INTERNATIONAL TRENDS IN IMMUNITY
ISSN 2326-3121 (Print) ISSN 2326-313X (Online)
VOL.2 NO.1
http://www.researchpub.org/journal/iti/iti.html
JANUARY 2014
E-learning for Continuing Medical Education: an
Instrument to Expand Knowledge and
Awareness on Primary Immune Deficiencies
C. Militoa, F. Pulvirenti a, S. Tabolli b, I. Quinti a

Abstract - Continuing professional education is vital to
reduce underdiagnosis and misdiagnosis of patients
affected by Primary Immune Deficiencies. According to the
mission of The Jeffrey Modell Centres Network aimed to
provide the infrastructure for diagnosis and appropriate
treatment for PID, we organized an E-learning course on
PID consisting in a six tutorial modules, self-directed.
Advices for registration have been sent by e-mail for a
period of one year to all the 17.000 Italian General
Practitioners and to the 3.500 Paediatric Family
Practitioners. Professionals who correctly completed the
questionnaire received credits from the Italian Ministry of
Health. Learner satisfaction was assessed by a set of 4
questions. A total of 2.226 users had registered and 1.736
had completed the course. Participants were General
Practitioners (60%), Paediatric Practitioners (18%), and
Specialists (22%). Most of physicians had diagnosed or
referred a patient with PID in the last 5 years. 69% passed
the test, 9% failed and 22% did not complete it. An older
age was identified among physicians who failed the test.
Better scores (80% of correct answers) were found for
themes on antibody deficiencies diagnosis, immunoglobulin
therapy, the 10 Warning Signs.
The worse scores (<50% of correct answers) were found for
themes on the use of vaccines, PID diagnosis other than
antibody deficiencies.
A continuous education of General Practitioners and
healthcare professionals on PID appears to be necessary in
order to ensure prompt recognition and referral to
specialists with expertise in the care of PID patients.
I. INTRODUCTION
Delayed primary immunodeficiency disorder (PID) diagnosis
leads to increased morbidity and mortality [1-5]. PID is more
common than had been previously estimated in that a large
population of patients is still undiagnosed [6]. Principal factors
leading to misdiagnosis and ensuing complications can be the
lack of knowledge and the proper evaluation of physicians
working as General Practitioners (GP), such as family doctors
and family paediatricians. GP are usually the first to identify
"unusual" patients that might have these rare diseases. Prompt
identification of PID is important for prognosis, but this may
not be an easy task. Subsequent referral for specialist
assessment is mandatory to lead to an appropriate therapy to
prevent or limit structural organ and tissue damage [7-8]. As a
consequence, continuing professional development and
education is vital to the provision of better health services and
outcomes. It has already been demonstrated the potential of the
Internet as a medium for teaching basic and applied
immunology, to illustrate complex concepts in new ways for
audiences that are diverse and often geographically dispersed
[9]. E-learning could be used as a tool for educational and for
awareness evaluation. The aim of this study was to expand
the PID awareness and knowledge by the use of a Web-based
education course targeted to provide information and
instruments for PID identification and diagnostic criteria
leading to correct diagnosis and treatment. According to the
mission of The Jeffrey Modell Centres Network aimed to
provide the infrastructure for referral, diagnosis and appropriate
treatment for PID [10] we prepared an e-learning course on PID.
Web-based educational resources have been demonstrated to
enhance practitioners' ongoing learning and clinical
competence [11]. Here, we demonstrated that a more
comprehensive postgraduate medical education about PID
appears to be necessary for all physicians and in particular for
those older than 50 years.
