Patient Activation to Improve Health Outcomes

The patient is 50% of the clinical equation, but as medical educators, we haven’t always saved a seat for the patient at the education table. We at CME Outfitters would like to share some of our goals and commitments to make some educational adjustments in 2015 to change that scenario.

Few would deny that patient-centered care is the guiding principle of healthcare. Treating patients with respect, hearing and valuing their concerns, and involving them as decisions about their care is the foundation of the National Quality Strategy Prioirities1 and the “triple aim” of improving care, health, and cost of care.

An involved, aware, and informed patient is more prepared to engage in their care decisions and manage their health costs. An activated patient does more than follow the advice of their health care provider, they proactively engage to have skin in the game.

Judith Hibbard, PhD and colleagues described a model of patient activation—the willingness to take ownership of one’s health and gain the knowledge and skill to use that knowledge to participate in managing chronic illness that involves four stages:

Stage 1: Believing the patient role is important

Stage 2: Having the confidence and knowledge to take action

Stage 3: Using skills to take action to improve health

Stage 4: Staying the course to maintain health, even under stress.2

 The evidence supports the activation model as an influencer in positive patient outcomes. Sacks and colleagues found that higher patient activation predicted better depression outcomes and support of patient activation may be an effective approach to reduce depression severity.3

Health care providers have played an important role in educating and empowering patients and beginning in 2015, there are provisions in the Affordable Care Act to reimburse providers $42/patient per month for engagement of Medicare patients with three or more chronic illnesses outside of the clinic visit for services and education to assess medical and psychosocial needs; assess adherence to medication; and transition patients from the hospital to home or nursing home.

Where to begin? That’s where we come in. CME Outfitters is committed to devoting time in each of our activities to help you better activate your patients—provide the tools to increase knowledge, skills, and confidence—to take an active role to improve outcomes, reduce readmissions, and reduce overall health care costs of chronic illnesses. We’ve started the process by using real patient scenarios and vignettes to demonstrate our educational objectives. Look to our revised Clinical Compass newsletter for new opportunities to place the patient at the center of your education and translate the education to patient activation and healthy behaviors in your practice.


1 National Quality Strategy Overview. Accessed 5/6/14.

2 Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patients and Consumers. Health Serv Res. 2004;39(4 Pt 1): 1005-1026.

3Sacks RM, Greene J, Hibbard JH, Overton V. How will do patient activation scores predict depression outcomes one year later? J Affect Disord, 2014;169:1-6.

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Mobile App for Assessment of Traumatic Brain Injury FDA Approved

danasmallA new app called the Defense Automated Neurobehavioral Assessment (DANA), runs on multiple mobile platforms and was recently granted U.S. Food and Drug Administration (FDA) approval. The app will soon be available to help clinicians diagnose traumatic brain injury in as little as five minutes in almost any setting, including a combat environment.

According to the U.S. Army Medical Research and Materiel Command (USAMRMC), DANA operates much like a video game. Service members will undergo a baseline series of on-screen exercises during which both their speed and accuracy are recorded. Those who may have had a serious head injury will then participate in a series of both cognitive efficiency tests and self-administered questionnaires. Afterward, a clinician will review the results, comparing them with the results of the baseline exercises. The combination of the app’s cognitive and psychological components allows for insight into the prevalence of symptoms related to both traumatic brain injury and posttraumatic stress disorder.

Additional Info

Lathan C Mil Med. 2013 PubMed Article website

Posted in Digital medicine, Games, PTSD, Research, Traumatic Brain Injury | Tagged | Comments Off

Assessment of Global Internet Addiction

cybercoverAccording to a meta-analysis of 31 nations across seven world regions, the global prevalence of internet addiction is estimated at 6 percent. The prevalence of Internet addiction varies among regions around the world, as shown by data from more than 89,000 individuals in 31 countries analyzed for a study published in Cyberpsychology, Behavior, and Social Networking this month.

The authors from the University of Hong Kong describe that “societies worldwide are facing new challenges that the convenience and excitement gained through Internet use can result in individuals hooked on online activities to gratify needs. An extreme form of this phenomenon is known as Internet addiction (IA), an impulse control problem characterized by an inability to inhibit Internet use that exerts an adverse impact on major life domains (e.g., interpersonal relations, physical health).”

