State-Required Continuing Medical Education Does Not Affect Heart Attack Care
NEW ORLEANS -- 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 proven 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
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 today
(March 7, 2004) by cardiologist Manesh Patel, M.D., Duke
Clinical Research Institute, at the annual scientific sessions
of the American College of Cardiology.
"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 to 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 been
proven effective in improving outcomes by large multi-center
clinical trials. The researchers also measured 30-day and
one-year mortality rates.
States with and without CME requirement had similar rates of
aspirin use at admission and discharge (79.9 percent vs. 79.4
percent, 72.5 percent vs. 72.5 percent), as well as
beta-blocker use at discharge (53.6 percent vs. 55.3 percent),
Patel said. Additionally, there was no association between CME
requirements and 30-day or one-year mortality rates, he
"However, the rate of reperfusion therapy at admission was
significantly higher -- 53.1 percent -- in states requiring CME
when compared to states that do not -- 47.9 percent," 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
percent 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, Md., and the U.S. Centers for Medicare
and Medicaid Services (formerly the Health Care Financing
Other members of the Duke team were Trip Meine, M.D.,
Jasmina Radeva, Lesley Curtis, Ph.D., Sunil Rao, M.D., Kevin
Schulman, M.D., and James Jollis, M.D.