A Simulated Diabetes Learning Intervention

Improves Provider Knowledge and Confidence in Managing

DiabetesJoAnn Sperl-Hillen, MD

Co-director of Center for Chronic Care Innovation

HealthPartners Research Foundation, Minneapolis, MN

Wednesday May 2, 2012 8-9:30am

18th Annual HMO Research Network Conference

Seattle, WA

Accelerating excellence in health performance through education, advocacy, and collaboration

Team Members

JoAnn Sperl-Hillen Patrick O’Connor Heidi Ekstrom William Rush Omar Fernandes Jerry Amundson Deepika Appana

Steve Asche George Biltz* Deb Curran Paul Johnson* Andrew Rudge Todd Gilmer**

HealthPartners Research Foundation and HealthPartners

Institute for Medical Education, Minneapolis, MN;

* Carlson School of Management, University of Minnesota,

Minneapolis MN;

** Department of Family and Preventive Medicine, University of

California, San Diego, La Jolla, CA

Presenter Disclosures

NIH research support Listed inventor on a U.S. patent application filed

related to simulation technology HPRF has recently entered into a royalty-bearing

license agreement with a third party to commercialize the simulated learning technology for the purpose of broader dissemination.

Non-paid director on the board of directors for that licensee (SimCare Health)

Why is provider training needed?

Provider performance varies, even within the same clinic populations

Clinical inertia is common, particularly for insulin treatment

Provider knowledge varies The cognitive processes and tasks

related to diabetes are complex

Barriers to Provider Training

Time constraints Lack of continuity experiences Relatively limited ambulatory

experience in residency training Complicated diseases with need for

personalization of care Experts & opinion leaders are often not

available or affordable, and teaching is difficult to standardize

What is simulation?

“Simulation is a technique—not a technology—to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.” Gaba (2004)

AviationNASAMilitaryMedical

1960s First Mannequin: Resusci-Annie1960s-70s Computer-assisted learning program in medicine 1990 High fidelity mannequins become available

History of Simulation

What are the advantages to simulation?

Efficient & cost effective Sustainable & standardized In line with adult learning principles Personalized (case-based). Case-based

simulations provide a context for learning People are more likely to remember learning

and replicate in real-world situations. Capture the importance of continuity of care Proven satisfaction & effectiveness

Elements needed to create a simulated learning program

1. Identify the learning needs and create a library of case scenarios

2. Create an interactive web-interface

3. Model and program the physiology

4. Program the feedback – to critique action the provider takes between encounters

Patient “snapshot” screen shot

Demo of SimCare available at www.simcarediabetes.org

Visit navigator screen shot

Feedback between every encounter

Early SimCare Study

57 consented PCP’s and their 2,020 patients. Randomized to one of 3 groups:

(A) no intervention (B) learning intervention (SimCare) consisting

of 3 simulated learning cases (1 hr) (C) SimCare + physician opinion leader

Results: SimCare reduced risky prescribing of

metformin in patients with renal impairment (p=0.03).

Group B (SimCare alone) achieved slightly better glycemic control than A or C (p=.04)

Funding through R01HS10639, Physician Intervention to Improve Diabetes Care

2001-03

SimCare Version 2

Eleven clinics with 41 consenting PCP’s

Randomized to receive or not receive an improved version of SimCare (12 cases assigned based on profiled “needs”, 3 hrs)

Results: Patients of intervention providers with baseline A1c > 7% had significantly greater A1c reduction (-.19%) relative to patients of non-intervention providers.

Funding through R01DK068314, Reducing Clinical Inertia in Diabetes

2006

SimCare Version 3

19 eligible residency programs linked to 723 residents

341 residents consented

Intervention – Early learning 10)Residents (177)

Control – Late learning (9)Residents (164)

382 residents did not consent

Completion rates Learning cases (142)

Assessment cases (97) Knowledge survey (92)

Evaluation (94)

Completion rates Assessment cases (135) Knowledge survey (128)

Funding through R18DK079861, Simulated Diabetes Training for Resident Physicians

2009-present

Implementing the learning program Residents at 19 programs were given a brochure that

we provided and asked to sign up online Resident participation was voluntary. Time commitment – 18 cases, 1 hour/month for 8

months if randomized to the early intervention group Incentives - $50 Target gift card on completion of the

assigned tasks Promotions – 4 iPad raffle promotions and 1 Target

gift card promotion to achieve acceptable learning and assessment case completion rates

Baseline characteristics of residentsIntervention

(n=92)Control(n=128)

