When Old Beliefs Won’t Budge: Evaluating Entrenched Attitudes and Resistance to Change Among Health Care Professionals. Presented at the 2013 ACEHP Annual Meeting.

1. Years in Practice
Patients with T2DM
Seen/Treated Per Week
When Old Beliefs Won’t Budge: Evaluating Entrenched Attitudes
and Resistance to Change Among Health Care Professionals
>25
27%
16-25
24%
0-5
21%
6-15
26%
>50
20%
41-50
7%
Case 2
0-20
46%
The patient is a 68-year-old man who was diagnosed with T2DM 9 years ago.
His medical history is significant for hyperlipidemia and hypertension.
31-40
12% 21-30
17%
Current Medications
5.0
3.7
4.0
3.3
Carole Drexel, PhD, CCMEP; Anne Jacobson, MPH, CCMEP; Jay M. Katz, 2.1 CCMEP, Potomac Center for Medical Education. Columbia, MD
MA,
3.0
2.0
Background
Aims
Results: Participant Demographics
Case 1
1.0
0.0 audience with many years in practice and high volume of patients
• Live activities remain
• High-level
The patient is a 52-year-old obese African American woman with a long2011 ACCME Report • Compare the performance of various
Pre-activity
Post-activity
Follow-up
Physician Participants
popular educational
qualitative and quantitative assessment
with T2DM
standing complaint of generalized fatigue that she describes as being “under
by Activity Type
formats in CME
methods, including pre-activity, post-activity,
the weather.” She has been told that “her sugar trends high,” but she has not
• 29% endocrinologists; 13% PCPs; 12% diabetes educators; 7% pharmacists;
and follow-up tools, in measuring entrenched
followed up on this. She has no other complaints.
Performance
• How effective are
7% RNs/NPs/PAs; 33% others (including research)
Internet Search Improvement
beliefs among health care professionals
1%
≤1%
stand-alone CME
Physical Examination
Select Labs
activities in addressing Journal CME
• Describe the advantages and limitations
Years in Practice
Patients with T2DM
• BMI: 24.6 kg/m2
• FBG: 190 mg/dL and HbA1C: 8.9%
9%
Courses
Seen/Treated Per Week
persistent gaps
of specific educational activity formats in
16%
• BP: 130/85 mmHg; pulse: 78
• Serum creatinine: 1.3 mg/dL
in knowledge and
addressing entrenched beliefs and facilitating
• Remaining physical exam
• GFR: 73 mL/min/1.73 m2
competency?
change toward evidence-based clinical
Internet
0-5
unremarkable
Regularly
>50
• ALT: 15 U/L
Enduring
21%
Scheduled
>25
practice
20%
0-20
35%
Series
• TC: 170; non-HDL: 138; HDL: 42 mg/dL
27%
46%
38%
41-50
• Identify opportunities to close knowledge
7%
6-15
and competence gaps with optimal program
31-40
26%
16-25
Manuscript Review
Case 1: HbA1C Target
12% 21-30
Internet Live
planning, design, and outcomes measurement,
<1%
24%
1%
17%
against a backdrop of entrenched beliefs
According to ADA recommendations, what is her recommended HbA1C target?*
Activity Description
• A CME-certified dinner symposium held in conjunction with the American Diabetes Association (ADA)
71st Scientific Sessions, Saturday, June 25, 2011
• Upon successful completion of Emerging Options for Type 2 DM Management: Glucose Control and The
Kidney, participants were meant to be able to:
– Cite the results of key clinical trials that have shown the long-term benefits of glycemic control in
patients with T2DM
– Make therapeutic decisions driven by patient presentation, as well as the safety and efficacy of
therapeutic agents
– Understand the role of the kidney in glucose regulation and outline how the mechanism of action
of SGLT2 inhibitors differs from that of currently available hypoglycemic agents
– Highlight the data from key clinical trials of investigational SGLT2 inhibitors and discuss the
potential role of these agents in the treatment of patients with T2DM
Educational Design
A 2-hour satellite symposium with 4 live interactive lectures (20 to 40 min each), including polling
questions using ARS and interactive discussions with questions and answer sessions after each
presentation
• Two lectures covered basic T2DM care, including ADA guideline recommendations, HbA1C targets, and
