An Introduction to Pulmonary Arterial Hypertension (PAH ...€¦ · An Introduction to Pulmonary...
Transcript of An Introduction to Pulmonary Arterial Hypertension (PAH ...€¦ · An Introduction to Pulmonary...
An Introduction to Pulmonary Arterial Hypertension (PAH): Diagnosis, Referral, and TreatmentInterim Outcomes Report (as of May 11, 2020)
Actelion Grant ID: 54654195Bayer Grant ID: 23249
Series Description: Dr. Beverly Jordan and Dr. Dan Schuller reviewed primary care implications of emerging PAH treatments and recent changes to clinical practice guidelines during the Alabama state chapter of the American Academy of Family Physicians 2019 annual meeting. The discussion introduced strategies for improved assessment, diagnostics, referral practices, and overall patient care.
Release/Expiration: February 4, 2020 – February 4, 2021
Credit: 1.0 AMA PRA Category 1 Credit™ and 1.0 AAFP prescribed credit
Sponsors: Academy for Continued Healthcare Learning (ACHL) and the New Jersey Academy of Family Physicians (NJAFP).
Supporters: Actelion and Bayer
Intended Audience: Primary care physicians and other community-based practitioners who may encounter at-risk patients who should be assessed for PAH and/or referred to specialty PAH care.
Activity Availability: • myCME: https://www.mycme.com/an-introduction-to-pah-diagnosis-referral-and-treatment/activity/6436/• ACHLcme: https://www.achlcme.org/Detail/4118/An-Introduction-to-PAH-Diagnosis-Referral-and-Treatment
Direct Video Access: https://www.achlcme.org/digital/PAH-regional/index.html
Overview
Interim Participation (as of May 11, 2020)812 Clinical Participants; 304 Certificates Issued (1500 Learners Guaranteed)
Practicing Type26% Physicians, 29% Physician Assistants, 11% Nurse Practitioners, 7% Nurses, 3% PharmDs and 24% Other HCPs
Objectivity & BalanceObjectivity and balance rated as good/excellent by 98% of learners
Learning Objectives
99% of learners strongly agree or agree that all learning objectives were met, with an average rating of 3.51
Faculty
Drs. Jordan and Schuller were rated as excellent or good by 98% of learners
Executive Summary
Executive SummaryAn effect size of 0.89 indicates that learners are now ~51.18% more knowledgeable of the content assessed than prior to participating in this education.
88% of learners will change their practice! Most notably, 56% will improve screening processes for patients at high-risk for PAH and 46% will start the steps to make a diagnosis of exclusion.
96% indicated participation in this activity will improve their patient outcomes.
Changes will impact 666 to more than 2,488 PAH patients each month.
Insurance/reimbursement issues, lack of equipment or necessary resources, and patient adherence issues were reported as the most common barriers to implementing changes in practice
Following the activity learners demonstrated increased knowledge surrounding the diagnosis of PAH including recognition, differential diagnosis and associated causes, as well as therapy selection.
Future Education Opportunities
Reinforcement on value of early identification, referral, and management of patients outside of a specialist
Competency in applying and interpreting echocardiography for a differential diagnosis
Review of treatment guidelines, including new and emerging therapies
Outcomes Reporting Methodology• First-attempt posttest scores are reported throughout:
• Initial answer choices for the posttest provide insight into the learners’ ability to immediately recall and apply the education.
• For post-activity questions administered as part of the evaluation (versus the online survey), only first-attempt was collected.
• Pre- and posttest responses have been paired/matched. Non-completer data has been omitted from the analysis to ensure comparison groups are equivalent.
• Participant: term used to describe an HCP who reviewed CME front matter and took action to begin the education.
Cohen’s d Effect Size
An effect size of 0.89 indicates that learners are now ~51.18% more knowledgeable of the content assessed than prior to participating in this education.
Pretest Posttest
44%Mean
0.217Standard Deviation
310Sample Size
67%Mean
0.294Standard Deviation
310Sample Size
Cohen’s d Effect Size = 0.89
This Effect Size calculation includes all learner completers and encompasses all pre/post-test questions. Paired data was used to calculate means and standard deviations.
Cohen (1988): .2 = small, .5 = medium, .8 = largeWolf (1986): .25 = educationally significant, .50 = clinically significant
Participation
29%
26%11%
7%
3%
24%
Participation by Clinician Type
Physician AssistantPhysicianNurse PractitionerNursePharmacistOther HCP
Participants Certificates 812 304
29%
11%
8%7%4%
4%3%
3%
31%
Participation by Specialty
CardiologyFamily Medicine/Primary CareInternal MedicineEmergency MedicinePulmonologySurgeryAllergy/ImmunologyOrthopedicsOther
Learning Objectives
99% of learners strongly agree or agree that all learning objectives were met, with an average rating of 3.51.
