Objective. —To review the literature relating to the effectiveness of education strategies designed to change physician performance and health care outcomes. Data Sources. —We searched MEDLINE, ERIC, NTIS, the Research and Development Resource Base in Continuing Medical Education, and other relevant data sources from 1975 to 1994, using continuing medical education (CME) and related terms as keywords. We manually searched journals and the bibliographies of other review articles and called on the opinions of recognized experts. Study Selection. —We reviewed studies that met the following criteria: randomized controlled trials of education strategies or interventions that objectively assessed physician performance and/or health care outcomes. These intervention strategies included (alone and in combination) educational materials, formal CME activities, outreach visits such as academic detailing, opinion leaders, patient-mediated strategies, audit with feedback, and reminders. Studies were selected only if more than 50% of the subjects were either practicing physicians or medical residents. Data Extraction. —We extracted the specialty of the physicians targeted by the interventions and the clinical domain and setting of the trial. We also determined the details of the educational intervention, the extent to which needs or barriers to change had been ascertained prior to the intervention, and the main outcome measure(s). Data Synthesis. —We found 99 trials, containing 160 interventions, that met our criteria. Almost two thirds of the interventions (101 of 160) displayed an improvement in at least one major outcome measure: 70% demonstrated a change in physician performance, and 48% of interventions aimed at health care outcomes produced a positive change. Effective change strategies included reminders, patient-mediated interventions, outreach visits, opinion leaders, and multifaceted activities. Audit with feedback and educational materials were less effective, and formal CME conferences or activities, without enabling or practice-reinforcing strategies, had relatively little impact. Conclusion. —Widely used CME delivery methods such as conferences have little direct impact on improving professional practice. More effective methods such as systematic practice-based interventions and outreach visits are seldom used by CME providers. ( JAMA . 1995;274:700-705)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=JAMA&articleId=389532&pdfFileName=jama_274_9_018.pdf

Changing Physician Performance: A Systematic Review of the Effect of Continuing Medical Education Strategies

ContextAlthough physicians report spending a considerable amount of time in
continuing medical education (CME) activities, studies have shown a sizable
difference between real and ideal performance, suggesting a lack of effect
of formal CME.ObjectiveTo review, collate, and interpret the effect of formal CME interventions
on physician performance and health care outcomes.Data SourcesSources included searches of the complete Research and Development Resource
Base in Continuing Medical Education and the Specialised Register of the Cochrane
Effective Practice and Organisation of Care Group, supplemented by searches
of MEDLINE from 1993 to January 1999.Study SelectionStudies were included in the analyses if they were randomized controlled
trials of formal didactic and/or interactive CME interventions (conferences,
courses, rounds, meetings, symposia, lectures, and other formats) in which
at least 50% of the participants were practicing physicians. Fourteen of 64
studies identified met these criteria and were included in the analyses. Articles
were reviewed independently by 3 of the authors.Data ExtractionDeterminations were made about the nature of the CME intervention (didactic,
interactive, or mixed), its occurrence as a 1-time or sequenced event, and
other information about its educational content and format. Two of 3 reviewers
independently applied all inclusion/exclusion criteria. Data were then subjected
to meta-analytic techniques.Data SynthesisThe 14 studies generated 17 interventions fitting our criteria. Nine
generated positive changes in professional practice, and 3 of 4 interventions
altered health care outcomes in 1 or more measures. In 7 studies, sufficient
data were available for effect sizes to be calculated; overall, no significant
effect of these educational methods was detected (standardized effect size,
0.34; 95% confidence interval [CI], −0.22 to 0.97). However, interactive
and mixed educational sessions were associated with a significant effect on
practice (standardized effect size, 0.67; 95% CI, 0.01-1.45).ConclusionsOur data show some evidence that interactive CME sessions that enhance
participant activity and provide the opportunity to practice skills can effect
change in professional practice and, on occasion, health care outcomes. Based
on a small number of well-conducted trials, didactic sessions do not appear
to be effective in changing physician performance.

Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes?

