well as system factors hampering guideline-compliant care implementation and communication. These gaps should be addressed by targeted educational and advocacy efforts.

Challenges That Hinder the Translation of Clinical Advances Into Practice: Results From an International Assessment in Colorectal Cancer.

BACKGROUND: Over the past decade, individualization of treatment for colorectal cancer (CRC) has been improved by: (1) approval of several new agents by national agencies such as the US Food and Drug Administration (FDA); and (2) rapid advances in mutation analysis. However, data are sparse on the clinical challenges experienced by oncologists as they address the increased complexity created by the growing potential for individualization of CRC treatment. MATERIALS AND METHODS: To identify clinical challenges experienced by oncologists regarding CRC treatment, an international assessment was conducted. A mixed methods approach was used, with the collection and analysis of qualitative (semistructured telephone interviews) and quantitative (online survey) data. Participants were oncologists actively practicing in 1 of 7 targeted countries with a minimum caseload of 10 CRC patients per year. RESULTS: The sample included 358 oncologists from China (n = 68), France (n = 44), Germany (n = 44), Italy (n = 45), Spain (n = 44), the United Kingdom (n = 45), and the United States (n = 68). Mixed methods findings indicated that oncologists' treatment selection is hindered by practice challenges in: (1) mutation analysis and subsequent adaptation of treatment; (2) optimal sequential use of treatment choices; (3) treatment individualization based on patient and tumor profile; (4) management of side effects and toxicities; (5) chemoresistance, cross-resistance, and combinations to overcome resistance; and (6) access to new emerging treatments. CONCLUSION: In the context of increased complexity created by the approval of new agents and advances in mutation analysis, challenges are experienced by practicing oncologists in the individualization of treatment for CRC patients. Details of these challenges should stimulate dialogue among oncologists, and development of interventions to improve clinical practice.

Perspective: delivering effective and engaging continuing medical education on physicians' disruptive behavior.

Education about physicians' disruptive behavior is relevant for practicing physicians, who must demonstrate competence in professionalism for maintenance of certification. In addition, physicians need to know about newer regulatory standards that define disruptive behavior and mandated processes for dealing with such behavior, as health care organizations are now charged with having formal policies addressing this issue. There is a growing literature about dealing with disruptive behavior, but it has not addressed education, including continuing medical education (CME), aimed at reducing or preventing disruptive behavior. The authors suggest specific strategies for such CME educational programs, including knowing the audience before the presentation, avoiding potential pitfalls, defusing defensiveness, and increasing audience "buy-in." They present two viewpoints from which to approach the topic of disruptive behavior, depending on the audience: "rekindling of values" and "risk reduction." The authors also recommend interactive teaching methods designed to maximize audience participation and foster self-awareness and reflection.

Atrial fibrillation care: challenges in clinical practice and educational needs assessment.

BACKGROUND: Current debates around the choice of management strategy for patients with atrial fibrillation (AF) combined with limited efficacy and frequent adverse effects of current pharmacotherapies cause uncertainty and confusion, challenging optimal care delivery to AF patients. OBJECTIVES: To determine gaps in knowledge, skill, and competencies of Canadian physicians caring for patients with AF as well as underlying causes of these gaps. METHODS: A mixed-method approach --consisting of qualitative (semistructured interviews) and quantitative data collection techniques (online survey) --was conducted. Findings were triangulated to ensure the reliability and trustworthiness of findings. The combined sample (n = 161) included 43 family physicians/general practitioners, 23 internal medicine specialists, 48 cardiologists, 28 emergency physicians, 14 neurologists, and 5 patients. RESULTS: Gaps and barriers impeding optimal care were related to an unclear definition of AF, uncertainty of its pathophysiology, and knowledge gaps across the care continuum, including screening, diagnosis, and treatment. Clinical decision-making, individualized patient therapy, communication with patients and between professionals, and application of guidelines were found to be particularly challenging. These issues are discussed in the context of the newly revised Canadian Cardiovascular Society (CCS) AF Guidelines. CONCLUSIONS: Educational gaps exist across the entire continuum of care. Results from this study, along with the 2011 CCS guidelines for AF management, provide direction for solutions through physician education and professional development.

