Table Of ContentKühne-EversmannandFischerBMCResearchNotes2013,6:14
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RESEARCH ARTICLE Open Access
Improving knowledge and changing behavior
towards guideline based decisions in diabetes
care: a controlled intervention study of a
team-based learning approach for continuous
professional development of physicians
Lisa Kühne-Eversmann* and Martin R Fischer
Abstract
Background: Continuing Professional Development (CPD) courses should ideally improvea physician’s knowledge
and change their professionalbehavior indaily practice towards a best clinical practice reference model and
guideline adherence. Interactivemethodssuch as team-basedlearning and case-based learning, as compared to
lectures, can impart sustainableknowledge and lead to highsatisfactionamong participants.We designed an
interactive case-based CPD-seminar on diabetes care using a team-based learning approach to evaluate whether it
leads to an improvementofshort-term knowledge and changing of behavior towards guideline based decisions
and how this learning approach is perceived by participants.
Methods: Questionnaires and an electronic voting system were used to evaluate motivation, acceptanceand
knowledge of voluntary participants.Furthermore, we analyzed data onindex diagnostic tests and referrals of
patients withdiabetes of participating physicians over a periodof sixmonths before and after thecourse in
comparison with a matched control group in a quasi-experimental design.
Results: Participants (n=103) rated the interactivity and team-baseddiscussions as the main reasons for enhanced
learning. They also expectedthatthecourse would change their professional behavior. Participants scored a mean
of43.9%right answers before and 62.6% after thecourse (p<0.001). The referral to diabetes specialists increased by
30.8% (p<0.001). Referral for fundoscopy also increased (8.5%,n.s.) while it dropped in thecontrol group.
Furthermore, the participating physicians tested their patients more often for microalbuminuria (7.1%, n.s.).
Conclusions: Our team-basedlearningCPD-approach was highly accepted and resulted inan increase of
short-term knowledge. It significantly increased thereferral to diabetes specialists indaily practice whereasallother
key professionalbehavior indicators did change but notsignificantly.
Keywords: Team-based learning, Continuing professional development, Continuing medical education,
Postgraduate education, Guideline adherence, Objective behavior change
*Correspondence:lisa.eversmann@med.uni-muenchen.de
MedizinischeKlinikundPoliklinikIV,KlinikumderUniversitätMünchen,
Ziemssenstr.1,Munich80336,Germany
©2013Küehne-EversmannandFischer;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthe
termsoftheCreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricted
use,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
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Background CPD course was applied to a series of CPD activities on
For several years, physicians practicing in Germany and topics of internal and general medicine. Several courses
other countries have been required to participate regu- with numerous participants from Munich and the sur-
larly in clinical training and earn CPD credit points, rounding area took place and were evaluated [15]. The
after their specialization. This lifelong training in medi- course on diabetescare is evaluated inthe present study.
cine is called continuing medical education (CME) or Our aim was to design a CPD course with augmented
continuing professional development (CPD). Formal CPD activation of the participating physicians. To achieve this
courses for physicians are wide-spread. Several authors we used pre- and post-course knowledge tests and case
examined their effectiveness concerning objective behav- discussions in small groups as a key feature of the
ior change and enhanced patient outcomes in review course. We used a team-based learning approach with
articles [1-9]. In the most recent Cochrane Database re- carefully prepared patientcasesasproblems for casedis-
view Forsetlund et al. [2] concluded that educational cussions to allow for activation of pre-knowledge and
meetings can improve professional practice and patient self-directed learning. The lecture format was only used
outcomes. The effect is relatively small and similar to in a short introduction of the topic by an expert and an
other formats of CPD activities such as audit and feed- evidence-based summary in the end of the course. We
back and educational outreach visits. The effectiveness evaluated the acceptance of the new course and its
of interventions increases if mixed interactive and didac- learning outcomes as improved short-term knowledge
tic formats are used, outcomes that are perceived as ser- and change in practical behavior towards guideline ad-
ious by the physicians are focused on and attendance at herent decisions with respect to key learning objectives
educational meetings is high. Other authors [3-6] came of participating physicians. The key learning objectives
to a similar conclusion in their reviews of the effective- of the course we based on the guidelines of the German
nessofCPD courses. Diabetes Association [16] on management of diabetes
There is good evidence to suggest that interactive care regarding regular diagnostic tests and referrals to
methods such as team-based learning and case-based specialists (ophthalmologist, diabetes specialist). A few
learning,ascomparedtolectures,canimpart sustainable facts have to be explained about the health care system
knowledge and performance change and lead to high inGermanyconcerning thereferralsofpatientstoa spe-
satisfaction among participants [9-11]. We selected the cialist. Patients with diabetes can independently see a
team-based learning approach because it allows for flex- specialistwithoutreferralfromtheirgeneralpractitioner.
