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Online interactive spaced education (ISE) is a novel educational methodology based on the "spacing effect", the psychological finding that repeated presentations of educational material over spaced intervals increase learning efficiency and improve knowledge retention. ISE is delivered using periodic emails that contain clinical case scenarios and multiple-choice question. The investigators recently completed a randomized trial involving 95 VISN 1 primary care providers (PCPs) which demonstrated that an ISE intervention can significantly improve clinician's practice patterns. Those clinicians randomized to the ISE intervention on prostate cancer screening demonstrated a 26% relative reduction in inappropriate screening. The investigators propose to conduct a randomized controlled trial involving PCPs in VISN 1 to determine whether ISE can (1) increase knowledge of the appropriate treatment of hypertensive patients, (2) reduce clinical inertia in hypertension management, and (3) improve the blood pressure control in hypertensive patients.
Anticipated Impacts on Veterans' Healthcare: This study aims to demonstrate that online interactive spaced education (ISE) can improve providers' care of patients with hypertension. ISE is the type of intervention that can be deployed across the VHA with content tailored to meet specific needs and can be implemented as a tool to improve performance measures and clinical outcomes
Anticipated Impacts on Veterans' Healthcare: This study aims to demonstrate that online interactive spaced education (ISE) can improve providers' care of patients with hypertension. ISE is the type of intervention that can be deployed across the VHA with content tailored to meet specific needs and can be implemented as a tool to improve performance measures and clinical outcomes.
Project Background/Rationale: ISE is a novel educational methodology based on the "spacing effect", the psychological finding that repeated presentations of educational material over spaced intervals increase learning efficiency and improve knowledge retention. ISE is delivered using periodic emails that contain clinical case scenarios and multiple-choice questions. We recently completed a randomized trial involving 95 VISN 1 primary care providers (PCPs) which demonstrated that an ISE intervention can significantly improve clinician's practice patterns. Those clinicians randomized to the ISE intervention on prostate cancer screening demonstrated a 26% relative reduction in inappropriate screening.
Project Objectives: Lowering blood pressure in hypertensive patients unequivocally decreases the incidence of stroke and cardiovascular events and is highly cost-effective. The majority of patients with blood pressure above the treatment target do not have their anti-hypertensive medications appropriately intensified at clinician visits. A reduced frequency of treatment intensification is alternatively termed 'clinical inertia'. Our preliminary results show that clinicians' knowledge of hypertension management guidelines is limited, and few clinicians report following the guidelines consistently. We propose to conduct a randomized controlled trial involving PCPs in VISN 1 to determine whether ISE can (1) increase knowledge of the appropriate treatment of hypertensive patients, (2) reduce clinical inertia in hypertension management, and (3) improve the blood pressure control in hypertensive patients.
Project Methods: One hundred six VISN 1 primary care practitioners (physicians, nurse practitioners, and physician assistants) will be recruited via email to participate in the study. Participants will be randomized to one of two cohorts: (1) the intervention cohort will receive ISE over year 1, and (2) the control cohort will receive no intervention and will represent the "standard of education" on hypertension management. The ISE intervention will consist of an email every 4 days containing 1 multiple-choice questions based on a curriculum derived from clinical practice guidelines on appropriate hypertension management. Providers will submit answers to the questions online and immediately receive the correct answer and an explanation of the pertinent clinical issues. Using a new adaptive methodology, the spacing and content of the educational intervention will be individualized for each clinician based on their performance. The ISE intervention will be completed in 9-11 months. Hypertension knowledge will be assessed by a post-test at the end of year 1. Providers' clinical inertia and the blood pressures of their patients will be assessed over 2 years: initial changes attributable to ISE will be identified in year 1, while the retention of these changes will be monitored in year 2. Drawing on the interdisciplinary expertise of our investigator team, the study is positioned to enrich national debates about how best to improve the ways in which clinicians can meet their lifelong learning needs.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| SE Game Cohort | Experimental | Will receive ISE intervention. |
|
| Control Cohort | No Intervention | The control cohort will receive identical content online (with no ISE) |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Interactive Spaced Education (ISE) --- online education | Other | ISE is a novel educational methodology based on the "spacing effect", the psychological finding that repeated presentations of educational material over spaced intervals increase learning efficiency and improve knowledge retention. ISE is delivered using periodic emails that contain clinical case scenarios and multiple-choice questions. |
| Measure | Description | Time Frame |
|---|---|---|
