Physician Education on EHDI: A Method to the Madness

Physician Education on EHDI: A Method to the Madness February 19, 2004 2:00 – 3:00 pm

Presenters • Michelle Esquivel, MPH EHDI Project Coordinator American Academy of Pediatrics • Mary Pat Moeller, PhD Director, Center for Childhood Deafness Boys Town National Research Hospital

Overview of Session • History of Physician Knowledge and/or Education on EHDI Issues • Background Related to Efforts to Assess Physician Level of Knowledge on EHDI Issues • Models/Best Practices on Physician Education on EHDI

Session Objective • To share experiences, resources and models for education of primary care physicians and other pediatric health care professionals on early hearing detection and intervention issues.

CME: What Motivates Learning? • Specific problem or issue (e.g., question about a patient) • General problem (gaps in skills; knowledge related to new technology) • Cognitive dissonance (comparison with peers) • Intrinsic factorsDr. B. Schuster (2002)

Continuing Medical Education: Most Successful Methods • Learning linked to clinical practice (including tests of knowledge & evaluation of clinical practice needs) • Educational meetings with interactive components • Outreach events • Use of multiple interventions (e.G., Outreach + reminders; Grand rounds with case study discussion + reminders) Davis, et al, 1995; Davis & Maxmanian, 2002

Less effective methods Audit Feedback Local consensus process Influence of opinion leaders* LEAST Effective: Formal CME conferences without interactive elements Unsolicited educational materials (including clinical guidelines) Meta Analysis of CME Davis, et al, 1995

Adult Learning Methods • Diverse learning styles • Prefer activities that are:-Problem centered-Meaningful to life situation-Focused on immediacy of applicationBrookfield, 1986

Project with Pediatricians Formal Focus Group Work (N=27) Pilot Focus Groups (N = 21) Internet Based Survey (N=263); Extend through paper survey Resource Development Field test, revise & disseminate NIDCD supported

Themes from Focus Groups: Methods • Consider time constraints in daily practice & number of infants seen in practice life time; action oriented, just in time resources • Avoid dense content designed to make me an expert • Need for common language across disciplines • Low tech materials preferred by some

Themes from Focus Groups: Methods • Attend to credible sources of information (like AAP) • Avoid anecdotal in favor of evidence-based content • Use familiar formats (e.g., Grand Rounds, algorithms, patient education materials)…but consider how to challenge the “comfort zone?”

Themes from Focus Groups:Desired Content Areas • Guidance on protocols from AAP • Test accuracy, training of testers, costs • Evidence-based best practice guidelines • Expectations related to intervention (teamwork) • Linking systems with medical home • Counseling parents • Developmental indices • Medical/genetic issues

Themes from Focus Groups:Preferred Resources • Grand Rounds materials • Laminated cards with protocol steps • Some requested web based materials • Patient Education materials • Journal articles; AAP policies • Efficacy research • Multimedia CAN be effective….but….

Not useful: • Dense information, time consuming to access • Parent testimonial (depends on the approach) • Anecdotal examples without detail • Discipline specific terminology

On-line Quantitative Survey • Recruited through support from AAP (email blast, newsletters, Chapter Champion efforts) • Included traditional survey questions and streaming audio from focus groups • Effort to validate opinions of focus groups on larger scale

Demographics of Group

Survey Examples (Knowledge): • Q24. What is your best estimate of the time at which…d) A child can be definitively diagnosed as having a permanent hearing loss e) A child requiring amplification can be fitted with hearing aids

Survey Examples (Resources): • How likely would you be to use the following types of materials in your practice? (Rank very to not helpful)-Downloadable Grand Rounds materials-Laminated cards with clear protocol steps-CDs or DVDs to use in patient education-Web sites with frequently updated info-CME courses online

