Introduction
Nutrition counseling for patients with diabetes is a widely recommended primary care service. In 2015, the US Preventive Services Task Force (USPSTF) provided a Grade B recommendation that clinicians offer or refer patients with abnormal blood glucose levels to intensive behavioral counseling interventions to promote a healthful diet and physical activity.1
According to the Standards of Care in Diabetes set forth by the American Diabetes Association (ADA), diabetes self-management education and support, which includes nutrition counseling, should be provided yearly and/or when not meeting targeted goals.2 These recommendations are made on the evidence that Primary Care Providers (PCPs) are effective health counselors and when PCPs provide nutrition and lifestyle counseling to patients with diabetes, there is a decrease in morbidity and mortality. Among patients who receive monthly or more lifestyle counseling, the 10-year cumulative incidence rate of a cardiovascular (CV) event (eg heart attack or stroke) or death was 33.0% compared with 38.1% for less than monthly counseling.3
Primary care is usually a patient’s first contact with the health care system and provides continuity, coordination, and comprehensive services.4 It is within the primary care office setting where PCPs have an opportunity to improve the management and outcomes of patients living with diabetes. Patients look to PCPs to gain insightful recommendations to improve their health through diet and nutrition5. However, inadequate education and training may contribute to low rates of provider initiated counseling6. Studies have shown that there is a positive impact on physician knowledge when continuing medical education (CME) programs incorporate diet/lifestyle within its curricula.7–9 Lee et al found that after completing CME sessions, the counseling knowledge of PCPs improved 45%, the self-reported frequency of counseling increased 23%, and their diabetic patient’s glycosylated hemoglobin A1c (HbA1c) dropped 1.2% compared to baseline.10 Therefore, we can infer that CME does improve PCPs knowledge and performance while positively affecting clinical outcomes.
Despite the evidence of its effectiveness, nutrition counseling or referral by PCPs are often lacking in the primary care setting. Nutrition counseling or referral for patients with diabetes occurred in about a third of visits for episodic health complaints.11 The proportion of visits in which diet counseling occurred has not improved over time. National estimates for diet counseling among patients with diabetes in primary care were 27% in 2005 and 21% in 2015.12 Counseling behavior is associated with the quantity of nutrition education13, yet nutrition education is lacking in medical14 and advanced practice provider (APP) curricula.15,16
In early 2024, chart audits were completed at a community health center (CHC) in Massachusetts, USA, to evaluate the frequency in which diet/nutrition counseling or referral was delivered to patients with uncontrolled diabetes. The CHC discovered that counseling or referral was provided to less than 15% of patients with uncontrolled diabetes. The National Committee for Quality Assurance maintains the Healthcare Effectiveness Data and Information Set (HEDIS), which are national standards that look towards performance improvement across various chronic health conditions. According to HEDIS, HbA1c >8% is considered uncontrolled.17 The Quality Improvement Management team at the CHC requested the lead author to develop a single-course CME program focusing on nutrition and diabetes to be presented to its PCPs since the CHC does not have a Registered Dietitian/Nutritionists (RDN) on staff. This project had two specific aims:
Aim 1: To measure PCPs knowledge pertaining to the dietary and nutritional guidelines and recommendations for patients living with diabetes;
Aim 2: To increase the frequency of which PCPs document either diet/nutrition counseling or referral to patients with uncontrolled diabetes after completing an interactive online CME program.
The authors believe this CME program was unique compared to other diabetes nutrition-focused courses. Participants engaged in an interactive Zoom© program that provided up-to-date content related to diabetes diet/nutrition. There are several diet/meal plans that have been shown to improve HbA1c values in patients with diabetes.18 This program educated PCPs on the Low-Carbohydrate Diet, which has been shown to reduce HbA1c levels. The Low-Carbohydrate Diet also helps lower blood pressure, increase HDL, lower triglyceride levels, and assists in weight loss.18 Our program encouraged PCPs to provide diet/nutrition education to patients with Type 1 or Type 2 diabetes whose HbA1c was ≥8%. As this course was offered to PCPs who work in the primary care setting, this program did not discuss the diet/nutrition needs related to gestational diabetes. This analysis evaluated change in knowledge, attitude, and clinical practice after PCPs engaged in a CME program.