Although IA is not in DSM-5 it has been associated with disorders related to substance and behavioral addiction and “is often comorbid with mental disorders, such as attention deficit hyperactivity disorder and depression.” The IA prevalence rate was more than threefold higher than that of pathological gambling another impulse control disorder. The researchers also noted that there were considerable differences in the prevalence figures across world regions. The authors reported that the countries that demonstrated a perception of less life satisfaction in general, greater overall pollution (primarily air pollution), greater traffic commute time consumption, and lower national income. They conclude that “taken together, these results provided tentative support for the quality of (real) life hypothesis, which proposed an inverse link between IA prevalence and quality of (real) life.”

Internet Addiction Prevalence and Quality of (Real) Life: A Meta-Analysis of 31 Nations Across Seven World Regions

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Many Dementia Patients Never Screened

NeuroA study by researchers from the University of Michigan found that despite clear signs that their memory and cognitive abilities have diminished, more than half of seniors with these symptoms have not seen a doctor about them. The study, published in Neurology, documents a clear lack of clinical testing for seniors with signs of cognitive problems.

Individuals with severe symptoms of dementia and those who were married were more likely to have had their memory and thinking ability evaluated by a primary care doctor, neurologist or psychiatrist. The study included people with mild cognitive impairment through severe dementia, from all causes.

The study recommends early evaluation of seniors. according to the lead author, Vikas Kotagal, MD, MS,”the results of this study have implications in both primary care and specialty care settings. Recognizing cognitive impairment in older individuals is important, and physicians should explore reasons why dementia has occurred and communicate these findings clearly with patients and family members so that they can take this information with them when they leave the office.”

Source: Neurology

Posted in Cognition, Dementia, Diagnosis, Early intervention, Geriatrics, Memory | Comments Off

CME Is An Effective Learning Hub For Physicians

Why CME Providers Are Celebrating This Week: Decades Worth of CME Studies Found That CME Is Undeniably An Effective Learning Hub For Physicians
By: Haley Hoffman and Beth Brillinger, CCMEP

Last week, the Accreditation Council for Continuing Medical Education (ACCME) published data that has CME providers everywhere throwing their hats up in the air and proclaiming…FINALLY!  The ACCME published two reports, authored by Ronald M. Cervero, PhD, Professor and Associate Vice President for Instruction at the University of Georgia, that address, one: the effectiveness of CME, and two: the relationship between commercial support and perceived bias in CME activities. Dr. Cervero and colleagues compiled hundreds of individual CME studies over several decades and found that overall, research shows that physicians actually perceive very low levels of commercial bias in CME activities (3-5%), and furthermore, they report the same level of bias for activities that were not commercially supported. And as far as the overall effectiveness of CME programs, his research shows that CME has a positive impact on physician performance and patient health outcomes.

From his findings, Dr. Cerveo concluded many things about the effectiveness of CME, one being that CME “leads to greater improvement in physician performance and patient health if is more interactive, uses more methods, involves multiple exposures, is longer, and is focused on outcomes that are considered important by physicians.” Information like this reminds CME providers of the unique opportunity we have to raise the bar when it comes to quality improvements in health care. Formats are just as important as content, and it is critical that we continue to broaden our educational visions in order to really connect to the learner, and make a difference in clinical care.

On the issue of commercial bias, research findings suggest that there is no evidence that supports or refutes the belief that commercial support creates bias in CME activities. Check out this snippet from the article published by Policy and Medicine last week that gives you a glimpse of Dr. Cervero’s conclusions on the issue of commercial support affecting physician practice:

If you were looking at the negative effects of commercial support, you would expect to see more prescriptions for the pharmaceutical company that was supporting that education. That would be the worst outcome, that the physician was not making an independent clinical judgment about how to treat this patient and was unduly influenced by the CME activity because of how it was funded. I mean that would be, to me that would be the trail of action, and there hasn’t been anything that could document that.

