The Emerging Role of Reinforcement in the Clinician's Path from Continuing Education to Practice.

INTRODUCTION: Continuing education (CE) activities may affect clinicians' knowledge, skills, self-efficacy, and/or performance. Studies have suggested that self-efficacy may moderate or mediate the relationship between knowledge/competence and performance. Some results have shown that increases in knowledge/competence contributed to increases in self-efficacy. However, clinicians do not always learn something "new" when they participate in CE activities; rather, their knowledge or skills may be reinforced. This study examined whether self-efficacy was greater when clinicians reinforced what they already knew compared with when they learned something new. METHODS: Hierarchical linear modeling was conducted to examine the moderating role of status of knowledge/competence post-CE (reinforced/improved) in the relationship between post-CE knowledge/competence score and self-efficacy across 153 online continuing medical education- and/or CE-certified activities. RESULTS: The hierarchical linear modeling showed that learners with higher post-CE scores have higher post-self-efficacy ratings. Reinforced learners had higher post-CE-self-efficacy ratings than improved learners, controlling for post-CE score. DISCUSSION: This study contributes to an expanded understanding of the path from CE to practice. There was benefit to self-efficacy for learners who reinforced but did not improve their knowledge/competence. This study also suggests that pre-post questions can be considered part of the learning process.

The Impact of Web-Based Continuing Medical Education Using Patient Simulation on Real-World Treatment Selection in Type 2 Diabetes: Retrospective Case-Control Analysis.

BACKGROUND: Despite guidelines recommending the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in certain patients with type 2 diabetes (T2D), they are not being prescribed for many of these patients. Web-based continuing medical education (CME) patient simulations have been used to identify clinicians' practice gaps and improve clinical decision-making as measured within a simulation, but the impact of this format on real-world treatment has not been researched. OBJECTIVE: This study aimed to evaluate the effect of a simulation-based CME intervention on real-world use of GLP-1 RAs by endocrinologists and primary care physicians. METHODS: Two evaluation phases of the CME simulation were conducted: phase I, the CME simulation phase, was a paired, pre-post study of 435 physician learners in the United States; and phase II, the real-world phase, was a retrospective, matched case-control study of 157 of the 435 physicians who had claims data available for the study period. RESULTS: Phase I CME results showed a 29 percentage point increase in correct decisions from pre- to postfeedback (178/435, 40.9% to 304/435, 69.9%; P<.001) in selecting treatment that addresses both glycemic control and cardiovascular event protection. Phase II results showed that 39 of 157 (24.8%) physicians in the intervention group increased use of GLP-1 RAs, compared to 20 of 157 (12.7%) in the comparison group. Being in the intervention group predicted GLP-1 RA use after education (odds ratio 4.49; 95% CI 1.45-13.97; P=.001). CONCLUSIONS: A web-based CME simulation focused on secondary prevention of cardiovascular events in a patient with T2D was associated with increased use of evidence-based treatment selection in the real world.

Net Promoter Score (NPS): What Does Net Promoter Score Offer in the Evaluation of Continuing Medical Education?

Net promoter Score (NPS) has been used in many fields, such as software, clinical care, and websites, as a measure of customer satisfaction since 2003. With a single question, NPS methodology is thought to determine brand loyalty and intent to act based on experiences with the brand or product. In the current study, accredited continuing medical education or continuing education (CME/CE) was the product. Providers of CME have utilised NPS rating (the individual score on a scale of 0 to 10) to collect data about the value of the experience a clinician has with CME activities, but there has been no research to examine what it actually is associated with. This study looked to understand - relative to other self-reported and assessment outcomes in CME, what does NPS at the activity level indicate? From 155 online CME programmes (29,696 target audience learners with complete data), potential outcomes of CME, including whether knowledge or competence improved via assessment score, mean post-confidence rating, and whether one intended practices changes and was committed to those changes, were examined as predictors of NPS. NPS is unique in that it cannot be calculated at the individual level; individual scores must be aggregated, and then the percentage who selected ratings of 0 to 5 is subtracted from the percentage who selected 9 or 10. Results showed that percentage of learners who are committed to change predicts 70% of the variance in NPS, which suggests NPS is a valid indicator of intention to act. These results have implications for how we might, as a field, incorporate the utilisation of a single standardised question to examine the potential impact of online CME and call for additional research on whether NPS predicts change in clinical practice.

Knowledge of chronic intestinal failure among US gastroenterologists: Cause for concern and learning opportunity.