OBJECTIVE: To determine the effectiveness of different types of interventions in improving health professional performance and health outcomes. DATA SOURCES: MEDLINE, SCISEARCH, CINAHL and the Research and Development Resource Base in CME were searched for trials of educational interventions in the health care professions published between 1970 and 1993 inclusive. STUDY SELECTION: Studies were selected if they provided objective measurements of health professional performance or health outcomes and employed random or quasi-random allocation methods in their study designs to assign individual subjects or groups. Interventions included such activities as conferences, outreach visits, the use of local opinion leaders, audit and feedback, and reminder systems. DATA EXTRACTION: Details extracted from the studies included the study design; the unit of allocation (e.g., patient, provider, practice, hospital); the characteristics of the targeted health care professionals, educational interventions and patients (when appropriate); and the main outcome measure. DATA SYNTHESIS: The inclusion criteria were met by 102 trials. Areas of behaviour change included general patient management, preventive services, prescribing practices, treatment of specific conditions such as hypertension or diabetes, and diagnostic service or hospital utilization. Dissemination-only strategies, such as conferences or the mailing of unsolicited materials, demonstrated little or no changes in health professional behaviour or health outcome when used alone. More complex interventions, such as the use of outreach visits or local opinion leaders, ranged from ineffective to highly effective but were most often moderately effective (resulting in reductions of 20% to 50% in the incidence of inappropriate performance). CONCLUSION: There are no "magic bullets" for improving the quality of health care, but there are a wide range of interventions available that, if used appropriately, could lead to important improvements in professional practice and patient outcomes.

No magic bullets: a systematic review of 102 trials of interventions to improve professional practice

Background
Educational meetings are widely used for continuing medical education. Previous reviews found that interactive workshops resulted in moderately large improvements in professional practice, whereas didactic sessions did not.

Objectives
To assess the effects of educational meetings on professional practice and healthcare outcomes.

Search methods
We updated previous searches by searching the Cochrane Effective Practice and Organisation of Care Group Trials Register and pending file, from 1999 to March 2006.

Selection criteria
Randomised controlled trials of educational meetings that reported an objective measure of professional practice or healthcare outcomes.

Data collection and analysis
Two authors independently extracted data and assessed study quality. Studies with a low or moderate risk of bias and that reported baseline data were included in the primary analysis. They were weighted according to the number of health professionals participating. For each comparison, we calculated the risk difference (RD) for dichotomous outcomes, adjusted for baseline compliance; and for continuous outcomes the percentage change relative to the control group average after the intervention, adjusted for baseline performance. Professional and patient outcomes were analysed separately. We considered 10 factors to explain heterogeneity of effect estimates using weighted meta-regression supplemented by visual analysis of bubble and box plots.

Main results
In updating the review, 49 new studies were identified for inclusion. A total of 81 trials involving more than 11,000 health professionals are now included in the review. Based on 30 trials (36 comparisons), the median adjusted RD in compliance with desired practice was 6% (interquartile range 1.8 to 15.9) when any intervention in which educational meetings were a component was compared to no intervention. Educational meetings alone had similar effects (median adjusted RD 6%, interquartile range 2.9 to 15.3; based on 21 comparisons in 19 trials). For continuous outcomes the median adjusted percentage change relative to control was 10% (interquartile range 8 to 32%; 5 trials). For patient outcomes the median adjusted RD in achievement of treatment goals was 3.0 (interquartile range 0.1 to 4.0; 5 trials). Based on univariate meta-regression analyses of the 36 comparisons with dichotomous outcomes for professional practice, higher attendance at the educational meetings was associated with larger adjusted RDs (P < 0.01); mixed interactive and didactic education meetings (median adjusted RD 13.6) were more effective than either didactic meetings (RD 6.9) or interactive meetings (RD 3.0). Educational meetings did not appear to be effective for complex behaviours (adjusted RD -0.3) compared to less complex behaviours; they appeared to be less effective for less serious outcomes (RD 2.9) than for more serious outcomes.

Authors' conclusions
Educational meetings alone or combined with other interventions, can improve professional practice and healthcare outcomes for the patients. The effect is most likely to be small and similar to other types of continuing medical education, such as audit and feedback, and educational outreach visits. Strategies to increase attendance at educational meetings, using mixed interactive and didactic formats, and focusing on outcomes that are likely to be perceived as serious may increase the effectiveness of educational meetings. Educational meetings alone are not likely to be effective for changing complex behaviours.

Continuing education meetings and workshops: effects on professional practice and health care outcomes

