Online CKD education program for health-care professionals - Kidney ...

meeting report

http://www.kidney-international.org & 2013 International Society of Nephrology

Online CKD education program for health-care professionals Roberto Tapia-Conyer1, Hector J. Gallardo-Rincoń1, Guillermo Garcıá-Garcıá2, Rodrigo Saucedo-Martıńez1, Librado De la Torre-Campos2 and Karina Renoirte-Lopez2 1

Instituto Carlos Slim de la Salud, Mexico, DF, Mexico and 2Hospital Civil de Guadalajara ‘‘Fray Antonio Alcalde’’, Division of Nephrology, University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico

Online learning has become an increasingly popular approach to medical education. We describe the first E-learning Diploma to be offered to primary health-care professionals in Mexico that provides comprehensive training in the detection and treatment of chronic non-communicable diseases. The Diploma is divided into five consecutive modules. Each module includes workshops, case discussions, and selected readings that include elements of integrated prevention and early detection, changes in lifestyle, clinical care, and adequate use of technology. Between 1 March 2010 and February 2011, 844 students from eight states were enrolled. Three hundred sixty-two students were accredited from the course, with an average score of 9.6 out of 10; 19% of the students scored 10. The main reasons for not finishing the course were poor compliance and lack of motivation. The E-Learning Diploma offers a valuable educational tool for training health-care professionals in the detection and treatment of chronic kidney disease and other chronic non-communicable diseases. Kidney International Supplements (2013) 3, 174–177; doi:10.1038/kisup.2013.8 KEYWORDS: chronic non-communicable diseases; E-learning; internet education

Correspondence: Guillermo Garcia-Garcia, Hospital Civil de Guadalajara ‘‘Fray Antonio Alcalde’’, Division of Nephrology, Hospital 278, PO Box 2-70, Guadalajara, Jalisco 44280, Mexico. E-mail: [email protected] 174

INTRODUCTION

Chronic non-communicable diseases (CNCDs), such as obesity, diabetes mellitus, hypertension, and chronic kidney disease (CKD), have become a major public health problem in the Mexican population. Diabetes mellitus is present in as many as 14% of adult Mexicans, and 72% are overweight or obese.1,2 The incidence of kidney failure has increased dramatically in parallel with these risk factors3 and currently is among the 11 leading causes of death in the adult population.4 It has been estimated that 8% of the adult Mexican population has an estimated glomerular filtration rate o60 ml/min.5 Early CKD detection and intervention retards or may prevent progression of CKD to end-stage renal disease. However, specialized human resources are scarce and there are only B700 nephrologists in Mexico to look after this growing population (Consejo Mexicano de Nefrologia, unpublished data). Recent studies have shown that familypractice physicians who had undergone comprehensive training increased their clinical competence in the management of patients with diabetic nephropathy, and achieved better preservation of patients’ kidney function.6 Thus, there are good grounds to train other health professionals, such as nurses and primary-care physicians, to diagnose and treat CKD. E-learning has become an increasingly popular approach to medical education. The introduction of the World Wide Web in 1991 facilitated the use of the Internet, and its potential as an instructional tool was quickly recognized. Among its advantages, Internet-based education allows students to participate at a time and place convenient to them, facilitates instructional methods that might be difficult in other formats, and has the potential to tailor instruction to the individual’s learning needs.7 The key steps in developing an effective E-learning platform have been elegantly described by Cook and Dupras.8 The Carlos Slim Health Institute is a nonprofit organization established by the Carlos Slim Foundation to contribute to the generation of sustained health initiatives that aim to have a profound impact on the people in Mexico and Latin America. Its mission is the design, development, evaluation, and upscaling of integrated models of health care. It has a specific focus on the United Nations Millennium Kidney International Supplements (2013) 3, 174–177

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R Tapia-Conyer et al.: Online education for health-care professionals

Development Goals 4 and 5 (maternal and child health); the epidemiology of the critical burden of CNCDs; the generation of knowledge (research and its translation into public health policies); and the strengthening of human capital through E-learning platforms for health professionals and community health-care workers. Among the Institute’s initiatives, the Casalud model consists of strengthening the health-care services in governmental primary-care settings through three core pillars: (1) improvement of quality of care and infrastructure through the development of guidelines for physicians and patients, and the assured provision of technological equipment and connectivity; (2) strengthening of human resources, both professional and community health workers, through the implementation of an E-learning course accredited by the National Academy of Medicine, as well as tailored workshops; and (3) patient empowerment through the use of mobile technologies to improve lifestyle and achieve control of diabetes and hypertension. We describe the first E-learning course to be offered to health professionals in Mexico that provides comprehensive training in the detection and treatment of CNCDs. DESIGN

