We delivered high-quality, credible research evidence about CNCP management to clinicians and policy-makers throughout Alberta. We exceeded our target number of participants and provided an educational experience that exceeded their expectations.
In trying to select the most effective educational approach we made certain choices. Arguably the most important, and certainly the most difficult to execute, was that between the desire of the HTA specialists in our group to restrict our offerings to only those of the highest methodological quality, and the clinicians' wish to present as broad a range of therapeutic options for discussion as possible. This dichotomy is particularly strong in CNCP, where the quality of much of the evidence base is low.
The highly abbreviated summaries that appear on the 'Evidence in Brief' sheets were well received. The acceptability of this degree of abbreviation may have been enhanced by the perceived credibility of the ambassadors as content and methodology experts. The credibility of the source has been shown to play a major role in the way physicians use information to make treatment decisions [6].
The 61% response to our follow-up questionnaire exceeds the 50% generally considered acceptable in this type of investigation [7] but we cannot rule out the possibility that the non-respondent group had a different assessment of the workshop.
Our knowledge transfer product was a hybrid but contained several elements that were identified in a recent review of randomized trials as being effective elements of continuing medical education, namely two-way communication (between educator and audience), small group format, personal delivery of printed materials and the use of locally respected clinicians as educators [8]. Our decision to use case-based context arose from its demonstrated superiority over text-based content in increasing participants' knowledge [9].
We offered information on 18 CNCP treatments, most of which focused on chronic low back pain. The ability to deliver wider selection of content might have made the sessions even more appealing, but would have made even greater demands of our HTA specialists and clinical ambassadors, in the context of an already highly resource-intensive program.
We did not change interest in or attitudes toward the importance of CNCP as a health issue. We think that this merely means that those who already regarded CNCP as an important health care issue were preferentially selected for our sessions.
Our measure of participants' knowledge of CNCP was a self-reported surrogate measure rather than a knowledge test per se. This is a weak measure and therefore only suggests rather than verifies that increases in knowledge occurred.
Known obstacles to the effectiveness of research transfer in health services include ineffective continuing education programs, poor access to best evidence guidelines and organizational barriers [10]. Our strategy addressed the first two factors, but we could not control factors at play in participants' own institutions, such as a lack of institutional had a culture of or infrastructure for fostering new knowledge. In addition, we were compelled to conduct our program in a relatively short time frame. Buckley et al [11] noted that even when the intentions of workshop participants have changed from pre- to post-test, even a twelve-week interval (twice as long as ours) may be insufficient to observe a subsequent change in practice.
Several participants indicated that they were surprised by the non-conventional teaching methods we employed. It is known that when participants know what to expect in the training session, they learn more and are better able to implement what they learned in practice [12]. Knowing what to expect might have improved participants' learning still further.
We would have preferred to see a greater number of physicians in the participant group, in the belief that physicians are better placed to influence the course of care than other professions. Despite our best efforts, we may not have offered sufficiently compelling reasons for the prototypical overworked rural physician to attend. In this respect, our program differed significantly from the Swedish model, which is targeted exclusively at physicians.
Of the session components, the action planning was the least successful. We had hoped that the acquisition of new content knowledge on CNCP would rapidly result in the synthesis of ideas and plans for its clinical implementation. In reality, learning and strategic planning are different activities that, while related, require different participants, skills and logistics to be successful.
The Alberta Ambassador Program in CNCP therefore succeeded in achieving five of its seven objectives: a new research transfer model was developed and tested, the best evidence in CNCP management was promulgated widely in the province, awareness of the existence of AHFMR's HTA unit was increased, other possible areas for HTA and knowledge transfer activities were identified and some changes in participants' practice in the area of CNCP were reported. We were unable to document significant changes in clinician attitude towards CNCP or promote the development of action plans or interest networks. We suggest that this is a model of health care education that has significant potential to advance the usefulness of HTA in general.
