Thomas F. Finnegan, PhD; Stacey L. Hughes Medscape, LLC, New York, NY, USA

THE EFFECT OF ONLINE CASE-BASED CONTINUING EDUCATION ON PHYSICIAN KNOWLEDGE AND COMPETENCE FOR THE MANAGEMENT OF NARCOLEPSY COMORBID WITH PSYCHIATRIC ILLNESS

INTRODUCTION

Narcolepsy is a primary disorder of the central nervous system that is thought to reflect the autoimmune destruction of hypocretin-containing neurons of the anterior hypothalamus.1 Patients with narcolepsy may unexpectedly fall asleep at work, while studying, during a conversation, or while driving. Patients experiencing this condition suffer from lower quality of life, higher rates of depression, and other psychiatric comorbidities.2 Due to the psychosocial impairment of many patients, the ability to maintain relationships and employment is reduced.3,4 It is therefore important to recognize narcolepsy and any potential psychiatric comorbidities. However, many physicians are challenged to differentiate narcolepsy from psychiatric comorbidities, a situation that can be amplified in pediatric patients.5,6 Furthermore, management of narcolepsy, with or without psychiatric comorbidities, is suboptimal.7,8 We sought to determine if an online, case-based continuing medical education (CME) program could improve the ability of neurologists and psychiatrists to manage narcolepsy comorbid with psychiatric illness.

RESULTS

METHODS

Instructional Method

■ This online, CME-certified case challenge was presented in the form of 2 case scenarios that included questions assessing clinical decision making9

■ Clinical decision questions provided tailored feedback and clinical consequences based on the specific answer choice selected and allowed learners who answered the question incorrectly on the first attempt an opportunity to answer it again (a second attempt) after feedback had been provided [Figure 1]

■ The educational intervention launched online on June 26, 2015 and data were collected through July 30, 2015

A total of 173 neurologists and 500 psychiatrists were included in the data analyses. A medium effect size (neurologists: d=0.60; psychiatrists: d=0.64) resulted for the educational impact of the learning on clinical decision making. As a result of participating in the educational intervention, specific areas of improvement included:

■ Between 24% and 71% of neurologists made correct clinical decisions with respect to the use and interpretation of tools for the diagnosis of narcolepsy, the relationship between attention-deficit/hyperactivity disorder (ADHD) and sleep, and addressing the patient’s symptomology. Between 17% and 47% of responders improved their decisions after receiving tailored feedback (Figure 2A)

■ Between 27% and 69% of psychiatrists made correct clinical decisions with respect to the use and interpretation of tools for the diagnosis of narcolepsy, the relationship between ADHD and sleep, and addressing the patient’s symptomology. Between 18% and 49% of responders improved their decisions after receiving tailored feedback (Figure 2B)

■ Significant pre- vs post-educational improvement was observed in the identification of major depression as the most common psychiatric comorbidity associated with narcolepsy (neurologists, 90% improvement, P <.05; psychiatrists, 47% improvement, P <.05)

Acknowledgments

The educational intervention and outcomes measurement were funded through an independent educational grant from Jazz Pharmaceuticals.

For more information, contact Thomas F. Finnegan, PhD, Associate Director, Educational Strategy, Medscape, LLC, tfinnegan@medscape.net.

Assessment Method

■ To determine measurable improvements in knowledge/competence, first- and second-attempt answer choices were evaluated for the clinical decision questions

■ An overall effect size was calculated using the Cohen’s d statistic to show the magnitude and strength of the consequence-based feedback learning method, along with a percent change in the proportion of correct answers (effect sizes greater than 0.8 are considered large, between 0.8 are 0.4 are medium, and less than 0.4 are small)

■ Pearson’s χ2 statistic was used to measure changes in responses to individual questions

■ Probability values (P values) were also calculated to determine significance level (α); a P value of less than .05 indicates statistical significance

FIGURE 1. Design of Practice Challenge Format

FIGURE 2A. Clinical Assessment Question Results for Neurologists (correct in parentheses)

FIRST ATTEMPT

EDUCATION

SECOND ATTEMPT

EFFECT OF EDUCATION

Correct

Educational Reinforcement

Reinforced Clinical Competence

Improved Clinical Competence

Una�ected Clinical Competence

Educational Intervention

Incorrect

IncorrectCorrect

FIGURE 2B. Clinical Assessment Question Results for Psychiatrists (correct in parentheses)

0%

25%

50%

75%

100%

First Attempt Correct Second Attempt Correct

QUESTION 1Which one of the

following diagnostic instruments would be

most useful in assessing Markʼs current complaints? (Epworth Sleepiness Scale)

QUESTION 2Based on Markʼs history and these

test results, what is your diagnosis?