ible small group formation in large group settings and Butthis isunlikely becausepatientshavetopaya special
has been proven to activate the pre-knowledge of parti- fee of €10 for each visit per quarter unless they have a
cipants and to lead to high-quality learning groups. It referral from their GP and furthermore because of the
was first described by Michaelsen and colleagues [12]. mostly low compliance of patients with diabetes in
They defined team-based learning as an instructional Germany [17]. This is in addition to the fact that the
strategy that is based on procedures of developing high physicians could have made a referral to specialists but
behavior learning teams that can dramatically enhance thepatientschose nottogo.
the quality of learning. In team-based learning activities
each group formulates its own responses to the pro- Methods
blems posed. Then an expert leads a comparison of the DesignoftheCPDcourse
different responses by the groups and offers feedback on The CPD course is characterized by the following
the quality of their responses. Case-based learning is an features: voluntary, interactive, evidence-based, and
educationalmethodthatisbasedonapracticalortheor- case-based related to medical practice, innovative in di-
etical problem which the learners can solve on their dactic terms and independent of pharmaceutical influ-
own. This strategy allows for self-structured learning in ences. The learning and teaching methods included
small groups in a realistic environment. In medicine the team-based and case-based learning, a formal lecture by
problem usually consistsofapatientcase[13]. the expert and plenary discussions. The content of the
Unfortunately, few CPD courses in Germany are inter- CPD courseondiabetes wasthemanagementofpatients
active or case-based. Currently most certified CPD with type2diabetesindailypractice.
courses follow the traditional lecture format with subse- The interactive seminars comprise five hours of teach-
quent discussion, producing no significant change in ing on two topical units with three to four key learning
physician behavior [1,8,14]. Therefore there is a strong goals for guideline adherent behavior ineach topic. They
need forhigh-quality CPD courses. begin and end with a knowledge test with multiple-
We designed an interactive, team-based CPD concept choice (MC) questions in the single best answer format
and launched it in a series of seminars on endocrinology using an electronic audience response system (see
and diabetes care. After a pilot phase, the design of the Figure 1). This technology has been shown to improve
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How often should patients with diabetes be referred to an ophthalmologist for fundoscopy?
A) Every 3 months
B) Every 6 months
C) Every 12 months
D) Every 18 months
E) Every 24 months
Figure1(Pre-andpost-courseknowledgetest).Howoftenshouldpatientswithdiabetesbereferredtoanophthalmologistforfundoscopy?
A)Every3months,B)Every6months,C)Every12months,D)Every18months,E)Every24months.
interaction in large groups and enhance learner atten- practitioners and internists (60.3% vs. 22.7%) from
tion, involvement and initiate discussions. Teachers Munich (Germany) and the surrounding area (75.2% vs.
found it useful for obtaining immediate results and 24.8%). The mean time since their specialization was
thereby receiving feedback on their teaching [18,19]. 13.0years(SD=9.0);12.6%wereresidents.
After a short introduction of the topic by an expert (ca.
