An Interactive Web Based Curriculum to Improve Skin Cancer Detection by Primary Care Clinicians EIDE
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Transcript of An Interactive Web Based Curriculum to Improve Skin Cancer Detection by Primary Care Clinicians EIDE
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Effectiveness of a Web-based Effectiveness of a Web-based Course for Practicing Primary Care Course for Practicing Primary Care Providers to Improve Skin Cancer Providers to Improve Skin Cancer
Identification and ManagementIdentification and Management
Melody J. Eide, MD MPHMelody J. Eide, MD MPHHenry Ford Health SystemHenry Ford Health System
Detroit, MI USADetroit, MI USA
For the For the InInternet Course ternet Course ForFor MMelanoma elanoma EEarly arly DDetectionetection (INFORMED) Team (INFORMED) Team
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IntroductionIntroductionMelanoma burden is risingMelanoma burden is rising
Primary prevention efforts have improved Primary prevention efforts have improved use of sunscreenuse of sunscreen
Secondary prevention is potentially Secondary prevention is potentially important for this easily visualized organimportant for this easily visualized organ
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IntroductionIntroductionFor secondary prevention to be effective, For secondary prevention to be effective, practicing primary care providers (PCPs)—practicing primary care providers (PCPs)—the frontline—must be involved the frontline—must be involved – 30% of primary care residents report receiving 30% of primary care residents report receiving
adequate skin exam training adequate skin exam training – Two web-based skin cancer programs aimed Two web-based skin cancer programs aimed
at PCPs have been developed & evaluatedat PCPs have been developed & evaluated
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ObjectivesObjectivesDevelop an interactive web-based course Develop an interactive web-based course to train practicing PCPs in skin cancer to train practicing PCPs in skin cancer detection, emphasizing melanomadetection, emphasizing melanoma
Evaluate the course’s effect on PCPs’ Evaluate the course’s effect on PCPs’ – Ability to diagnose and manage skin lesions Ability to diagnose and manage skin lesions
that might be skin cancer that might be skin cancer – Practice and utilization of dermatology Practice and utilization of dermatology
consultantsconsultants
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Methods: Course DevelopmentMethods: Course Development
Developed by a team of dermatologists, Developed by a team of dermatologists, primary care clinicians, and medical primary care clinicians, and medical educators educators Covered the three most common skin Covered the three most common skin cancers and their differentialcancers and their differential
Melanoma Melanoma Basal cell carcinoma (BCC)Basal cell carcinoma (BCC)Squamous cell carcinoma (SCC)Squamous cell carcinoma (SCC)
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Methods: Course DevelopmentMethods: Course Development
Designed withDesigned with– Feedback from PCP focus groupsFeedback from PCP focus groups– Choice of two different learning formats: Choice of two different learning formats:
Traditional textbook format Traditional textbook format
Case-vignette formatCase-vignette format
– InteractivityInteractivitySelf-assessment exercises with immediate feedbackSelf-assessment exercises with immediate feedback
– Emphasis on diagnosis and management, Emphasis on diagnosis and management, using 450 high quality images and pearlsusing 450 high quality images and pearls
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Methods: Course DeliveryMethods: Course DeliveryTwo HMOs:Two HMOs:– Henry Ford Health System Henry Ford Health System – Kaiser Permanente Northern CaliforniaKaiser Permanente Northern California
Recruitment of eligible volunteersRecruitment of eligible volunteers– Surpassed recruitment goal: 54 practicing Surpassed recruitment goal: 54 practicing
PCPs from 9 practices (June 2011)PCPs from 9 practices (June 2011)
Duration~ 3 hours Duration~ 3 hours – Including a meal, consent, pre- & immediate Including a meal, consent, pre- & immediate
posttests, and debriefingposttests, and debriefing
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Methods: Course EvaluationMethods: Course EvaluationBefore-After DesignBefore-After DesignAssessed skills with pretest, immediate posttest, and Assessed skills with pretest, immediate posttest, and six-month posttestsix-month posttest– 25 Images of skin lesions25 Images of skin lesions
Diagnosis and management (referral or reassurance) Diagnosis and management (referral or reassurance)
Assessed aAssessed attitudes and confidence changesttitudes and confidence changesAssessed practice Assessed practice – Six months post-course (late 2010) to the same period of Six months post-course (late 2010) to the same period of
the previous year (late 2011)the previous year (late 2011)Dermatology referrals or office visits, Dermatology referrals or office visits, Skin biopsies & cancersSkin biopsies & cancers