Preliminary Survey Results (N=263) • Strong support for screening (90%) • Concern about test accuracy (53%) and false positive rates (74%) • Most (69%) do not believe screening causes undue anxiety for parents • Most (70.2%) refer immediately, but almost 30% wait 4 weeks to 3 months • 23% do not regularly receive screening results • Only 33% felt trained to address this need

How Confident Are You That You Know What to Do If an Infant in Your Practice Does Not Pass a Newborn Hearing Test? Response Category

When can an infant be fit with hearing aids? Response Category (months)

Thinking About Physicians You Know and Work With, How InformedAre They About the Following:

Content Needs Identified in Quantitative Survey • Protocols for follow up (81% great need) • Guidelines for informing families (63%) • Impact of varying degrees of hearing loss on child language (74%) (unilateral, mild, late onset > severe to profound) • Screening for late onset SNHL (73%) • Useful contacts & patient education (75%)

Content Needs Identified in Quantitative Survey • Desire on-line CME course (66%) • Medical interventions for SNHL (83%) • Educational and audiological interventions for hearing loss (84%) • Genetics of HL (11%)

Trends by Professional Category 5 8 9 2 6 11 10 7 12 3 4 1 Otolaryngologist Family Physician Pediatrician

CME and Resource Creation: • Based on effective assessment of learning needs & removal of barriers • Should encourage self-assessment • Address gaps and extend educational resources in a strategic manner

AAP EHDI Program • Began in August 2001 • Establishment of network of pediatricians in states to champion this issue • Phase I: Education of Champions • Phase II: Education of General Membership

Education of Champions • Monthly EHDI E-Mail Express • Participation in National EHDI Conferences • Mentoring by National Experts/Task Force members • Mini-Grant Opportunities

Education of Champions • Visiting Professorship/Lectureship Opportunities • Participation in medical home training conferences • Participation in CDC EHDI Ad Hoc Conference Calls

Education of General AAP Membership • Articles in “AAP news” • Dissemination and promotion of resource materials and information • Articles in chapter newsletters • Sessions at AAP national conference and exhibition • Sessions/materials at AAP practical pediatrics courses • CME teleconference series • Visiting professorship/lectureship opportunities

Practical Pediatrics Courses • Include information in sessions on developmental and behavioral pediatrics • Distribution of flow chart, “Universal Newborn Hearing Screening Diagnosis and Intervention Guidelines” • Distribution of patient chart companion piece when available

CME Teleconference Series • Audience:Primary care pediatricians, family physicians • Faculty:Nationally renowned – Betty Vohr, MD; Judy Gravel, PhD; Albert Mehl, MD; and Mary Pat Moeller, PhD

CME Teleconference Series: Content Areas • Definitions of types of congenital hearing loss • Major genetic and environmental causes of congenital hearing loss • Newest technologies used in hearing screening • Importance of diagnostic confirmation of hearing loss • Physician’s medical work-up • Amplification choices

CME Teleconference Series: Content Areas (cont) • Cochlear implantation • Parental concern about delayed language development • Case studies • Parenting issues • AAP “Universal Newborn Hearing Screening, Diagnosis, and Intervention Guidelines for Pediatric Medical Home Providers” and how to implement

Costs and reimbursement issues related to amplification devices Empowering families to advocate effectively for their child for the appropriate resources Roles of early intervention and why intervention services are recommended Important referrals needed for children with permanent hearing loss National resources CME Teleconference Series:Content Areas (cont)

CME Teleconference Series • CME credit for participants • Noontime sessions to accommodate those in practice • Toll-free call in • Presentation slides and resource materials in advance • Free for participants!