Objective. —To assess the impact of diverse continuing medical education (CME) interventions on physician performance and health care outcomes. Data Sources. —Usingcontinuing medical educationand related phrases, we performed regular searches of the indexed literature (MEDLINE, Social Science Index, the National Technical Information Service, and Educational Research Information Clearinghouse) from 1975 through 1991. In addition, for these years, we used manual searches, key informants, and requests to authors to locate other indexed articles and the nonindexed literature of adult and continuing professional education. Study Selection. —From the resulting database we selected studies that met the following criteria: randomized controlled trials; educational programs, activities, or other interventions; studies that included 50% or more physicians; follow-up assessments of at least 75% of study subjects; and objective assessments of either physician performance or health care outcomes. Data Extraction. —Studies were reviewed for data related to physician specialty and setting. Continuing medical education interventions were classified by their mode(s) of activity as being predisposing, enabling, or facilitating. Using the statistical tests supplied by the original investigators, physician performance outcomes and patient outcomes were classified as positive, negative, or inconclusive. Data Synthesis. —We located 777 CME studies, of which 50 met all criteria. Thirty-two of these analyzed physician performance; seven evaluated patient outcomes; 11 examined both measures. The majority of the 43 studies of physician performance showed positive results in some important measures of resource utilization, counseling strategies, and preventive medicine. Of the 18 studies of health care outcomes, eight demonstrated positive changes in patients' health care outcomes. Conclusion. —Broadly defined CME interventions using practice-enabling or reinforcing strategies consistently improve physician performance and, in some instances, health care outcomes. (JAMA1992;268:1111-1117)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=jama&articleId=399544&pdfFileName=jama_268_9_014.pdf

Evidence for the effectiveness of CME. A review of 50 randomized controlled trials.

In 1973 the division of continuing medical education of the University of Saskatchewan initiated a 3-year study to determine the effect of hospital-based education on the prescribing accuracy of physicians. This study was undertaken in response to an urgent need to develop more effective methods of continuing medical education and improved techniques of measuring their effectiveness. The educational program focused on common prescribing problems that had previously been defined by experts in the field. Problem frequency was determined by the monitoring of hospital records prior to institution of the educational program and at 3, 6 and 12 months after the program had concluded; this was found to be a satisfactory method of identifying educational needs and is considered to provide a measure of the quality of medical care. Fifteen physicians at three rural hospitals participated in the study. Seventeen physicians at two similar hospitals served as controls. The average problem frequency for topics selected at the study hospitals was reduced by 63% (the percentage of possible improvement), whereas at the control hospitals the frequency of the same problems declined by 32% over the same period. The results of this study provide evidence that an intensive, problem-based program on therapeutics can improve physician performance.

Improving physician performance by continuing medical education

Twenty family physicians in Saskatchewan participated in this randomized controlled study which examined the effects of relatively low-cost educational techniques on the office management of hypertension. We measured 1,538 episodes of care relating to the office management of hypertension by chart review, prior to, and at six and 12 months following education. The family physicians who participated in the education were found to perform the recommended behaviours significantly more often at six and 12 months post education than those physicians who did not have the education. Our findings indicate that carefully planned, inexpensive educational techniques can improve clinical behaviour in areas where there is identified educational need.

Desirable behaviours in the office management of hypertension addressed through continuing medical education.

Family doctors play a very important role in determining the health of the populace; however, surveys and expert opinions indicate that there is considerable room for improvement in the knowledge and skills of family physicians concerning the prevention, early detection and management of the major causes of death and disability. Effective Continuing Medical Education (CME) could help greatly to resolve this problem. THere is, however, little evidence that presently available systems of CME, though costly, are effective in improving either physician competence or patient health. Attractive and cost-effective CME methods are greatly needed. This study develops, field tests and evaluates more efficient office-based CME programs for family doctors. Prevention, early detection and improved management of cardiovascular disease and cancer are the primary goals. A pretest posttest control group and time series approach was chosen for the experimental design. Thirty-one family physicians are participating. Physician performance and patient outcome prior to and after education are being assessed largely through office record review.

Designing educational interventions to improve physician performance in office practice. A study in progress

Summary. A randomized controlled study was conducted to determine if specifically designed continuing medical education in the fields of cardiovascular and cancer medicine could change doctor office behaviour significantly. Thirty-one volunteer family doctors from 25 offices participated.



Six (three cardiovascular and three cancer) learning objectives were defined. Two educational formats were selected as the independent variables: (1) group interaction opportunities (face-to-face and teleconference); and (2) concisely written newsletters. Chart measures of doctor performance prior to and 6 and 12 months following education served as the dependent variables.



The family doctors receiving education were found to perform the recommended behaviours significantly more than those who did not receive the education (P<0.05) at 6 months post-education. This difference was maintained at the 12-month post-educational period for one of the educational programmes offered.



A carefully planned programme of continuing medical education will result in favourable changes in the office practice of volunteer doctors. These changes can persist for as long as 12 months. Adherence to several essential learning principles is required.

The effects of continuing medical education on family doctor performance in office practice: a randomized control study

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Improving physician performance by continuing medical education

Desirable behaviours in the office management of hypertension addressed through continuing medical education.

Designing educational interventions to improve physician performance in office practice. A study in progress

The effects of continuing medical education on family doctor performance in office practice: a randomized control study