Methods
Study Setting
A quality improvement (QI) project utilizing a pretest-posttest design was conducted at a CHC in Massachusetts in September 2023. A 50-min virtual CME program entitled “Diet & Nutrition Therapy for Patients with Diabetes” was offered to all medical providers from the CHC. The CME course was developed internally and provided by the project lead, who is a practicing Primary Care Nurse Practitioner and an RDN, having extensive knowledge in medical nutrition therapy for chronic illnesses (or diseases). The population targeted for this intervention were internal or family medicine doctors/doctors of osteopathic medicine (MD/DO), nurse practitioners and physician assistants (collectively known as APP), who serve as PCPs. Participants were recruited by having the CME program during a dedicated one-hour medical department provider meeting, where attendance is expected. The primary focus of the program was to deliver the current standards of care guidelines and recommendations related to diet/nutrition and diabetes management. Utilizing 2023 ADA standards of care guidelines/recommendations2, evidence-based practice research18, and education material from the Academy of Nutrition and Dietetics19, the following four main learning objectives were developed:
1) Epidemiology/prevalence of diabetes;
2) Complications associated with uncontrolled diabetes;
3) Discuss goals of diet/nutrition therapy for patients living with diabetes;
4) Review evidence-based practice standards of care and guidelines/recommendations regarding diet/nutrition and diabetes.
The curriculum was designed using the 4A (anchor, add, apply, away) learning task model.20 This model was chosen because it is interactive and geared to adult learners. Participants who attended the live session were awarded one AMA PRA Category 1 CreditTM, which was accredited by the American Academy of Family Physicians (see Supplementary Appendix 1).
Data Collection and Analysis
Prior to the CME program, participants were surveyed regarding background characteristics, including provider type, years in practice, and gender, as well as their nutrition counseling knowledge and attitude about nutrition counseling. A web-based software application for electronic collection and management of research and clinic data, Research Electronic Data Capture (REDCap©), was used for its ease of survey distribution, data collection, and analysis. Participants accessed the CME program via Zoom© during a dedicated medical department provider meeting. A program evaluation survey was distributed immediately after the CME intervention and was accessible for one week. Two weeks after the intervention, PCPs completed the post survey assessing their nutrition counseling knowledge and attitude about nutrition counseling. Lastly, a chart review was completed utilizing the CHCs electronic medical record (EMR), which evaluated documentation of counseling practices by PCPs.
Knowledge and Attitude
Knowledge of diet/nutrition and diabetes was assessed using an internally developed 10-item assessment tool, the Nutrition Management of Diabetes Assessment (NMDA) (see Supplementary Appendix 2). The NMDA was constructed from Recommendations 5.10 to 5.17 found in Table 5.1 of the ADA 2023 Standards of Care for Medical Nutrition Therapy Recommendations, as well as educational material from the Academy of Nutrition and Dietetics.2,19 All questions were reviewed for their relevance and understandability by 13 Certified Diabetes Educators (CDEs) and RDNs from Massachusetts General Hospital in Boston, MA.
Attitude about nutrition in patient care was evaluated using a validated self-reported tool,the Nutrition in Patient Care Survey (NIPS). Utilizing a 5-point Likert scale, the NIPS is a 45-item survey that contains five subscales. The NIPS instrument demonstrates content and structural validity with factor analysis revealing a Kaiser–Meyer–Olkin index of 0.78 for the five dimensions. The subscale intercorrelation are low (median = 0.07), therefore subscales data are independent.21 It has also demonstrated reliability evidence with the subscale’s alpha coefficients ranging from 0.67 to 0.82, indicating internal consistency reliability. To reduce the total number of questions for the pre and post survey as to maximize participants response rate, PCPs completed two sections of the NIPS: “Nutrition in routine care” (8 items) and “Physician efficacy” (6 items).
Counseling Practices and Referrals
Chart audits from the CHC were conducted to assess counseling and/or referral practices among patients with an HbA1c ≥8% who had an office visit to a PCP between August 1 and October 20, 2023. Exclusion criteria included patients under 18 years old, unfinished documentation at the time of audit, and the charts of the project lead. To assess diet/nutrition counseling frequency, the Assessment & Plan portion of the note, where diabetes was addressed, was analyzed. Visits were scored as having included counseling if the pre-populated Smart Phrases that were written and distributed as part of the project were documented or documentation of a counseling word, or conjugate, along with a nutrition word, or conjugate as noted in Table 1. Visits that included counseling on topics other than nutrition were not scored positive.
