1. What Clinicians Know... After CME Merry-K. Moos Professor (retired) Department of Obstetrics and Gynecology University of North Carolina mkmoos@med.unc.edu

3. Sponsorship and Partnership for www.beforeandbeyond Content managers: Merry-K. Moos (UNC) and Peter Bernstein (Einstein) Technical support and “home base” UNC Center for Maternal-Infant Health and Dennis Rodriguez CME support: Albert Einstein College of Medicine Financial support: Almost none--Mostly donated time and resources

4. Purpose Impact the knowledge and clinical practices of the most providers possible in order to help women and families achieve high levels of preconceptional health

5. CME Courses Created for Site Preconception Care: What It is and What It Isn’t Every Woman, Every Time Maximizing Prevention: Targeted Care for Those with High Risk Conditions

6. Features Free 1.5 AMA Category 1 CME credits (appropriate to physicians, advanced practice nurses and physician assistants) awarded through Albert Einstein College of Medicine Each module has 7 post test questions; passing grade is 70% (which requires 5 correct responses) Except for first module, the education combines fact and case-based learning All modules include some limited interactivity

7. Use and Credit Launched late Fall, 2008 To date, 3,904 hits on Modules Page (18,602 hits on home page) Credit was attempted and achieved by the following numbers Preconception Care: What It is and What It Isn’t: 124 individuals/54.8% passed Every Woman, Every Time: 31 individuals/77% passed Maximizing Prevention: Targeted Care for Those with High Risk Conditions: 18 individuals/94.4% passed

8. PRECONCEPTION CARE: WHAT IT IS and WHAT IT ISN’T The National Preconception Curriculum & Resources Guide for Clinicians MODULE 1 Reviewed and updated on November 4, 2009 Release Date: December 1, 2009 Termination Date: December 1, 2010 CME sponsored by Albert Einstein College of Medicine, New York Next

9. Module 1: What It Is and What It Isn’t People who completed module and took post test: 124 (54.8% passed)—3 didn’t complete test; have data on 114 -MDs: 9 (44% passed) includes ob/gyns, gyns, psychiatrist, pediatric hospitalist, etc -NPs and CNMs*: 35 (43% passed) -RNs: 50 (60% passed) -Others: 20 (70% passed) includes pharmacist, community health educators, students, general studies in cello (!), social worker, etc.

10. Question 1: What % of NTDs are considered preventable by adequate intake of folic acid? a: 90-100% b: 75-90% c: 50-70% d: 20-30%

11. Slide from Module: EXAMPLES OF PRIMARY PREVENTION of Congenital Anomalies Prevention of neural tube defects Birth Defects related to poor glycemic control of mother (including sacral agenesis, cardiac defects and neural tube defects ) 50-70% of NTDs can be prevented if a woman has adequate levels of folate during earliest weeks of organogenesis Can be reduced from 10% to 2-3% through glycemic control of the mother before organogenesis Next

12. Question 1: What % of NTDs are considered preventable by adequate intake of folic acid? a: 90-100% b: 75-90% c: 50-70% d: 20-30% 60% of participants answered correctly

13. Question 3: The CDC definition of preconception care is: a. a single visit for women when they stop using a method of contraception b. more than a single visit and less than all well woman care c. a series of special visits for all women to assure the highest level of health achievable before conception d. all of well woman care for all women between ages 15-45

14. Slide From Module: CDC Definition of Preconception Care Preconception care is a set of interventions that aim to identify and modify biomedical, behavioral and social risks to a woman’s health or pregnancy outcome through prevention and management It is more than a single visit and less than all well-woman care CDC and Select Panel, 2006 Next

15. Question 3: The CDC definition of preconception care is: a. a single visit for women when they stop using a method of contraception b. more than a single visit and less than all well woman care c. a series of special visits for all women to assure the highest level of health achievable before conception d. all of well woman care for all women between ages 15-45 47% of participants answered correctly

16. Question 6: By promoting higher levels of health for all women who might someday conceive, which of the following could be achieved. a. higher levels of wellness for women b. higher levels of preconceptional wellness should the woman conceive c. better pregnancy outcomes for mothers and infants. d. all of the above are possible but not proven e. none of the above

