Case-Compare Impact Report October 8, 20 For CME Activity: Developed through an independent educational grant from Genentech: Moderate to Severe Persistent Asthma: A Case-Based Panel Discussion (March 4, 20) Available at: Summary http://www.medscape.org/viewarticle/746367 Launched online: 07/27/20 Available for credit through: 07/27/202 Healthcare Provider Performance Gaps: Medscape, LLC identified an educational need and a clinical performance gap in the area of assessment and management of asthma and submitted a proposal for the development of a CME activity and metrics reporting. This activity was supported by an independent educational grant from Genentech. Education Delivered: The CME activity was developed for pulmonologists who treat patients with severe asthma. National Jewish Health designated this educational activity for a maximum of 0.5 AMA PRA Category credit(s) TM. Educational Metrics Results: Pulmonologist participants showed improvement ranging from 30-64 percentage points in practice choices related to the initial assessment and long-term management of patients with severe asthma. Further education is recommended in the areas of disease severity assessment, follow-up, and long-term management. Table of Contents Executive Summary...2 Background Method Main Findings Conclusions Faculty Insights and Recommendations...2 Study Design...3 Metrics Results: Participant Response Data Analysis...4 Qualitative Participant Feedback... 8 Summary of Findings...8 Recommendations...8 Addendum : Data Tables...9 Addendum 2: References for Evidence-Based Activity...3
Executive Summary Background With the goal of improving patient care, Medscape, LLC and National Jewish Health identified performance gaps among pulmonologists in adherence to current National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3 (EPR- 3) Guidelines for the Diagnosis and Management of Asthma, which contributes to substantial variation in asthma outcomes. An independent educational grant was awarded to Medscape, LLC and National Jewish Health by Genentech to develop a CME activity and to report metrics on the effects of education. Main Target Audience Pulmonologists Other Target Audiences Allergists, primary care physicians, and all other healthcare professionals who help care for patients with asthma. Method An Internet-based CME activity posted on Medscape was developed for the target audience using a patient case example: a 48-year-old man with severe persistent asthma. It was modeled on the interactive grand rounds approach of testing participant knowledge first and then providing answers and explanations. The success of education was assessed by comparing intra-activity question responses with post-assessment question responses to demonstrate measurable improvements in a patient care scenario. Main Findings For pulmonologists who participated in the CME activity, responses to patient case-based questions demonstrated improvements directly related to the educational learning objectives. Faculty Course Director Rohit Katial, MD Professor of Medicine National Jewish Health and University of Colorado Denver Program Director of Allergy & Immunology Director of Weinberg Clinical Research Unit Director of Allergy & Immunology Clinical Services National Jewish Heath Denver, Colorado Rohit Katial, MD, reviewed the analysis of the metrics within this report. Improvement was shown by: 64% improvement in appropriate assessment of a patient s asthma severity 45% increase in appropriate selection of a patient s initial treatment regimen 30% increase in understanding the role of a follow-up visit after a change in a patient s treatment regimen Conclusions Improved quality of patient care by the pulmonologists who completed the CME activity demonstrates success of education. Improvement was seen in the areas of initial assessment and long-term management of patients with severe asthma. Pulmonologists continue to need additional education in the initial assessment, treatment, and long-term management of patients with asthma. October 8, 20 PAGE 2