 |
Table 1 Words Used to Determine the Presence or Absence of Counseling or Referral |
Referrals for nutrition counseling to an outside healthcare facility were also measured, because the CHC did not have a RDN on staff. Visits were scored as having included referral if the Assessment & Plan portion of the note mentioned that the patient has been referred to or is being managed by a dietitian/nutritionist or referred to another provider or facility (eg endocrinologist) with the specific intent of receiving diet/nutrition counseling. In other words, the provider combined a referral word or conjugate, along with a nutrition word or conjugate, as listed in Table 1. Visits that included referral on topics other than nutrition were not scored positive. Four weeks prior and six weeks after the CME program, the frequency in which diet/nutrition counseling or referral was evaluated.
Statistical Analysis Plan
A two-sample independent t-test compared the NMDA and NIPS group means pre and post intervention and Cronbach’s alpha was used to assess the internal consistency reliability. Chi-Square was used to assess change in the proportion of respondents correctly answering individual NMDA questions. Additionally, the point biserial (PBS) for each question was calculated by correlating the correct vs incorrect response to the overall score on the remaining nine items of the NMDA. To assess the impact of the intervention on counseling and referral rates, chi-square was used to test the pre-post change and Kendall’s tau was used to test the trend. Statistical significance was set at P < 0.05.
Results
PCPs (N = 32) at a CHC in Massachusetts were eligible to participate in the intervention. Roughly, 91% of PCPs (n = 29) were in attendance for the live CME program. Four-fifths of PCPs (n = 23) completed the pre-survey assessment before the CME intervention. Roughly 66% of PCPs (n = 19) completed the post-survey assessment that was available to them two weeks after the CME program. Table 2 shows the characteristics of the study participants.
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Table 2 Baseline Characteristics of PCP (n = 23) |
Knowledge and Attitude
The NMDA yielded acceptable internal consistency reliability, given Cronbach’s alpha coefficient of 0.73. The CME intervention significantly improved knowledge by an average score of 36% (P < 0.001) (Figure 1). A score of 80% or better was targeted as a “passing” grade. While no PCPs achieved this score before the CME intervention, roughly 21% (n = 4) of PCPs accomplished this score in the post test. The 10 questions were analyzed separately at both pre and post CME intervention. There was a significant gain of knowledge (P < 0.05) in seven of the ten questions. Furthermore, eight questions showed PBS scores ranging between 0.24 and 0.64 (Table 3).
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Table 3 NMDA Score per Question (% Correct) |
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Figure 1 Change in NMDA Score. Pre-test versus post-test NMDA score after a continuing medical education program. Bar height indicates mean score and error bars indicate standard deviation. Significance indicated as ***=p<0.001. Abbreviation: NMDA, Nutrition Management of Diabetes Assessment. |
In terms of attitude, there was no statistically significant difference between mean scores of the pre and post survey results in Nutrition in patient care of the NIPS. This subscale had acceptable internal consistency reliability, given an alpha coefficient of 0.777. There was a difference between mean scores of the pre and post-survey results (P < 0.01) in Physician efficacy of the NIPS (Figure 2). This subscale had good internal consistency reliability, given an alpha coefficient of 0.896.
 |
Figure 2 Change in NIPS Subscales. Pre-test versus post-test NIPS sub-scales after a continuing medical education program. Bar height indicates mean score and error bars indicate standard deviation. Significance indicated as **=p<0.01. Abbreviation: NIPS, Nutrition in Patient Care Survey. |
Counseling and Referrals
Pre-intervention diet/nutrition counseling was provided by PCPs in roughly 16% (5 out of 31) of visits, and no referrals were placed. For the six weeks following the CME intervention, roughly 47% (27 out of 58) of visits addressed either diet/nutrition counseling or referral (P < 0.05). The six weeks post intervention showed a positive difference in the trend of diet/nutrition counseling (P < 0.05), while there was no significant difference in trend of just referrals (P = 0.30). When considering either diet/nutrition counseling or referral, there was a trend difference (P < 0.05) (Figure 3).
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Figure 3 Trend in Diet/Nutrition Counseling, Referral, or Either (among visits with HbA1c ≥8%). Rates of counseling (Orange bar), referral (teal bar), or either (blue line) delivered to patients with uncontrolled diabetes among visits by primary care providers. Abbreviation: HbA1c, glycosylated hemoglobin A1c. |
Program Evaluation
Roughly 76% of participants (n = 22) that were in attendance completed the program evaluation. While 82% rated the program as “excellent” and 18% rated it as “good”, 95% endorsed they were likely/extremely likely to recommend this CME program to other PCPs.
