Improved knowledge and competence by cardiologists (n=531; P <.05; large effect size of 1.799) and primary care providers (PCPs) (n=533; P <.05; large effect size of 1.836)

Primary Care Providers

results

Patient #1John, a 65-year-old former smoker, presented at 11 PM on Tuesday to the emergency department with a prolonged episode of chest pain. His medical history was significant for type 2 diabetes (longer than 15 years’ duration), hypertension, obesity, dyslipidemia, and an ischemic stroke 7 years ago from which he recovered completely without any residual neurologic deficits. His medications included ramipril 20 mg/d, atenolol 200 mg/d, simvastatin 40 mg/d, metformin 1000 mg/d, and insulin.

Patient #2One month after discharge, John presented at 9 PM to the ED with severe recurrent angina. His blood pressure was 142/90 mm Hg, and his pulse was 95 bpm. ECG revealed ST-segment depression of 0.8 mm. Attempts to relieve his anginal symptoms with nitroglycerin failed. His laboratory results indicated an elevated troponin level, A1c 8.2%, and a creatinine level of 142 μmol/L. His Global Registry of Acute Coronary Events (GRACE) risk score was 153 for a 4% risk of in-hospital death and 215 for a 19% risk of in-hospital death or MI. His TIMI risk score was 7 for a 41% risk of all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization at 14 days. He was taken emergently to the cardiac catheterization laboratory. He reported taking his last dose of ticagrelor at 9 AM.

Case-Based CME Improves on Clinical Decision-Making in NSTEMI

Cardiologists (n = 533) PCPs (n = 531)

Pre-assessment Post-assessment Pre-assessment Post-assessment

% (n) % (n) % (n) % (n)

AAdminister 325-mg loading dose of aspirin, dicontinue clopidogrel, and administer 60-mg loading dose of prasugrel

11% (61) 4% (22) 18% (96) 15% (78)

BAdminister 325-mg loading dose of aspirin and 600-mg loading dose of clopidogrel

19% (99) 4% (20) 34% (180) 12% (62)

CAdminister 325-mg loading dose of aspirin, discontinue clopidogrel, and administer 180-mg loading dose of ticagrelor

26% (136) 89% (474)* 19% (101) 69% (364)*

DAspirin 81 mg and clopidogrel 75 mg daily can be continued until treatment strategy is defined

44% (237) 3% (17) 29% (154) 5% (27)

*P <.05

*P <.05

Cardiologists (n = 533) PCPs (n = 531)

Pre-assessment Post-assessment Pre-assessment Post-assessment

% (n) % (n) % (n) % (n)

A Seven days after discontinuing ticagrelor 12% (65) 4% (19) 18% (93) 10% (54)

B Five days after dicontinuing ticagrelor 48% (254) 93% (497)* 20% (106) 78% (415)*

C Three days after discontinuing ticagrelor 17% (93) 1% (7) 21% (110) 6% (34)

D At least 24 hours after dicontinuing ticagrelor 23% (121) 2% (10) 42% (222) 5% (28)

*P <.05

*P <.05

*P <.05

Cardiologists (n = 533) PCPs (n = 531)

Pre-assessment Post-assessment Pre-assessment Post-assessment

% (n) % (n) % (n) % (n)

A Immediately 22% (118) 6% (31) 44% (236) 12% (62)

B 2 to 3 days later 6% (33) 3% (15) 14% (74) 8% (43)

C Not until medical therapy is optimized 4% (19) 0% (1) 10% (55) 3% (15)

D Within 24 hours 68% (363) 91% (486)* 31% (166) 77% (411)*

Cardiologists (n = 533) PCPs (n = 531)

Pre-assessment Post-assessment Pre-assessment Post-assessment

% (n) % (n) % (n) % (n)

A Continue aspirin 325 mg/d indefinitely 12% (64) 2% (12) 10% (55) 10% (53)

B Continue aspirin 325 mg/d and add clopidogrel 75 mg/d 9% (46) 2% (11) 21% (111) 8% (40)

C Decrease aspirin dosage to 81 mg/d 34% (182) 3% (14) 21% (111) 5% (26)

D Decrease aspirin dosage to 81 mg/d and restart ticagrelor 45% (241) 93% (496)* 48% (254) 78% (412)*

Question #1What changes, if any, would you make with respect to John’s antiplatelet therapy after admission?

(Correct answer is highlighted in yellow.) Question #3How soon can CABG be performed on John?

(Correct answer is highlighted in yellow.)