10–15 minutes), participants are divided into small Evaluationofbehaviortowardsguidelinestandards
groups of four to six participants. The group work uses To evaluate if an objective behavior change occurred we
team-based learning [12] with prepared paper cases on formulated key indicators for guideline adherent deci-
realistic patient problems in diabetes care and a discus- sions of the evidence-based course content and analyzed
sion of the group’s joint solutions in a plenary session data on diagnostics and referral practice of patients with
with the expert. In our CPD course, an additional diabetes of the participants a half year before and after
evidence-based summary is presented by the expert at the course and compared it with a matched control
theendofthe course(ca.20–30minutes). group. In Germany, the doctor’s billing is processed
every quarter of a year and some diagnostic tests should
Instruments be done once every three or six months. That is why we
Two questionnaires with 46 items were used to evaluate used a half year before and after the course for the
the characteristics, motivation, expectations, self-reported evaluation of performance. The control group consisted
pre-course knowledge level, and validation of the CPD of an aggregated match of general practitioners and
course participants immediately before and after the internists in Munich and suburbs (87 of 1023, approxi-
courseusingaLikertscalefrom1to6(1=stronglydisagree mately 10%) with similar characteristics (e.g. number of
to 6=strongly agree) and open questions. The question- overalltreatedpatients).Physicianswereexcludedifthey
naires were developed using items of validated question- did not work in the whole period (January to July 2006
naires of former studies of our research group regarding and 2007) or if they could be identified by certain char-
motivations, expectations und characteristics of partici- acteristics (size of practice, specialization). We used this
pants. Then the questionnaires were validated in the random sample to compare two groups of similar size.
pilot study. The participating physicians as well as the control group
To evaluate the pre- and post-course knowledge of the had constant numbers of patients with diabetes and
participants, ten MC-questions in single best answer for- showed consistent behavior regarding basic laboratory
mat were asked at the beginning and the end of the diagnostics. But it is important to note that the number
course using an electronic audience response system. of treated patients with diabetes was much higher in the
The MC-questions were written using evidence-based intervention group. The data was provided and anon-
principles of item writing and were identical in the pre- ymized by the Bavarian Association of Statutory Health
andpost-coursetests. Insurance Physicians (“Kassenärztliche Vereinigung
Bayern”) and analyzed by the first author of this article.
Participants We focused the comparative part of our study on the
The total number of participants in September 2006 was evaluation of professional behaviour because there are
103. Course and study participation was voluntary. The numerous studies which have shown that an interactive
participants were informed about the course and the intervention results in a knowledge gain compared to no
interactive coursedesignpriortothe courseinaninvita- intervention.
tion letter. Prior to the course each participant created a
unique code to allow for anonymized data analysis. The Results
age of the participants ranged from 27 to 68 years, AcceptanceofCPDcourseformat
mean: 48.4 years (SD=9.1). 56% of physicians were The pre-course questionnaire showed that an important
women, 44% men. The participants were mainly general reason to participate was the interactivity of the CPD
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course design, case discussions and the relevance of the Changesofprofessionalbehaviour
topics for their clinical work. The participants had high We could show that the percentage of patients re-
expectations of a gain in knowledge and practical guide- ferred to a diabetes specialist once a year (as recom-
lines for decision making. They rated their own know- mended in the guidelines of the German Diabetes
ledge about diabetes carepriortothe courseasaverage. Association, 16) was significantly increased (30%) in
The post-course questionnaire showed that they the intervention group while it decreased in the con-
considered the contents of the course to be approp- trol group. Furthermore, the referral of patients to
riate for their pre-knowledge and strongly agreed an ophthalmologist for fundoscopy had increased by
that the cases enhanced thinking and learning. Fur- 8.5%, which was not statistically significant. In con-
thermore they highly expected that the learned topics trast, the referrals of the control group decreased.
would change their professional behavior. Addition- The frequency of tests for microalbuminuria also
ally they appreciated the course in general and con- increased, but to similar degrees both in the inter-
sidered their expectations for the course to be vention and the control group (7.1% and 10%) and
fulfilled. The participants considered the guidelines with no statistical significance (Table 3). Remarkably,
and theoretical information provided sufficient (see physicians of the intervention group had done the
Tables 1 and 2). test twice as often as the control group even before
the intervention (10% versus 5%).
