Gregg Sherman, MD National Association for Continuing Education Family Practice Margate, Florida

Transcription

1 /26/11 National Association for Continuing Education Copyright 211 National Association for Continuing Education Requests for permission or further information should be addressed to: Outcome Study of Comparison of Stages A and C and Participants Evaluation of the Overall PI-CME Activity Harvey C. Parker, Ph.D. National Association for Continuing Education 786 Peters Road, Suite F-111 Plantation, FL hparker@naceonline.com (954) Report Date: October 12, 211 Activity Start and End Dates: August 1, 2 to July 31, 211 Supported by Eli Lilly Grant ID Collabora'ng Organiza'ons Course Directors, Planning Commi7ee, and Faculty NACE accredited provider, content development, analysis of self-assessment data DLC Solutions developed PI-CME platform CE Outcomes LLC developed chart audit questions and analysis of chart audit data Educational Measures archived self-assessment data online using EducationalTrak Canadian ADHD ADD Research Association (CADDRA) provided guidelines for diagnosis and treatment of adult ADHD and some assessment tools Children and Adults with Attention Deficit Hyperactivity Disorder (CHADD) provided patient education materials. (Results of this activity will be presented at 23 rd Annual CHADD Conference, Nov. 8-, 211, Orlando, Florida as poster and live symposium.) Course Directors and Planning Committee Members Harvey C. Parker, Ph.D., CCMEP Director of Continuing Education National Association for Continuing Education Plantation, FL Anne Teeter Ellison, Ed.D. Professor Emeritus University of Wisconsin Milwaukee, WI Gregg Sherman, MD National Association for Continuing Education Family Practice Margate, Florida Planning Committee Member Michelle Frisch, MPH, CCMEP National Association for Continuing Education Plantation, FL Faculty and Planning Committee Members Lenard A. Adler, MD Departments of Psychiatry and Child and Adolescent Psychiatry New York New York University School of Medicine Russell A. Barkley, Ph.D. Clinical Professor of Psychiatry Medical University of South Carolina Kevin Murphy, Ph.D. The Adult ADHD Clinic of Central Massachusetts Foxboro, MA Faculty (continued) J. Russell Ramsay, Ph.D. Associate Director, ADHD Treatment and Research Program, Assistant Professor of Psychology in Psychiatry University of Pennsylvania Anthony Rostain, M.D., M.A. Director of Education, Department of Psychiatry University of Pennsylvania Health System Richard L. Rubin, MD Director, The Vermont Clinical Study Center Adjunct Associate Adjunct Associate Professor Dartmouth Medical College Hanover, NH 1

