Pulmonary Hypertension: New Definitions, New ApproachesFinal Live Outcome Report
Prepared For Actelion Pharmaceuticals US, Inc.: Grant ID 55783073January 21, 2020
Persistent Educational Gapsv Though improvements were observed, learners demonstrated persistent gaps in the several areas including:
v Diagnosing PAH and interpreting the impact of pulmonary pressures
v Recognizing the difference between Ventilation-Perfusion scanning and CT Pulmonary Angiogram for the diagnosis of CTEPH
v Treatment strategies for PAH and how to further adjust treatment based on risk
v Management of medication related adverse events
The post-test scores, and self reported confidence regarding the management of patients with PAH, signifies a clear gap in knowledge
and an unmet need among clinicians. It continues to be an important area for future educational programs.
Executive Summary
*These numbers represent the total number of attendees, irrespective of assessment participation
917 total attendees
on site: 97 attendees
National online simulcast: 820 attendees
v This activity focused on improving the diagnosis of Pulmonary Arterial
Hypertension (PAH) with updated guidelines, using risk stratification to adjust
therapy and addressing adverse effects while improving patient adherence.
v 917 attendees in multiple professional specialties were reached in this program.
v Improvement across all learning domains was noted ranging from 29% to 65%.
v Overall, the program improved the ability of learners to recognize how to
diagnosis and manage PAH.
Learning Objectives
4
3
1 Describe new definitions of PAH and approaches to improving diagnosis
Outline an approach to rule out and appropriately manage chronic thromboembolic pulmonary hypertension (CTEPH), if present
Utilize risk stratification for selecting and escalating therapy in patients with PAH
Describe the management of adverse events with PAH therapies and strategies to improve patient adherence
2
Course DirectorFranck Rahaghi, MD, MHS, FCCPChairman, Department of Pulmonary MedicineDirector, Pulmonary Hypertension ClinicHead, Pulmonary Education and RehabilitationDepartment of Pulmonary and Critical CareCleveland Clinic FloridaWeston, FL
Gregg Sherman, MD
Michelle Frisch, MPH, CCMEP
Sandy Bihlmeyer M.Ed
Franck Rahaghi, MD, MHS, FCCP
Sheila Lucas, CWEP
Joshua F. Kilbridge
Cedric Nazareth, MBBS
Deborah Paschal, CRNP
Sandhya Khurana, MDProfessor, Pulmonary and Critical Care MedicineDirector, Mary Parkes Center for Asthma, Allergy & Pulmonary CareUniversity of Rochester School of MedicineRochester, NY
Mehdi Mirsaeidi MD, MPHDirector of UM and VA Sarcoidosis ProgramsIRB Vice-Chairman, Miami VA Healthcare SystemDivision of Pulmonary, Critical Care,Sleep and AllergyDepartment of MedicineUniversity of MiamiMiller School of MedicineMiami, FL
Franck Rahaghi, MD, MHS, FCCPChairman, Department of Pulmonary MedicineDirector, Pulmonary Hypertension ClinicHead, Pulmonary Education and RehabilitationDepartment of Pulmonary and Critical CareCleveland Clinic FloridaWeston, FL
Farbod N. Rahaghi, MD, PhD *Instructor, Harvard Medical SchoolApplied Chest Imaging LaboratoryPulmonary Vascular Disease ProgramBrigham and Women's HospitalPulmonary and Critical Care Internal MedicineBoston, MA
Gregory Cosgrove, MDAssociate ProfessorAssistant Director, Interstitial Lung Disease ProgramDepartment of MedicineDivision of Pulmonary, Critical Care & Sleep MedicineEndowed Chair in Interstitial Lung DiseaseNational Jewish HealthDenver, CO
Samuel Gurevich, MD, FCCPMedical Director, Respiratory TherapyCleveland Clinic FloridaClinical Assistant Professor of MedicineCleveland Clinic Cleveland Clinic Lerner College of Medicine of Case Western Reserve UniversityWeston, FL
Sajive Aleyas, MDInterventional PulmonaryCleveland Clinic FloridaWeston, FL
Faculty
Activity Planning Committee
*Presented PAH lecture
Commercial Support
The Challenges in Pulmonary and Critical Care: 2019 CME activity was supported through educational grants or donations from the following companies:
vActelion Pharmaceuticals US, Inc.
vGenentech
vNovartis Pharmaceuticals Corporation
vCSL Behring, LLC.
vGrifols
vMallinckrodt, LLC
vShire
Levels of EvaluationConsistent with the policies of the ACCME, NACE evaluates the effectiveness of all CME activities using a systematic process based on Moore’s model. This outcome study reaches Level 5.
