attitudes, knowledge and practices of physicians related to ehdi national ehdi conference feb, 2006...

Attitudes, Knowledge and Practices of Physicians

Related to EHDI

National EHDI Conference

Feb, 2006

Mary Pat Moeller, Ph.D.Boys Town National Research Hospital

Karl White, Ph.D.Utah State University

Faculty Disclosure Information

In the past 12 months, we have not had a significant financial interest or other relationship with the manufacturers of product or providers of the services that will be discussed in our presentation

This presentation will not include discussion of pharmaceuticals or devices that have not been approved by the FDA nor will the presentation discuss unapproved or "off-label" uses of pharmaceuticals or devices.

Overview of Presentation

Project Rationale

Results of National Survey of 1,968 physicians

Implications for EHDI teams

Project Rationale

Newborns seen regularly by primary care physician

Key role in promoting follow up, making referrals and supporting families

Attitudes, Knowledge and Experiences influence behaviors

Need to understand physician perspectives

Project with Pediatricians

Pilot Focus Groups (N = 21)

Formal Focus Group Work (N=27)

Internet Based Survey (N=263); Paper Survey (N = 1,968)

Resource Development

Field test, revise & disseminateNIDCD & MCHB

supported

Themes from Focus Groups: Methods 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:

Methods 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?”

NHS PHYSICIAN SURVEY

BTNRH and NCHAM Collaboration

Mary Pat Moeller, Ph.D., Karl White, Ph.D., Lenore Shisler

Methods

Designed survey based on focus groups and internet responses

Field tested survey at medical society meetings; developed Spanish version

Invited state EHDI coordinators to participate

Mailed survey & cover letter; reminder postcard 2 weeks later

Survey Question Examples

Attitudes:Do you think NHS causes parents

undue anxiety or concern?Do you believe UNHS is worth what it

costs?Please list any concerns you have

about NHS, diagnosis and intervention.

Survey Questions Examples

Practices:Approximately how many children with

permanent hearing loss (EXCLUDING OTITIS MEDIA) have you had in your practice over the past 3 years?

List any specialists to whom you routinely refer the family of a child with permanent hearing loss (list the types of specialists).

Survey Question Examples

Knowledge: What is your best estimate of the earliest

age at which:• A child not passing the screening should be seen

for follow up testing• A child can be definitively diagnosed with

permanent hearing loss• A child can begin wearing hearing aids• A child with permanent hearing loss should be

referred to early intervention

Enter age estimates _________________

States Involved in Survey of Physicians

N = 21 States + Puerto Rico

Physician Survey: Demographics

60.3

27.8

30.5 0.3 1.8 2.8

0

10

20

30

40

50

60

70

Pe

rce

nt

of

Re

sp

on

de

nts

Pediatrician

Family Pr

ENTO

B/GYN

Internal

Resident

Neonatology

Gender:

53.2% Male

46.8% Female

Location:

62.5% Metro

24.1% Small town

13.3% Rural

N = 1,968

Moeller, White & Shisler, 2006

Practice Settings

Private/Community Clinic 75.6%

Hospital 10.4%

Medical School/University 5.8%

Other 3.6%

Unknown 3.7%

Practice with 0-5 Population

0

10

20

30

40

50

60

Pe

rce

nt

of

Pra

cti

ce

Total Group Pediatricians Family Practice

Group of Respondents

0-10 years = 40.2%

11-20 years = 28.6%

21-30 years = 22.5%

31+ years = 8.7%

Children with SNHL in past three years of practice

3.133.32

1.25

0

0.5

1

1.5

2

2.5

3

3.5

National Pediatricians Family Practice

Mea

n N

um

ber

of

Ch

ild

ren

ENT X = 16.95

Importance of testing all newborns

0102030405060708090

Per

cen

t R

esp

on

den

ts

Very Imp

Somew

hatU

nsure

Not Im

p

Very Unim

p

4.4%

3% Pediatricians;

6% Family Practice

p < .001

Does NHS cause undue parental anxiety?

0102030405060708090

Pe

cen

t o

f R

esp

on

den

ts

No Yes Unsure

Category of Response

Total Group

Pediatricians

Family Practice

Positive Findings:

Most of our physicians receive screening results (88.61% >)

But…12% of pediatricians and 17% of family physicians receive < 50% of results!

Most know that infants should be referred immediately for additional testing (89.2 < 3 mos >)

But…24.3% unsure NHS is worth what it costs

Concerns about NHS

Too many false positives Costs outweigh benefits Loss to follow up Need for training Unclear about procedures; complex Inconclusive results Need for parent education Need for funding & better equipment

Confidence in Counseling Parents following Screening

05

101520253035404550

Pe

rce

nt

Re

sp

on

de

nts

Very

Somew

hat

Unsure

Not

Level of Confidence

11%

Risk for late onset SNHL

0102030405060708090

100

Per

cen

t R

esp

on

den

ts

Menigitis*

NICU*

Cleft Palate*CM

V*Syphilis*Fam

ily*M

om >40

HeartColdsHypotonia

Risk Factor

Referral to Specialists

0

20

40

60

80

100

Pe

rce

nt

Re

sp

on

de

nts

Specialist Type

9.7

Follow Up & Intervention

0102030405060708090

100

Pe

rce

nt

Re

sp

on

de

nts

<1 mo

1-3 mos

3-6 mos

6-9 mos

9-12 mos

>12 mos

Wear Hearing Aids

0102030405060708090

100

Perc

ent R

espo

nden

ts

Age Diagnosis Possible

27% 41.5%

Ages at which….(1-3-6?)