2 /26/11 Accredita)on and Designa)on Statements The National Association for Continuing Education (NACE) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The National Association for Continuing Education designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity. Physicians will receive 5 AMA PRA Category 1 Credits for each completed stage and an additional 5 AMA PRA Category 1 Credits for completing all three stages in succession, for a maximum of 2 AMA PRA Category 1 Credits. Non-physicians will earn a certificate of completion. Please note that this activity is for participants seeking continuing medical education credit only. Statement of Need ADHD in adults is associated with increased health risks and increased healthcare costs, higher divorce rates, lower levels of socioeconomic attainment, lower academic achievement, unemployment and work place issues, increased risks for motor vehicle accidents, greater likelihood of other psychiatric disorders, and higher rates of substance use and abuse. Despite this being a disorder with serious impact on health and overall functioning, the vast majority of adult patients with ADHD remains undiagnosed and, therefore, untreated. 1, 2 This activity will enable participants to have a better understanding of the etiology of ADHD, characteristics of ADHD in adults, and appropriate assessment tools to collect meaningful data (interview protocols, rating scales, symptom checklists, etc) for the evaluation of ADHD and co-existing psychiatric conditions. Participants will become more aware of treatment guidelines, safety and efficacy of pharmacologic interventions, and benefits of psychosocial interventions such as cognitive-behavioral therapy, coaching, work/school accommodations, community resources and ADHD education that can help adults with ADHD. Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler O, Faraone SV, Greenhill LL, Howes MJ, Secnik K, Spencer T, Ustun TB, Walters EE, Zaslavsky AM. (26). The Prevalence and Correlates of Adult ADHD in the United States: Results from the National Comorbidity Survey Replication. Amer. Jour. of Psychiatry, 163: Barkley, R.A., Murphy, K.R., & Fischer, M. (28). ADHD in Adults: What the science says. Guilford Press, New York.. Target Audience and Instruc)onal Format Target Audience Primary care providers including physicians, physician assistants, and nurse practitioners. Instructional Format Performance Improvement Activity Stage A: Pre-assessment Stage Stage B: Action Stage Stage C: Post-Assessment Stage Start Date August 1, 2 End Date July 31, 211 Note: Registration for this activity was closed on July 31, 211, but the activity will remain open until December 31, 211 to allow time for registered participants to Complete Stage C and earn credit. Ac)vity Overview (1) Goal: NACE iden)fied gaps in primary care providers assessment and management of adults with ADHD and implemented a PI- CME ac)vity to improve the performance of providers to care for adult pa)ents with ADHD. Methods: Six key performance measures were iden)fied based on guidelines published by the Canadian ADD ADHD Research Associa)on for the management of adults with ADHD. At Stage A of the ac)vity, par)cipants rated their current use of these key measures and their confidence in applying them. They also completed five chart audits. Based on their self- assessment, par)cipants selected one or more Quality Improvement Plans to implement. At Stage B they were sent the NACE Adult ADHD Toolkit containing tools (scales, pa)ent educa)on materials, and webcasts and monographs) to improve their skills on each key performance measure. At Stage C they once again did a self- assessment and completed five more chart audits and evaluated their progress. Outcome Results: Two outcome studies were completed. This slide set, prepared by NACE, compares the self- assessments of par)cipants at Stages A and C on their u)liza)on of key performance measures, confidence in applying them, and overall evalua)on of the PI ac)vity. Another outcome study, prepared by CE Outcomes, compares chart audit data submised by par)cipants at Stages A and C. 2

3 /26/11 Stage A Pre-Assessment Stage B Action Stage Stage C Post-Assessment Ac)vity Overview (2) Participants evaluated existing practices in providing care to adults with ADHD by completing a self-assessment survey and answering chart-review questions. Participants selected one or more Quality Improvement Plans (QIP) to improve care to adults with ADHD. Participants implemented one or more of the QIP selected in Stage A by using the materials found in the NACE Adult ADHD Toolkit. Comprehensive educational and informational resources were provided at this stage with online and printed materials. Participants re-evaluated performance by again completing the self-assessment survey and answering chart-review questions on a second set of 5 patients. Feedback provided to participants explained the improvements that were made in caring for adults with ADHD. Levels of Outcomes 1. Participation 2. Satisfaction 3. Learning Moore s Levels of Outcomes 3A = Declarative knowledge 3B = Procedural knowledge 4. Competence 5. Performance 6. Patient health 7. Community Health Moore DE Jr, Green JS, Gallis HA. Achieving desired results and improved outcomes: integrating planning and assessment throughout learning activities. J Contin Educ Health Prof. 29 Winter;29(1):1-15. Summary of Findings (1) Level-5 Participants of the Activity reported that they made improvements in their practice across multiple key performance measures, including: Performing comprehensive interviews to assess ADHD history and symptoms. Using adult ADHD rating scales to assess symptom frequency and severity. Using interviews or rating scales to corroborate patient self-report and assess functional impairment. Initiating a pharmacologic treatment plan for adult ADHD patients. Recommending non-pharmacologic treatments and providing patient education for adult ADHD patients. Providing timely and consistent follow-up care. Summary of Findings (2) Participants reported that after completing the Adults with ADHD: Making Exam Room Decisions activity they felt more confident in the following key areas: Use of clinical assessment tools Identifying co-morbid conditions Selecting appropriate pharmacologic treatments Discussing both pharmacologic and non-pharmacologic treatments with patients Utilizing patient education materials in their practice Following up with patients to manage their ADHD symptoms 3