first- and second-line drug management
• Two lectures covered topics that were new to the target audience, including renal physiology, glucose
metabolism, and clinical experience with SGLT2 inhibitors
Outcomes Assessments
• Level 1 through 4 Outcomes
– ARS questions were designed to evaluate knowledge of a number of topics in the management of
T2DM
– A paper-based survey was developed using case vignettes to evaluate competence in applying the
guidelines for T2DM management
– Knowledge and competence assessments were performed immediately prior to, immediately after,
and 2 months after the live activity
• Level 5 Outcomes
– Self-reported intent to change was measured immediately after the activity
– Post-activity responses were compared with answers obtained during the follow-up survey
Pre-Test
• Participants’ self-assessment of competence was high in the following areas:
– managing patients with T2DM to recommended HbA1C target goals, while
minimizing weight gain and CV and hypoglycemia risks [mean rating, 3.7]
– selecting an initial T2DM therapy [4.0]
2011 ACCME Report
– selecting add-on therapy [3.9] Participants
Physician
Improvement
≤1%
On 5-point Likert scale, rightward move in knowledge regarding the role of
Journal CME
9%
the kidney and the SGLT2 co-transporter in glucose regulation
Courses
16%
5.0
4.0
3.0
2.0
1.0
0.0
Scheduled
Series
38%
3.7
2.1
Manuscript Review
<1%
Internet Live
1%
<7.5%
0%
3%
5%
80%
86%
<6.5%
20%
10%
16%
<6.0%
0%
0%
0%
Case 1: Treatment Recommendations
The patient was counseled about the importance of lifestyle modifications. What
other steps do you recommend to lower the patient’s HbA1C?*
3.3
Pre-Test
Post-Test
Follow-up
No other intervention; follow-up in 3
months
9%
7%
0%
Initiate treatment with metformin
86%
83%
43%
38%
3%
3%
7%
Follow-up
Add a TZD to metformin and glyburide
25%
22%
10.5%
Add incretin-based agent to metformin and
glyburide
44%
4%
31.6%
Discontinue glyburide, add basal insulin
28%
52%
42.1%
A. 90%
Discontinue glyburide, add once daily
intermediate or long-acting insulin and add
rapid-acting insulin to meal with highest
excursion
60%
80%
3%
22%
15.8%
26%
16%
B. 50%
9%
1%
C. 20%
4%
2%
D. 10%
Case 2: AACE Treatment Guidelines
Pre-Test
Post-Test
Follow-up
Add insulin to metformin and glyburide
25%
17%
22%
Add a TZD or incretin-based agent to
metformin and glyburide
41%
57%
28%
22%
13%
28%
Discontinue glyburide, add once daily
intermediate or long-acting insulin and add rapidacting insulin to meal with highest excursion
13%
13%
22%
Case 2: Glycemic Control and Cardiovascular Risk
Which of the following statements best describes your approach to managing a
patient with a positive history for MI and hypoglycemia?*
Post-Test
Follow-up
5%
13%
4%
0%
I would do everything I could to get his HbA1C
to a goal of ≤7.0%
63%
71%
53%
25%
25%
26%
Pre-Test
Post-Test
Follow-up
No other intervention; follow-up in 3
months
17%
4%
11%
Initiate treatment with metformin
33%
11%
37%
Initiate treatment with TZD
22%
36%
32%
Areas for Practice Change
Please identify one concept you learned from this program that you will try to
incorporate into your practice:
Post-Test
Follow-up
Better use of management guidelines
18%
26%
Treat earlier or more aggressively
14%
53%
47%
21%
*The most correct answer appears in the shaded row of each table.
Disclosures: Disclosures – Drexel, C.; Jacobson, A.; Katz, J.: Nothing to disclose. The symposium, Emerging Options for Type 2 DM Management: Glucose Control and The Kidney, was supported by an educational grant from Bristol-Myers Squibb and AstraZeneca, LP
2011 ACCME Report
Physician Participants
by Activity Type
Initiate prevention strategies
0%
Use of evidence-based treatment/management
32%
21%
Address poor patient adherence
4%
26%
Incorporate new techniques/technologies
50%
SGLT2 co-transporters are responsible for reabsorbing up to XX% of the
glucose filtered at the glomerulus.
The most correct answers above are marked with a star.
