Virtual Patient Simulation in Continuing Education: Improving the Use of Guideline-Directed Care in Venous Thromboembolism Treatment

Figures & data

Table 1. Case descriptions

Case	Description
#1 Doreen	History of Present Illness Doreen is an 85-year-old woman who has been seen in this practice for >10 years. She came in early this morning accompanied by her daughter with no appointment complaining of right-sided back pain. She is concerned about the pain, which she rates as 3 to 5 out of 10, but she does not wish to go to the hospital. She says the pain began about 3 days ago and gets worse with inspiration. She does note a dry cough occasionally with deep inspiration. She denies dyspnoea, fever, or syncope. She has no history of heart disease, cancer, or asthma. She does note that her left leg has been moderately painful and swollen for the past week. No recent falls or injuries. Past medical history: hypertension (controlled with losartan) and chronic kidney disease Surgical history: cataract removal (both eyes) 18 months ago Current medications: losartan 50 mg once daily Review of systems: Negative except as above
#2 Clem	Clem is a 65-year-old man who was diagnosed with colonic adenocarcinoma 18 months ago after he noticed bloody stools. Colonoscopy showed a nonobstructing mass in the descending colon. About 13 months ago, he underwent partial colectomy. Preoperative computed tomography (CT) scans of the chest/abdomen/pelvis showed no evidence of metastatic disease. Pathology showed invasion into the subserosa with no evidence of cancer in the resected regional lymph nodes (T3, N0, M0). Margins were negative and no high-risk features were identified. Clem was followed thereafter with periodic imaging and labs, and 7 months ago, CT scans showed metastatic disease to the liver and lungs. He has been receiving systemic chemotherapy (FOLFOX with bevacizumab) since that time and undergoing CT imaging every 3 months while on chemotherapy for assessment of treatment response. Six months ago, Clem developed chest pain and dyspnoea and went to the emergency department. There, CT angiography was performed that showed bilateral lower lobe segmental pulmonary emboli. Since then he has been receiving anticoagulant therapy with low molecular weight heparin (LMWH). His dyspnoea improved within a few weeks of beginning treatment and he has no new symptoms today. Clem is having difficulty with his anticoagulation therapy: he does not like needles, hates injecting himself, and is tired of the bruising on his abdomen at the injection sites. He would like to stop therapy today if that is possible. He has some neuropathy from FOLFOX but it is quite minimal, disappears during his week off, and does not interfere with functioning. Clem’s most recent CT, in addition to showing stable or smaller metastatic lesions, showed near-resolution of the previously visualised pulmonary emboli and no new large pulmonary embolus. Past medical history: colorectal cancer and hypertension Surgical history: partial colectomy 13 months ago Current medications: enalapril 5 mg twice daily, FOLFOX (leucovorin calcium, 5-fluorouracil, oxaliplatin) with bevacizumab every 2 weeks, enoxaparin 80 mg subcutaneously twice daily Review of systems: negative except as above

