Physician Education on EHDI: Physician Education on EHDI: A Method to the MadnessA Method to the Madness

February 19, 2004

2:00 – 3:00 pm

PresentersPresenters

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 SessionOverview 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 ObjectiveSession 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 CME: What Motivates Learning?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 factors

Dr. B. Schuster (2002)

Continuing Medical Education: Continuing Medical Education: Most Successful MethodsMost 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

Meta Analysis of CMEMeta Analysis of CME

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)

Davis, et al, 1995

Adult Learning MethodsAdult Learning Methods

Diverse learning styles

Prefer activities that are:-Problem centered-Meaningful to life situation-Focused on immediacy of application

Brookfield, 1986

Project with PediatriciansProject with Pediatricians

Pilot Focus Groups (N = 21)

Formal Focus Group Work (N=27)

Internet Based Survey (N=263); Extend through paper survey

Resource Development

Field test, revise & disseminate

NIDCD supported

Themes from Focus Groups: Themes from Focus Groups: MethodsMethods

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: Themes from Focus Groups: MethodsMethods

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:Themes from Focus Groups:Desired Content Areas 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:Themes from Focus Groups:Preferred ResourcesPreferred Resources

Grand Rounds materials Laminated cards with protocol stepsSome requested web based materialsPatient Education materialsJournal articles; AAP policiesEfficacy research Multimedia CAN be effective….but….

Not useful:Not useful:

Dense information, time consuming to access

Parent testimonial (depends on the approach)

Anecdotal examples without detailDiscipline specific terminology

On-line Quantitative SurveyOn-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 GroupDemographics of Group

Type N Rural Metro Male Female

Pediatrician 192 85 105 92 98

Neonatology 29 24 5 14 15

Family Practice

20 16 4 14 6

ENT 11 0 11 10 1

Other 11 5 6 6 5

Total 263 130 131 136 125

Survey Examples Survey Examples (Knowledge):(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 Survey Examples (Resources):(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 Preliminary Survey Results (N=263)(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 How Confident Are You That You Know What to Do If an Infant in Your Practice What to Do If an Infant in Your Practice Does Not Pass a Newborn Hearing Test?Does Not Pass a Newborn Hearing Test?

0102030405060708090

100

Per

cen

t o

f R

esp

on

den

ts

NotConfident

Somewhat VeryConfident

Unsure

Response Category

When can an infant be fit with When can an infant be fit with hearing aids?hearing aids?

0

10

20

30

40

50

60

70

80

90

Num

ber

of Physi

cians

birth 1-5m 6m 7-11 m 12 m >12m DK

Response Category (months)

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

0

10

20

30

40

50

60

Per

cen

t o

f R

esp

on

den

ts

Uniformed

Somew

hat UN

Somew

hat IN

Well Inform

ed

Testing

Early Rx

Content Needs Identified in Content Needs Identified in Quantitative SurveyQuantitative 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 Content Needs Identified in Quantitative SurveyQuantitative 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 CategoryTrends by Professional Category

OtolaryngologistOtolaryngologist Family PhysicianFamily Physician PediatricianPediatrician

11

22

33 44

55

66

77

88 99

1010

1111

1212

CME and Resource Creation:CME and Resource Creation:

Based on effective assessment of learning needs & removal of barriers

Should encourage self-assessmentAddress gaps and extend educational

resources in a strategic manner

AAP EHDI ProgramAAP EHDI Program

Began in August 2001Establishment of network of pediatricians in

states to champion this issuePhase I: Education of ChampionsPhase II: Education of General

Membership

Education of ChampionsEducation of Champions

Monthly EHDI E-Mail ExpressParticipation in National EHDI ConferencesMentoring by National Experts/Task Force

membersMini-Grant Opportunities

Education of ChampionsEducation of Champions

Visiting Professorship/Lectureship Opportunities

Participation in medical home training conferences

Participation in CDC EHDI Ad Hoc Conference Calls

Education of General AAP Education of General AAP MembershipMembership

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 CoursesPractical 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 SeriesCME 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: CME Teleconference Series: Content AreasContent 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: CME Teleconference Series: Content Areas (cont)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

CME Teleconference Series:CME Teleconference Series:Content Areas (cont)Content Areas (cont)

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 SeriesCME Teleconference Series

CME credit for participantsNoontime sessions to accommodate those in

practiceToll-free call in Presentation slides and resource materials in

advanceFree for participants!

CME Teleconference SeriesCME 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 SeriesCME Teleconference Series

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

Successes:

CME Teleconference Series:CME Teleconference Series:

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

Successes:

CME Teleconference SeriesCME 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 SeriesCME 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 Visiting Professorship/Lectureship Professorship/Lectureship

OpportunitiesOpportunitiesAvailable to Chapter ChampionsCriteria: 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 Visiting Professorship/Lectureship Professorship/Lectureship

OpportunitiesOpportunities

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 Visiting Professorship/Lectureship Professorship/Lectureship

OpportunitiesOpportunities 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 Visiting Professorship/Lectureship Professorship/Lectureship

OpportunitiesOpportunities 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 Additional Resource Development (NIDCD Grant)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

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….

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.

 

Future Directions: Nurses’ Future Directions: Nurses’ Knowledge about EHDIKnowledge 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: NursingPreferred Resources: Nursing

Frequently updated web siteOn-line CME coursesWritten protocol guidesHandouts for parentsClear, understandable, brief teaching pieces

Summary: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 and Physician Education and EHDIEHDI

Contact information:

Michelle Esquivel847/608-6550mzesquivel1@yahoo.com

Mary Pat Moeller402/498-6521moeller@boystown.org