17. Slide from Module: Potential Advantages of Regularly Addressing these Issues with Every Woman Who Might Someday Conceive Higher levels of wellness for the woman Higher levels of preconceptional health should a woman become pregnant Improved pregnancy outcomes Likely higher rates of pregnancy intendedness for those who become pregnant Next

18. Question 6: By promoting higher levels of health for all women who might someday conceive, which of the following could be achieved. a. higher levels of wellness for women b. higher levels of preconceptional wellness should the woman conceive c. better pregnancy outcomes for mothers and infants. d. all of the above are possible but not proven e. none of the above 40% of participants answered correctly

19. Every Woman, Every Time: Integrating Preconceptional Health into Routine Care The National Preconception Curriculum & Resources Guide for Clinicians MODULE 2 Release Date: December 9, 2009 Termination Date: December 31, 2010 Sponsored by Albert Einstein College of Medicine and Montefiore Medical Center in joint sponsorship with the University of North Carolina Center for Maternal & Infant Health. Next

20. Case Study 1: Lisa Lisa is a 24 yo presenting for her annual exam and contraceptive care. When reviewing her history and pre-exam assessments, you uncover the following: Next

21. What Are Specific Issues that Lisa’s Profile Suggests Need Attention? Routine Health Promotion Issues? Click here for a list of routine health promotion issues that are important for Lisa, whether she ever becomes pregnant or nothere Specific Preconception Issues? Click here for a list of preconception topics that are important for Lisahere Next

22. Module 2: Every Woman, Every Time People who completed module and took post test: 31 (77% passed) -MDs: 3 (66% passed) -NPs and CNMs*: 7 (71% passed) -RNs: 16 (81% passed) -Others: 5 (80% passed)

23. Maximizing Prevention: Targeted Care for Those with High Risk Conditions The National Preconception Curriculum & Resources Guide for Clinicians MODULE 3 Release Date: December 1, 2009 Termination Date: December 1, 2010 CME sponsored by provided by Albert Einstein School of Medicine Next

24. Slide from Module 3: High Risk Conditions Case Study: Chronic Hypertension 32 yo social worker who was diagnosed with chronic hypertension 3 years ago 32 yo social worker who was diagnosed with chronic hypertension 3 years ago Presents for an annual visit, not currently taking any medications Presents for an annual visit, not currently taking any medications BP at visit is 160/100 BP at visit is 160/100 Does not desire a pregnancy in the near future but is getting married in 2 months Does not desire a pregnancy in the near future but is getting married in 2 months Next

25. Slide from Module 3: High Risk Conditions Preconception Care Goals: Chronic Hypertension Implications for the woman if she conceives (click here) Implications for the woman if she conceives (click here)here Implications for pregnancy outcome if she conceives (click here) Implications for pregnancy outcome if she conceives (click here)here Medication considerations (click here) Medication considerations (click here)here Family planning needs (click here) Family planning needs (click here)here Looking beyond the disease to the whole woman (click here) Looking beyond the disease to the whole woman (click here)here Next

26. Module 3: Targeted Care for High Risk Conditions People who completed module and took post test: 18 (94.4% passed) -MDs: 1 (100% passed) -NPs and CNMs*: 2 (50% passed) -RNs: 10 (100% passed) -Others: 5 (100% passed)

27. What Do These Findings Suggest? People may not want on-line CME People may take the exams without studying the content That the best pass rates were associated with the least formal education suggests the more highly educated are the least amenable to learning in this format The content/tests may be of poor quality (although they were refereed the results are disappointing...and we thought the tests were easy) The “n”s may be too small to make any conclusions Changing knowledge to change practice behaviors will take far more than online CME offerings Others???

28. Recent Improvements in Traffic and Pass Rates Mid-March, 2011 Module 1: 124 completed/55% passed Module 2: 31 completed/67.7% passed Module 3: 18 completed/17 passed June 6, 2011 Module 1: 167 completed/64.7% passed Module 2: 71 completed/ 83.1% passed Module 3 unchanged