2015 Needs Assessment Report Edit

2015
Needs Assessment Report
Prepared by:
Elizabeth Rutan
Candidate, Master of Public Health
University of Georgia, School of Public Health
August 2015

ARMC CME Program
2015 Annual Needs Assessment
2
Table of Contents
Introduction and Background 2
Methods 3
a) Data collection
b) Sources consulted
c) Strengths and limitations
Key Findings and Recommendations for Program Planning 4
a) Implications from the data and recommendations for CME activities
Specific Disease State Summaries (alphabetical order)
a) Antibiotics 5
b) Chronic Obstructive Pulmonary Disease 7
c) Congestive Heart Failure 8
d) Diabetes 9
e) Diet/Nutrition 10
f) End-of-life care 12
g) Heart disease 13
h) HIV/AIDS 14
i) Hypertension 15
j) Influenza 16
k) Pain Management 17
Appendices 18

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Introduction and Background
In our 2015 Medical Association of Georgia (MAG) accreditation report, we were cited as non-
compliant with Criterion 2. This criterion requires the identification of the professional practice gaps
and the educational needs (knowledge, competence, or performance) that underlie the practice gap. To
address this issue, one of our action steps was to perform a comprehensive needs assessment in order
to identify potential topics for our CME activities.
The 2015 Needs Assessment incorporated various methods for identifying professional practice
gaps and educational needs to be used in the planning of CME activities for 2015/2016.
Five strategies were employed to identify performance gaps:
• Assessing national databases and comparing mortality and morbidity data for the ARMC
service area,
• Identifying new guidelines for clinical care,
• Soliciting expert opinions and conducting interviews with physicians,
• Analyzing responses from surveys of target audiences
• Reviewing Up-to-Date Topics Reports
Eleven topic areas were identified during this process. Background material and references for each of
these areas are detailed in this document.

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Methods
The needs assessment began through the use of national government databases including the
National Healthcare Quality and Disparities Reports (NHQDR) by the Agency for Healthcare Research
and Quality. Another useful database, Online Analytical Statistical Information System (OASIS), is
provided by the Georgia Department of Public Health. This method allows for a state to state and county
to state comparison to objectively assess the strengths and weaknesses of the area surrounding Clarke
County and the state of Georgia.
Through Survey Monkey, the annual needs assessment survey was distributed to more than
1,000 physicians in the Athens and surrounding area. Some surveys were distributed in person outside
of the physicians’ lounge. This method identified CME medical topics that the physicians view as
particularly beneficial. The survey also addressed the preferred day, time, and method of receiving CME.
Meetings with experts in the field or those with key opinions proved especially helpful. For
example, Dr. Apaloo, the director of the residency program revealed many areas of need. Additionally,
Heather Alexander, the director of Quality and Patient Safety identified several areas that the
department considers in need of improvement. Several of the identified topics have new or updated
guidelines for physicians developed by the Veterans Association, Department of Defense, U.S.
Preventive Services Task Force, Centers for Disease Control and Prevention, American College of
Physicians, or The Joint Commission.

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Key Findings
Through research of national databases the following medical topics presented the strongest evidence
of need for improvement:
• diabetes,
• heart disease,
• HIV/AIDS, and
• influenza.
Through the annual needs assessment survey, physicians most strongly suggested the following medical
topics:
• antibiotics,
• end-of-life care,
• diabetes, and
• pain management.
The following medical topics have new guidelines published as of 2014:
• chronic obstructive pulmonary disease,
• diabetes,
• heart disease,
• HIV/AIDS,
• hypertension, and
• pain management.