Level 1: Participation
Level 2: Satisfaction
Level 3: Declarative and Procedural Knowledge
Level 4: Competence
Level 5: Performance
Level 6: Patient Health
Level 7: Community Health
Moore DE Jr, Green JS, Gallis HA. Achievingdesired results and improved outcomes: integratingplanning and assessment throughout learningactivities. J Contin. Educ. Health Prof. 2009 Winter;29(1):1-15
917 total attendees
On site: 97 attendees
90%Provide direct patient care
National online simulcast : 820 attendees
Level 1:Participation
November 23, 2019 Coral Springs, FL
Profession Years in Practice
Patient Care Focus: 90%
Level 1: Demographics and Patient Reach
Patients seen each week, in any clinical setting:Specialty
4%
56%
6% 3% 4%
26%
Pulmonology InternalMedicne/Primary
Care
Cardiology Hospitalist EmergencyMedicine
Other
17%
2%
59%
12%7% 3%
MD DO NP PA RN Other
30%
27%
20%
23%
0% 20% 40% 60% 80% 100%
<25
25-50
51-75
>75
26%17% 21%
36%
<5 5-10 11-20 >20
88% rated the activity as excellent
89% indicated the activity improved their knowledge
88% stated that they learned new and useful strategies for patient care
91% said they would implement new strategies that they learned
98% said the program was fair-balanced and unbiased
Level 2: Satisfaction
Please rate your confidence in your ability to manage patients with PAH:(Learning Objectives 2, 3, 4)
Confidence Assessment
Pre: 342 PCA: 161N=
54%
33%
8%3% 2%
12%
41%
32%
12%
3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Not at all confident Slightly confident Moderately confident Pretty much confident Very confident
246 249 161
Which of the following is NOT a critical reason for the necessity of right heart catheterization in the diagnosis of PH?(Learning Objective 1)
Knowledge Assessment
Pre: Post: PCA:N=
8%
18%
28%
14%
31%
8%14%
37%
18%
48%
14%
22%
31%
21%
13%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Obtaining accurate measuresof mean pulmonary pressure
for the purpose ofestablishing the diagnosis of
PH
Distinguishing precapillaryand post-capillary PH
Pulmonary vasodilatorytesting
Obtaining accurate measuresof pulmonary pressures for
prognostication/riskassessment
Measuring Cardiac Index toevaluate degree of heart
failure
P<=.05
Pre to Post Change 29%Pre to PCA Change 49%
257 259 161
25 y/o female with history of contraceptive use and obesity who was admitted for acute shortness of breath and diagnosed with acute pulmonary embolism comes in for follow up 6 month after the diagnosis. She has remained on anticoagulation and has been adherent to therapy. She says that although she feels better she still feels short of breath. Her chest x-ray remains clear. Which of the following tests would best rule out chronic thromboembolic disease. (Learning Objective 2)
Knowledge Assessment
8% 9%
32%
4%
47%
9% 8%
49%
3%
31%
8%13%
40%
6%
34%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Planar PulmonaryAngiography
Echocardiogram Ventilation-Perfusion lungscanning
Cardiopulmonary ExerciseTesting
CT pulmonary angiography
Pre to Post Change 53%Pre to PCA Change 8%
P<=.05
Pre: Post: PCA:N=
Which of the following is true of therapies in patients with pulmonary arterial hypertension?(Learning Objective 3)
Pre: Post: PCA:
Knowledge Assessment
N= 249 251 161
22% 21%17%
40%
18%14%
28%
40%
24% 26%
19%
31%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
In high risk patients, monotherapy withIV Prostacyclin is recommended, as
additional agents add very little to thistherapy
Transition from high risk to intermediaterisk after therapy suggests that no
further escalation of therapy isindicated
Oxygen requirements are not a majorcomponent of the decision to escalate
treatment in PAH
Upfront combination therapy is notrecommended in a patient with a new
diagnosis of PAH who is deemed to below-risk
P<=.05
Pre to Post Change 65%Pre to PCA Change 12%
Which of the following is true about adverse event management in treatments of PAH:(Learning Objective 4)
Pre: Post: PCA:
Knowledge Assessment
N= 175 162 161
22%
13%
21%
9%
35%
16%
9%14%
5%
56%
18% 17% 19%
10%
36%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Switching medications withina class rarely effects tolerance
of specific adverse events
Constipation is a commonside-effect of IV Prostacyclin
therapy
Headache associate withprostacyclin therapy shouldnot be treated with over the
counter medications
Edema is not a side-effect ofpulmonary vasodilators
Upfront combination therapycan increase the incidence of
certain adverse events
Pre to Post Change 60%Pre to PCA Change 3%
P<=.05
Timely referralPatient education Patient engagement
Disease state awareness Non-pharmacotherapy
Please select the specific areas of skills, or practice behaviors, you have improved regarding the screening, diagnosis and treatment of Pulmonary Arterial Hypertension since this CME activity. (Select all that apply.)N=117
(4-week Post Assessment)
37% 34% 20%
55% 16%
Insurance/Financial issues
Medication costs Time constraints
Patient adherence/compliance
Lack of knowledge
What specific barriers have you encountered that may have prevented you from successfully implementing screening, diagnosis and treatment of Pulmonary Arterial Hypertension since this CME activity? (Select all that apply) N=117
(4-week Post Assessment)
36%
42%33%
13%36%
Persistent Educational Gaps After 4 Weeks
Diagnosing PAH and interpreting the impact of pulmonary pressures
Recognizing the difference between Ventilation-Perfusion scanning and CT Pulmonary Angiogram for the diagnosis of CTEPH
Treatment strategies for PAH and how to further adjust treatment based on risk
Management of medication related adverse events
Greater recognition of the benefits of right heart catheterization in the diagnosis of PAH but that it is not required for prognostication/risk stratification
More aware that Ventilation-Perfusion lung scanning is most appropriate to rule out chronic thromboembolic disease
Greater awareness that oxygen requirements are not a major component of the decision to escalate therapy in PAH
More aware of adverse events associated with PAH therapy and how to manage it
Participant Educational Gains
Key Take-home Points
Significantly improved learner confidence in the ability to manage patients with PAH
90% of learners are engaged in direct patient care and 91% reported that they will implement new strategies they learned
After 4 weeks, participants reported the following barriers regarding the screening, diagnosis and treatment of PAH: 42% lack of knowledge, 33% patient adherence/compliance, 36% insurance/financial issues
After 4 weeks, participants reported the following improved skills regarding the screening, diagnosis and treatment of PAH: 55% disease state awareness,37% timely referral, and 34% patient education