Please rate the following objectives to indicate if you are better able to: Analysis of RespondentsRating scale:
4=Strongly Agree; 1=Strongly Disagree
Evaluate recent changes to PAH clinical practice guidelines and their impact on primary care assessment, diagnostics, and referrals. 3.56
Describe primary care strategies for assessing/referring potential PAH cases to specialty care at earlier disease stages. 3.51
List effective community-based clinical support strategies of PAH cases in the primary care setting. 3.51
Discuss primary care impact of updates to PAH disease classifications/risk stratifications and related therapeutics. 3.51
Review emerging clinical research initiatives in PAH/novel therapies and their potential impact on patient care plans in the primary care setting. 3.48
Objectivity & Balance
Activity was perceived as objective, balanced and non-biased.
99%
1%
The education was free of commercial bias
Yes No
66%
32%
2%0%
10%
20%
30%
40%
50%
60%
70%
Excellent Good Fair Poor
Rating of objectivity & balance
N=304
Faculty Evaluation
The faculty were rated good or excellent across all areas by 98% of learners, with an average rating of 3.67.
Please rate the faculty on the criteria listed
Rating scale: 4=Excellent; 1=PoorAbility to effectively convey
the subject matter
Ability to present scientifically rigorous
information
Dan Schuller, MD 3.69 3.64
Beverly Jordan, MD 3.70 3.64
N=304
Beverly Jordan, MDProfessional Medical AssociateEnterprise, Alabama
Dan Schuller, MDProfessor and ChairDepartment of Internal Medicine: TransmountainTexas Tech University Health Sciences CenterPaul L. Foster School of MedicineEl Paso, Texas
Pretest vs. Posttest Summary
Participants demonstrated improved knowledge and competence on five of five pre/posttest questions.
45%
59%
44%
32%39%
68%76%
72%
57%61%
0%
20%
40%
60%
80%
100%
Topic 1 Topic 2 Topic 3 Topic 4 Topic 5
Pre 1st Attempt Post
Topic % Change
1 Hemodynamic definition 51%
2 Differential diagnosis 29%
3 Diagnosis 64%
4 Therapy selection 78%
5 Guidelines 61%
Overview of Correct Responses57% Average
Increase
15%
45%
16%24%
13%
68%
7%12%
A B C D0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pre (n=310) 1st Attempt Post (n=310)
Knowledge Acquisition: Definition
Following participation in this activity, learner's knowledge of the hemodynamic definition of PH increased by 51%. Given the recent
update to the definition of PH and emphasis of education in this activity, clinicians may consider PAH in more patients that were previously
considered borderline.
1. Which of the following best describes the updated definition of pulmonary hypertension (PH) in terms of mean pulmonary arterial pressure (mPAP)?
A. mPAP > 15 mm Hg
B. mPAP > 20 mm Hg
C. mPAP > 22 mm Hg
D. mPAP > 25 mm Hg
Hemodynamic Definition of PH
59%
13%20%
8%
76%
7%13%
4%
A B C D0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pre (n=310) 1st Attempt Post (n=310)
Knowledge Acquisition: Differential Diagnosis
Post activity 76% of learners were able to identify the first step in making a differential diagnosis of PAH .
Future education should build upon this strong knowledge base and focus on competency in applying and interpreting echocardiography.
Notably, 44% of learners indicated an interest in more education on the diagnosis of exclusion.
2. In patients with symptoms, signs, and history suggestive of PAH, the guidelines recommended which first step for making a differential diagnosis?
A. Echocardiography
B. Cardiac catheterization
C. Ventilation/perfusion lung scan
D. High-resolution computed tomography
Differential Diagnosis
44%
35%
13%8%
72%
17%
6% 5%
A B C D0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pre (n=310) 1st Attempt Post (n=310)
Clinical Competence: Diagnosis
Baseline competence surrounding PAH diagnosis was 44% and showed an increase of 64% post activity; this improvement in diagnostic
competence among healthcare professionals can improve PAH patient outcomes through early diagnosis and referral.
3. Which of the following clinical scenarios may describe a patient in early-stage PAH (eg, WHO Functional Class I or II) that should be referred to a PAH specialist for further clinical evaluation? A. A 32-year-old female with persistent fatigue and dyspnea on exertion
that has not responded to 3+ months of conventional asthma treatments, and has a negative methacholine bronchoprovocation test
B. A 64-year-old male, current smoker, with obesity-related COPD, chronic cough, and daytime fatigue that has not improved after use of a CPAP
C. 54-year-old female with frequent dyspnea, history of poorly controlled asthma, recurrent bronchitis, and seasonal allergies
D. 19-year-old male with a recent history of pneumothorax and syncope during athletic exertion
Diagnosis of PAH
18%
31% 32%
19%13%
17%
57%
13%
A B C D0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pre (n=310) 1st Attempt Post (n=310)
Knowledge Acquisition: Therapy Selection
Post activity 57% of learners were able to immediately recall the clinical implications from the AMBITION trial.