4 /26/11 Summary of Findings (3) Levels-2, 3, 4 and 5 Participants reported that the Adults with ADHD: Making Exam Room Decisions activity was effective in: Improving their knowledge of adult ADHD Explaining guidelines for management of adult ADHD Explaining the use of new strategies and tools to assess and treat ADHD in adults Helping them evaluate their practice behavior with respect to assessment and treatment of adults with ADHD Helping them create and implement quality improvement plans to improve assessment, treatment, and patient education in the area of adult ADHD Learning Objec)ves of this Ac)vity After completion of this activity, participants should be able to: 1. Evaluate their current practice behavior and confidence with respect to diagnosing and treating adults with ADHD 2. Describe existing guidelines and best practices in the diagnosis and treatment of ADHD in adults 3. Identify evidence-based and consensus-based tools to evaluate symptoms, level of impairment, and relevant history in adult patients suspected of having ADHD 4. Identify risks for co-morbidities in adult patients with ADHD with emphasis on anxiety disorders, mood disorders, and substance use/abuse disorders 5. Plan a pharmacologic treatment program for adults diagnosed with simple ADHD and more complex ADHD that is complicated by co-morbidities 6. Identify psychosocial treatments for adults diagnosed with ADHD 7. Discuss treatment follow-up to optimize success 8. Create an action plan that addresses their specific practice behavior that needs improvement with respect to the care of adults with ADHD # Registered 13 () # Registered But Not Enrolled Total* MD/DO NP PA RN Other 328 (24) 413 () 6 (35) 24 (2) 132 (9) # In Stage A # In Stage B # In Stage C # Completed All 3 Stages Level 1 Par)cipa)on* *There are currently an additional171 participants in the Action Stage Stage B or Stage C. During this time they have access to an online Adult ADHD Toolkit at: Quality Improvement Plans After completing Stage A of the activity, participants entered Stage B where they were required to choose from the following Quality Improvement Plans to initiate changes in their practice behavior with respect to managing adults with ADHD. Plan 1: Assessment of Adults with ADHD. This action plan focuses on the understanding of ADHD in adults and the use of ADHD assessment tools. Providers will have access to educational material that will enable them to conduct an efficient assessment of ADHD in adult patients in a primary care setting. See tools in this QIP to help you assess adults with ADHD. Plan 2: Treatment of Adults with ADHD. This action plan focuses on the understanding of ADHD in adults and providing pharmacotherapy and psychosocial interventions when appropriate in a primary care setting.see tools in this QIP to help you treat adults with ADHD. Plan 3: Patient Education about ADHD in Adults. This action plan focuses on patient education about ADHD in adults and provides patient educational materials that will help patients become more aware of what ADHD is, how it can affect them, and the steps they can take to improve the quality of their lives. See tools in this QIP that will help your patients learn more about ADHD. 4

5 NACE Outcome Study: Adults with /26/11 NACE Adult ADHD Toolkit to Implement QIPs hsp:/// QIPs Selected by Par)cipants Assessment Tools Treatment Tools Patient Education Materials 58 Plan 1 Plan 2 Plan 3 Toolkit was sent to all participants who reached the end of Stage A. 2 Par)cipants who chose 1 or more Of the par)cipants who chose Of the par)cipants who chose Of the par)cipants who chose of the QIP Plans to implement Plan 1 they also chose Plan 2 or 3 Plan 2 they also chose Plan 1 or 3 Plan 3 they also chose Plan 1 or 2 Results: Performance Measure # 1 Levels- 4 and 5 In doing an assessment of ADHD in adults, do you conduct an interview that reviews the patient's current complaints, history, domains of impairment, and other relevant areas of ADHD diagnostic criteria, as well as the most common comorbid disorders likely to be present with ADHD? Results: Performance Measure # 2 Levels- 4 and 5 Do you include rating scales such as the Conner's Adult Rating Scale, Quick-Check for Adult ADHD Diagnosis, ADHD-RS, or an ADHD symptom checklist of some type to assess the presence and frequency of core ADHD symptoms (inattention, hyperactivity, impulsivity) in adults? 6 P Value: <.1 - Significant 9 P Value: <.1 - Significant Stage A Stage C Always Usually Some)mes Rarely Never Always Usually Some)mes Rarely Never Stage A Stage C

