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