A Simulated Diabetes LearningIntervention Improves Provider Knowledge and Confidence in Managing Diabetes JoAnn Sperl-Hillen, MD Co-director of Center for Chronic Care Innovation HealthPartners Research Foundation, Minneapolis, MN Wednesday May 2, 2012 8-9:30am 18th Annual HMO Research Network Conference Seattle, WAAccelerating excellence in health performancethrough education, advocacy, and collaboration
Team Members JoAnn Sperl-Hillen Steve Asche Patrick O’Connor George Biltz* Heidi Ekstrom Deb Curran William Rush Paul Johnson* Omar Fernandes Andrew Rudge Jerry Amundson Todd Gilmer** Deepika Appana HealthPartners Research Foundation and HealthPartners Institute for Medical Education, Minneapolis, MN; * Carlson School of Management, University of Minnesota, Minneapolis MN; ** Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, CA
Presenter Disclosures NIH research support Listed inventor on a U.S. patent application filed related to simulation technology HPRF has recently entered into a royalty-bearing license agreement with a third party to commercialize the simulated learning technology for the purpose of broader dissemination. Non-paid director on the board of directors for that licensee (SimCare Health)
Why is provider training needed? Provider performance varies, even within the same clinic populations Clinical inertia is common, particularly for insulin treatment Provider knowledge varies The cognitive processes and tasks related to diabetes are complex
Barriers to Provider Training Time constraints Lack of continuity experiences Relatively limited ambulatory experience in residency training Complicated diseases with need for personalization of care Experts & opinion leaders are often not available or affordable, and teaching is difficult to standardize
What is simulation?―Simulation is a technique—not a technology—to replaceor amplify real experiences with guided experiences thatevoke or replicate substantial aspects of the real world ina fully interactive manner.‖ Gaba (2004) History of Simulation Aviation NASA Military Medical 1960s First Mannequin: Resusci-Annie 1960s-70s Computer-assisted learning program in medicine 1990 High fidelity mannequins become available
What are the advantages to simulation? Efficient & cost effective Sustainable & standardized In line with adult learning principles Personalized (case-based). Case-based simulations provide a context for learning People are more likely to remember learning and replicate in real-world situations. Capture the importance of continuity of care Proven satisfaction & effectiveness
Elements needed to create a simulated learning program1. Identify the learning needs and create a library of case scenarios2. Create an interactive web-interface3. Model and program the physiology4. Program the feedback – to critique action the provider takes between encounters
Demo of SimCare available at www.simcarediabetes.org Patient “snapshot” screen shot
Early SimCare StudyFunding through R01HS10639, Physician Intervention to Improve Diabetes Care 57 consented PCP’s and their 2,020 patients. Randomized to one of 3 groups: (A) no intervention (B) learning intervention (SimCare) consisting of 3 simulated learning cases (1 hr) (C) SimCare + physician opinion leader Results: SimCare reduced risky prescribing of metformin in patients with renal impairment (p=0.03). Group B (SimCare alone) achieved slightly better glycemic control than A or C (p=.04)
SimCare Version 2 Funding through R01DK068314, Reducing Clinical Inertia in Diabetes Eleven clinics with 41 consenting PCP’s Randomized to receive or not receive an improved version of SimCare (12 cases assigned based on profiled ―needs‖, 3 hrs) Results: Patients of intervention providers with baseline A1c > 7% had significantly greater A1c reduction (-.19%) relative to patients of non-intervention providers.