6 /26/11 Levels- 4 and 5 Results: Performance Measure # 3 Do you gather corroborating evidence to determine symptom presence and functional impairment (e.g., interview significant individuals with knowledge of the adults' problems, observer report version of rating scale, review of school, medical, employment, criminal, mental health, and driving records)? P Value: <.1 - Significant Levels- 4 and 5 Results: Performance Measure # 4 When indicated, do you develop a pharmacologic treatment plan that includes FDA approved medications indicated to treat adults with ADHD? P Value: <.1 - Significant Always Usually Some)mes Rarely Never Stage A Stage C Always Usually Some)mes Rarely Never Stage A Stage C Levels- 4 and 5 Results: Performance Measure # 5 When indicated, do you recommend or provide psychosocial interventions such as patient education about ADHD, cognitive behavior therapy, activities to address executive function deficits such as poor working memory and time management, academic accommodations, workplace accommodations, and other coping strategies? P Value: <.1 - Significant Always Usually Some)mes Rarely Never Stage A Stage C Do you provide frequent follow-up contacts that allow sufficient time to monitor the patient's clinical status, environmental conditions, and, if appropriate, medication side effects to adjust the pharmacologic treatment plan? Levels- 4 and 5 Performance Measure # P Value: <.1 - Significant Always Usually Some)mes Rarely Never Stage A Stage C

7 /26/11 Confidence in Iden)fying Risk Factors How confident are you in your ability to identify risk factors for ADHD in your adult patients? Confidence in Discussing ADHD Medica)on Op)ons with Pa)ents How confident are you in your ability to discuss appropriate ADHD medication options with your adult ADHD patients? 6 P Value: <.1 - Significant P Value: <.1 - Significant Stage A Stage C Stage A Stage C Confidence in Taking a Relevant History for ADHD How confident are you in your ability to take a patient history that will identify the essential components of an ADHD? P Value: <.1 - Significant Stage A Stage C Confidence in Using Clinical Assessment Tools (Ra)ng Scales, etc) How confident are you in your ability to employ clinical assessment tools (e.g., ADHD symptom checklists, structured diagnostic interview, etc.) in the diagnosis of ADHD in your adult patients? P Value: <.1 - Significant Stage A Stage C

8 /26/11 Confidence in Iden)fying Co- morbid Psychiatric Disorders How confident are you in your ability to identify co-morbid psychiatric disorders (e.g., depression, anxiety, substance use/abuse disorders) in your adult patients presenting with symptoms of ADHD? Confidence in Selec)ng Appropriate Pharmacotherapy to Treat Adult ADHD How confident are you in your ability to select the appropriate pharmacotherapy for treating ADHD, taking into account your patient's overall health status? 7 P Value: <.1 - Significant P Value: <.1 - Significant Stage A Stage C Stage A Stage C How confident are you in your ability to determine when psychosocial interventions such as cognitive behavioral therapy (CBT) or workplace or academic accommodations are indicated as a part of an ADHD treatment plan for your patients? Confidence in Recommending Psychosocial Interven)ons P Value: <.1 - Significant Level- 2 Effec)veness of This Ac)vity in Enhancing Confidence to Care for Adults with ADHD Overall, to what degree was this activity effective in enhancing your confidence in caring for adult patients with ADHD? Stage A Stage C Stage C

9 /26/11 Levels 2 and 3- Effec)veness of This Ac)vity in Improving Knowledge of Adult ADHD Overall, to what degree was this activity effective in improving your knowledge in the content areas presented? Level 3- To What Degree Did Par)cipants Learn New Strategies for Assessment and Treatment As a result of this overall activity, to what degree did you learn new strategies for assessing and treating adults with ADHD? Stage C Stage C Level 5- Likelihood of Implemen)ng New Strategies Learned Into Prac)ce As a result of this activity, how likely are you to implement these new strategies in your practice? Level 2- To What Degree Did Par)cipants Believe the Content was Presented in Fair and Balanced Manner and Free of Commercial Bias Overall, to what degree do you believe that the subject matter was presented fairly, balanced, and free of commercial bias? N = Stage C N = Stage C