The E-learning Diploma is offered through an online platform that enables health professionals and community health workers to acquire up-to-date health information in CNCDs. It is an effective and reliable platform that can be used as a training, educational, and information tool. The Diploma is structured in core modules with a multidisciplinary approach, including clinical, community, and human development content. Instruction is provided by experts using You Tube-type lectures synchronized with presentations and support material. In addition, users can interact with these virtual professors and resolve any questions they might have regarding the video lessons. Finally, through the platform students can answer online surveys and study reports. Thus, the E-learning platform offers much more in the way of resource materials beyond the mere videos; it is a powerful teaching tool that combines the flexibility of online educational information and learning with continuous interactions with health experts. The platform has been widely tested in different settings in order to secure a flexible, user-friendly yet structured course, and the Diploma is accredited by the National Academy of Medicine. The platform is continuously available, thus enabling a large of number of participants from various geographical areas to be trained simultaneously. Access is restricted to health professionals and community health workers who work at the Casalud health units, and each of them has an individualized plan so that they can study at their own pace. Each video-lesson is evaluated and graded automatically and the student coursework can be monitored online by the coordinators who have premium access to customized Kidney International Supplements (2013) 3, 174–177

Casalud model 5 Sessions

Type II DM 25 Sessions

Obesity and Dyslipidemia 24 Sessions

Arterial Hypertension 23 Sessions

Chronic Kidney Disease 25 Sessions

Human Development 8 Sessions

Figure 1 | E-learning Diploma for the prevention and integrated care of chronic non-communicable diseases.

reports of their activity. The Diploma covers the different aspects of overweight and obesity, type II diabetes mellitus, hypertension, dyslipidemia, and CKD. The course is divided into five consecutive modules (Figure 1), presented in video lessons that last an average of 20 min each. Each course comprises workshops, case discussions, and selected readings. Each section includes elements of integrated prevention and early detection, changes in lifestyle, clinical care, and adequate use of technology. Lessons consist of: (a) introduction; (b) presentation of the most relevant and practical information, including graphics, tables, algorithms, practical examples, and additional readings; (c) review of prevention and early detection strategies and integrated medical care; and (d) conclusions and take-home remarks. The CKD course includes 25 sessions, including epidemiology, risk factors, definition and classification; complications; risk factor modification; interventions to retard CKD progression; timely nephrological referral; healthy lifestyle and self-care recommendations; team work and patient empowerment. PLATFORM OPERATION

Experts run each of the lessons. The platform synchronizes the speaker’s lesson with a PowerPoint presentation on two different screens. Participants can either view both screens or choose between them at any point of the lesson. In addition, there is a small library on the computer screen for each of the lessons where participants can access additional teaching materials such as guidelines, self-care manuals, academic articles, and a complete list of activities and procedures for a comprehensive integrated practice evaluation. Through the premium access, coordinators can view the number of times the participant has accessed the course, the grades for each of the lessons, and the number of practical exercises he or she has completed. STUDENT PROFILE

The student must be a health-care professional–primary-care physician, nurse, nutritionist, or social worker, with the ability to work both individually and in collaboration, and possessing basic computer skills. 175

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ADMISSION AND PERMANENCE REQUIREMENTS

The Diploma is restricted to health professionals who work in Casalud units and it is offered free of charge. Governmental state health authorities propose the candidates. Their place of work must meet the minimum requirements, including direct patient care, access to a computer from anywhere (with Intel Pentium II processor or greater, internet connection and speakers), and must commit to a minimum of 6 h per week to the coursework. Lessons are ordered sequentially and students must complete all of them. The whole Diploma is designed to run over 3 months, although some flexibility was allowed in the pilot study: The minimum grade that needs to be achieved in order to receive the Diploma is 8.0. In the event that a student fails to achieve a pass mark in a given module, he or she is allowed to take that section again. If he or she fails again, they are dismissed from the course. There is no penalty for dropping out. ACCREDITATION

The E-learning platform allows the registration of the number of hours accessed to the course and evaluation results. The National Academy of Medicine and the General Practice National Regulatory Committee accredit the program. Once the user successfully completes the whole course, and has approved the online, multiple-choice question evaluation tests, a certificate is issued automatically by the platform and students can print it themselves. RESULTS

