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The American Journal of Managed Care May 2012
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Impact of Certified CME in Atrial Fibrillation on Administrative Claims
Stephanie A. Stowell, MPhil; Allison J. Gardner, PhD; Joseph S. Alpert, MD; Gerald V. Naccarelli, MD; Thomas P. Harkins, MA, MPH; Anthony M. Louder, PhD, RPh; and Leonardo Tamariz, MD, MPH
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Impact of Certified CME in Atrial Fibrillation on Administrative Claims

Stephanie A. Stowell, MPhil; Allison J. Gardner, PhD; Joseph S. Alpert, MD; Gerald V. Naccarelli, MD; Thomas P. Harkins, MA, MPH; Anthony M. Louder, PhD, RPh; and Leonardo Tamariz, MD, MPH
Use of administrative claims data is an innovative way of measuring the effect of continuing medical education on physician practice behavior and patient outcomes.
Objective: To determine whether changes in physician behavior associated with a continuing medical education (CME) activity on atrial fibrillation (AF) can be measured using an administrative claims database.

Study Design: A retrospective, analytical review of physician practice changes and AF patient– related healthcare utilization and costs derived from an administrative claims database was performed on a cohort of Humana health system physicians.

Methods: The Humana physicians participated in a specified CME activity on the management of patients with AF. Treatment patterns of these providers and clinical outcomes of a cohort of established AF patients were compared 6 months before and 6 months after physician participation in the AF CME activity.

Results: Analysis of administrative claims data from Humana providers who participated in an AF CME activity and their patients demonstrated a significant reduction in AF-related healthcare costs and utilization, including decreased length of stay. Humana providers, in addition to the other CME activity participants, demonstrated significant gains in knowledge of evidence-based care strategies when presented with real-world scenarios of patients with AF.

Conclusions: The use of administrative claims data is an innovative way of measuring the effectiveness of CME. These observations support the need for further investigation into the drivers of change in patient outcomes that may be associated with CME activities, as well as the utility of healthcare claims data as a possible valid measure of the impact of CME on physician performance and patient outcomes.

(Am J Manag Care. 2012;18(5):253-260)
Participation in a certified continuing medical education (CME) webcast activity on management of patients with atrial fibrillation (AF) was associated with a significant decrease in AF-related healthcare utilization and costs.

  •  CME can improve physician confidence and knowledge.

  •  Improved physician competence may translate into healthcare savings through better patient care.

  •  CME can help physicians provide quality care, which may affect reimbursements in the new pay-for-performance era of healthcare.
Atrial fibrillation (AF) is associated with significant morbidity and mortality, and affects nearly 2.3 million Americans.1 AF is becoming increasingly prevalent with the aging of the US population; the incidence of AF doubles with each decade of age, and an estimated 5.6 million people are expected to be diagnosed by the year 2050. The economic burden of AF is also significant. Annual healthcare costs exceed 5 times the normal healthcare costs of an average individual, with the majority of these costs driven by interventional procedures and inpatient care.2,3

AF is a complex disease that demands a high degree of individualized patient care. For physicians, this care requires keeping abreast of rapidly changing clinical practice guidelines and an expanding selection of available therapeutic agents. In addition, as the Centers for Medicare & Medicaid Services shifts toward a quality-centric approach to healthcare reimbursements, physician performance and quality patient care are becoming increasingly more important.4 Several definitive measures for quality AF patient care exist, including the assessment for thromboembolic risk factors as well as the provision and appropriate monitoring of anticoagulation therapy.5,6

Despite the existence of quality measures, many challenges remain in the management of this multifaceted disease. Although guidelines continually change to reflect the most recent evidence available, current guidelines do not provide definitive measures on how to provide individualized patient care. Furthermore, treatment challenges can be compounded when comorbid conditions are present.7 Taken together, these factors create a significant need for education on current evidence and best practices for the comprehensive management of AF.

To routinely update, improve, and reinforce practice behaviors, clinicians are required to regularly engage in continuing medical education (CME) activities. Typically, evaluation of CME efforts is limited to self-reporting of participant satisfaction and questions designed to assess the educational objectives of the activity. However, the ever-increasing focus on improving the quality of care demands more stringent and sophisticated methods for measuring changes in clinician performance associated with CME activity teachings. To this end, a new type of outcomes measure was adopted. Administrative claims data have long been used to evaluate the effects of various healthcare practices and interventions; however, the impact of CME teachings on physician behavior has not been commonly evaluated by these means. Here we describe a pilot study that used data from an administrative claims database to explore the potential connection between a CME-certified intervention and improvements in physician knowledge and competence in AF-related healthcare decisions and patient outcomes.


A 60-minute, CME-certified webcast activity was developed for clinicians who treat patients with AF. The activity incorporated interactive patient case–based questions and an expert panel discussion on current clinical data and guideline-recommended best practices for the optimal management of this patient population. Specific discussion topics included the clinical consequences of AF and the negative effects of the disease on quality of life; the use of risk assessment criteria to optimize antithrombotic treatment decisions for stroke prophylaxis; and the implementation of strategies to individualize care plans that incorporate specific patient needs along with clinical evidence for rate control, rhythm control, and thromboembolic prevention. In accordance with Accreditation Council for Continuing Medical Education standards for commercial support, the content of the webcast activity was examined by an independent, third-party review board; met criteria for objectivity, balance, and scientific rigor; and was determined to be free of commercial bias.8

To assess the impact of the CME activity on clinical practice, a retrospective cohort analysis of physician practices and AF patient outcomes was conducted. The study population consisted of cardiologists, electrophysiologists, and internal medicine physicians who participated in the AF CME activity between October 2009 and May 2010, and who were also identified as being contracted US-based physicians within the Humana, Inc health plan electronic data warehouse. A 12-month study period was identified for each physician participant based upon an index date (ie, the date the individual physician completed the specified CME activity); this period was defined as the 6 months prior to and following the index date (pre-CME period and post-CME period, respectively). Patients of these physicians who had at least 1 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9- CM) coded claim for AF (427.3x) in the pre-CME period, who were 18 to 89 years of age, and who were enrolled in a Medicare Advantage or commercial full-insured health plan were also included in the analysis.