Discussion
The quality of care delivered to patients living with diabetes is a significant challenge for healthcare systems in the USA22 and across the world23. It is within the primary care setting that PCPs serve as a critical point in the management of chronic health conditions. In order to care for chronic health conditions, such as diabetes, PCPs need to stay up-to-date on guidelines, recommendations, and evidence-based practice. As a result of the COVID-19 pandemic, the delivery of online CME has proven to be effective, positively influencing healthcare professional’s competency and performance in clinical practice.24 Few studies have examined if online CME changes practice in the management of type 2 diabetes.25 Similar to prior research,9 this QI project demonstrated an improvement in knowledge following a CME program. Our work expands on previous literature by including an objective measure of practice, using a previously validated measure of attitude, and providing evidence on the development and reliability of our knowledge assessment.
Change in Knowledge
Our results are consistent with two studies that showed an online single session CME is an effective strategy to improve diet/nutrition knowledge in the management of diabetes amongst medical providers.8,9 A large-scale study by Emami et al evaluated over 500 PCPs change in knowledge pre-post CME session that assessed knowledge on lifestyle modifications, which included advice on healthy diet. This study concluded there was a significant change difference in advice on healthy diet of about 28%.8 Similarly, Hicks & Murano9 evaluated 43 medical providers, 18 of which were either family medicine or internal medicine providers, who took part in pretest-posttest design that evaluated change in knowledge on diabetes diet/nutrition. The authors reported a statistically significant improvement in knowledge of about 30%.
Although the percent change is reasonably similar amongst the two studies and this study, it is important to be aware of the differences in baseline characteristics of population and knowledge-based assessments. Future studies should consider evaluating PCPs diabetes diet/nutrition knowledge utilizing the same knowledge-based assessment tool. The two studies and this study only involved a single CME program, not multi-modular. Future studies should consider using the same knowledge-based tool, however have a single vs multi-module CME session on diet/nutrition and diabetes.
Change in Attitude
One important finding related to PCPs attitude is the significant improvement in provider efficacy. Approximately, 90% of PCPs acknowledged that their patient-education efforts would be effective in increasing patient compliance. This study offered several tools and resources, which likely contributed to the increase in provider efficacy. An interactive online CME program developed and led by an expert in the field, who is also a colleague to the participants, may have caused an improvement in efficacy. Furthermore, to help guide their education and counseling practices, PCPs were provided an educational handout that could be given to patients. Additionally, Smart Phrases were developed in the EMR which could be utilized for providing education and to aid in office visit documentation.
The findings in our study are consistent with a pretest–posttest study that utilized the NIPS to evaluate the attitude of third year medical residents before and after completing novel curricular activity discussing nutrition.26 Unlike our intervention that utilized a single CME program, Ramsetty et al26 used case-based modules. Despite these differences, Ramsetty et al and our study found statistically significant differences in physician efficacy at 5% and 15%, respectively. By contrast, the Nutrition in patient care subscale was found not to be statistically significant. Similarly, Ramsetty et al and our study found no significant change difference in Nutrition in patient care at 1% and 4%, respectively. The attitude of PCPs may not have changed in this subscale since the education session provided was geared largely to improving knowledge and ability to provide appropriate education and counseling. The Nutrition in patient care subscale reflects attitude about the value of counseling in primary care.
Change in Clinical Practice
While the results are similar to prior literature in the change in attitude and knowledge, this project builds upon that literature by demonstrating an improvement in clinical practice after receiving an educational intervention. Similar to this study, Lee et al10 utilized a pre-post design that evaluated change in performance of PCPs counseling practices after viewing a CME session. In their study, there was a significant change difference of about 23% in counseling practice after an online CME, while our study showed a 30% change difference. Lee et al also recorded a 1.15 percentage point change in HbA1c levels at follow-up from baseline, suggesting that our study has the potential for clinically significant findings.10 Furthermore, as a result of increased lifestyle counseling and improved HbA1c levels, there are fewer CV events or deaths amongst patients living with diabetes.3
Due to the short nature of this study, future studies should evaluate if primary care-based diabetes diet/nutrition counseling alone can reduce HbA1c level. In order to ensure that practice change continues, efforts can be made for sustainability. PCPs should seek diabetes education courses that focus not only on pharmacological therapy but non-pharmacological therapy like diet/nutrition. Additionally, education material and handouts can be printed and placed in exam rooms for PCPs use with their patients.