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Methods: Statistical AnalysisMethods: Statistical Analysis
Descriptive analysesDescriptive analyses
Generalized linear mixed effects models Generalized linear mixed effects models (GLMMs) with logit link utilized to account (GLMMs) with logit link utilized to account for within-clinician and within-image for within-clinician and within-image clustering and correlation (OR, 95%CI)clustering and correlation (OR, 95%CI)– Used for determining effect on PCP diagnosis Used for determining effect on PCP diagnosis
and management skillsand management skills
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Results: Participant Characteristics Results: Participant Characteristics (N=54)(N=54)
%
Eligible non-participants had similar demographic and training backgroundEligible non-participants had similar demographic and training background
85
41
74
20
48
6
61
46
50
15
59
26
80
52
94
39
54
50
0 20 40 60 80 100
Women
Age ≥50 yrs
Men
Age <50 yrs
WhiteNon-white
MD degreeOther
US TrainedForeign Trained
General Internal MedicineOther PCP
<10 years practice≥10 years practice
Residency trainingNo training
No educationCME
Percent (%)
%
%
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Skills: Overall ChangeSkills: Overall ChangeM
ean
Tes
t S
core
%
*
*P<0.05 vs. pretest
*
36.1
46.7
41.3
0
5
10
15
20
25
30
35
40
45
50
Pretest Posttest 6-mon Posttest
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Mean Test Scores for Pretest, Immediate Posttest and Mean Test Scores for Pretest, Immediate Posttest and Six-month Posttest Among Participants by Initial Quartile Six-month Posttest Among Participants by Initial Quartile
of Performanceof Performance
15 .8%
41.7%
40.0%
2 9.8%
43.8%
39.1%
43.1%
46.7%
44.9%
5 9.0%
5 3.8%
47.9%
0%
10%
20%
30%
40%
50%
60%
70%
Pretest ImmediatePosttest
Six-monthposttest
Mea
n T
est
Sco
re (
%)
1s t Q u artile
2n d Q u artile
3rd Q u artile
4th Q u artile
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Skills: DiagnosisSkills: Diagnosis
* p<0.05 vs pretest
Mea
n te
st s
core
%
1616
Skills: ManagementSkills: Management
**
Mea
n te
st s
core
%
1717
ConfidenceConfidence
*p<0.05 compared to baseline
Mea
n sc
ore
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Dermatology Utilization by Site and Dermatology Utilization by Site and YearYear
0
100
200
300
400
500
600
700
800
Referrals Biopsies Melanoma NMSC New Visits Biopsies Melanoma NMSC
2010 2011
2011
2011
2011
2011
2011
2011
2011
2010
2010
2010
2010
2010
2010
2010
Site A Site BN=24 N=29
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LimitationsLimitationsNot a randomized trial and depended on Not a randomized trial and depended on volunteers volunteers Tired participants Tired participants – Donated their time after completing full clinic days, Donated their time after completing full clinic days, – Spent slightly more than one hour on courseSpent slightly more than one hour on course– May have underestimated the effect of the May have underestimated the effect of the
intervention because of these factors intervention because of these factors
Different measures of dermatology utilization Different measures of dermatology utilization at the two sitesat the two sites
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ConclusionConclusionWe developed a web based skin cancer course We developed a web based skin cancer course for practicing PCPs thatfor practicing PCPs that– Improved PCPs' overall ability to diagnose and Improved PCPs' overall ability to diagnose and
manage skin lesions from 36% to 47% manage skin lesions from 36% to 47% – Improved diagnosis and management of benign skin Improved diagnosis and management of benign skin
lesionslesions especially especially
– WWas particularly effective improving skills among as particularly effective improving skills among participants with lowest quartile pretest scores participants with lowest quartile pretest scores
– Demonstrated evidence of effectiveness six months Demonstrated evidence of effectiveness six months after taking the course after taking the course
– Did not increase false positive referrals to dermatologyDid not increase false positive referrals to dermatology
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INFORMED teamINFORMED team
Martin A Weinstock, MD PhD, Brown Univ, Team LeaderMartin A Weinstock, MD PhD, Brown Univ, Team Leader
Maryam Asgari, MD MPH, Kaiser Permanente Northern CAMaryam Asgari, MD MPH, Kaiser Permanente Northern CA
Suzanne Fletcher, MD, MSc, Harvard PilgrimSuzanne Fletcher, MD, MSc, Harvard Pilgrim
Alan Geller, RN, MPH, Harvard School of Public HealthAlan Geller, RN, MPH, Harvard School of Public Health
Allan Halpern, MD MSc, MSKCCAllan Halpern, MD MSc, MSKCC
Lingling Li, PhD, Harvard PilgrimLingling Li, PhD, Harvard Pilgrim
Gwen L. Alexander, PhD MPH Andrea Altschuler, PhDGwen L. Alexander, PhD MPH Andrea Altschuler, PhD
Waqas ShaikhWaqas Shaikh Ashfaq Marghoob, MDAshfaq Marghoob, MD
Monica Sokil, RD Monica Sokil, RD E. Margaret Warton, MPHE. Margaret Warton, MPH
Elizabeth Quigley, MDElizabeth Quigley, MD Stephen Dusza, DrPHStephen Dusza, DrPH
Jacqueline Goulart, MD Michelle GroesbeckJacqueline Goulart, MD Michelle Groesbeck