| Project Objectives / Summary:
Much evidence has been gathered about the means of delivering CME but little has been written about the selection of appropriate CME topics. This is in spite of the fact that there is little evidence that CME conducted on areas of interest or existing competence does little to improve clinical performance, whereas CME done in areas of poor knowledge or skill increases the level of clinical performance. The key question therefore becomes: how does one determine what are the areas of poorest confidence or current performance? The research question posed then, "Is it feasible to employ evidence-based methodology to develop educational prescriptions derived from GP medical records"?
Aim: To determine the feasibility of employing doctors' case notes to identify General Practitioners' educational needs for CME
Objectives:
- To identify and rank the most common clinical conditions from an audit analysis of GP case records
- To develop evidence-based criteria for the diagnosis, prevention, and management of these conditions
- To compare evidence-based information for these conditions with GP's diagnosis, and management recorded in the case records
- To develop CME programs based on a comparative analysis GP management recorded in case notes and evidence-based "best" practice
- To compare and contrast the content of the derived CME programme with division and individual CME programmes planned for the same period.
Project Outcomes:
Forty GPs from a potential 130 participated in the project (31%). Eight hundred chart audits were carried out and nine hundred and ninety three reasons for encounters were identified. The consultation notes of twenty randomly selected patient encounters were collected from forty GPs. These notes were transcribed, and coded using the ICPC classification instrument. The ten most common conditions were: diabetes, hypertension, acute respiratory infection, depression and anxiety, earache / wax in ears, headaches, urinary symptoms, low back pain, red / sore eyes and nausea / vomiting & diarrhoea.
Evidence based best practice was identified using the text Clinical Evidence, as well as searches of the Cochrane library, Medline and PubMed. The conditions were ranked according to the greatest dissonance between published evidence of practice and actual practice as recorded in the notes.
The actual CME delivered by the Division in the previous two years and the stated preference of practitioners for CME topics was collated before the project intervention. There was virtually no resemblance between the desired, or delivered CME, and the CME list generated from the audit process. A table comparing the results can be found in the final report.
The sample size used to determine if the process of a chart audit could be used to generate individual CME agendas was too small. However, it was adequate to determine the needs of the group. The list of most common conditions generated compared favourably with the BEACH data for 1998 - 99.
Recommendations:
- Identify the reason for the survey - to guide a divisional CME programme, or develop individual programmes. For a divisional survey, a sample size of 20 per doctor is reasonable providing that a large percentage of divisional members participate. For individuals, sample between 50 and 100 would be more appropriate.
- Test the acceptance of the method and the CME programme that derives from it by a follow up survey in one year's time.
- Consider periodic repeating of this process to inform the content of divisional CME activity.
- Consider offering training to interested individuals to conduct this process themselves. This could be done through offering scholarships to GPs to undertake specific training on Evidence based practice through the University of Queensland.
- That the Division encourages the use of internet-based databases and on line library resources.
- That the Division hosts training in evidence based practice and the utilisation of electronic databases to seek evidence efficiently.
- That the Division considers purchasing a subscription to Clinical Evidence. This resource is a collection of evidence on a range of clinical topics, updated and released 6 monthly. Future editions will be on CD.
Lessons:
Several factors impacted on the conduct of this project including an upsurge in concern over the threat of litigation, and breaching of the privacy legislation, which led to a reluctance of some GPs to participate. This led to a timetable blow out of the project which resulted in another difficulty. A principal incentive for GPs to participate was the opportunity to earn Clinical Audit points for the current QA CE triennium. This proved to be a weak incentive as the project moved further behind schedule and most participants had fulfilled their obligations by the time they were requested to complete follow up work. This resulted in a poor response rate. |