Community group practices in Canada: are they ready to reform their practice?

INTRODUCTION: Governments and healthcare organizations in Canada are reforming the clinical practice structures and policies to deliver primary care to the population. A key component of primary healthcare reform is the establishment of an interdisciplinary, community-based team approach to patient care. This study was undertaken to provide in-depth insight regarding primary healthcare providers' beliefs and attitudes in regard to their current group practice, what changes they believe are occurring and those necessary to reform group practice settings, their willingness to embrace changes, and the challenges they face to realize the proposed reform. METHODS: This study employed a mixed-method research design (qualitative and quantitative data collection techniques) through day-long focus groups of primary healthcare professionals (eg, family physicians, specialists, dieticians, psychologists) from across Canada. RESULTS: There is considerable variation in the composition of primary care group practices across Canada. Respondents report that group practices are little more than an economic convenience to facilitate sharing of resources. Even when a practice is composed of several disciplines, there is little to no organized or systematic interaction among healthcare professionals aimed at improving patient care, lack of clarity as to identified leaders/managers of the team, and inconsistencies in the model of care provided to patients. However, there is a perception of value and benefit in working in a cohesive group practice to improve patient care. DISCUSSION: Findings revealed that although healthcare providers report themselves ready to make the necessary changes and willing to move to interdisciplinary team-based practices, there are substantive challenges that impede a movement to truly effective interdisciplinary team practice and functioning. These challenges include the type and allocation of funding, interprofessional healthcare provider education, changing the healthcare provision model, and barriers among healthcare professionals regarding shared and equitable team accountability for patient health outcomes.

Issues and challenges in the assessment, diagnosis and treatment of cardiovascular risk factors: assessing the needs of cardiologists.

BACKGROUND: This needs assessment, initiated by the Academy for Healthcare Education Inc. in cooperation with AXDEV Group Inc., explored the knowledge, attitudes, behavior, and skills of community-based and academic-affiliated U.S. cardiologists in the area of CV risk assessment, treatment, and management from July 2006 to December 2006. METHODS: The needs assessment used a multistage, mixed-method approach to collect, analyze, and verify data from two independent sources. The exploratory phase collected data from a representative sampling of U.S. cardiologists by means of qualitative panel meetings, one-on-one interviews, and quantitative questionnaires. In the validation phase, 150 cardiologists from across the United States completed a quantitative online questionnaire. Data were analyzed with standardized statistical methods. RESULTS: The needs assessment found that cardiologists have areas of weakness pertaining to their interpersonal skills, which may influence patient-physician communication and patient adherence. Cardiologists appeared to have little familiarity with or lend little credence to the concept of relative CV risk. In daily clinical practice, they faced challenges with regard to optimal patient outcome in areas of patient referral from primary-care providers, CV risk assessment and treatment, and patient monitoring. Community-based and academic-affiliated cardiologists appeared to be only moderately interested in educational interventions that pertain to CV risk-reduction strategies. CONCLUSION: Educational interventions that target cardiologists' interpersonal skills to enhance their efficacy may benefit community-based and academic-affiliated specialists. Other desirable educational initiatives should address gaps in the patient referral process, improve patient knowledge and understanding of their disease, and provide supportive educational tools and materials to enhance patient-physician communication.

Assessing the true learning needs of health care professionals in epilepsy care.

This needs assessment, initiated by the American Epilepsy Society (AES) in cooperation with AXDEV Group Inc. (AXDEV), used a mixed-method approach to explore the educational and clinical practice needs of health care professionals in epilepsy care and to identify significant barriers to caring for people with epilepsy. The multiphase assessment began with key informant interviews with AES educational leaders. In Phase II, 26 stakeholders, including epileptologists, neurologists, professionals in epilepsy care, and people with epilepsy, shared their experiences in epilepsy care during four focus groups at the AES annual meeting. In Phase III, a quantitative online survey based on Phase II results was distributed to 228 respondents, including epileptologists (n=84), neurologists (n=55), professionals in epilepsy care (n=69), and others (n=20). Results of the comprehensive analysis of Phase III quantitative data are presented here. They reveal the unmet needs of health care professionals in this therapeutic domain and are discussed in terms of their implications for epilepsy care.