– Ronald M. Cervero, PhD

At CME Outfitters, we already know the importance and value of delivering evidence-based and balanced education to clinicians. For every activity CME Outfitters delivers we evaluate, identify, and resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data and research, and a multidisciplinary peer review process. As a CME provider we know how critical our education is to our audiences, but this new research helps prove to skeptics everywhere that providing continuing medical education programs to clinicians is imperative, as it truly does make a difference in clinical practice and patient care. And to top it all off: these findings can help the healthcare community keep worries at bay about perceived commercial bias having an impact on physician performance. Please click on the links below to review the in-depth research reports published by the ACCME.

Effectiveness of Continuing Medical Education: Updated Synthesis of Systematic Reviews

Is There A Relationship Between Commercial Support and Bias in Continuing Medical Education Activities? An Updated Literature Review

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Development and Regulation of Abuse-Deterrent Opioid Medications – FDA Public Meeting

fdaThe FDA is hosting a public meeting on October 30 and 31, 2014 to discuss the development, assessment, and regulation of abuse-deterrent formulations of opioid medications. The meeting will focus on scientific and technical issues related to the development and in vitro assessment of these products, as well as FDA’s approach towards assessing the benefits and risks of all opioid medications, including those with abuse-deterrent properties.

This year the FDA has approved three opioid analgesics with an abuse-deterrent label. In April, FDA approved Evzio (naloxone hydrochloride injection) for the emergency treatment of known or suspected opioid overdose. Naloxone is a medication that rapidly reverses the effects of opioid overdose. Evzio is the first auto-injector designed to deliver a dose of naloxone outside of a healthcare setting.

On July 23, FDA approved Targiniq ER, an extended-release pain reliever that contains a combination of oxycodone and naloxone. Targiniq ER is the second extended-release/long-acting (ER/LA) opioid analgesic with FDA-approved labeling describing the product’s abuse-deterrent properties.

This month the FDA approved new labeling for Embeda (morphine sulfate and naltrexone hydrochloride), an extended-release (ER) opioid analgesic to treat pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate. The new labeling includes a claim indicating that Embeda has properties that are expected to reduce oral and intranasal abuse when the product is crushed.

Links to FDA meeting materials and webcast information can be found at

Posted in Drugs, FDA, Opioids, Substance abuse | Comments Off

Chair Summit 2014


A very successful 7th Annual Chair Summit 2014 took place this past weekend in Tampa, Fla. Faculty leading this interesting series of plenaries, breakout sessions and chart reviews are Chairmen of departments of psychiatry and neurology and the leading researchers and clinicians in the field. They shared a mix of cutting edge science and practical, clinical pearls of wisdom to a sold-out audience. The focus of these timely discussions was ‘clinical connections’ that can be useful in everyday practice.

Interactivity is a key element of this 3 day conference. Larger sessions incorporated audience participation through a network of laptop computers, tablets and smartphones – all connected to the faculty. Questions, comments, and Twitter posts expanded the dialogue beyond the usual ‘audience response system’ to create an immersive sense that everyone was part of this educational network. Small group sessions were hands-on workshops where participants could discuss clinical challenges and many asked questions about difficult cases in their own practice. There were also sessions to complete part of the performance-in-practice component of the ABPN maintenance of certification requirements in which attendees presented cases from their own practice to expert faculty in areas of schizophrenia, bipolar disorder, neurocognitive disorders and multiple sclerosis.

Topics offered were a spectrum of interesting, relevant new science and latest clinical approaches in areas of psychiatry and neurology and beyond. These included: schizophrenia, bipolar depression, major depression, PTSD, borderline personality, ADHD, multiple sclerosis, epilepsy, in addition to hot topics in medicine such as chronic pain, traumatic brain injury, obesity, food and substance addictions and sleep disorders.

The agenda, faculty and information about next years Chair Summit can be viewed at:


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Sense of Smell May Predict Risk for Cognitive Decline

alz-assnTwo studies presented at the 2014 Alzheimer’s Association International Conference (AICC) in Copenhagen this month demonstrated that a decrease in the ability to identify odors was significantly associated with loss of brain cell function and progression to Alzheimer’s disease. There is growing evidence that the decreased ability to correctly identify odors is a predictor of cognitive impairment and an early clinical feature of Alzheimer’s disease.

Researchers from the Harvard Brain Study, evaluated olfaction via the University of Pennsylvania Smell Identification Test (UPSIT) in 215 clinically normal elderly individuals and administered a battery of cognitive tests. Also measured was the size of two brain structures – the entorhinal cortex and the hippocampus and levels of amyloid deposits in the brain.  They found that a smaller hippocampus and a thinner entorhinal cortex were associated with worse smell identification and worse memory.