There was a high standard deviation of the number of
Knowledgegain patients treated, the provision of medical services and
Our CPD course led to a significant short-term gain in the referrals by the participating physicians. This means
the participants’ knowledge with a previously identified that their expert knowledge and behavior was possibly
pre-knowledge level. In the pre-course knowledge test heterogeneous.
they achieved a mean of 43.9% right answers and in the
post-course test a mean of 62.6% right answers. That
means an overall improvement of knowledge about pre- Discussion
sented and discussed topics of 42.9% (SD=16.9, AcceptanceofCPDcourseformat
p<0.001). As stated in the method section we did not Our findings about participating physicians’ expecta-
testtheknowledgegainofthe control group. tions and acceptance are consistent with a study of
Table1Pre-coursequestionnaire
N Min Max Mean SD
Reasonstoparticipatewere...
...topicalfocusesoftheCMEcourse. 152 2 6 5.29 .93
...theinteractivityandproblem-basedformat. 148 1 6 4.57 1.41
...theselectionoftheexperts. 146 1 6 3.65 1.60
...thetime-frameofthecourse. 142 1 6 4.04 1.57
OfthisCMEcourseIexpect... .
...againintheoreticalknowledge. 154 1 6 5.39 .95
...practicalguidelinesfordecisionmaking 153 1 6 5.36 .99
...thepresentationofnewestresearchfindings. 153 1 6 4.92 1.20
...socialcontactwithcolleagues. 147 1 6 3.35 1.48
...togettoknowanewdesignofCMEcourse. 144 1 6 3.28 1.59
IaminterestedinthetopicsoftheCMEcourse. 153 1 6 5.52 .87
Ienjoydealingwithtopicsonendocrinology/diabetes. 152 1 6 5.36 1.03
ThetopicsoftheCMEcoursearehighlyrelevantformyclinicalwork. 152 1 6 5.28 1.01
IwouldliketoknowmoreaboutthetopicsoftheCMEcoursethanIknownow. 150 1 6 5.01 1.20
Learningmoreaboutendocrinology/diabetesisageneralchallengeforme. 146 1 6 4.75 1.32
Iratemyknowledgeaboutthetheoreticalbackgroundofendocrinology/diabetespriortothecourseaslow. 145 1 6 2.59 1.13
Iratemyknowledgeaboutthemanagementofpatientswithendocrinediseasesordiabetesmellitusprior 143 1 6 2.48 1.23
tothecourseaslow.
N=Numberofparticipantswhocompletedthequestionnaire,Min=lowestscore,Max=highestscore,Mean=meanscore,SD=standarddeviation.
Likert-Scale:1=stronglydisagree,6=stronglyagree.
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Table2Post-coursequestionnaire,Likert-Scale:1=stronglydisagree,6=stronglyagree
N Min Max Mean SD
Thecontentswereappropriatetomypre-knowledge. 95 1 6 4.96 1.23
Thecoursewasdiversified. 95 2 6 5.21 1.01
Thecasesenhancedthinkingandlearning. 95 3 6 5.46 .75
Ilearnedalotinthiscourse 95 3 6 5.16 .84
WhatIlearnedwillchangemyprofessionalbehavioranddecisions 93 1 6 4.83 .02
Thecoursefulfilledmyexpectations. 94 2 6 5.21 .91
Iexpectedmorepracticalguidelinesfordecisionmaking 94 1 6 2.60 1.46
Iexpectedmoretheoreticalbackgroundinformation 94 1 6 2.42 1.47
Ienjoyedthecourseverymuch 95 2 6 5.37 .96
N=Numberofparticipantswhocompletedthequestionnaire,Min=lowestscore,Max=highestscore,Mean=meanscore,SD=standarddeviation.