SimCare Version 3Funding through R18DK079861, Simulated Diabetes Training for Resident Physicians 19 eligible residency programs linked to 723 residents 382 residents did not consent 341 residents consented Intervention – Early learning 10) Control – Late learning (9) Residents (177) Residents (164) Completion rates Completion rates Learning cases (142) Assessment cases (135) Assessment cases (97) Knowledge survey (128) Knowledge survey (92) Evaluation (94)
Implementing the learning program Residents at 19 programs were given a brochure that we provided and asked to sign up online Resident participation was voluntary. Time commitment – 18 cases, 1 hour/month for 8 months if randomized to the early intervention group Incentives - $50 Target gift card on completion of the assigned tasks Promotions – 4 iPad raffle promotions and 1 Target gift card promotion to achieve acceptable learning and assessment case completion rates
Baseline characteristics of residents Intervention Control P-value (n=92) (n=128)% female 48% 57% 0.31% white 48% 58% 0.41Age (median) 29 29 0.69Specialty Family Medicine 34% 49% Internal Medicine 54% 42% 0.15 Med-Peds 8% 7% Other 4% 2%Post graduate year 35% 34% 1 36% 34% 2 0.70 28% 28% 3 1% 4% 4
Example Knowledge Question2. A 77 year old black man is seeing you for follow up. He has a 13 year history of type 2diabetes, coronary heart disease (CABG at age 58), chronic stable angina, anddyslipidemia. He has been eating out a lot and gaining weight. His current medications aremetformin 1000 mg bid, atenolol 50 mg qd, and simvastatin 40 mg qd. His BMI is 37, BP is165/86, A1c 9.3%, Cr 2. 2 mg/dl, eGFR 28, LDL 94 mg/dl, HDL 36 mg/dl, and TG 278mg/dl.Which of the following would be your MOST likely recommended action?A. Start basal insulin and treat to an A1c goal of < 7%. No change in other glycemiamedications.B. Discontinue metformin and start basal insulin. Follow up with patient for insulinadjustments with an A1c goal of < 7%.C. Start basal insulin and follow up with the patient for insulin adjustments with an A1c goalof < 8%. No change in other glycemia medications.D. Discontinue metformin and start basal insulin. Follow up with patient for insulinadjustments with an A1c goal of < 8%.E. No change now because I would address other patient problems Correct answer D (59% intervention, 26% control)
P-Q# Knowledge topics covered Early Late value1 Screen for DM (using an A1c) 75.0 75.8 .8942 Basal insulin start, individualized A1c goal < 8% 58.7 25.8 <.0001 Check ketones in newly diagnosed symptomatic patients &3 31.5 28.1 .586 start insulin Reduce basal insulin due to nocturnal hypoglycemia4 64.1 70.3 .333 (Somogyii)5 Relax A1c target due to hypoglycemia unawareness 57.6 32.8 .00026 Start insulin in a newly diagnosed symptomatic patient 33.7 11.7 <.0001 Use of a loop diuretic rather than thiazide in patient with renal7 insufficiency. Fenofibrate not beneficial in addition to statin. 44.6 19.5 <.0001 DC metformin due to renal contraindication. Initiate BP tx (without confirmatory testing) if BP > 180/100.8 59.8 44.5 0.026 Statins may be helpful for most patients with DM.9 Start a statin, screen for depression, basal insulin start 66.3 57.0 .164 Geriatric polypharmacy concerns, depression screening,10 46.7 41.4 .431 hypoglycemia management, statin use in the elderly
Results of Knowledge TestingNumber of items Intervention Controlcorrect out of 10 0-4 29% 66% 5-7 60% 32% 8-10 11% 2% Mean score 5.31 4.10 p < .001 (95% CI) (4.87-5.75) (3.69-4.50)N=220 completers of knowledge survey
Results of self-rated confidence and knowledge about diabetes management Topic Intervention Control P-valueHow knowledgeable are you about how touse all available drug classes to manage 61 25 <.001 patients with diabetes?How knowledgeable are you about how to 83 45 <.001 start and adjust insulin? How knowledgeable are you aboutinterpreting patient self-monitored glucose 85 59 .009 values (SMBGs)?How knowledgeable are you about settingindividualized treatment goals for people 83 44 <.001 with diabetes?How confident are you in managing patients 79 44 <.001 with diabetes?
Evidence for learning transfer to actual patient care 77% applied learning to actual patients 63% shortened visit intervals 78% more likely to add or increase drugs if patient is not at goal 92% more confident about insulin use in actual patients ….and results of two trials had demonstrated improved outcomes of actual patients of practicing providers who used earlier versions of SimCare
Study limitations Voluntary participation, not all completed the learning program and completed evaluations No outcome data on non-completers Survey completion rates were lower in the intervention (52%) than the control groups (78%) No actual patient data to evaluate Assessment case outcomes not yet available
Thank you! For additional questions, please contact… JoAnn Sperl-Hillen: firstname.lastname@example.org Patrick O’Connor: email@example.com Heidi Ekstrom: firstname.lastname@example.org
Talk References Simulated Physician Learning Intervention to Improve Safety and Quality of Diabetes Care: A Randomized Trial O’Connor PJ, Sperl-Hillen JM, et al. Simulated physician learning intervention to improve safety and quality of diabetes care: A Randomized Trial. Diabetes Care. 2009;32(4): 585-590. Simulated Physician Learning Program Improves Glucose Control in Adults with Diabetes Sperl-Hillen JM, O’Connor PJ, Rush WA, Johnson PE, Gilmer TP, Biltz G, Asche SE, Ekstrom HL. Simulated Physician Learning Program Improves Glucose Control in Adults with Diabetes. Diabetes Care. 2010;33(8): 1727-1733.