Study Design Intent Medscape, LLC and National Jewish Health developed the CME activity with expert faculty Rohit Katial, MD, as an Internet-based test-and-teach activity modeled on the interactive grand rounds approach. The activity content addresses healthcare provider performance gaps identified in the needs assessment to meet the educational learning objectives listed to the right. Patient Case Introduction A 48-year-old man who has shortness of breath, wheezing, and chest tightness for several months presents to the clinic. His medical history is notable for gastroesophageal reflux disease, rhinitis, and anxiety. In addition, he had required prednisone bursts in the past year. Analysis Metrics results of participant responses for all intra-activity questions are reported. Paired comparison of intra-activity questions with corresponding post-assessment questions shows the effect of education for 3 questions, noted below. INTRA-ACTIVITY QUESTION 2 3 4 5 CORRESPONDING POST-TEST QUESTION 2 3 - - CORRESPONDING LEARNING OBJECTIVE 2 2, 3, 3 2, 3 Learning Objectives Upon completion of this activity, participants will be able to: 2 3 Identify patients who have moderate-to-severe persistent asthma and determine the need for step-up therapy Implement a step-up approach to therapy for patients with uncontrolled asthma based on NAEPP EPR-3 guideline recommendations Outline communication strategies for optimal referral and co-management of patients with severe asthma between primary care providers and specialists October 8, 20 PAGE 3
Metrics Results: Participant Response Data Analysis Analysis of target pulmonologist learner responses* to interactive questions are represented, including insight on clinical relevance of the findings to patient care. Complete data for the main target audience and other target audiences are available in Addendum 2. Activity participants not within the main target audience are not represented in the findings of this study. Note that correct answer choices are highlighted in yellow and that percentages have been rounded to the nearest whole number. *Number of learner responses varies by question and is included below the data for each question. How would you characterize the severity of this patient s asthma? Post-test Question. A 48-year-old man comes into the office after experiencing shortness of breath, wheezing, chest tightness, and night awakening for the past several months. His medical history is notable for a diagnosis of anxiety and cold-induced rhinitis. In addition, he has taken prednisone 3 times in the past year. His social history is notable for tobacco use although he does not smoke daily. A pulmonary function test reveals that his forced expiratory volume in second (FEV) is 72% of predicted and his FEV to forced vital capacity ratio is 62%. Finally, he had a 3% improvement in his FEV after use of a bronchodilator. Based on the available information how would you classify the severity of this patient s asthma? 4% Mild intermittent 3% Mild persistent 62% Moderate persistent 2% *Severe persistent 0% Mild intermittent 3% Mild persistent 2% Moderate persistent 85% *Severe persistent n = 278 n = 54 ANALYSIS: Establishment of a patient s asthma disease severity is necessary to determine the initial treatment regimen. Misclassification of asthma severity may result in over- or undertreatment, unnecessary morbidity, or even death. Although nearly 80% of pulmonologists incorrectly assessed the patient s severity in the presented case, significant improvement occurred immediately following participation in the activity. However, additional education is needed to reinforce the education gained on how to properly assess a patient s asthma severity so that learning is maintained long term. EDUCATION EFFECT: Comparing intra-activity and post-assessment scores shows an increase of 64 percentage points in appropriate response to classification of a patient s asthma severity among pulmonologists who participated in the CME activity. October 8, 20 PAGE 4
Metrics Results: Participant Response Data Analysis 2 In addition to addressing the patient s smoking and environmental exposures, which of the following treatment regimens would be most appropriate? Post-test Question 2. Based on your assessment of the patient s disease severity, which of the following treatment regimens would be most appropriate? % Short-acting beta-2 agonist as needed 5% Low-dose ICS plus LABA 39% *Medium-dose ICS plus LABA 55% High-dose ICS plus LABA n = 243 0% Short-acting beta-2 agonist as needed 6% Low-dose inhaled corticosteroid plus long-acting beta-agonist 86% *Medium-dose inhaled corticosteroid plus long-acting beta-agonist 8% High-dose inhaled corticosteroid plus long-acting beta-agonist n = 56 ANALYSIS: As demonstrated by this patient case, lack of clinician familiarity with proper assessment of asthma severity and how it guides treatment decisions can result in inappropriate therapy recommendations. Specifically, the patient in this case would have been overtreated by over half of the pulmonologists who took this activity, which would have put him at an increased risk for adverse events. EDUCATION EFFECT: Comparing intra-activity and post-assessment scores shows an increase of 45 percentage points in appropriate response about a patient s initial treatment regimen among the pulmonologists who participated in the CME activity. October 8, 20 PAGE 5