This 78% shift in knowledge on the use of combination therapy across clinicians supports specialty care recommendations as HCPs are more
aware of the benefits of initial combination therapy, which offers opportunity to play a greater role in community-based PAH patient
monitoring.
4. Results from the AMBITION trial support which clinical practice?
A. Preferential use of tadalafil over ambrisentan
B. Incorporation of sequential add on therapy when clinical response inadequate
C. Initial combination therapy with ambrisentan and tadalafil
D. Initial therapy with ambrisentan
Therapy Selection
39%
18%
31%
12%
61%
10%
20%
9%
A B C D0%
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100%
Pre (n=310) 1st Attempt Post (n=310)
Knowledge Acquisition: Guidelines
Following participation, learners’ knowledge of the 2019 CHEST guidelines increased by 56%.
Given that these guidelines recommend incorporation of community-based clinical support strategies, this knowledge increase should persuade clinicians to offer more support for their PAH patients.
5. The 2019 CHEST guidelines recommend incorporation of which community-based clinical support strategies into the management of PAH?
A. Supervised exercise and palliative care
B. Spiritual support
C. Social support
D. Rehabilitation and spiritual support
2019 Chest Guidelines
11%
49%
40%
29%
65%
6%
A B C0%
10%
20%
30%
40%
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60%
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90%
100%
Pre (n=310) Post (n=310)
Clinical Confidence: PAH Diagnoses
Prior to participation, 60% of learners were “very” or “somewhat” confident in their ability to diagnose PAH early in the disease course.
This percentage increased to 94% after participation.
How confident are you in making a diagnosis of PAH early in the disease course?
A. Very confident
B. Somewhat confident
C. Not at all confident
PAH Diagnoses
Behavioral Assessments
59%28%
14%
If you suspect your patient has PAH, which will you do first?
Initiate tests to make a differential diagnosisRefer patient to expert centerSeek support for treatment for an internal care team/specialist
60%37%
3%
How likely are you to refer your patients with suspected PAH earlier to a PAH specialty center or PAH specialist?
Very likely Somewhat likely Not at all likely
The majority of learners understand that PAH is a diagnosis of exclusion and are comfortable initiating this process and referring out to a specialist when alternative diagnoses are ruled out. Importantly, sixty percent of learners will
refer their patients earlier, which may translate into better outcomes.
Practice Change
88% of learners will change their practice! Most notably, 56% will improve screening processes for patients at high-risk for PAH and 46% will start the steps to make a diagnosis of exclusion.
12%
7%
20%
33%
46%
56%
0% 10% 20% 30% 40% 50% 60%
This activity validated my current practice; no changes will bemade
Other changes
Review and update treatment plans for my PAH patients basedon change to guideline recommendations
Provide supportive care for PAH patients in partnership withspecialists
Start the steps to make a diagnosis of exclusion
Improve screening processes for patients at high-risk for PAH
N=304 Multiple responses allowed
Patient Care Impact
31%
54%
12%3%
Number of patients with PAH seen per month:
01-1011-2021-50
Changes will impact 666 to more than 2,488 PAH patients each month. This assumes data in chart above is representative of all HCP completers (304), who indicated they would change their practice as a result of their
participation in this activity (88%).
N=304
Barriers to Planned Change
21%
2%
3%
4%
9%
11%
16%
16%
18%
18%
22%
0% 5% 10% 15% 20% 25%
No barriers
Lack of supporting evidence in the literature
Lack of consensus or professional guidelines
Other
Organizational/institutional culture
Do not have an implementation strategey
Cost
Lack of staff time to implement change
Patient adherence/compliance issues
Lack of equipment or necessary resources
Insurance/reimbursement issues
Participants indicated insurance/reimbursement issues (22%) as most common barrier to implementing changes in their practice, followed by lack of equipment or necessary resources (18%) and patient adherence issues (18%). Of those who identified barriers, 92% will attempt to address these barriers in order to improve their
performance.N=304; multiple responses allowed
Topics of Interest
23%
37%
38%
44%
0% 20% 40% 60% 80% 100%
Post-diagnosis risk-stratification
PAH supportive care
Evaluating PAH treatment
Diagnosis of exclusion criteria for PAH
Diagnosis of exclusion criteria and evaluation PAH treatment were rated with highest interest for future education.