Between 1 March 2010 and February 2011, 844 primary health-care physicians from eight Mexican states were enrolled in a pilot study (Table 1). In total 362 (44%) students accredited the course, with an average score of 9.6. 19% of the students scored 10.0. The main reasons for not finishing the course were poor compliance and lack of motivation; only one participant actually failed the course. The average time required to take the course was 160 days (range 82–346 days). During this period 21,965 web hits and 72,722 video reproductions were recorded.

there is a wide selection of renal resources on the web,13 none meets the criteria of computer-assisted instruction in which computers play a central role in the means of information delivery and provide direct interaction with the learner (in contrast to the use of computer applications such as PowerPoint), and to some extent replace the human instructor.7 In a recent review of internet-based learning in the health professional publications, among 201 studies none of the topics were related to CKD.7 Our E-learning Diploma is among the first that includes the education of primary health-care physicians and other health professionals on CKD detection and prevention as a part of a comprehensive course on chronic non-communicable diseases. The large number of participants who did not finish the course was probably due in part to poor student selection by the local state health authorities, the complexity of the course, and lack of motivation. However, it is encouraging that among those who completed the course, only one failed to pass it. A significant number of participants did not complete the course on time. This was probably because of its complexity. To facilitate the acquisition of the Diploma and because of the variable knowledge base of the participants, the course has now been divided and restructured into three levels of complexity: (a) essential (basic); (b) intermediate; and (c) integral (advanced). Our report has a number of limitations. Although the system allows the grading of the content and quality of the lessons, the participants’ satisfaction with the course was not evaluated. Additionally, no pre-test was done to assess their clinical knowledge on CNCDs. We have made the necessary adjustments to overcome these limitations. In conclusion, the E-Learning Diploma offers what we believe is a valuable alternative educational tool for the training of health-care professionals in the detection and treatment of CKD and other CNCDs. DISCLOSURE

The study was financed by the Carlos Slim Institute of Health. The faculty received a nominal fee for their services.

DISCUSSION

E-learning has become an increasingly popular approach to medical education. Online learning programs for diabetes, dyslipidemia, and hypertension have led to improved knowledge of treatment guidelines9–11 and complications.12 Although Table 1 | Results of 844 participants enrolled in the pilot study n (%) Enrolled students (n) Participating states (n) Did not finish the course (%) Finished the course (%) Average scoring Average days needed to finish the course (n) Web hits (n) Video reproductions (n) 176

844 8 472 (56) 362 (44) 9.6 160 21,965 72,722

ACKNOWLEDGMENTS

Publication of this article was supported in part by the National Health and Medical Research Council of Australia through an Australia Fellowship Award (511081: theme Chronic Disease in High Risk Populations) to Dr Wendy Hoy, School of Medicine, the University of Queensland, and the National Institutes of Health— NIDDK DK079709, NCRR RR026138, and NIMHD MD000182. REFERENCES 1.

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Olaiz G, Rojas R, Barquera S et al. Encuesta Nacionalde Salud 2000. Tomo 2. Instituto Nacional de Salud Pu´blica: Cuernavaca, Morelos, Me´xico, 2003. Olaiz-Fernańdez G, Rivera-Dommarco J, Shamah-Levy T et al. Encuesta Nacional de Salud y Nutricioń 2006. Instituto Nacional de Salud Pu´blica: Cuernavaca, Morelos, Me´xico, 2006. US Renal Data System. Atlas of End-Stage Renal Disease in the United States International Comparisons. USRDS 2009 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases: Bethesda, MD, 2011. Kidney International Supplements (2013) 3, 174–177

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4. Sistema Nacional de Informacioń en Salud-SINAIS. Estadisticas por tema. http://www.sinais.salud.gob.mx (accessed 18 March 2012). 5. Amato D, Alvarez-Aguilar C, Castan˜eda-Limones R et al. Prevalence of chronic kidney disease in an urban Mexican population. Kidney Int 2005; 68 (Suppl 97): 11–17. 6. Corte´s-Sanabria L, Cabrera-Pivaral CE, Cueto-Manzano AM et al. Improving care of patients with diabetes and CKD: a pilot study for a cluster-randomized trial. Am J Kidney Dis 2008; 51: 777–788. 7. Cook DA, Levinson AJ, Garside S et al. Internet-based learning in the health professions. JAMA 2008; 300: 1181–1196. 8. Cook DA, Dupras DM. A practical guide to developing effective web-based learning. J Gen Intern Med 2004; 19: 698–707.

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