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Antibiotics
The Centers for Disease Control and Prevention (CDC) reported that two million people in the
United States acquire serious infections with bacteria that are resistant to one or more of the antibiotics
designed to treat those infections. At least 23,000 people die each year as a direct result of these
antibiotic-resistant infection and up to fifty percent of all the antibiotics prescribed are not needed or
are not optimally effective as prescribed (CDC, 2013, p. 11)1
. Several knowledge gaps exist in the area of
antibiotic resistance. For example, there are advanced technologies that can identify threats much
faster than the current practice; however these are not widely used. Additionally, programs to improve
antibiotic prescribing are show significant results; however these are also not widely used (CDC, 2013, p.
27). The CDC suggests that improving antibiotic prescribing through antibiotic stewardship could be the
single most important action needed to greatly slow down the development and spread of antibiotic-
resistant infections (CDC, 2013, p. 31). For ARMC, the combined searches for infections treated with
antibiotics or resistant to antibiotics are the most frequently searched inquiries on UpToDate. For
example, Clostridium difficile treatment, extended-spectrum beta-lactamases, and treatment of
hospital-acquired, ventilator-associated, and healthcare-associated pneumonia in adults rank in the top
third through fifth inquiries respectively (2015)2
.
Performance Gap:
Physicians lack oversight when prescribing antibiotics. A program to improve antibiotic prescribing can
reduce antibiotic resistance threats, improve patient outcomes, and save healthcare dollars.
1
Antibiotic Resistance Threats in the United States. ( 2013). Centers for Disease Control and Prevention. Retrieved
from
http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=13
2
Top Topics Report. (2015). UpToDate Confidential. Courtesy of Pam Queen, ARMC Medical Librarian.

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Sources of Information:
 Reference to national health care quality standards, CDC
 Performance improvement data
 Annual needs assessment survey
 UpToDate Top Topics Report

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Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease is the third leading cause of death in the United States and
fifth cause for Clarke County (Georgia Department of Public Health, 2015)3
. Fifteen million Americans
report that they have been diagnosed with COPD (CDC, 2015, p. 1)4
. In December of 2014 the
Department of Veterans Affairs and the Department of Defense provided an update to their previous
recommendations from 2007. These new recommendations address the diagnosis, assessment, and
management of COPD in the outpatient setting (AHRQ, 2015)5
.
Performance Gap:
Physicians lack guidance on counseling patients about the health risks associated with COPD.
 Key opinion/expert interviews, Dr. Apaloo
 Reference to clinical practice guidelines, VA/DoD
 Basic epidemiology of disease state
o NHQDR
o OASIS
3
ONLINE ANALYTICAL STATISTICAL INFORMATIONS SYSTEM (OASIS): Community Health Needs Assessment
Dashboard. (2015) Georgia Department of Public Health. Retrieved from
https://oasis.state.ga.us/CHNADashboard/Default.aspx
4
Chronic Obstructive Pulmonary Disease: COPD among Adults in GEORGIA (2015). Centers for Disease Control and
Prevention. Retrieved from: http://www.cdc.gov/copd/maps/docs/pdf/GA_COPDFactSheet.pdf
5
VA/DoD clinical practice guideline for the management of chronic obstructive pulmonary disease. (2015). Agency
for the Healthcare Research and Quality: Advancing Excellence in Health Care. Retrieved from
http://www.guideline.gov/content.aspx?id=48952#Section420

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Congestive Heart Failure
Around 5.1 million people in the United States have heart failure. About half of people who
develop heart failure die within five years of diagnosis. Heart failure costs the nation an estimated $32
billion each year (CDC, 2013)6
. In Georgia, at a rate of 408, hospital admissions for congestive heart
failure are 128% away from the benchmark rate of 181 (AHRQ, 2014)7
. The 56th
search from ARMC
UpToDate top inquiries is an overview of the therapy of heart failure due to systolic dysfunction with 20
search hits in six months (2015)8
.
Performance Gap:
Health care practitioners lack guidance on counseling patients to prevent congestive heart failure and
the appropriate therapy after diagnosis.
o NHQDR
6
Heart Failure Fact Sheet. (2013). Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/DHDSP/data_statistics/fact_sheets/fs_heart_failure.htm
7
Georgia: Quality Measures Compared to Achievable Benchmarks. (2014). Agency for healthcare Research and
Quality. Retrieved from http://nhqrnet.ahrq.gov/inhqrdr/Georgia/benchmark/table/All_Measures/All_Topics
8