N=304 multiple responses allowed
Activity ImpactSelf-reported change in practice• 6 MWT, refer to center of excellence • Assist our facility with implementing these changes and keep staff
current with treatment options for patients• Be more aware of PAH early symptoms.• Be more aware of potential PAH as a diagnosis in patients with SOB
and refer earlier for evaluation of potential PAH.• Be more aware of RT and its sided pressures on echo, also add
walking test more frequently in office• Be more proactive in diagnosis PAH and refer patients to PAH centers
for evaluation and treatment.• Better assessment and workup• Better communication with PAH centers• Close monitoring of patients with exercise intolerance• Consider PAH as part of my differential, and feel comfortable initiating
the workup• Consider PAH in the differential of more patients and start work up
earlier• Consider PAH more often in differential diagnosis• Critically think about the sign and symptoms of the patient to find the
right diagnosis• Earlier referral and higher level of suspicion• Earlier referral to PAH specialists • Earlier referral, initially dual therapy.• Earlier referral. Quicker echo.• Echo then refer to Special ctr.
• Evaluate in pts charts possibility of PH diagnosis• Evaluate patients better and know what types of imaging they need• formally diagnose, more aggressive referral• Get together with specialist on treatment plans• Have a higher clinical index of suspicion for PAH in patients with no
identified dx for DOE and refer sooner after initial testing• Have higher index of suspicion for diagnosis, initiate quicker workup
and treatment execution.• High level of clinical suspicion in patients with unexplained dyspnea
and diagnosis of exclusion• higher index of suspicion for pulmonary hypertension (all classes)• History of patient and echo.• I refer a lot to our pulmonary hypertension specialist • I will be able to better identify PAH in my patient population and know
when to refer• Improve analysis of pt. w suspected PAH and improve selective care• Improve screening for diagnosis of patients at high risk for PAH which
improves steps to make diagnosis of exclusion• Improve screening process and provide supportive care• Improve screening processes for patients at high-risk for PAH and start
the steps to make a diagnosis of exclusion• Increase awareness about this diagnosis and use diagnostic tools to
help to identify this patients at an earlier stage.• Initiate referral and initiate PAH work up• Initiate tests to make a differential diagnosis and use combination
rather than single drug therapy
Activity Impact (cont)Self-reported change in practice• Instruct echo techs to focus in on clear TR Doppler envelopes and
instruct echo techs to evaluate IVC and hepatic veins• Keep diagnosis of PAH in forefront and take the steps to rule-out other
diseases.• Keep high index of suspicion and remember it is a diagnosis of
exclusion and refer to specialist as soon as suspicion is present.• Keep PAH in differential, refer suspected cases early to specialty • Keep PAH on my differential with dyspnea on exertion, refer when PAH
is suspected following ECG• Look for signs and symptoms sooner and continue to learn about PAH
and the S&S• More aggressive management/referral and implementing diagnostic
assessment earlier on in symptom course. • More aggressive with diagnostic test and refer earlier• more aware of survival enhancing therapies and risk stratification• More diagnostic testing, PFT's and Echocardiograms. • More supportive care for my patient's with PAH. Patient education
regarding PAH• Order echocardiogram in suspected PAH patient and encourage
exercise for these patients• Ordering tests to come with Dx of the right class, do 6MWT more often• PAH has to be part of my Differential Diagnosis with patients that
present with PAH type symptoms. Also, initiate prompt testing/workup to rule out other causes of a possible PAH case, so as a result a diagnosis can be made promptly.
• PAH supportive care, risk stratification
• Pay attention to echo results of patients with unexplained dyspnea and follow up on additional testing
• Refer to a specialist, consult specialist when I need, understanding new diagnostic criteria for PAH
• Review RVSP on echos and understand pt's with heart disease and PH better
• Screen for PH & PAH with more proficiency. I identify PH often in chronic resp and CHF patients, and now I will seek out Physicians capable of helping them
• Screen more, refer for Echo and specialist• Screen patients more effectively and make sure the proper steps are
taken to get correct diagnosis• Select appropriate PAH management strategies based on patient
characteristic • Starting initial workup, referring to specialist• Teaching pathophysiology; planning for function testing.• Think of P.H. in the differential diagnosis of my patients with S.O.B.
and order the appropriate tests to make the initial diagnosis• Treat more people with Pulm HTN and research more• Watch patient for continue s/s and ask how long this as been going on.• Will attempt to address these barriers in order to implement changes in
competence, performance, and/or patients' outcomes• Will continue to have a high index of clinical suspicion to make PAH
diagnosis and manage accordingly.• Will look at echos more closely, have a lower threshold for testing and
referral.
Contact InformationBrittany PusterVP, Education DevelopmentAcademy for Continued Healthcare Learning (ACHL)
E: [email protected]: 773-714-0705 ext. 134C: 303-829-2562