Gerlach et al. [20] that found that physicians expect in problem-based CPD courses for general practitioners.
knowledge transfer with practical guidelines, oppor- Chan et al. compared a web-based intervention with a
tunity for intensive discussion, imparting of the latest problem-based e-mail-course, Heale et al. a problem-
information, and case-based design from a high- based intervention in small groups with a formal CPD
quality CPD course. The authors conclude that there course (lecture followed by a discussion in the plenum).
is an explicit need for CPD courses that enhance the In summary, the findings of the study presented here
exchange of knowledge through the activation of phy- concerning the knowledge of the participants are con-
sicians, cover relevant clinical topics, and facilitate sistent with the conclusion of recent studies of inter-
knowledge and competence gain at the same time. active CPD courses especially those using team- and
Other studies have shown that physicians still prefer problem-based learning strategies. Compared to formal
traditional didactic lectures for CPD although numer- CPD interventions such as lectures which failed to
ous studies have shown their ineffectiveness [21,22]. change the knowledge significantly, there seem to be
clear benefitsfor interactiveinterventions.
Knowledgegain
Compared to our study Qureshi et al. [23] who Changesofprofessionalbehaviour
evaluated the effectiveness of an interactive, case-based We were able to show that primary health care of
intervention in changing the compliance with antihy- patients with diabetes in our sample does not meet the
pertensive medication, showed a knowledge gain of guidelines in a number of instances. For example just a
30.9%. Premi et al. [24] demonstrated a knowledge gain small percentage of patients was referred to a diabetes
of 12.1% of the participating general practitioners specialist and an ophthalmologist for fundoscopy once a
through a problem-based CPD course with small group year as recommended [16]. Also, the provision of med-
work. The control group, physicians who wanted to par- ical services like tests for microalbuminuria was low and
ticipate but did not get a ticket, had a knowledge gain of wasnotperformedbyallparticipatingphysicians.
2.8%. The comparison ofthese groups was highly signifi- In the most recent Cochrane Database review of the
cant. Unlike these studies Chan et al. [25] and Heale effects of continuing educational meetings and work-
et al. [26] could not show an effective gain of partici- shops Forsetlund et al. [2] identified a total of 81 trials
pants’ knowledge. Both authors did randomized studies and included 30 studies with 36 comparisons of
Table3Objectiveperformancechangeofthephysiciansintheinterventionandcontrolgroupregardingthekey
learninggoals(*firstandsecondquartalof2006and2007)
Keyprofessionalperformanceindicators Interventiongroup Controlgroup
2006* 2007* 2006* 2007*
Diagnosisofdiabetes 145.5 147.0 +1%p=0.661 87.4 87.8 +0.5%p=0.735
(meannumberofpatientswithdiabetesperphysician)
Referraltodiabetesspecialist 7.7% 10.2% +30.8%p<0.001 13.4% 13.0% −3%p=0.546
(percentageofpatientswithdiabetes)
Referraltoophthalmologistforfundoscopy 11.8% 12.8% +8.5%p=0.172 16.7% 16.2% −3%p=0.578
(percentageofpatientswithdiabetes)
Testsformicroalbuminuria 9.8% 10.5% +7.1%p=0.563 5% 5.5% +10%p=0.5
(percentageofpatientswithdiabetes)
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interventions inunivariate meta-regression analyses.The ticipants are consistent with the data from other recent
percentage change relativeto control in compliancewith studiesoninteractive CPD coursesespeciallythoseusing
desired practice was 6% (interquartile range 1.8 to 15.9) team- and problem-based learning strategies. The pro-
when a CME course was compared to no intervention. fessional performance of the participating physicians in
For continuous outcomes in professional performance our study has been improved in daily practice for two
the percentage change was 10% and for patient out- key indicators for guideline adherent decisions (referral
comes 3%. The performance changes found in our study to fundoscopy, test for microalbuminuria), with one
were of a similar degree. The authors concluded that additional statistically significant change (referral to dia-