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Diabetes
About 29.1 million people have diabetes. Risk of death for adults with diabetes is fifty percent
higher than for adults without diabetes. Medical costs for people with diabetes are twice as high as for
people without diabetes. Nine out of ten people do not know that they have pre-diabetes (CDC, 2015)9
.
In the state of Georgia and in Clarke County, diabetes is the number seven cause of death among adults
(GDPH, 2015)10
. Hospital admissions in Georgia for uncontrolled diabetes without complications per
100,000 adults have an incidence rate of 19.8, which is 355% away from the benchmark rate of 4.4
(AHRQ, 2014)11
. In 2014, The U.S. Preventive Services Task Force released a new recommendation
concerning gestational diabetes screening (2015)12
. According to UpToDate, the treatment for diabetic
ketoacidosis and hyperosmolar hyperglycemic state in adults is the 34th
search with 23 search hits in six
months. The clinical features, evaluation, and diagnosis of the same condition is the 79th
search with 17
search hits (2015)13
.
Performance Gap:
Physicians do not always appropriately identify patients at risk for developing diabetes.
Physicians lack guidance on counseling patients about the health risks associated with diabetes.
9
Infographics on Diabetes. (2015). Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/diabetes/library/socialmedia/infographics.html
10
ONLINE ANALYTICAL STATISTICAL INFORMATION SYSTEM (OASIS): Community Health Needs Assessment
Dashboard. (2015). Georgia Department of Public Health. Retrieved from
11
12
Gestational Diabetes Mellitus, Screening. (2015). U.S. Preventive Services Task Force. Retrieved from
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/gestational-diabetes-
mellitus-screening
13

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o NHQDR; OASIS
 Evaluation reports from participants in previous activities
 Reference to clinical practice guidelines, USPSTF

ARMC CME Program
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Diet/Nutrition
Healthy People 2020 supports an increase the proportion of physician office visits made by patients
with a diagnosis of cardiovascular disease, diabetes, or hyperlipidemia that include counseling or
education related to diet or nutrition from the 20.8% in 2007 to 22.9% by 2020 (Lin, Yancy, Pollak, et. al.,
2013)14
. According to a study in JAMA, the aggregate of 14 subcomponents of diet is a more important
factor associated with disease burden than either physical inactivity or high BMI (2013)15
. The U.S.
Preventive Services Task Force has developed a new guideline for healthful diet and physical activity
counseling for cardiovascular disease prevention in adults (USPSTF, 2015)16
.
Performance Gap:
There is a lack of recognition among physicians of the importance and impact of diet on health and how
to best relay this information and make recommendations to the patient.
• Physician interview
• Medical literature review
• Reference to clinical practice guidelines, USPSTF
14
Lin, P.-H., Yancy, W. S., Pollak, K. I., Dolor, R. J., Marcello, J., Samsa, G. P., … Svetkey, L. P. (2013). The impact of a
physician and patient intervention program on dietary intake. Journal of the Academy of Nutrition and Dietetics,
113(11), 1465–1475. doi:10.1016/j.jand.2013.06.343
15
US Burden of Disease Collaborators. (2013) The State of US Health, 1990-2010: A Burden of Diseases, Injuries,
and Risk Factors. JAMA: The Journal of the American Medical Association, 310(6), 591-606. doi:
10.1001/jama.2013.13805.
16
Healthful diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk
Factors: Behavioral counseling. (2015). U.S. Preventive Services Task Force. Retrieved from
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/healthy-diet-and-physical-
activity-counseling-adults-with-high-risk-of-cvd

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End-of-Life Care
Between 2010 and 2050, the number of Americans aged 65 and older is projected to more than
double its projected population in 2010. By 2030 nearly one in five U.S. residents will be aged 65 and
older (Vincent & Velkoff, 2010, p. 1)17
. While most people would say they prefer to die at home, only
about one-third of adults have an advanced directive expressing their wishes for end-of-life care. Even
among severely or terminally ill patients, fewer than 50% have an advance directive in their medical
record. Between 65 and 76% of physicians whose patients had an advance directive were not aware that
it existed (Benson & Aldrich, 2012, p. 1)18
.
Performance Gap:
Physicians do not always appropriately identify patients’ wishes within their advance directive.
Physicians’ understanding of communication with the patients and the patients’ families about end-of-
life issues is suboptimal.
There is a lack of recognition of the importance of an advance directive among patients.
• Annual needs assessment survey
• Key opinion/expert interviews, Dr. Apaloo
• Evaluation reports from participants in previous activities
17
Vincent, G.K., & Velkoff, V.A. (2010). The Next Four Decades, The Older Population in the United States: 2010 to
2050. Current Population Reports, P25-1138. Retrieved from
http://www.aoa.acl.gov/Aging_Statistics/future_growth/DOCS/p25-1138.pdf
18
Benson, W.F. & Aldrich, N. (2012). Advance Care Planning: Ensuring Your Wishes Are Known and Honored If You
Are Unable to Speak for Yourself. Centers for Disease Control and Prevention. Retrieved from www.cdc.gov/aging