Entrenched Beliefs in T2DM Management
After participating in this educational activity:
• Only one-quarter of clinicians selected the appropriate HbA1C
target for a patient with T2DM and high cardiovascular risk
• Only 35% were able to apply evidence from trials of tight glucose
control to current T2DM management
• Confusion remained about strategies available to manage
hyperglycemia and the role and place of the newest agents
(e.g. incretins)
• Only 32% were able to identify appropriate treatment options for a
patient with renal impairment
• Uncertainties about guideline recommendations also remained,
with only 28% able to identify the correct steps for a patient with
inadequate response to glyburide and metformin
21%
Consider whether your approach to this patient would be different if she had
evidence of renal impairment at baseline (eGFR: 56 mL/min/1.73 m2). In addition
to lifestyle modifications, what other steps do you recommend to lower her HbA1C?*
28%
“New” concepts show a greater degree of change between preand post-tests (+20), with most participants answering correctly
Post-Test
Pre-Test
Case 1: Renal Impairment
Initiate treatment with SU
The most correct answers above are marked with a star.
Pre-Test
I would do everything I could to get his HbA1C
to a goal of ≤6.5%
Follow-up
• Participation in the activity resulted in increased knowledge of newer
concepts that were taught (e.g. renal physiology and effects of SGLT2
inhibition):
Years 44% (pre-activity) to 100% (post-activity) of participants
Patients with T2DM
– Increase fromin Practice
Seen/Treated Per Week
who correctly identified the effects of SGLT2 inhibition on glucosuria,
systolic blood pressure, and weight
0-5
>50
– Increase from 60% to 80% of participants 20% correctly identified the
who
21%
>25
0-20
27% glucose filtered by the kidney
proportion of
46%
41-50
7%
6-15
• HOWEVER, confusion remained about basic clinical concepts in T2DM
31-40
26%
16-25
management, including the results from the12% 21-30
tight glucose control trials
24%
17%
(28% prior vs 35% post)
C. Intensive glycemic control is associated with increased risk for
hypoglycemic events, but it has no impact CV mortality
According to ADA guidelines, what should be your next step in treatment?*
I would be comfortable getting his HbA1C to
≤7.5% or 8%
3%
B. Intensive glycemic control is associated with increased
hypoglycemic events, but reduced CV mortality
28%
35%
Case 2: ADA Treatment Guidelines
A. There is a risk for increased CV mortality and hypoglycemia
episodes in patients whose A1C is close to 7%
30%
27%
• TC: 135 mg/dL; LDL-C: 112 mg/dL
• HDL-C: 42; TG: 187; non-HDL-C: 93 mg/dL
95%
Initiate treatment with sulfonylurea (SU)
Post-activity
• HbA1C: 8.4%
• FPG: 148 mg/dL; PPG: 216 mg/dL
“Old” concepts show little change between pre- and post-tests
(+7), with the majority of participants still answering incorrectly
Based on the results from ACCORD, VADT and ADVANCE, which of the
following is true regarding the effect of intensive glycemic control (A1C goal
of < 7.0%) on CV outcome and hypoglycemia risk:
Select Labs
79%
Initiate treatment with
thiazolidinedione (TZD)
Pre-activity
• Weight: 180 lbs; BMI: 24.4 kg/m2
• BP: 128/78 mmHg otherwise unremarkable
According to AACE guidelines, what should be your next step in treatment?*
<7.0%
Knowledge Improvement inRegularly
Selected Areas
Internet
Enduring
35%
Follow-up
Physical Examination
• Metformin 1500 mg/d
• Glyburide 5 mg BID
• Simvastatin 40 mg/d
Discontinue glyburide, add basal insulin
by Activity Type
Gains in Self-Reported Knowledge
Performance
Internet Search
1%
Post-Test
Discussion: What Are “Entrenched Beliefs”?
21%
47%
Other
11%
5%
Practice Pearls for the CME Educator
• Clinicians can make major gains in knowledge and competence
related to new material by participating in a single, 2-hour, live
CME activity
• However, many basic concepts in T2DM management remain
unclear, even in high-level diabetes professionals
• These data emphasize the need to proactively identify opportunities
to incorporate “old material” in CME activities, even as new
concepts are being taught
– Make time in the program agenda to review basic concepts
related to diagnosis, treatment goals, and guideline
recommendations
– Reiterate “old material” in case studies
– Test for knowledge and competence in the basics in all outcomes
assessments
• Until incorrect “entrenched beliefs” are unlearned, clinicians will
not be able to apply basic concepts in clinical practice
• Correction of “entrenched beliefs” is likely a major barrier to
clinical change