Metrics Results: Participant Response Data Analysis 3 How soon after initiation of therapy should this patient be seen for a follow-up visit? Post-test Question 3. How soon after initiating therapy should this patient be seen for a follow-up visit? 28% 2 weeks 67% *2-6 weeks 4% 2-6 months % The next time he is having trouble breathing n = 236 % 2 weeks 97% *2-6 weeks 2% 2-6 months 0% The next time he is having trouble breathing n = 54 ANALYSIS: The NAEPP EPR-3 guidelines recommend a follow-up visit for all patients within 2-6 weeks after initiating a new therapy or regimen. Most pulmonologists were aware that visits should occur within at least 2 weeks of a prior visit. EDUCATION EFFECT: Comparing intra-activity and post-assessment scores shows an increase of 30 percentage points in appropriate response to follow-up care among pulmonologists who participated in the CME activity. October 8, 20 PAGE 6
Metrics Results: Participant Response Data Analysis 4 How would you characterize this patient s asthma control? 3% Well controlled 60% Not well controlled 37% *Very poorly controlled n = 23 ANALYSIS: Although the patient in this case stated that he believed that he was doing better, several clinical factors (ie, albuterol use, night awakenings) and his asthma control test score indicated that his asthma was still not under control. In addition, pulmonary function testing revealed that a fairly significant level of obstruction remained even while on medium-dose combination therapy. Cumulatively, these data suggest that the patient s asthma is very poorly controlled and that a change in his regimen is needed to improve control of his asthma. However, only 37% of pulmonologists would classify this patient as having very poorly controlled asthma, which could put patients at risk for undertreatment and poor clinical outcomes. Further education on assessment of asthma control and step-up therapy is needed. 5 The patient s symptoms, lung function, and ACT score show that he has improved. You should: 3% Keep him on a daily dose of oral prednisone (5-0 mg per day) indefinitely 6% Add montelukast 46% *Increase his regimen to a high-dose ICS + LABA 4% Add omalizumab 4% Consider reducing the dose of the ICS 0% Stop the ICS and return to albuterol as needed ANALYSIS: Although a short course of oral prednisone helped the patient in this case obtain control of his asthma, it is likely that he will need to have his controller medication increased at least temporarily to maintain control. Unfortunately, 4% of pulmonologists would have reduced the dose of the inhaled corticosteroid putting the patient back at risk for poorly controlled asthma, an exacerbation of his asthma, and unnecessary morbidity when and if the asthma symptoms return. n = 20 October 8, 20 PAGE 7
Qualitative Participant Feedback CME participants were given the opportunity to provide comments on the activity via a free-text form. The following is a representative sampling: This Enjoyed Great was an excellent format with a case-based discussion that incorporated much more than the specific case being discussed. Very nice job! this CME! topic, very well presented. Participants submitted requests for additional educational activities on: Pneumonia Emergent exacerbations of asthma Spirometry interpretation Moderate-to-severe asthma Allergic asthma Summary of Findings For pulmonologists who participated in the CME activity, overall responses to patient case-based questions demonstrate improved quality of patient care related directly to the learning objectives of the activity. Specifically, improved patient care choices were shown by 30%-64% improvement in their knowledge about assessment of disease severity, follow-up, and treatment regimen selection. Success of education is demonstrated by the improved quality of patient care by the pulmonologists who completed the CME activity, specifically in the areas of assessment and initial treatment selection. Recommendations for Future Education On the basis of the CME participants responses to clinical practice questions and the qualitative feedback from faculty, further education is needed for pulmonologists on assessment of asthma severity, initial treatment regimens, and use of step-up therapy. October 8, 20 PAGE 8