Physician and patient data were obtained from 5 electronic databases, including a provider file containing physician practice, specialty, and geographic information; a member file containing demographic and enrollment information for each patient per encounter (age, sex, type of insurance, and geographical region); a medical file containing up to 9 recorded ICD-9-CM codes per encounter and related payment information; a pharmacy file containing all Generic Product Identifier numbers of pharmacy-dispensed medications per claim and related payment information; and a lab file containing Logical Observation Identifiers Names and Codes and test results per encounter.


Administrative Claims Data

Therapeutic interventions and AF-related healthcare utilization and costs were obtained from the administrative claims databases for qualifying Humana patients treated by participating physicians. Specifically, AF-related healthcare costs and utilization, rate and rhythm control therapies, stroke prevention treatments and associated monitoring, medical devices and procedures related to AF, cardiovascular comorbidities, CHADS2 scores, Charlson Comorbidity Index scores, and patient demographic information were evaluated. All analyses were conducted using SAS 9.2/SAS Enterprise Guide 4.2 (SAS Institute Inc, Cary, North Carolina). Study exemption was provided by the University of Miami Institutional Review Board prior to data collection.

Administrative claims data corresponding to the predetermined study measures were collected and evaluated on the same group of eligible patients in both the pre-CME and post-CME activity periods of the study. Descriptive analyses were completed on all study variables. Unadjusted preindex and postindex date comparisons on key measures, such as drug utilization and costs, were performed. Wilcoxon matched-pairs, signed-rank tests were used for non–normally distributed continuous outcomes, and McNemar tests were used for binary outcomes. P values for 2-sided tests were calculated with statistical significance set at P <.05.

CME Activity Outcomes

A quantitative analysis of the CME-certified AF webcast was performed to assess changes in participant confidence and knowledge. Participants responded to 1 confidence question on a 4-point Likert scale as well as 5 knowledge questions with only 1 correct answer. Chi-squared tests were conducted to assess immediate gain, retention, and longer-term gains in knowledge. Results were considered statistically significant if the resulting x2 or t test would have occurred by chance less than 10% of the time (P <.10).


Administrative Claims Data

Provider Characteristics. In an effort to explore possible changes in physician practice patterns and AF patient outcomes after heightened awareness of guideline measures and current evidence, 395 physicians were identified who completed both the presurvey and postsurvey of the AF CME activity. Of these physicians, 204 were excluded due to incomplete name information, missing activity completion date, foreign residence, or completion of the activity after June 1, 2010. The remaining 191 providers were merged with the Humana electronic data warehouse. A total of 114 providers encountered Humana member patients during the

study period. Of those providers, a total of 84 encountered 932 Humana member patients with a diagnosis of AF in the pre-CME period.

All study participants were physicians, and the majority specialized in cardiology (Table 1). Of the study participants who provided practice information, more than one-half practiced in community or private practice, and nearly one-fourth were associated with hospital practices. Sixteen percent of study physicians did not provide practice details.

Patient Characteristics. The majority of patients included in the study were male (57%) and patients had a mean age of 74 years. Overall, 24% of patients were in their 60s, 39% of patients were in their 70s, and 32% were in their 80s. The mean Charlson comorbidity score was 2.7 (SD 1.9), and the most common comorbidities were hypertension (88%), heart failure (53%), cardiovascular disease (42%), and diabetes (14%). The mean CHADS2 score was 2.3.

Prescription Patterns. Evaluation of prescriptions for rhythm and rate control therapies revealed that 83% of patients were being treated with at least 1 of these approaches; 78% were treated with rate control agents, and 28% were treated with rhythm control agents. A significant increase in the use of dronedarone was observed during the study period, with nearly a 3-fold increase in new users in the post-CME activity period (7 vs 20, P = .0004). A trend toward decreased use of flecainide was also observed after the CME intervention, although these results were not statistically significant.

According to American College of Cardiology/American Heart Association AF guideline recommendations, patients with AF and a CHADS2 score of 2 or more should receive combination therapy with a rate or rhythm control agent and an anticoagulant.6 At the time of this study, warfarin was the only guideline-recommended anticoagulant agent for stroke prevention in patients with AF.7 Overall, 70% of patients had a CHADS2 score of 2 or more and should have received some form of combination therapy (ie, anticoagulant and rate control therapy, anticoagulant and rhythm control therapy, or all 3 therapies together). Of these patients, 60% in the pre-CME period and 57% in the post-CME period received some form of combination therapy. Sixty-two percent of patients were on warfarin for stroke prevention; however, no significant changes in anticoagulant use were observed in the overall cohort between the pre-CME and post-CME activity periods. Althoug 53 patients in the post-CME activity period were started on warfarin therapy, a slightly greater number of patients (n = 56) discontinued this anticoagulant for a net loss of 3 warfarin users.

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