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Heart Disease
Heart disease is the leading cause of death for both men and women in the state of Georgia and in
Clarke County (GDPH, 2015)19
. Coronary heart disease is the most common type of heart disease, killing
more than 370,000 people annually (CDC, 2015)20
. The U.S. Preventive Services Task Force has
developed a new guideline for behavioral counseling for cardiovascular disease prevention in adults
(USPSTF, 2015)21
.
Performance Gap:
Physicians do not always appropriately identify patients at risk for developing hypertension.
Physicians lack guidance on counseling patients about the health risks associated with hypertension.
• Basic epidemiology of disease state
o OASIS
• Reference to clinical practice guidelines, USPSTF
19
20
Heart Disease Fact Sheet. (2015). Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm
21
Healthful diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk
Factors: Behavioral counseling. (2015). U.S. Preventive Services Task Force. Retrieved from
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/healthy-diet-and-physical-
activity-counseling-adults-with-high-risk-of-cvd

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HIV/AIDS
More than 1.2 million people in the United States are living with HIV infection, and almost one in
eight (12.8%) are unaware of their infection (CDC, 2015)22
. In 2013, Georgia ranked number five in
nation for total number of new diagnoses of HIV infections among adults and adolescents. In Clarke
County, HIV in adults aged 35-44 in Clarke County is the sixth leading cause of death (GDPH, 2015)23
. The
incidence rate of AIDS cases per 100,000 population age 13 and over was 27.9 in 2011. This incidence
rate is 896% away from the benchmark rate of 2.8 (AHRQ, 2014)24
. In 2014, the CDC introduced a new
clinical recommendation for prophylaxis use to reduce the likelihood of HIV transmission (CDC, 2014)25
.
Performance Gap:
There is a lack of recognition among physicians of the importance of recognizing substance abuse and/or
risky sexual behavior among HIV positive patients in order to provide or refer the patient for proper
health behavior counseling.
o NHQDR; OASIS; CDC
• Reference to clinical practice guidelines, CDC
22
HIV in the United States: At A Glance. (2015). Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/hiv/statistics/basics/ataglance.html
23
24
25
PREEXPOSURE PROPHYLAXIS FOR THE PREVENTION OF HIV INFECTION IN THE UNITED STATES. (2014). The
Centers for Disease Control and Prevention. Retrieved from https://docs.google.com/viewer?url=http%3A%2F
%2Fwww.cdc.gov%2Fhiv%2Fpdf%2Fprepguidelines2014.pdf

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Hypertension
About 70 million American adults (29%) have high blood pressure. Only about half of people with
high blood pressure have their condition under control. Nearly 1 of 3 American
adults has prehypertension.High blood pressure costs the nation $46 billion each year (CDC, 2015)26
.
Hypertension is the sixth leading cause of death in the state of Georgia and in Clarke County (GDPH,
2015)27
. The Veteran’s Association and Department of Defense published an updated clinical
recommendation for the diagnosis and management of hypertension in the primary care setting
(2014)28
. According to UpToDate, the evaluation and treatment of hypertensive emergencies in adults is
the 53th search with 20 search hits (2015)29
.
Performance Gap:
Physicians lack guidance on counseling patients about the health risks associated with hypertension.
o NHQDR
• Reference to clinical practice guidelines
• UpToDate Top Topics Report
26
High Blood Pressure Facts. (2015). Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/bloodpressure/facts.htm
27
High Blood Pressure Facts. (2015). Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/bloodpressure/facts.htm
28
VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE DIAGNOSIS AND MANAGEMENT OF HYPERTENSION IN THE
PRIMARY CARE SETTING. (2014). U.S. Department of Veterans Affairs. Retrieved from
http://www.healthquality.va.gov/guidelines/CD/htn/VADoDCPGfortheManagementofHTN.pdf
29