P-value

% female 48% 57% 0.31

% white 48% 58% 0.41

Age (median) 29 29 0.69

Specialty Family Medicine Internal Medicine Med-Peds Other

34%54%8%4%

49%42%7%2%

0.15

Post graduate year 1 2 3 4

35%36%28%1%

34%34%28%4%

0.70

 2. A 77 year old black man is seeing you for follow up. He has a 13 year history of type 2 diabetes, coronary heart disease (CABG at age 58), chronic stable angina, and dyslipidemia. He has been eating out a lot and gaining weight. His current medications are metformin 1000 mg bid, atenolol 50 mg qd, and simvastatin 40 mg qd. His BMI is 37, BP is 165/86, A1c 9.3%, Cr 2. 2 mg/dl, eGFR 28, LDL 94 mg/dl, HDL 36 mg/dl, and TG 278 mg/dl. Which of the following would be your MOST likely recommended action? A. Start basal insulin and treat to an A1c goal of < 7%. No change in other glycemia medications.B. Discontinue metformin and start basal insulin. Follow up with patient for insulin adjustments with an A1c goal of < 7%.C. Start basal insulin and follow up with the patient for insulin adjustments with an A1c goal of < 8%. No change in other glycemia medications.D. Discontinue metformin and start basal insulin. Follow up with patient for insulin adjustments with an A1c goal of < 8%.E. No change now because I would address other patient problems 

Example Knowledge Question

Correct answer D (59% intervention, 26% control)

Q# Knowledge topics covered Early Late P-value

1 Screen for DM (using an A1c) 75.0 75.8 .894

2 Basal insulin start, individualized A1c goal < 8% 58.7 25.8 <.0001

3 Check ketones in newly diagnosed symptomatic patients & start insulin 31.5 28.1 .586

4 Reduce basal insulin due to nocturnal hypoglycemia (Somogyii) 64.1 70.3 .333

5 Relax A1c target due to hypoglycemia unawareness 57.6 32.8 .0002

6 Start insulin in a newly diagnosed symptomatic patient 33.7 11.7 <.0001

7Use of a loop diuretic rather than thiazide in patient with renal insufficiency. Fenofibrate not beneficial in addition to statin.

DC metformin due to renal contraindication.44.6 19.5 <.0001

8 Initiate BP tx (without confirmatory testing) if BP > 180/100. Statins may be helpful for most patients with DM. 59.8 44.5 0.026

9 Start a statin, screen for depression, basal insulin start 66.3 57.0 .164

10 Geriatric polypharmacy concerns, depression screening, hypoglycemia management, statin use in the elderly 46.7 41.4 .431

Results of Knowledge Testing

Number of items correct out of 10

Intervention Control

0-4 29% 66%

5-7 60% 32%

8-10 11% 2%

Mean score (95% CI)

5.31 (4.87-5.75)

4.10 (3.69-4.50)

p < .001

N=220 completers of knowledge survey

Results of self-rated confidence and knowledge about diabetes management

Topic Intervention Control P-value

How knowledgeable are you about how to use all available drug classes to manage

patients with diabetes?61 25 <.001

How knowledgeable are you about how to start and adjust insulin?

83 45 <.001

How knowledgeable are you about interpreting patient self-monitored glucose

values (SMBGs)?85 59 .009

How knowledgeable are you about setting individualized treatment goals for people

with diabetes?83 44 <.001

How confident are you in managing patients with diabetes?

79 44 <.001

Evidence for learning transfer to actual patient care

77% applied learning to actual patients 63% shortened visit intervals 78% more likely to add or increase drugs if patient is

not at goal 92% more confident about insulin use in actual

patients

….and results of two trials had demonstrated improved outcomes of actual patients of practicing providers who used earlier versions of SimCare

Study limitations

Voluntary participation, not all completed the learning program and completed evaluations

No outcome data on non-completers Survey completion rates were lower in the intervention

(52%) than the control groups (78%) No actual patient data to evaluate Assessment case outcomes not yet available

Thank you! For additional questions, please contact…

JoAnn Sperl-Hillen: joann.m.sperlhillen@healthpartners.com

Patrick O’Connor: patrick.j.oconnor@healthpartners.com

Heidi Ekstrom:

heidi.l.ekstrom@healthpartners.com

Talk References

Simulated Physician Learning Intervention to Improve Safety and Quality of Diabetes Care: A Randomized Trial

O’Connor PJ, Sperl-Hillen JM, et al. Simulated physician learning intervention to improve safety and quality of diabetes care: A Randomized Trial. Diabetes Care. 2009;32(4): 585-590.

Simulated Physician Learning Program Improves Glucose Control in Adults with Diabetes

Sperl-Hillen JM, O’Connor PJ, Rush WA, Johnson PE, Gilmer TP, Biltz G, Asche SE, Ekstrom HL. Simulated Physician Learning Program Improves Glucose Control in Adults with Diabetes. Diabetes Care. 2010;33(8): 1727-1733.