BACKGROUND: Chronic intestinal failure (CIF) is an ultrarare disease, with an estimated national prevalence of ∼25,000 cases. There is a suspicion of widespread lack of expertise in CIF care, but no formal assessment tool or data exist. We developed and validated a knowledge test in CIF and now report our preliminary results from testing CIF knowledge in a cohort of US gastroenterologists. METHOD: We developed a 20-question knowledge test in CIF, covering four key components of IF. After internal testing, refinement, and revision, we administered the test to a convenience sample of experts and nonexperts in IF. We then deployed the validated test to a cohort of 100 US gastroenterologists. RESULTS: The test had a Cronbach alpha of 0.74, suggesting a reliable test, with a threshold score to discriminate experts and nonexperts of 13.4 (maximum 20) and with a sensitivity of 81.3% and specificity of 86.4%. The overall mean score of 8.2 for the 100 US gastroenterologists was at the level of nonexperts in our convenience sample. CONCLUSION: The preliminary results of our validated knowledge test in IF among a broad group of US gastroenterologists demonstrate lack of knowledge in IF.

Improving Appropriate Use of Omega-3 Fatty Acids for Patients With Dyslipidemia: Effect of Online CME.

Hypertriglyceridemia is associated with an increased risk of atherosclerotic cardiovascular (CV) disease. Clinical trials have demonstrated the effectiveness of eicosapentaenoic acid ethyl ester (EPA), an omega-3 polyunsaturated fatty acid, on triglyceride lowering and on CV risk reduction. However, many clinicians have limited understanding of the effects of EPA and limited experience using EPA to reduce the risk of CV disease. An analysis was conducted to determine whether an online continuing medical education (CME) intervention could improve knowledge and competence of primary care physicians (PCPs) and cardiologists related to the role of EPA in management of CV risk in patients with dyslipidemia. The intervention comprised 2 online video-based CME activities. The effects of education were assessed for learners who completed 4 pre- and postassessment questions for each activity, using a matched pre-/postassessment design. For all questions combined, a McNemar's χ2 test assessed differences from pre- to postassessment. Matched-learner data indicated that 34% of PCPs improved their knowledge as a result of participating in the activities, and 42% had their knowledge reinforced. Among cardiologists, 28% improved their knowledge, and 61% had their knowledge reinforced. For these learner subsets, there was a significant 17% relative increase in self-assessed confidence in appropriate use of EPA for PCPs (n = 1644, P < 0.001) and a 12% increase for cardiologists (n = 524; P < 0.001). The improvements observed in this online CME intervention demonstrate the benefits of educating the appropriate target audience base and suggest that this type of intervention can translate into improvements in clinical care.

What Do Reinforcement and Confidence Have to Do with It? A Systematic Pathway Analysis of Knowledge, Competence, Confidence, and Intention to Change.

The outcomes model most applied in continuing education for the health professions evaluation is Moore and colleagues' conceptual framework. Examination of how the levels interact and the role of confidence and intention to change can help outcomes professionals understand better how to impact clinician practice and conductand report outcomes studies. The current study examined the relationships among knowledge and competence change, confidence change, and intention to change across 57 online oncology certified education programmes published from 2018 to 2020 on Medscape.org. Findings indicate that not only improvement in knowledge and competence but also reinforcement of knowledge and competence are significant predictors of changes in confidence. They also indicate that knowledge and competence influence intention to change through confidence.

Virtual Patient Simulation in Continuing Education: Improving the Use of Guideline-Directed Care in Venous Thromboembolism Treatment.

Results of a CME-certified activity completed by a total of 986 cardiologists and 783 haematologists-oncologists (haem-oncs) from around the world were examined to determine whether virtual patient simulation could improve decision-making and performance within the simulation related to patient evaluation, tailoring anticoagulant therapy, and patient management to improve adherence using patient-centred care strategies. Results showed a significant overall impact of education from pre- to post-clinical guidance (CG) on correct decisions made in both cases for cardiologists, with a relative improvement of 22% for Case 1 (45% pre- to 55% post-CG, n = 475, t(474) = 14.12, P<.001, Cohen's d =.46) and 19% for Case 2 (62% pre- to 74% post-CG, n = 245, t(244) = 11.95, P<.001, Cohen's d =.59). Impact also was seen for haem-oncs, with a relative improvement of 27% for Case 1 (45% pre- to 57% post-CG, n = 280, t(279) = 11.91, P <.001, Cohen's d =.60) and 19% for Case 2 (63% pre- to 75% post-CG, n = 147, t(146) = 9.52, P <.001, Cohen's d =.58). Virtual patient simulation improved cardiologists' and haem-oncs management of patients with pulmonary embolism in a simulated environment.