<1 1-3 3-6 6-9 9+

51.9 10.8 12.4 15.4 9.6

38.1 9.1 11.2 22.3 19.3

61.6 8.0 9.8 13.2 7.4

Diagnosis

Hearing Aids

Early Intervention

Candidates for Cochlear Implants

74.3

15.5

5.9

27.1

0

20

40

60

80

100

Pe

rce

nt

Re

sp

on

de

nts

Bi Profound*

Bi M

ild-Mod

Unil M

ild-Mod

Unsure

Hearing Loss Category

48.5

Confidence in Talking with Parents about…

0

10

20

30

40

50

60

70P

erc

en

t R

esp

on

den

ts

Causes Comm Meth Unil/Mild Profound CIs

Topic Area

Very

Somewhat

Not Confident

Did your training prepare you?

0

10

20

30

40

50

60

70

80P

erce

nt

of

Res

po

nd

ents

Yes No Unsure

Category of Response

Total GroupPediatriciansFamily Practice

Primary Sources of Info on NHS

05

10152025303540

Per

cen

t R

esp

on

den

ts

Information SourceFrequent Internet Use = 51.7%

Policy Statement Awareness

Organization

AAP 56.8%

AAO 1.9%

AAFP 6.6%

State 1.1%

AMA .3%

CDC .5%

USPSTF .7%

Continuing Medical Education: Most 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

CME: What does the literature say? 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)

Adult Learning Methods

Diverse learning styles

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

Brookfield, 1986

Topics Judged as Needs (In prioritized order):1. Protocol for f/u

2. Early intervention

3. Contacts for more information

4. Screening for late onset SNHL

5. Patient Education Resources

6. Impact of HL on language

7. Screening at well-child visits

8. Hearing Aids and cochlear implants

9. Genetics and hearing loss

10. Counseling families about screening results

11. Screening methods

Useful Resources

0

10

20

30

40

50

60

70P

erc

en

t R

es

po

nd

en

tsVery Helpful

Somewhat

Most Recommended Resources

1. Protocol cards

2. Patient brochures

3. Web sites

4. On-line CME*

5. Peer education

6. Grand rounds materials

Less Recommended Resources

CDs or DVDs to use in patient education

Videotapes to use in parent education

…but some offices prefer this type of material

…reinforces need for multiple avenues

Big Picture: Physicians

Positive changes seen, but more education is needed

“One size” will not fit all; multiple strategies are needed

“Just in time” resources; protocol steps Action-oriented resources focused on

medical management, family counseling Many topics “needed” but at a manageable

level Additional resources (e.g., peer education

and internet) needed

Next Steps:

Manuscript (in preparation) Work with National Nursing, PA and

Nurse Practitioner Groups National Midwife organizations Sound Health Connections

Conference held in Oct, 2005 Action plans developed

Focus Group Themes: Consequences

NPs and nurses need no convincing about the developmental consequences of hearing lossBut they want resources to educate

families that “tell people why you need to care about this.”

Barrier: “My child is not sick. He looks fine. It’s “just” a hearing loss.

Focus Group Themes: Role of Experience

Limited experience with confirmed hearing loss in infants

Considerable experience with babies who pass second screening

Leads to some “complacency” or minimizing a “refer” in talking with families

Reporting barriers: “Most often we are under the assumption – which is a bad assumption – that if they were not told anything, then it was a pass.”

Focus Group Themes: Social Barriers

Practical strategies for Medicaid families:Recognize effects of “radar screen”Increase monitoring (WIC form,

checklist)Combine with immunization visitsIncrease public awarenessResources to make consequences

clear

Focus Group Themes: Time Barriers Timing of the

information “bookends”…prenatal

(classes or OB) and 2 day call; 2 week check

Don’t rely only on the hospital-based discussions

Moms are “overwhelmed, concerned with other issues”

Time is limited in office visits Can be a barrier to

continuity of care (“I just pass the buck”)

Other pressing issues may lower this one “on the radar screen”

Need resources that are sensitive to the time demands

Focus Group Themes: Target Groups

Audiences that need to learn with us: The Public! (example: lead) Specialists: OB, ENT, Lamaze Class

Teachers Parents Day Care Workers School Nurses Newborn Nursery Workers Office Staff (triage, med techs) Nursing Training Programs

Recommended Educational Strategies

Journal articles Newsletters Ad in journals Curriculum for prenatal

classes Courses with CEUs Prenatal packets Simple language for

parents; PSAs Nurse to nurse

educational materials

Simulations (demonstrate importance!)

On line resources (English & Spanish)

Local organization meetings

Outreach with lunch Booth at conference Educational CDs Free materials Orientation packets

Additional Project Collaborators Lenore Shisler, NCHAM William Eiserman, NCHAM Marjorie Brennan, BTNRH Leisha Eiten, BTNRH Joyce Bunger, Creighton University Russell Smith, University of Nebraska Diane Schmidt, BTNRH Roger Harpster, BTNRH Tom Behringer, NCHAM