educational meetings can improve professional practice betes specialists). Even statistically not significant
and patient outcomes but the effects tended to be small changes in guideline adherent decisions could have an
and appear to be higher when mixed interactive and di- important impact on patient outcomes. In summary, our
dactic components are used. Furthermore the effects are data showed that the primary health care of patients
lower for highly complex behaviors and less serious out- with diabetes is not fully compliant with guidelines and
comes. This last finding of Forsetlund et al. could be an that we need further incentives to evaluate the process
explanation for the mostly insignificant changes of the of changing professional behavior towards more guide-
performance change targeted in our study because we line adherent decisions. Furthermore, the transfer of
focused on the general care for patients with diabetes knowledge acquisition inCPD courses into daily medical
which hasserious outcomesbutjustinthelongterm. practice and patient and health care outcomes needs
more attentionand support. In our perceptiona promis-
Limitationsofthestudy ing strategy is to use the theories about transfer of
An important limitation of our study was that the con- knowledgeprovedtobeeffectiveinpedagogicalandpsy-
trol group included in the behaviour assessment did not chological research and implement and evaluate them in
participate in the knowledge assessment for practicality medical education. Barnett and Ceci [27] provide a very
reasons. There are many studies which have shown that helpfulframeworkforfartransferandprinciplestoteach
an interactive intervention results in a knowledge gain forsuccessfultransfer.
compared to no intervention. Therefore we focused the
comparative part of our study on the evaluation of pro- Availabilityofsupportingdata
fessional behaviour. Furthermore, the sample size for We added our supporting data as Additional file 1. It
assessingreal life behaviourdata wasrelatively small and contains the doctoral thesis of the corresponding author
there surely was a selection bias. Another limitation of written in German: “Fallbasierte interaktive Fortbildung
our study design is that a possible reason why the doc- für Allgemeinmediziner und Internisten: Akzeptanz,
tors who attended the CPD session were more adherent Lernerfolg und Verhaltensänderung durch ein modifi-
to the guidelines is that they are likely more interested ziertesTeam-basedLearning-Konzept”.
in diabetes care than the control group. Nevertheless,
our data showed that the guideline adherence was poor Additional file
in both group but is was improved in the intervention
group. Furthermore, we did not apply methods of direct Additionalfile1:Doctoralthesisofcorrespondingauthor(German):
observation of professional behaviour like audits. Finally, "FallbasierteinteraktiveFortbildungfürAllgemeinmedizinerund
Internisten:Akzeptanz,LernerfolgundVerhaltensänderungdurchein
we are aware of the fact, that there are numerous con-
modifiziertesTeam-basedLearning-Konzept".
founding variables on top of our CPD intervention that
influence the professional behaviour of the physicians in
Competinginterests
our sample. We tried to control for these confounders Theauthorsdeclarethattheyhavenocompetinginterests.
bymatchingcontrols but we are aware thatthis is not as
Authors’contributions
powerful as a true randomization of a larger group of
LKEservedastheprincipalinvestigatorinthisworkandwasresponsiblefor
physicians. thestudyconceptionanddesign,thecollection,analysisandinterpretation
ofthedata,andthedraftingofthemanuscript.MFsubstantiallycontributed
tothestudydesign,andtheacquisition,analysisandinterpretationofthe
Conclusions
data.Allauthorscontributedtothecriticalrevisionofthemanuscriptand
The team-based learning approach offers a promising approvedthefinalversionforpublication.Theauthorsarefundedbythe
format fordesigningeffectiveCPD-courses.Itwashighly universityhospitalinMunich.
accepted by participants, resulted in an increase of
Acknowledgements
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decisions. In summary, the findings of this study con-
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Kühne-EversmannandFischerBMCResearchNotes2013,6:14 Page7of7
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