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Influenza
In the United States, each year around five and twenty percent of the population contract influenza
and more than 200,000 are hospitalized from seasonal flu-related complications (CDC, 2015)30
. In Clarke
County, influenza is the ninth cause for emergency room visits, while in the state influenza only ranks
number sixteen (GDPH, 2015)31
. The state of Georgia ranks number 46 out of 50 states for percentage of
adults aged 65 and older who received the flu vaccine in the last year (UHF, 2014)32
. In Georgia, the rate
for hospital admissions for immunization-preventable influenza aged 65 and over is 208% away from the
benchmark (AHRQ, 2014)33
. For ARMC, the search for treatment of seasonal influenza in adults is ranked
41 with 22 search hits (UpToDate, 2015)34
.
Performance Gap:
There is a lack of recognition among patients of the importance of receiving the flu vaccination annually,
especially among at-risk adults.
o NHQDR
o OASIS
o United Health Foundation
• UpToDate Top Topics Report
30
Seasonal Influenza Q&A. (2015). Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/flu/about/qa/disease.htm
31
32
Flu Vaccine Georgia Rank: 46. (2014). AMERICA’S HEALTH RANKINGS: UNITED HEALTH FOUNDATION. Retrieved
from http://www.americashealthrankings.org/Measures/Measure/GA/flu_vaccine_sr
33
34

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Pain Management
According to the United Health Foundation, in Georgia pain management among adults aged 65 and
older with arthritis has decreased by 5% in the last year (2014)35
. The rate of long-stay nursing home
residents with moderate to severe pain is 70% away from the benchmark (AHQR, 2014)36
. Effective
January 1, 2015, The Joint Commission has revised a previous pain management standard to clarify their
recommendations so that the patient’s individual benefits and risks plays a more central role in deciding
treatment (The Joint Commission, 2014, p. 11)37
.
Performance Gap:
Physicians’ understanding of communication with the patients and the patients’ families about pain
management is suboptimal.
• Performance improvement data
o NHQDR
o UHF
• Evaluation reports from participants in previous activities
• Reference to clinical practice guidelines, The Joint Commission
35
State Data: Georgia. (2014). AMERICA’S HEALTH RANKINGS: UNITED HEALTH FOUNDATION. Retrieved from:
http://www.americashealthrankings.org/senior/GA
36
37
Clarification of the Pain Management Standard. (2014). The Joint Commission. Retrieved from
http://www.jointcommission.org/assets/1/18/Clarification_of_the_Pain_Management__Standard.pdf

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2015 Needs Assessment Email Survey Questions
1. The goal of CME is to provide educational opportunities that will assist the physician in providing
the highest quality patient care. To do this, we need to identify the gap between the ideal
practice and the actual practice. With the ideal clinical practice in mind, what are three areas
that are most in need of improvement in the practice of clinical medicine?
2. With a constant influx of new drugs, better clinical treatments, and new diagnostic tests, what
CME topics would best address the difference between your current knowledge and what you
need to know?
3. Which of the following are most important to you when choosing a CME course?
a. New diagnostic approaches
b. New therapeutic approaches
c. New drugs/ or drug therapies
d. Topics specific to my specialty
e. Other____________
4. What day(s) of the week is/are best for you to attend CME educational activities? (Select all that
apply).
a. Monday
b. Tuesday
c. Wednesday
d. Thursday
e. Friday
f. Saturday
5. What time(s) of day is best for you to attend CME? (Select all that apply).
a. Morning (before 8 am)
b. Midday (12 noon)
c. Evening (after 5 pm)
d. Other _____

6. Which format(s) do you prefer to obtain CME credit?
a) In-person live conferences
b) Internet live
c) Enduring materials (on-demand learning online)
d) Journal based CME
e) Performance Improvement CME
f) Internet searching and learning
g) Learning from teaching
h) Other__________________
7. Specialty: ____________________________
20

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