| Cross-cohort Comparison of the Average Time Needed to Normalize Patients' Blood Pressure | A unique hypertensive period served as the unit of analysis. A hypertensive period started on the first day during the study when a patient's BP was elevated. It ended on the first subsequent day when it was <140/90 mm Hg or on the last day BP was recorded during the study. Duration of the hypertensive period (days) was the outcome measure. BP measurements obtained in the course of routine care were used to ascertain study outcomes, whether obtained by the PCP or at other clinic visits. These measurements were obtained from structured data (ie, BP recordings in the electronic medical record) and natural language processing of provider notes as previously described. If several measurements were recorded on the same day, the lowest mean arterial BP was used. | Months 1-24 |
| Measure | Description | Time Frame |
|---|---|---|
| Cross-cohort Comparison of Patients' Average Blood Pressure at 12 Months After Trial Launch (Last Measured Blood Pressure in Months 1-12) | Months 1-12 | |
| Cross-cohort Comparison of Patients' Average Change in Blood Pressure Over Months 1-12 (Last Measured Blood Pressure in Months 1-12) |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| B. Price Kerfoot, MD EdM | VA Boston Healthcare System Brockton Campus, Brockton, MA | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| VA Boston Healthcare System Brockton Campus, Brockton, MA | Brockton | Massachusetts | 02301 | United States |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 24847084 | Result | Kerfoot BP, Turchin A, Breydo E, Gagnon D, Conlin PR. An online spaced-education game among clinicians improves their patients' time to blood pressure control: a randomized controlled trial. Circ Cardiovasc Qual Outcomes. 2014 May;7(3):468-74. doi: 10.1161/CIRCOUTCOMES.113.000814. |
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| ID | Title | Description |
|---|---|---|
| FG000 | SE Game Cohort | SE game clinicians were e-mailed one question every 3 days. Adaptive game mechanics re-sent questions in 12 or 24 days if answered incorrectly or correctly, respectively. Clinicians retired questions by answering each correctly twice consecutively. Posting of relative performance among peers fostered competition. |
| FG001 | Control Cohort | Control clinicians received identical educational content in an online posting with email reminders. |
| Title | Milestones | Reasons Not Completed | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
Participants' baseline demographic characteristics were similar between randomized cohorts.
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| ID | Title | Description |
|---|---|---|
| BG000 | SE Game Cohort | SE game clinicians were e-mailed one question every 3 days. Adaptive game mechanics re-sent questions in 12 or 24 days if answered incorrectly or correctly, respectively. Clinicians retired questions by answering each correctly twice consecutively. Posting of relative performance among peers fostered competition. |
| BG001 |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | Mean |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Cross-cohort Comparison of the Average Time Needed to Normalize Patients' Blood Pressure | A unique hypertensive period served as the unit of analysis. A hypertensive period started on the first day during the study when a patient's BP was elevated. It ended on the first subsequent day when it was <140/90 mm Hg or on the last day BP was recorded during the study. Duration of the hypertensive period (days) was the outcome measure. BP measurements obtained in the course of routine care were used to ascertain study outcomes, whether obtained by the PCP or at other clinic visits. These measurements were obtained from structured data (ie, BP recordings in the electronic medical record) and natural language processing of provider notes as previously described. If several measurements were recorded on the same day, the lowest mean arterial BP was used. | Posted | Median | Full Range | days | Months 1-24 |
|
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Arm 1 | SE game clinicians were e-mailed one question every 3 days. Adaptive game mechanics re-sent questions in 12 or 24 days if answered incorrectly or correctly, respectively. Clinicians retired questions by answering each correctly twice consecutively. Posting of relative performance among peers fostered competition. |
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| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Dr. B. Price Kerfoot | Veterans Affairs Boston Healthcare System | 7742869230 | price.kerfoot@gmail.com |
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| ID | Term |
|---|---|
| D006973 | Hypertension |
| ID | Term |
|---|---|
| D014652 | Vascular Diseases |
| D002318 | Cardiovascular Diseases |
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|
| Months 1-12 |
| Cross-cohort Comparison of Patients' Average Blood Pressure at 24 Months After Trial Launch (Last Measured Blood Pressure in Months 13-24) | Months 13-24 |
| Cross-cohort Comparison of Patients' Average Change in Blood Pressure Over Months 13-24 (Last Measured Blood Pressure in Months 13-24) | Months 13-24 |
| Cross-cohort Comparison of Patients' Average Blood Pressure at 24 Months After Trial Launch (Last Measured Blood Pressure in Months 1-24) | Months 1-24 |
| Cross-cohort Comparison of Patients' Average Change in Blood Pressure Over Months 1-24 (Last Measured Blood Pressure in Months 1-24) | Months 1-24 |
| Cross-cohort Comparison of Frequency of Treatment Intensification | Months 1-24 |
| Cross-cohort Comparison of Patients' Follow-up Intervals After Clinical Encounters With Elevated Blood Pressure | Months 1-24 |
| Pre-test Performance Differences by Provider-related Variables (Site of Care, Age, Date of Recertification, Etc.) | Month 1 |