CME Teleconference Series • Logistics/Coordination - Staff/time intensive - Volunteer/faculty intensive – development of content outline and information, slides, practice session, unfamiliar presentation scenario - Phone Company Preparation (Call taped) - Registration Coordination, documentation - Promotion/Marketing

CME Teleconference Series Successes: • Comprehensive curriculum • Resources useful and valuable • Approximately 50-70 participants per call despite somewhat limited promotion • More than individuals registered participated (practice-wide participation) • Faculty well prepared and knowledgeable • Informative question-and-answer period

CME Teleconference Series: Successes: • Extremely positive evaluation results • Content provided information useful to practice • Changes will be made in practice as a result of participation • Very likely to share information learned with colleagues • Teleconference format was convenient and effective • Relatively easy model to replicate

CME Teleconference Series • Challenges -Last minute registrations -No shows -Resource material dissemination in advance -Technology (downloading slides, connecting to the call) -Time zone(s)

CME Teleconference Series • Costs • Graphic Design and Printing for Program Brochure/Marketing Materials • CME Application Fee • Express Mail and Postage (for marketing/promotion and registration packets and CME follow up) • Telephone Conferencing Service for planning calls and the teleconference series calls • Indirect Costs (staff time, volunteer time)

Visiting Professorship/Lectureship Opportunities • Available to Chapter Champions • Criteria: Grand rounds presentation as well as other smaller, more focused meetings and presentations • Funds available for speaker travel, expenses and honorarium • Held in Delaware, Louisiana, Ohio, California, Hawaii (March 2004)

Visiting Professorship/Lectureship Opportunities • Faculty: Betty Vohr, MD; Christine Yoshinaga-Itano, PhD; Karl White, PhD; Mary Pat Moeller, PhD; Noel Matkin, PhD • Topics: Dependent on the needs identified by the Chapter Champion who applied • Examples: Early Intervention; Cost/reimbursement issues related to hearing aids; state requirements for education for children identified with hearing loss; physician contributions to EHDI programs; resident education on screening issues; EHDI challenges and opportunities; EHDI guidelines on UNHS; evaluation and management of children with hearing loss; outcomes; and genetics of hearing loss.

Visiting Professorship/Lectureship Opportunities • Successes - Opportunity for national experts to present locally - Several presentations coordinated and held in various locations in each state/hospital - Multidisciplinary approach - Cost effective, i.e., funds expended compared to number of individuals educated

Visiting Professorship/Lectureship Opportunities • Challenges - Time intensive to coordinate - Availability of experts to coincide with availability of time slots for presentations - Incredible amount of detail orientation - No staff available on-site to handle logistics; rely on Chapter Champion and others - Difficult to collect and truly analyze overall summary and evaluation instruments

Additional Resource Development (NIDCD Grant) • Grand Rounds materials on CD (currently in field testing stage) • Support for development of AAP Pedialink module on newborn hearing screening and follow up • Patient education materials (downloadable) • Web site development & expansion

Perhaps you have recently been told that your newborn or infant has a hearing loss. You may be feeling overwhelmed or confused….and you are searching for helpful information. 24,000 children are born each year in the U.S. with some degree of hearing loss. Most of these children are born to parents with normal hearing, who have had no experience with deafness or hearing loss of any kind. It is natural to feel overwhelmed and unprepared to deal with the situation. It is important to remember that you are not alone. This website will give you information, answer questions and provide support. We will introduce you to other parents who have walked in your footsteps. Let’s begin by exploring some next steps in your communication journey with your baby….

Future Directions: Nurses’ Knowledge about EHDI • Few studies have been conducted • Pilot data collected at BTNRH (N = 20) showed the following informational needs:-medical and educational interventions-screening/testing methods-impact of HL of varying degree on language-surveillance, useful contacts-patient education materials-50% “not confident,” but doctors are • Foresee a major role in patient education

Preferred Resources: Nursing • Frequently updated web site • On-line CME courses • Written protocol guides • Handouts for parents • Clear, understandable, brief teaching pieces

Summary: • Effective CME design related to EHDI should include:-physician self-assessment-just in time resources-variety of strategies; multiple interventions-techniques relevant to practice -evaluation of impact from varied sources-sensitivity to practice constraints • Use what is already in existence!

Physician Education on EHDI: A Method to the Madness