Figure 1. Patient Simulation

Table 2. Case 1 results by learning objective and decision points

Speciality	Learning Objective (LO) Decision Point	% Correct Pre-CG	% Correct Post-CG	Test Statistic^a (df)	P Value
Cardiologists	LO1 – Performing appropriate workup for the risk stratification of patients with PE	48%	56%	10.62 (474)	<.001
Cardiologists	B-type Natriuretic Peptide (BNP)	45%	53%	37.10 (474)	<.001
Cardiologists	Chemistry Screen	51%	60%	38.10 (474)	<.001
Cardiologists	Coagulation Studies	51%	61%	45.08 (474)	<.001
Cardiologists	Complete Blood Count (CBC) – Basic	54%	61%	31.11 (474)	<.001
Cardiologists	Compression Ultrasound Study of Leg Veins	67%	71%	13.24 (474)	<.001
Cardiologists	CrCl (Estimated Creatinine Clearance)	35%	49%	66.06 (474)	<.001
Cardiologists	Electrocardiogram (ECG)	54%	61%	27.13 (474)	<.001
Cardiologists	Estimated Glomerular Filtration Rate (eGFR)	30%	47%	76.05 (474)	<.001
Cardiologists	Oxygen Saturation	49%	56%	30.12 (474)	<.001
Cardiologists	Pulmonary Multidetector CT Angiography (MDCTA)	59%	62%	12.25 (474)	<.001
Cardiologists	Transthoracic Echocardiography (TTE)	44%	53%	38.10 (474)	<.001
Cardiologists	Troponin	41%	49%	35.10 (474)	<.001
Cardiologists	LO2 – Tailoring anticoagulant therapy in patients with PE	39%	51%	16.47 (474)	<.001
Cardiologists	Oral anticoagulation therapy	31%	63%	87.04 (474)	<.001
Cardiologists	warfarin	2%	5%	9.31 (474)	<.01
Cardiologists	LO3 – Selecting appropriate patient-centred care strategies to improve adherence to long-term anticoagulant therapy	38%	52%	9.69 (474)	<.001
Cardiologists	First Follow-up Visit	36%	50%	63.06 (474)	<.001
Cardiologists	Patient Education and Counselling	40%	53%	61.06 (474)	<.001
Haem-oncs	LO1 – Performing appropriate workup for the risk stratification of patients with PE	48%	59%	9.55 (279)	<.001
Haem-oncs	B-type Natriuretic Peptide (BNP)	38%	53%	39.09 (279)	<.001
Haem-oncs	Chemistry Screen	52%	64%	30.12 (279)	<.001
Haem-oncs	Coagulation Studies	66%	75%	22.15 (279)	<.001
Haem-oncs	Complete Blood Count (CBC) – Basic	64%	73%	21.16 (279)	<.001
Haem-oncs	Compression Ultrasound Study of Leg Veins	74%	79%	9.31 (279)	<.01
Haem-oncs	CrCl (Estimated Creatinine Clearance)	34%	53%	50.07 (279)	<.001
Haem-oncs	Electrocardiogram (ECG)	51%	60%	24.14 (279)	<.001
Haem-oncs	Estimated Glomerular Filtration Rate (eGFR)	30%	50%	54.07 (279)	<.001
Haem-oncs	Oxygen Saturation	53%	60%	19.17 (279)	<.001
Haem-oncs	Pulmonary Multidetector CT Angiography (MDCTA)	60%	65%	11.75 (279)	<.001
Haem-oncs	Transthoracic Echocardiography (TTE)	42%	53%	1.00 (279)	.317
Haem-oncs	Troponin	25%	40%	39.09 (279)	<.001
Haem-oncs	LO2 – Tailoring anticoagulant therapy in patients with PE	34%	50%	42.09 (279)	<.001
Haem-oncs	Oral anticoagulation therapy	36%	48%	12.71 (279)	<.001
Haem-oncs	warfarin	21%	51%	57.07 (279)	<.001
Haem-oncs	LO3 – Selecting appropriate patient-centred care strategies to improve adherence to long-term anticoagulant therapy	5%	11%	13.24 (279)	<.001
Haem-oncs	First Follow-up Visit	41%	54%	7.11 (279)	<.001
Haem-oncs	Patient Education and Counselling	39%	53%	36.10 (279)	<.001
Haem-oncs	B-type Natriuretic Peptide (BNP)	43%	55%	30.12 (279)	<.001

^aTest statistic is reported as t-statistic for Learning Objectives (LOs), and chi-square statistic is reported for McNemar’s test for the decision points under LOs.

Table 3. Case 2 results by learning objective and decision points

Speciality	Learning Objective or Decision Point	% Correct Pre-CG	% Correct Post-CG	Test Statistic^a (df)	P Value
Cardiologists	LO1 – Performing appropriate workup for the risk stratification of patients with PE	82%	86%	4.65 (244)	<.001
Cardiologists	Chemistry Screen	81%	87%	11.27 (244)	<.001
Cardiologists	Complete Blood Count (CBC) – Basic	85%	87%	2.67 (244)	.102
Cardiologists	Estimated Glomerular Filtration Rate (eGFR)	79%	85%	11.27 (244)	<.001
Cardiologists	LO2 – Tailoring anticoagulant therapy in patients with PE	49%	66%	10.27 (244)	<.001
Cardiologists	Discontinue: enoxaparin	56%	59%	4.50 (244)	<.05
Cardiologists	Start: NOAC therapy	41%	72%	59.06 (244)	<.001
Cardiologists	LO3 – Selecting appropriate patient-centred care strategies to improve adherence to long-term anticoagulant therapy	45%	64%	8.40 (244)	<.001
Cardiologists	Follow-Up Appointment with Provider	44%	64%	46.08 (244)	<.001
Cardiologists	Patient Education and Counselling	46%	64%	41.09 (244)	<.001
Haem-oncs	LO1 – Performing appropriate workup for the risk stratification of patients with PE	83%	86%	2.61 (146)	<.05
Haem-oncs	Chemistry Screen	80%	85%	4.50 (146)	<.05
Haem-oncs	Complete Blood Count (CBC) – Basic	85%	88%	1.80 (146)	.18
Haem-oncs	Estimated Glomerular Filtration Rate (eGFR)	82%	84%	1.00 (146)	.317
Haem-oncs	LO2 – Tailoring anticoagulant therapy in patients with PE	47%	66%	9.04 (146)	<.001
Haem-oncs	Discontinue: enoxaparin	54%	58%	3.57 (146)	.059
Haem-oncs	Start: NOAC therapy	41%	74%	35.10 (146)	<.001
Haem-oncs	LO3 – Selecting appropriate patient-centred care strategies to improve adherence to long-term anticoagulant therapy	49%	68%	6.38 (146)	<.001
Haem-oncs	Follow-Up Appointment with Provider	48%	67%	25.14 (146)	<.001
Haem-oncs	Patient Education and Counselling	49%	69%	26.13 (146)	<.001

^aTest statistic is reported as t-statistic for Learning Objectives (LOs), and chi-square statistic is reported for McNemar’s test for the decision points under LOs.