Keywords: awareness, e-learning, general practitioners,
misdiagnosis, Primary Immune Deficiencies
Received Oct. 4th, 2013. Accepted after revision Oct 29th, 2013
a
JMF Italian Diagnostic and Research Centre and Department of Molecular
Medicine, Sapienza University of Rome, and b Health Services Research Unit,
IDI IRCCS, Rome, Italy
Corresponding Author: Isabella Quinti. Tel.: +390649972007; Fax:
+390649972007. [email protected]. Viale dell’Università 37, 00186
Rome, Italy
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INTERNATIONAL TRENDS IN IMMUNITY
ISSN 2326-3121 (Print) ISSN 2326-313X (Online)
VOL.2 NO.1
http://www.researchpub.org/journal/iti/iti.html
JANUARY 2014
relevance of topics (85% very relevant, 12% relevant, 3%
sufficiently relevant), and for the utility of the update (62%
very high, 30% high, 8% sufficient). The time spent for the
course was the same indicated by us (20 hours) for 41%, longer
for 30%, shorter for 41% and much longer for 15% of the
participants (Fig.3).
Results of the knowledge validation
II. METHODS
Web-based resources for general and paediatric family
practitioner’s education were provided by our Jeffrey Modell
Centre for Primary Immunodeficiencies. The course consisted
in a six tutorial modules, self-directed.
Healthcare professionals were invited to undertake an
E-learning course by advices for registration repeatedly sent by
e-mail for a period of one year to all the 17.000 Italian GP and
to the 3.500 Paediatric Family Practitioners. It has to be noted
here that, differently from most of the world Countries, the
National Health Service (NHS) provides a Paediatric GP for all
Italian children up to the age of 14 years. Time spent for the
e-learning course was calculated in a 20 hours stand-alone
Web-based education course. Knowledge validation was done
by a set of 40 questions with pre-defined answers. The
E-learning modules were developed, comprising also key
messages taken from the 10 Warning Signs developed by the
Jeffrey Modell Foundation (Supplementary Fig. 1), and 2 case
histories relating to the care of PID patients designed to mirror
real- life clinical scenarios. The course was organized in
collaboration to the Italian Ministry of Health and it was free of
charge. Professionals who correctly completed the
questionnaire received 12 credits from the Ministry. Learner
satisfaction was also assessed by a set of 4 questions.
Results of the sets of 40 questions filled at the end of the course
revealed that those responders who correctly completed the test
were more likely to be younger. 69% of participants passed the
test and got credits from the Ministry of Health, 9% failed and
22% did not completed the test. There were no differences
among the different settings of work, in that the same
percentage of physicians who passed and failed were working
as NHS employees, General and Paediatric Practitioners, and
physicians working in private practice. Major differences were
found in relation to the age of participants. An older age (>50
years) was identified among physicians who failed the test. We
separately analysed the validation test results obtained in four
major cities: Rome, Naples, Bari and Palermo. All cities
showed the same trend observed in the overall Italian analysis:
physicians who failed were the oldest with the exception of
Palermo where we observed no differences related to the age.
Knowledge validation contents
The e-learning tutorial was organized in six modules: 1) general
principles of the immune system; 2) primary immune
deficiencies; 3) 10 Warning Signs for PID; 4) treatments; 5)
case report n.1 (Common Variable Immunodeficiency); case
report n.2 (X-linked Agammaglobulinemia). The set of 40
questions was organized in order to verify knowledge level
acquired through the course: 10 questions were related to the 10
Warning Signs; 10 questions to the mistakes inserted into the
clinical description of the 2 case reports; 10 questions were
related to immunoglobulin replacement therapy and adverse
events; 10 questions were related to PID diagnostic criteria.
In table 1 we reported the questions with the highest rate of
correct answers (upper part) and the lowest rate of correct
answers (lower part). Better scores (80%) were found when
examining answers related to questions relative to antibody
deficiencies
diagnosis,
immunoglobulin
therapy,
immunoglobulin dosing for PID, 10 Warning Signs. The worse
scores (<50%) were found for the questions concerning the use
of vaccines, immunoglobulin subcutaneous adverse reactions,
diagnosis of PID other than antibody deficiencies.