Limitations
This study has several limitations. One limitation was the small sample size and that participants were from one CHC in Massachusetts. Given this context, our study may not be generalizable to all PCPs at CHC across the USA or the world. A second limitation was that CME intervention was a single program, in which nutrition concepts were discussed with the hopes that PCPs would integrate the knowledge gained into their counseling practices. The CME program primarily reviewed carbohydrate counting in the context of the Low Carbohydrate Diet. We could have included additional sessions reviewing additional meal plans (eg Mediterranean Diet), case studies, and ways to incorporate motivational interviewing, which could have enhanced counseling practices amongst PCPs. A third limitation was that we utilized self-reported surveys. This study could potentially have biases in how participants respond. For example, participants may have thought they were knowledgeable about diabetes diet/nutrition, while the NMDA scores revealed they were suboptimal. A fourth limitation of the study was not being able to assess the degree of counseling practices. Our assessment of counseling frequency relied on documentation, as we were not able to analyze how much time was spent nor capture in detail the content taught during office visits.
Conclusion
This project appears to be the first to evaluate the change in knowledge, attitude, and counseling practices amongst PCPs after completing a single online CME program focused on diet/nutrition management of diabetes in the primary care setting of a CHC. PCPs improved their knowledge and efficacy, which likely contributed to improved counseling practices. Providing PCPs with CME on up-to-date and evidence-based practice diet/nutrition guidelines and recommendations can lead to improved counseling practices, which in turn may improve the health and well-being of patients. Due to the short nature of this project, future studies should examine clinic outcomes by following HbA1c levels of patients for 3–6 months after PCPs have received diet/nutrition education and provided counseling.
Ethical Approval
This quality improvement (QI) project was deemed non-human subject research (NHSR) by the Mass General Brigham Institutional Review Board, and therefore did not require IRB approval.
Acknowledgments
The authors would like to thank the PCPs and the Quality Improvement team of the CHC for their active participation of this project. We would also like to thank the CDEs and RDNs for their time and expertise in reviewing the NMDA. Dr. Kahn wants to specifically thank Dr. Hoyt for his dedication, commitment, and guidance in completing this Doctor of Nursing Practice (DNP) project. He would also like to thank his DNP project team (Stephen Dunn, Jane L. Hubbard, and Valerie Sweeney) and Dr. Jennifer Spadano-Gasbarro for their assistance.
Disclosure
The author(s) report no conflicts of interest in this work.
References
1. Jonas DE, Crotty K, Yun JDY, et al. Screening for prediabetes and type 2 diabetes: updated evidence report and systematic review for the US preventive services task force. JAMA. 2021;326(8):744–760. doi:10.1001/jama.2021.10403
2. ElSayed NA, Aleppo G, Aroda VR, et al. Facilitating positive health behaviors and well-being to improve health outcomes: standards of care in diabetes—2023. Diabetes Care. 2023;46(Supplement_1):S68–96. doi:10.2337/dc23-S005
3. Zhang H, Goldberg SI, Hosomura N, et al. Lifestyle counseling and long-term clinical outcomes in patients with diabetes. Diabetes Care. 2019;42(9):1833–1836. doi:10.2337/dc19-0629
4. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502. doi:10.1111/j.1468-0009.2005.00409.x
5. Hiddink G, Hautvast J, van Woerkum C, Fieren C, Van’t Hof M. Consumers’ expectations about nutrition guidance: the importance of primary care physicians. Am J Clin Nutr. 1997;65(6):1974–1979. doi:10.1093/ajcn/65.6.1974S
6. Crowley J, Ball L, Hiddink GJ. Nutrition care by primary-care physicians: advancing our understanding using the COM-B framework. Public Health Nutr. 2020;23(1):41–52. doi:10.1017/S1368980019003148