Question #2When should cardiac catheterization be performed in John?

(Correct answer is highlighted in yellow.)

Question #4How would you manage antithrombotic therapy post-CABG in John?

(Correct answer is highlighted in yellow.)

Amy Larkin, PharmD1; Michael LaCouture, MA1; Caroline Padbury, BPharm1

Medscape Education, New York, NY

This CME-certified activity was supported by an independent educational grant from AstraZeneca Pharmaceuticals LP.

Conclusion Source of Support Notes Disclosures

Scan here to view this poster online.

Nothing to disclose for all authors.• Online case-based CME activities modeled after the interactive grand rounds approach prompted changes in clinical knowledge, showing that when effectively constructed, this methodology is an effective tool to improve clinical application of guidelines and clinical decision making in NSTEMI.

• The greatest improvements were seen in selecting an antiplatelet therapy for a patient experiencing an ACS event and recognizing the time needed before CABG after discontinuing a P2Y12 inhibitor.

• This interactive educational format should be applied to CME for future activities.

Question #1 Question #2 Question #7 Question #8

Relative Percent Change% Correct Pre % Correct Post

Percentage of Participants With Correct Response by Question(Pre- and Post-assessment Questions)

Pre-assessment Scoring Distribution

Number of Questions Correct/All Questions Number of Questions Correct/All Questions

Post-assessment Scoring Distribution100%

80%

60%

40%

20%

0%0/4 1/4 2/4 3/4 4/4 0/4 1/4 2/4 3/4 4/4

100%

80%

60%

40%

20%

0%

100%

19%

69%77%

31%20%

78%

48%

78%

75%

50%

25%

0%260% 148% 292% 62%

Pre-assessment Scoring Distribution

Number of Questions Correct/All Questions Number of Questions Correct/All Questions

Post-assessment Scoring Distribution100%

80%

60%

40%

20%

0%0/4 1/4 2/4 3/4 4/4 0/4 1/4 2/4 3/4 4/4

100%

80%

60%

40%

20%

0%

Question #1 Question #2 Question #7 Question #8

Relative Percent Change% Correct Pre % Correct Post

Percentage of Participants With Correct Response by Question(Pre- and Post-assessment Questions)

100%

26%

89%68%

91%

48%

93%

45%

93%

75%

50%

25%

0%249% 34% 96% 106%

Cardiologists

introduction

Evolving therapies and guideline recommendations to treat non-ST-segment elevation myocardial infarction (NSTEMI) create clinical confusion. Impact on knowledge and performance of a case-based design of continuing medical education (CME) were measured on clinical decision making related to NSTEMI treatment.

methods

instructional Design: text-BaseD interactive case

This 5000-word, interactive, text-based CME format included 2 patient cases that offered detailed scenarios and posed questions exploring the learner’s current knowledge and therapeutic approach. Learners were prompted to determine the appropriate treatment and follow-up for the patient. After each question, a carefully detailed, fully referenced explanation of the most appropriate response was presented. By combining a case-based format with 4 to 6 questions per case, this format “tests” learners’ level of understanding on each item before delivering any education and “teaches” by correcting or reinforcing their existing understanding. The activity launched online on April 16, 2014 and data were collected through July 24, 2014.

assessment methoD: linkeD learning assessment (lla)

An LLA compares individual participants’ paired responses to questions before exposure to educational content (pre-assessment questions) with responses to the same questions after participation in the educational activity (post-assessment questions). The LLA shows the overall effect of the educational activity. Only participants who answered every assessment question are included in this analysis. Each question in the LLA is directly related to the learning objectives of the educational activity.

statist ical analysis

For all questions combined, the effect size was calculated by comparing pre-assessment means and post-assessment means of linked learners to show the size of the effect of the educational intervention. Effect sizes (calculated using Cohen’s D) greater than 0.8 are large, between 0.8 and 0.4 are medium, and less than 0.4 are small. A paired 2-tailed t-test was used to assess whether the mean pre-assessment score was different from the mean post-assessment score. A Pearson’s χ2 statistic was used to determine significance. P values are shown as a measure of significance; P values less than 0.05 indicate a statistically significant result.

Guidelines-based Approach in the Treatment of Patients With NSTEMI CME

Dr Dominick Angiolillo presents a challenging case study of a patient who presents with chest pain 7 months after having a stent placed.

April 16, 2014

For more information contact Amy Larkin, PharmD Director of Clinical Strategy, Medscape, LLC alarkin@medscape.net.

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