From 2004 to 2010, Columbia University Medical Center researchers studied a multi-ethnic group of 1,037 senior citizens without a diagnosis of cognitive dysfunction to determine whether a relationship exists between the inability to identify smells and a diagnosis of mild cognitive decline. The research showed that in subjects with low UPSIT scores, “210 participants transitioned to either dementia or Alzheimer’s disease (AD) during follow-up two to four years after initial UPSIT was administered. Transition to dementia and AD was correlated with lower odor-identification scores on the UPSIT.”

Of all of the subjects who were followed over the years,  lower odor-identification scores were significantly associated with the transition to dementia and Alzheimer’s disease. For each point lower that a person scored on the UPSIT, the risk of Alzheimer’s increased by about 10%. In addition, lower baseline UPSIT scores, but not measures of verbal memory, were significantly associated with cognitive decline in participants without baseline cognitive impairment. “Odor identification deficits were associated with the transition to dementia and Alzheimer’s disease, and with cognitive decline in cognitively intact participants, in our community sample.”

For many years, olfactory deficits have been associated with Parkinson’s disease. “Impairment of olfaction is a characteristic and early feature of Parkinson’s disease. Recent data indicate that >95% of patients with Parkinson’s disease present with significant olfactory loss.”

According to the Alzheimer’s Association, “In the face of the growing worldwide Alzheimer’s disease epidemic, there is a pressing need for simple, less invasive diagnostic tests that will identify the risk of Alzheimer’s much earlier in the disease process.”

This same sense of urgency applies to Parkinson’s disease.

Alzheimer’s Association International Conference press release
Haehner A, et al Olfactory Loss in Parkinson’s Disease


Posted in Alzheimer's Disease, Biomarker, Clinical trials, Cognition, Dementia, MCI | Comments Off

Watching Individual Neurons Respond During Transcranial Magnetic Stimulation

natureneuroTranscranial magnetic stimulation (TMS) is used to treat refractory major depression. Until now, there was no way of knowing exactly what changes were taking place in the brain as a result of treatment. Duke University neuroscientists and engineers have developed a way to measure the response of an individual neuron to TMS.

Measuring neural responses during the procedure has been difficult as the comparatively tiny activity of a single neuron is lost in the tidal wave of current being generated by TMS. The research team at Duke engineered new hardware that could separate the TMS current from the neural response, which is thousands of times smaller. They were able to focus in and successfully recorded the action potentials of an individual neuron moments after TMS pulses and observed changes in its activity that significantly differed from activity following placebo treatments.

This study is published in Nature Neuroscience, June 29, 2014

Mueller, JK et al.
Nature Neuroscience

Posted in Depression, Neuroscience, Transcranial magnetic stimulation, Treatment, Treatment resistant depression | Comments Off

Comparison of DSM-IV Versus DSM-5 ADHD Criteria Supports Revision

A study published in the Journal of the American Academy of Child and Adolescent Psychiatry compares ADHD diagnosed via the DSM-IV criteria and the new DSM-5 in youth.  Researchers from the National Institute of Mental Health compared the prevalence and clinical correlates of ADHD as described in the two DSM editions in a nationally representative sample of U.S. youth with a particular focus on the age-of-onset criterion. The sample included nearly 1,900 participants aged 12 to 15 from cross-sectional National Health and Nutrition Examination Survey (NHANES) surveys conducted from 2001 to 2004.

The results demonstrated that the DSM-5 extension of the age-of-onset criterion from 7 to 12 led to an increase in the prevalence rate of ADHD from 7.38% (DSM-IV) to 10.84% (DSM-5). Importantly, youth with later age of onset did not differ from those with earlier age of onset in terms of severity and patterns of comorbidity. The researchers concluded that “the comparability of the clinical significance of the early and later age-of-onset groups supports the DSM-5 extension of the age-of-onset criterion in ADHD.”

Article in Press
Impact of the DSM-5 Attention-Deficit/Hyperactivity Disorder (ADHD) Age of Onset Criterion in the U.S. Adolescent Population

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