10 /26/11 Levels 2, 3 and 4- To What Extent Did Par)cipa)on Enable The Par)cipants to Evaluate Current Prac)ce Behavior with Respect to Adults with ADHD To what extent did your participation in the entire ADHD in Adults Performance Improvement Activity (Stages A, B, and C together) enable you to evaluate your current practice behavior and confidence with respect to diagnosing and treating adults with ADHD in your practice. 6 Levels 2, 3 and 4- To What Extent Did Par)cipa)on Enable Par)cipants to Describe Exis)ng Guidelines To what extent did your participation in the entire ADHD in Adults Performance Improvement Activity (Stages A, B, and C together) enable you to describe existing guidelines and best practices in the diagnosis and treatment of ADHD in adults N = Stage C Stage C Levels 2, 3, and 4- To What Extent Did Par)cipa)on Enable Par)cipants to Iden)fy Tools to Evaluate Adults with ADHD To what extent did your participation in the entire ADHD in Adults Performance Improvement Activity (Stages A, B, and C together) enable you to identify evidence-based and consensus-based tools to evaluate symptoms, level of impairment, and relevant history in adult patients suspected of having ADHD. 6 Levels 2,3, and 4- To What Extent Did Par)cipa)on Enable Par)cipants to Iden)fy Risks for Co- morbidi)es in Adults with ADHD To what extent did your participation in the entire ADHD in Adults Performance Improvement Activity (Stages A, B, and C together) enable you to identify risks for co-morbidities in adult patients with ADHD with emphasis on anxiety disorders, mood disorders, and substance use/abuse 6 disorders Stage C Stage C

11 /26/11 Levels 2, 3 and 4- To What Extent Did Par)cipa)on Enable Par)cipants to Plan a Pharmacologic Treatment Program To what extent did your participation in the entire ADHD in Adults Performance Improvement Activity (Stages A, B, and C together) enable you to plan a pharmacologic treatment program for adults diagnosed with simple ADHD and more complex ADHD that is complicated by comorbidities. 6 Levels 2 and 3- To What Extent Did Par)cipa)on Enable Par)cipants to Iden)fy Psychosocial Treatments for Adult ADHD To what extent did your participation in the entire ADHD in Adults Performance Improvement Activity (Stages A, B, and C together) enable you to identify psychosocial treatments for adults diagnosed with ADHD Stage C Stage C To what extent did your participation in the entire ADHD in Adults Performance Improvement Activity (Stages A, B, and C together) enable you to discuss treatment follow-up to optimize success for adults with ADHD Levels 2, 3 and 4- To What Extent Did Par)cipa)on Enable Par)cipants To Discuss Follow- Up Treatment Levels 2, 3 and 4- To What Extent Did Your Par)cipa)on Enable Par)cipants to Create an Ac)on Plan To Improve Your Prac)ce Behavior with Respect to Adult ADHD To what extent did your participation in the entire ADHD in Adults Performance Improvement Activity (Stages A, B, and C together) enable you ate an action plan that addresses your specific practice behavior that needs improvement with respect to the care of adults with ADHD Stage C Stage C

