Education of rural and remote general practitioners (GPs) in Australia on type 2 diabetes: impact of online continuing medical education on GPs’ knowledge, attitudes and practices and barriers to online learning

Background: The gap between current and evidence-based management of type 2 diabetes is widely acknowledged in Australia. Therefore, there is a need to find effective strategies to encourage GP awareness and uptake of evidence-based diabetes guidelines. A well-developed and evaluated web-based education strategy is considered to be an appropriate method for practising GPs in rural and remote areas to undertake continuing medical education. This PhD research forms one part of an NHMRC project entitled “The effectiveness of continuing medical education and feedback in altering diabetes outcomes at a population level-A RCT”. Aims: 1) to examine the current knowledge, attitudes and practices of Australian rural and remote GPs regarding type 2 diabetes management, 2) to test the impact of an online education intervention on GPs’ learning outcomes, and 3) to identify barriers to GPs undertaking and completing the online educational intervention and online learning in general. Methods: The research design consisted of seven complementary studies: three systematic reviews of the literature; a cross-sectional national survey; a quasi-experimental study; and a mixed methods study comprising a short cross-sectional survey and semi-structured telephone interviews. The systematic literature reviews were conducted applying systematic approaches to the literature search, study selection and data extraction. The first systematic review (Study 1) aimed to assess evidence in the literature for the effectiveness of type 2 diabetes educational interventions specifically targeting practising GPs, and where possible, those practising in rural and remote locations. The second systematic review (Study 2) aimed to assess evidence in the literature for the effectiveness of online continuing medical education (CME) specifically targeting GPs. The third systematic review (Study 3) aimed to examine barriers to GPs undertaking and completing online CME. A national cross-sectional survey (Study 4) was conducted with 854 general practitioners (GPs) currently practising in rural and remote Australian communities with populations of between 10,000 and 30,000. A quasi-experimental design (Study 5) was used to compare the knowledge, attitudes and reported changes in practice of GPs who completed an online diabetes active learning module (ALM). The module has been offered by the main NHMRC project to 146 rural and remote GPs in the 11 intervention towns of NSW and QLD which have populations of 10,000 to 30,000. A mixed methods study, involving a short cross-sectional survey (Study 6) and semi-structured interviews (Study 7), were then used to identify enabling and inhibiting factors in undertaking and completing the online ALM. Findings: The national cross-sectional survey (Study 4) revealed that 209 completed surveys were returned, yielding an overall response rate of 24.5 %. GPs reported on their education preferences, knowledge, attitudes and practices relating to type 2 diabetes. GPs indicated a strong preference for face-to-face education options such as conferences and seminars (75.2 %). Whilst structured online education activities were less utilised than face-to-face options, GPs reported a desire to undertake more of their education online in the future. Survey findings revealed gaps in GP knowledge of the medical management of diabetes. The most prevalent self-reported learning needs related to pharmacological management (N = 87, (45.5 %)). Correspondingly, in the GP knowledge test, GPs received the lowest mean score for the section on medication management. GPs also reported having the least confidence in providing effective insulin treatment, compared with other aspects of diabetes management. GPs identified an array of difficulties encountered in providing best practice diabetes care, which were classified into three main categories: GP clinical management problems, patient-related challenges and health system-related difficulties. The quasi-experimental study (Study 5) failed to demonstrate the effect of the online ALM on learning outcomes due to inadequate responses to generate statistical inferences. Findings from the systematic review (Study 2) indicated that online CME has the capacity to improve GP satisfaction, knowledge and practice. However, there are very few well-designed studies that focus on this delivery method for GP education. A systematic review (Study 1) also showed that few studies have examined the effectiveness of GP type 2 diabetes education. Evidence to support their effectiveness in improving GP satisfaction, knowledge, practices and/or patient outcomes is partial and weak. GPs reported reasons for non-participation in the online diabetes CME (Study 6) that correspond with the findings from the systematic reviews (Study 3). Barriers to GP online learning were grouped into four main domains: 1) structure, 2) learners, 3) facilitator and 4) the online program itself. However, GPs rarely reported difficulties inhibiting their completion of the online ALM (Study 6 and Study 7). Contribution of the research: This research adds new knowledge to the field of general practice education in Australia and internationally. The research addresses some of the widespread challenges of CME evaluation: there are currently few well-designed studies focusing on (1) GP CME in general; (2) GP diabetes CME (Study 1); (3) GP online CME (Study 2). The research also provides new insights into the current knowledge, attitudes and practices of Australian rural and remote GPs regarding their type 2 diabetes management. This may further assist CME providers and policy-makers in developing and providing education that addresses GPs’ needs. Conclusions and Recommendations: The national cross-sectional survey highlights a number of barriers to GP provision of best practice diabetes care in rural and remote Australia. Despite the availability of education programs and clinical practice guidelines, the GP respondents revealed deficits in knowledge and confidence in type 2 diabetes management. GPs identified numerous challenges to effective patient care, some but not all of which can be addressed through CME. Online CME has the capacity to improve GP satisfaction, knowledge and practices, but there are very few well-designed studies that focus on this delivery method for GP education. In order to overcome challenges identified in this research, improvements are needed in planning, developing and selecting the topics of education that are needed for GPs. Based on the doctoral research findings, the following recommendations are made: First, in order to provide CME programs for GPs or health care professionals, the learning needs should be clearly identified prior to program implementation. CME providers need to tailor education programs that specifically focus on and address current GP needs. Second, there is a noticeable absence of research focussing on diabetes CME, specifically for GPs practising in rural and remote areas. The use of multiple combined education techniques showed mixed effects. Future studies may need to examine specific combinations of educational techniques and delivery methods tailored to specific desired outcomes for rural and remote GPs. Third, in order to provide online learning activities for GPs, providers who develop the learning programs need to take into account barriers to undertaking and completing online CME. The number of studies examining GP online education is very limited. Therefore, further research is warranted specifically targeting GPs. In addition, future research should focus on clarifying when to use online CME for GP education and how online teaching technologies can be used most effectively. Fourth, future studies need to examine strategies to improve GPs’ participation in CME programs, and in research evaluating these programs