Management of alcohol use disorder in cirrhosis: effect of a clinician-targeted alcohol use disorder in cirrhosis educational intervention on knowledge, attitudes, and practice habits
Creators: Johnson, Emily Colleen 
Publisher: name: University of Alberta Library
Year: 2022

<p>Introduction: Alcohol use disorder (AUD) is a common cause of liver cirrhosis. Low knowledge and comfort managing AUD among well-intentioned clinicians impacts the number of patients with cirrhosis who receive AUD treatment. Structured education focused on screening, brief intervention, referral to treatment, and prescription of pharmacotherapy for relapse prevention are proposed as key skills for clinicians caring for this patient population, but no studies to date have developed and evaluated the effect of education that employs these components. Additionally, no studies have reported on Self Determination Theory, a theory about human motivation, in the context of a clinician educational intervention about AUD in cirrhosis. </p>

<p>Objectives: The purpose of this study was to systematically develop and assess the effect of an AUD in cirrhosis educational intervention on clinicians’ knowledge, attitudes, and practice habits (preparedness, comfort, intention). Additionally, we wanted to assess participants perception of the learning environment using satisfaction of three basic psychological needs (autonomy, competence, and relatedness) as identified by Self Determination Theory.</p>

<p>Methods: Kern’s 6-step Framework for Curriculum Development was used for development of the 1.5-hour virtually delivered educational intervention. Based on a qualitative descriptive method, clinicians participated in one-on-one interviews about their experiences and perceived barriers to caring for patients with concomitant cirrhosis and AUD. Development of education objectives and implementation of a pilot educational intervention followed a literature search and interview findings. The pilot session was didactic, and the adapted session adopted a flipped classroom strategy including a 30-minute video, case-based discussion, breakout sessions, and question and answer. Participants completed questionnaires at baseline, immediately following the intervention (pilot), and four weeks following the intervention (adapted sessions). </p>

<p>Data analysis: A team of two coders analyzed transcripts from qualitative interviews using a deductive approach. Participant demographics were analyzed descriptively. Comfort, knowledge, and attitudinal measures were analyzed using a paired t-test after testing for normality. Self-determination theory measures were analyzed descriptively. Effect sizes were analyzed using Cohen’s d. </p>

<p>Results: 16 clinicians completed the one-on-one interviews. Four themes emerged related to previous experienced and perceived barriers to caring for patients with AUD and cirrhosis: (i) Practicing within knowledge constraints, (ii) Navigating limited resources and systems challenges, (iii) Balancing complexity of cirrhosis and AUD, and (iv) Acknowledging the influence of provider perceptions on care. 86 clinicians participated in the pilot sessions and 38 consented and completed pre-post questionnaires (44.2%). Participants reported significant improvements in preparedness and intention to screen, provide a brief intervention, refer patients to treatment and prescribe pharmacotherapy for relapse prevention. Minor changes in attitudinal measures included the domains of role adequacy and motivation. Relatedness was the lowest domain (2.73/5), followed by competence (4.10/5), and autonomy (4.31/5). </p>

<p>229 clinicians participated and 95 (30-36 per session) consented and completed pre-post questionnaires (41.5%) in the adapted sessions. Preparedness to diagnose (pretest M=2.56, posttest M=3.47, p&lt;0.011) and manage (pretest M=2.32, posttest M=3.26, p&lt;0.001) alcohol withdrawal significantly improved after exposure to the adapted session. Preparedness to screen and identify alcohol use (pretest M=3.17, posttest M=3.93, p=0.001), provide medical advice (pretest M=2.50, posttest M=3.33, p&lt;0.001), and refer patients to treatment (pretest M=2.80, posttest M=3.67, p&lt;0.001) significantly improved following participation in the adapted session. Intention to provide a brief intervention improved significantly from baseline (pretest M=5.00, posttest M=5.4, p=0.010). Comfort prescribing acamprosate (p&lt;0.001), baclofen (p=0.032), and gabapentin (p&lt;0.001) significantly improved from baseline despite non-significant improvement in intention to prescribe pharmacotherapy for relapse prevention. Significant improvements occurred in 4/5 attitudinal domains: role adequacy, role legitimacy, role support, and work satisfaction. </p>

<p>Conclusions: The 1.5-hour virtually delivered educational intervention had a positive effect on self-reported knowledge, attitudes, and practice habits. Adopting Kern’s curriculum, involving clinicians from the outset, maximizing interactivity, and assessing how interventions meet the needs of learners appear to be key components in facilitating improvements in practice habits, knowledge, and attitudes. The findings from this study warrant further investigation using administrative data to evaluate actual versus perceived changes in practice habits. Future studies should continue to work with clinicians and continuing clinician professional development bodies to create medical education focused on AUD and cirrhosis.</p>