(Narcolepsy type 2)

QUESTION 5Considering Markʼs history and diagnosis, which of the following medications is the

most suitable first-line treatment for Mark?

(Modafinil 200 mg at noon)

QUESTION 6Which of the following aspects

of Davidʼs history is least consistent with a diagnosis

of attention-deficit/hyperactivity disorder (ADHD)? (Age of onset of

attentional problems)

QUESTION 7In evaluating Davidʼs

symptoms and interpreting results of sleep studies, your

management should be informed by the fact that: (Children with ADHD are

more sleepy than controls but less sleepy than narcoleptics)

QUESTION 9Which of the following medications would you recommend to improve

Davidʼs daytime sleepiness, episodes of weakness, and

nocturnal sleep disturbance? (Sodium oxybate

4.5 g nightly)

18%

62%

19%

69%

49%

27%

18%

66%

48%

29%

28%

46%

CONCLUSIONS

The online education format consisting of 2 case challenges was successful in improving the competency of neurologists and psychiatrists in differentiating narcolepsy from narcolepsy comorbid with a psychiatric illness. A significant number of learners were also able to improve their knowledge of major depression as the most common psychiatric comorbidity associated with narcolepsy. Future education should focus on educating neurologists and psychiatrists on the etiology of narcolepsy, sleep disorders associated with ADHD, and environmental triggers of narcolepsy.

References

1. Schwartz JR, Roth T, Hirshkowitz M, Wright KP. Recognition and management of excessive sleepiness in the primary care setting. Prim Care Companion J Clin Psychiatry. 2009;11:197-204.

2. Nishino S, Okuro M, Kotorii N, et al. Hypocretin/orexin and narcolepsy: new basic and clinical insights. Acta Physiol (Oxf). 2010;198:209-222.

3. Jennum P, Ibsen R, Petersen ER, Knudsen S, Kjellberg J. Health, social, and economic consequences of narcolepsy: a controlled national study evaluating the societal effect on patients and their partners. Sleep Med. 2012;13:1086-1093.

4. Reynolds CF 3rd. Sleep disorders: an overview. Psychiatr News. 2012;47:4-9.

5. Moturi S, Ivanenko A. Complex diagnostic and treatment issues in psychotic symptoms associated with narcolepsy. Psychiatry (Edgmont). 2009;6:38-44.

6. Nevsimalova S. The diagnosis and treatment of pediatric narcolepsy. Curr Neurol Neurosci Rep. 2014;14:469.

7. Rosenberg R, Kim AY. The AWAKEN survey: knowledge of narcolepsy among physicians and the general population. Postgrad Med. 2014;126:78-86.

8. Scammell T, Bogan R, Kotagal S, Mignot E. Facing the challenges in narcolepsy management: issues and answers. Medscape Education. July 25, 2013. http://www.medscape.org/viewarticle/807895. Accessed July 6, 2014.

9. Sateia MJ. Intersection of Narcolepsy and Psychiatric Disorders: Case Challenges. Medscape Education. June 26, 2015. http://www.medscape.org/viewarticle/842660. Accessed March 30, 2016.

Scan here to view this poster online.

0%

25%

50%

75%

100%

First Attempt Correct Second Attempt Correct

QUESTION 1Which one of the

following diagnostic instruments would be

most useful in assessing Markʼs current complaints? (Epworth Sleepiness Scale)

QUESTION 2Based on Markʼs history and these

test results, what is your diagnosis?

(Narcolepsy type 2)

QUESTION 5Considering Markʼs history and diagnosis, which of the following medications is the

most suitable first-line treatment for Mark?

(Modafinil 200 mg at noon)

QUESTION 6Which of the following aspects

of Davidʼs history is least consistent with a diagnosis

of attention-deficit/hyperactivity disorder (ADHD)? (Age of onset of

attentional problems)

QUESTION 7In evaluating Davidʼs

symptoms and interpreting results of sleep studies, your

management should be informed by the fact that: (Children with ADHD are

more sleepy than controls but less sleepy than narcoleptics)

QUESTION 9Which of the following medications would you recommend to improve

Davidʼs daytime sleepiness, episodes of weakness, and

nocturnal sleep disturbance? (Sodium oxybate

4.5 g nightly)

17%

71%

18%

71%

47%

24%

25%

46%

34%

43%

18%

53%