12 /26/11 Level 2- Comments from Par)cipants (1) Level 2- Comments from Par)cipants (2) Please share any additional comments about the program that you may have. A great CME! Would like to see more of this. Too lengthy. Good source of CME. Provided good tools for diagnosis and treatment. I am pleased with the patient education and screening resources it provided. I really appreciate the tool kit that was mailed to me. Simply enhanced my knowledge of ADHD and surely felt very comfortable to treat patients. Excellent, comprehensive program. ADHD interests me because I have it myself and so does my son. I didn t like entering my own charts. I would rather have case-based learning. Amazing. I am the only provider in a small clinic for the US navy as a fnp I did have some knowledge but I gained 2 patients that I was never able to assess so looking now at all the adults I have started doing a tool kit ADHD checklist and putting it in there allowed me to review my assessment skills. Con)nued I have found that younger adults are doing better on longer acting medicines to treat ADHD whereas older adults seem to fare better on shorter acting agents. Thought it was very good. Helped me learn and better manage ADHD patients. The information presented will be applied in my practice to more effectively manage my patients with adult ADHD It was a very informative and focused materials in regard to ADHD. Excellent program, broaden my knowledge of ADHD I thought the information was very helpful in both the diagnosis and treatment of adult ADHD pts. This was a good program. the supplemental material was helpful Excellent presentation of this subject, I plan to implement strategies & recommendations into my practice. I found this program to be very helpful in clarifying, and gaining appropriate knowledge needed to effectively treat and assess these patients. Level 2- Comments from Par)cipants (3) Level 2- Comments from Par)cipants (4) Con)nued It made me pay more attention to how I was treating my patients and how I was or was not offering them guidance and offering them outside help. It would have been great if there would have been more information evaluating the different pharmacological therapies for the treatment of ADHD - including a comparison of each side-by-side, dosing/titration recommendations, and how to incorporate other non-fda approved medications into the therapeutic regimen. The toolkit patient education handouts were especially helpful in enhancing the pharmacological treatment so it feels that patients are being treated more holistically and gives patients a greater sense of the importance that its not just meds only thereby increasing their sense of empowerment I am developing a treatment plan for our behavioral clinic based on this plan. I did not need over 45 days to be able to re-start the program once more. I feel everyone is at different level. I enjoyed participating in this CME. Con)nued Being able to exam my own practice was very helpful and insightful. Thank you. Very complete and informative. Appreciate the "toolkit" Use it regularly to educate pts and myself. will share the webcasts w/ colleagues. Thanks Great supplemental info I appreciate this program which helped me become more confident in treating the adult with ADD. Thanks for the program and it really helped my patients. Good program with good infromation. I appreciated the packet recieved in the mail. Good program. Liked all the CMEs it offered and handouts that were received. I enjoyed the personal application of this CME. It was great to apply the process to my own case studies. I found this program to be very helpful in clarifying, and gaining appropriate knowledge needed to effectively treat and assess these patients. 12

13 NACE Outcome Study: Adults with Level 2- /26/11 Comments from Par)cipants (5) Level 2- Con)nued Con)nued I really liked this program. enjoyed it.. it will help me greatly in my assessment & treatment of adhd individuals. Well organized, easy to complete program flowed nicely, Liked the reminders. Very informative overview. Excellent presentation of this subject, I plan to implement strategies & recommendations into my practice. I hope you can address children as well Very good format. Enhance my knowlege in the treatment of adult with ADHD. This was a good program. the supplemental material was helpful. I thought the information was very helpful in both the diagnosis and treatment of adult AHDH pts. Could use more information on how to handle patients that are reluctant to use medications for their ADHD. Comments from Par)cipants (6) This was a good program and it was nice to actually implement within my practice. Excellent program. Excellent program, broaden my knowledge of ADHD. Too repetitive Good program, would recommend to others. liked the med sheet that came with the packet in the mail along with scales and patient education materials. It was a very informative and focused materials in regard to ADHD. More information on CBT and non medication interventions. I have found that younger adults are doing better on longer acting medicines to treat ADHD whereas older adults seem to fare better on shorter acting agents. I did not like the format of this activity, and it really taught very little. Needs total overhaul!!! Excellent Comparison of This PI Ac)vity to Others Par)cipants Have Taken Level 2- If you have participated in other PI CME programs besides this one, how did this program compare? This program rates as an A++. More interesting Superior Very direct and informative. Above average This was the first and I enjoyed it and learned a lot This is my first one. I am favorably impressed Lengthy, but helpful This program was more effective because it made me apply the information directly to my patients, rather than a case study, which reinforced my confidence in carrying out the treatment plan. I have never done anything like this just at a conference loved this one it gave me step by step ways to ensure I have met or exceeded the diagnostic standards. This was first ADHD CME course I participated in. 13