| Cross-cohort Comparison of Providers' Post-test Scores (Score Improvements) | Months 1-12 |
| Baseline Knowledge Levels of Providers Assessed Via Their Initial Responses to Spaced Education Items (Spaced Education Cohort Only) | Months 1-12 |
| Performance Differences by Provider-related Variables (Site of Care, Age, Date of Recertification, Sex, Etc.) in the Spaced Education Program (Spaced Education Cohort Only) | Months 1-12 |
| Provider-perceived Acceptability of Spaced Education Intervention | Months 1-12 |
| Provider-perceived Effectiveness of Spaced Education Intervention | Months 1-12 |
| Providers' Perceptions of the Optimal Parameters for the Spaced Education Intervention | Months 1-12 |
| Provider-perceived Barriers and Facilitators to the Spaced Education Intervention | Months 1-12 |
| Control Cohort |
Control clinicians received identical educational content in an online posting with email reminders. |
| BG002 | Total | Total of all reporting groups |
| years |
|
| Sex: Female, Male | Count of Participants | Participants |
|
| OG001 | Control Cohort | Control clinicians received identical educational content in an online posting with email reminders. |
|
|
| Secondary | Cross-cohort Comparison of Patients' Average Blood Pressure at 12 Months After Trial Launch (Last Measured Blood Pressure in Months 1-12) | PI and project staff no longer have access to the raw data and are no longer able to generate any more data analyses. | Posted | Months 1-12 |
|
|
| Secondary | Cross-cohort Comparison of Patients' Average Change in Blood Pressure Over Months 1-12 (Last Measured Blood Pressure in Months 1-12) | PI and project staff no longer have access to the raw data and are no longer able to generate any more data analyses. | Posted | Months 1-12 |
|
|
| Secondary | Cross-cohort Comparison of Patients' Average Blood Pressure at 24 Months After Trial Launch (Last Measured Blood Pressure in Months 13-24) | PI and project staff no longer have access to the raw data and are no longer able to generate any more data analyses. | Posted | Months 13-24 |
|
|
| Secondary | Cross-cohort Comparison of Patients' Average Change in Blood Pressure Over Months 13-24 (Last Measured Blood Pressure in Months 13-24) | PI and project staff no longer have access to the raw data and are no longer able to generate any more data analyses. | Posted | Months 13-24 |
|
|
| Secondary | Cross-cohort Comparison of Patients' Average Blood Pressure at 24 Months After Trial Launch (Last Measured Blood Pressure in Months 1-24) | PI and project staff no longer have access to the raw data and are no longer able to generate any more data analyses. | Posted | Months 1-24 |
|
|
| Secondary | Cross-cohort Comparison of Patients' Average Change in Blood Pressure Over Months 1-24 (Last Measured Blood Pressure in Months 1-24) | PI and project staff no longer have access to the raw data and are no longer able to generate any more data analyses. | Posted | Months 1-24 |
|
|
| Secondary | Cross-cohort Comparison of Frequency of Treatment Intensification | PI and project staff no longer have access to the raw data and are no longer able to generate any more data analyses. | Posted | Months 1-24 |
|
|
| Secondary | Cross-cohort Comparison of Patients' Follow-up Intervals After Clinical Encounters With Elevated Blood Pressure | PI and project staff no longer have access to the raw data and are no longer able to generate any more data analyses. | Posted | Months 1-24 |
|
|
| Secondary | Pre-test Performance Differences by Provider-related Variables (Site of Care, Age, Date of Recertification, Etc.) | PI and project staff no longer have access to the raw data and are no longer able to generate any more data analyses. | Posted | Month 1 |
|
|
| Secondary | Cross-cohort Comparison of Providers' Post-test Scores (Score Improvements) | PI and project staff no longer have access to the raw data and are no longer able to generate any more data analyses. | Posted | Months 1-12 |
|
|
| Secondary | Baseline Knowledge Levels of Providers Assessed Via Their Initial Responses to Spaced Education Items (Spaced Education Cohort Only) | PI and project staff no longer have access to the raw data and are no longer able to generate any more data analyses. | Posted | Months 1-12 |
|
|
| Secondary | Performance Differences by Provider-related Variables (Site of Care, Age, Date of Recertification, Sex, Etc.) in the Spaced Education Program (Spaced Education Cohort Only) | PI and project staff no longer have access to the raw data and are no longer able to generate any more data analyses. | Posted | Months 1-12 |
|
|
| Secondary | Provider-perceived Acceptability of Spaced Education Intervention | PI and project staff no longer have access to the raw data and are no longer able to generate any more data analyses. | Posted | Months 1-12 |
|
|
| Secondary | Provider-perceived Effectiveness of Spaced Education Intervention | PI and project staff no longer have access to the raw data and are no longer able to generate any more data analyses. | Posted | Months 1-12 |
|
|
| Secondary | Providers' Perceptions of the Optimal Parameters for the Spaced Education Intervention | PI and project staff no longer have access to the raw data and are no longer able to generate any more data analyses. | Posted | Months 1-12 |
|
|
| Secondary | Provider-perceived Barriers and Facilitators to the Spaced Education Intervention | PI and project staff no longer have access to the raw data and are no longer able to generate any more data analyses. | Posted | Months 1-12 |
|
|
| 0 |
| 55 |
| 0 |
| 55 |
| EG001 | Arm 2 | Control clinicians received identical educational content in an online posting with email reminders. | 0 | 56 | 0 | 56 |
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