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Duke University: State-required continuing medical education does not affect heart attack care
Cardiovascular Device Liability Week (April 4, 2004)

In the first such analysis, Duke University Medical Center researchers have found that state-mandated programs for continuing medical education (CME) for physicians have little impact in improving outcomes for heart attack patients or in increasing the use of therapies proved effective by clinical trials.

Just as interestingly, the researchers found that heart attack patients in states requiring CME were significantly more likely to receive brands of thrombolytic, or artery-opening, drugs manufactured by drug companies that often sponsor CME events.

Currently, 34 states mandate that physicians must complete a certain number of CME hours each year, at an annual cost of more than $1.5 billion to the health-care system, the researchers said. Requirements vary from state to state, with mandated CME ranging from 25 hours to 75 hours each year.

The results of the current analysis were presented by cardiologist Manesh Patel, MD, Duke Clinical Research Institute, at the annual scientific sessions of the American College of Cardiology in New Orleans.

"Last year, the Institute of Medicine (IOM) issued a report saying that health-care professionals should participate in continuing education programs that have proven effective through process of care and outcome measures," Patel said. "However, there have been no studies to date to measure whether current programs are working.

"According to our analysis, state-mandated CME had little association with heart attack care or outcome, other than a small increase in the use of the 'branded' thrombolytic therapy," Patel continued. "We need further research to maximize the measurable effects of CME regardless of whether or not 'branded' or generic medications are used."

To conduct their study, the Duke team consulted the Cooperative Cardiovascular Project, a database of more than 130,000 patients admitted to U.S. hospitals with a heart attack from 1994-1996. They then compared the treatment options and outcomes for patients who were treated in states with CME and without CME programs.

As performance measures, the researchers examined the use of aspirin and reperfusion therapies (such as thrombolytics) on admission, as well as the prescribing of aspirin and beta-blockers at discharge. These treatments have all proved effective in improving outcomes by large multicenter clinical trials. The researchers also measured 30-day and 1-year mortality rates.

States with and without CME requirement had similar rates of aspirin use at admission and discharge (79.9% vs. 79.4%, 72.5% vs. 72.5%), as well as beta-blocker use at discharge (53.6% vs. 55.3%), Patel said. Additionally, there was no association between CME requirements and 30-day or 1-year mortality rates, he continued.

"However, the rate of reperfusion therapy at admission was significantly higher - 53.1% - in states requiring CME when compared to states that do not - 47.9%," Patel said. "Patients in CME-required states were significantly more likely to receive reperfusion therapy, mainly due to the 'branded' thrombolytic therapies."

According to the Accreditation Council on Continuing Medical Education (ACCME), industry funding for CME represented 60% of the $1.5 billion spent in 2002. Recent studies have shown the industry-sponsored CME courses tend to highlight the sponsor's therapies and that they can be effective in influencing a physician's prescribing decisions.

"The possible synergy between pharmaceutical marketing and greater use of evidence-based therapy is of interest," Patel said. "The similar rates of aspirin and beta-blocker prescription also raise concern regarding the ability of CME to improve care across all types of medications, including generic therapies that do not represent marketing opportunities."

The researchers said that during the period of data collection, the medications most commonly being heavily marketed were thrombolytics. Unlike the older medications such as aspirin and beta blockers, these "branded" thrombolytic agents had little competition as agents for quickly reopening clogged arteries, they said.

Since regulations vary from state to state for those state with CME, the researchers believe a nationwide standardized effort is needed not only to ensure that physicians receive appropriate training in their specialties, but that there is a mechanism in place to measure the effects of this training.

The study was supported by the Delmarva Foundation for Medical Care, Easton, Maryland, and the U.S. Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration).

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