7. Bo S, Ciccone G, Baldi C, et al. Effectiveness of a lifestyle intervention on metabolic syndrome. A randomized controlled trial. J Gen Intern Med. 2007;22(12):1695–1703. doi:10.1007/s11606-007-0399-6
8. Emami Z, Kouhkan A, Khajavi A, Khamseh ME. Knowledge of physicians regarding the management of type two diabetes in a primary care setting: the impact of online continuous medical education. BMC Med Educ. 2020;20(1):374. doi:10.1186/s12909-020-02212-3
9. Hicks KK, Murano PS. Online nutrition and T2DM continuing medical education course launched on state-level medical association. Adv Med Educ Pract. 2017;8:413–418. doi:10.2147/AMEP.S138278
10. Lee B, Trence D, Inzucchi S, et al. Improving type 2 diabetes patient health outcomes with individualized continuing medical education for primary care. Diabetes Ther. 2016;7(3):473–481. doi:10.1007/s13300-016-0176-9
11. Peek ME, Tang H, Alexander GC, Chin MH. National prevalence of lifestyle counseling or referral among African-Americans and Whites with diabetes. J Gen Intern Med. 2008;23(11):1858–1864. doi:10.1007/s11606-008-0737-3
12. Shah MK, Moore MA, Narayan KMV, Ali MK. Trends in lifestyle counseling for adults with and without diabetes in the U.S. 2005–2015. Am J Prev Med. 2019;57(5):e153–61. doi:10.1016/j.amepre.2019.07.005
13. Khandelwal S, Zemore SE, Hemmerling A. Nutrition education in internal medicine residency programs and predictors of residents’ dietary counseling practices. J Med Educ Curric Dev. 2018;5:2382120518763360. doi:10.1177/2382120518763360
14. Bassin SR, Al-Nimr RI, Allen K, Ogrinc G. The state of nutrition in medical education in the United States. Nutr Rev. 2020;78(9):764–780. doi:10.1093/nutrit/nuz100
15. Chao AM, Zhou Y, Wei X, Wisdom-Goulbourne T, Dowd M, Compher C. Nutrition education in primary care adult and family nurse practitioner programs. Nurse Educ. 2022;47(1):47–50. doi:10.1097/NNE.0000000000001050
16. Sullivan SY. Nutrition education in physician assistant programs: a national survey. J Physician Assist Educ. 2000;11(1):18–24. doi:10.1097/01367895-200011010-00002
17. Hemoglobin A1c control for patients with diabetes [Internet]. NCQA. [cited January 5, 2023]. Available from: https://www.ncqa.org/hedis/measures/hemoglobin-a1c-control-for-patients-with-diabetes/. Accessed October 3, 2024.
18. Evert AB, Dennison M, Gardner CD, et al. Nutrition therapy for adults with diabetes or prediabetes: a consensus report. Diabetes Care. 2019;42(5):731–754. doi:10.2337/dci19-0014
19. Basic-carbohydrate-counting.pdf [Internet]. [cited August 3, 2023]. Available from: https://med.virginia.edu/vcdpe/wp-content/uploads/sites/287/2015/12/Basic-Carbohydrate-Counting.pdf. Accessed October 3, 2024.
20. Norris J. From Telling to teaching: A Dialogue Approach to Adult Learning. Learning By Dialogue; 2003.
21. McGaghie W. Development of a measure of attitude toward nutrition in patient care. Am J Prev Med. 2001;20(1):15–20. doi:10.1016/S0749-3797(00)00264-6
22. Alencherry B, Bruemmer D. Quality of diabetes care in the USA. Curr Cardiol Rep. 2021;23(7):73. doi:10.1007/s11886-021-01503-5
23. Al-Alawi K, Al Mandhari A, Johansson H. Care providers’ perceptions towards challenges and opportunities for service improvement at diabetes management clinics in public primary health care in Muscat, Oman: a qualitative study. BMC Health Serv Res. 2019;19(1):18. doi:10.1186/s12913-019-3866-y
24. Jang A, Kim MR, Lee SMK, et al. Evaluating the effectiveness of online continuing medical education during the COVID-19 pandemic. Med Teach. 2023;45(8):852–858. doi:10.1080/0142159X.2023.2183787
25. Cervero RM, Gaines JK. The impact of CME on physician performance and patient health outcomes: an updated synthesis of systematic reviews. J Contin Educ Health Prof. 2015;35(2):131–138. doi:10.1002/chp.21290
26. Ramsetty A, Adams C, Berini C, Watson KH. Medical student attitudes on nutrition counseling after implementation of a novel curricular activity. J Am Coll Nutr. 2020;39(4):333–337. doi:10.1080/07315724.2019.1659191