Addendum : Data Tables How would you characterize the severity of this patient s asthma? (n = 278) (n = 36) (n = 23) Mild intermittent 4% % 2% 2 Mild persistent 3% 7% 9% 3 Moderate persistent 62% 63% 63% 4 *Severe persistent 2% 29% 6% Post-test Question. A 48-year-old man comes into the office after experiencing shortness of breath, wheezing, chest tightness, and night awakening for the past several months. His medical history is notable for a diagnosis of anxiety and cold-induced rhinitis. In addition, he has taken prednisone 3 times in the past year. His social history is notable for tobacco use although he does not smoke daily. A pulmonary function test reveals that his forced expiratory volume in second (FEV) is 72% of predicted and his FEV to forced vital capacity ratio is 62%. Finally, he had a 3% improvement in his FEV after use of a bronchodilator. Based on the available information how would you classify the severity of this patient s asthma? (n = 56) (n = 76) (n = 36) Mild intermittent 0% 0% 0% 2 Mild persistent 3% % 3% 3 Moderate persistent 2% 9% 9% 4 *Severe persistent 85% 90% 78% October 8, 20 PAGE 9
Addendum : Data Tables 2 In addition to addressing the patient s smoking and environmental exposures, which of the following treatment regimens would be most appropriate? (n =243) (n = 9) (n = 95) Short-acting beta-2 agonist as needed % 2% % 2 Low-dose ICS plus LABA 5% 4% 3% 3 *Medium-dose ICS plus LABA 39% 50% 48% 4 High-dose ICS plus LABA 55% 44% 38% Post-test Question 2. Based on your assessment of the patient s disease severity, which of the following treatment regimens would be most appropriate? (n = 56) (n = 76) (n = 36) Short-acting beta-2 agonist as needed 0% 0% % 2 Low-dose inhaled corticosteroid plus long-acting beta-agonist 6% 0% 4% 3 *Medium-dose inhaled corticosteroid plus long-acting beta-agonist 86% 84% 84% 4 High-dose inhaled corticosteroid plus long-acting beta-agonist 8% 6% % October 8, 20 PAGE 0
Addendum : Data Tables 3 How soon after initiation of therapy should this patient be seen for a follow-up visit? (n =236) (n = 4) (n = 89) 2 weeks 28% 26% 45% 2 *2-6 weeks 67% 70% 50% 3-6 months 4% 4% 4% 4 The next time he s having trouble breathing % 0% % Post-test Question 3. How soon after initiating therapy should this patient be seen for a follow-up visit? (n = 54) (n = 76) (n = 35) 2 weeks % % 3% 2 *2-6 weeks 97% 95% 95% 3 2-6 months 2% 3% 2% 4 The next time he is having trouble breathing 0% % 0% October 8, 20 PAGE
Addendum : Data Tables 4 How would you characterize this patient s asthma control? (n =23) (n = ) (n = 82) Well controlled 3% 2% 6% 2 Not well controlled 60% 49% 62% 3 *Very poorly controlled 37% 49% 32% 5 The patient s symptoms, lung function, and ACT score show that he has improved. You should: (n =20) (n = 95) (n = 72) Keep him on a daily dose of oral prednisone (5-0 mg per day) indefinitely 3% % 2% 2 Add montelukast 6% 0% 6% 3 *Increase his regimen to a high-dose ICS + LABA 46% 38% 37% 4 Add omalizumab 4% 3% 9% 5 Consider reducing the dose of the ICS 4% 46% 45% 6 Stop the ICS and return to albuterol as needed 0% 2% % October 8, 20 PAGE 2
Addendum 2: References for Evidence-Based Activity. Nathan RA, Sorkness CA, Kosinski M, et al. Development of the asthma control test: a survey for assessing asthma control. J Allergy Clin Immunol. 2004;3:59-65. 2. Juniper EF, O Byrne PM, Guyatt GH, Ferrie PJ, King DR. Development and validation of a questionnaire to measure asthma control. Eur Respir J. 999;4:902-907. 3. Vollmer WM, Markson LE, O Connor E, et al. Association of asthma control with health care utilization and quality of life. Am J Respir Crit Care Med. 999;60:647-652. 4. Food and Drug Administration. New safety requirements for long-acting inhaled asthma medications called long-acting beta-agonists (LABAs). Available at: http://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ucm200776.htm Accessed June 7, 20. October 8, 20 PAGE 3