III. RESULTS
Characteristics of participants
After the modules have been available on line for one year, a
total of 2.226 users had registered and a total of 1.736 had
completed them, a figure documenting that family doctors
working as GP or Paediatric Practitioners members of NHS or
working in private medicine showed awareness and interest for
PID. Physician participants were General Practitioners (60%),
Paediatric Practitioners (18%), and Specialists in different
disciplines (22%) (Fig.1). Regional distribution covered the
entire Country with a similar participation rate in North, Centre
and South of Italy. Overall, most of physicians had diagnosed,
treated, or referred a patient with PID in the last 5 years: 45%
had 1-2 patients, 14% 3-4 patients, 28% more than 4 patients
and 19% had no PID patients attending their clinics (Fig.2). For
comparison, the number of patients with other immunological
disorders attending their clinic is shown in the Figure. When a
possible PID case presented, 65% of physicians referred the
PID patient to a local regional reference centre for PID, 11% to
a haematologist, 17% to an immunologist, and 7% to other
specialists.
IV. DISCUSSION
Rare diseases are a serious public health problem and are a
threat to the health of EU citizens [12]. Important role in the
area of rare diseases have the medical specialists who diagnose
and monitor the course of the disease of each patient. However,
and even more important it is the GP’s awareness and
knowledge about rare diseases as a strong factor for the timely
and accurate diagnosis and adequate treatment. Efficient early
Quality feedback
In the satisfaction questionnaire, the E-learning course was
judged in a positive way by participants: 80% declared a very
high quality and 15% a good quality. Only 4% declared a
sufficient quality. The same satisfaction was declared for the
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ISSN 2326-3121 (Print) ISSN 2326-313X (Online)
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identification of PID is important for prognosis, but is not an
easy task for non-immunologists. Some studies addressed the
issue of medical awareness on PID using questionnaires
distributed among doctors working in different fields [13-14].
As a part of The Jeffrey Modell Centers Network that includes
518 Expert Physicians at 196 Academic Teaching Hospitals in
191 cities, 68 countries and 6 continents and still expanding
every day we chose to verify the usefulness of a different
approach by the use of a PID related E-learning course. Online
systems of training for healthcare workers have previously
been established for knowledge transfer as equivalent to other
forms of teaching [15-16]. It has the advantage that users can
determine the time, duration, and place of learning.
Because PIDs may present at all ages, the E-learning course
was targeted at both general and paediatric practitioners. The
responses of registered doctors indicate a good level of
knowledge acquired through the E-learning course. However, a
low level of knowledge was identified in older physicians
working in South of Italy. This means that older practitioners
from the NHS could not provide sufficient in quality and
timeliness specific information to their patients with PID. The
majority of medical practitioners provided correct answers to
the final validation questionnaire and got credits from our
Ministry of Health. Even with these fairly positive results, we
were surprised by the apparently good score (>80%) of correct
answers relative to the themes on recommendations for
complementary/alternative medicine. The other way to read
this figure is that >10% of participants still believed that there
might be alternative therapies to immunoglobulin
administration in patients with primary defects of humoral
immunity, as already demonstrated by a recent paper describing
results of a survey by the Primary Immunodeficiency
Committee of the American Academy of Allergy Asthma and
Immunology [17]. Differences between GP were identified.
The main difference was not related to the different setting
where clinical practices are performed but on the age of
participants. Thus, the need for expanded educational efforts
targeting older medical doctors should be defined. Moreover,
whether these efforts might result in a long-term change of
practice should also be assessed. Results of this E-learning
course were received by the Italian Ministry of Health. They
underlined the need of a continuous education of healthcare
professionals, required to ensure prompt recognition and
referral to specialists with expertise in the care of PID patients.
The results were also sent to The Ministry of University and
Education who recently inserted a course on rare diseases
during the medical undergraduate training program. As it was
already been demonstrated by critical care educators and
practitioners [18-20], E-learning might be actively integrated
into training programs for continuing medical education. The
positive attitude to PID learning demonstrated by the high
number of physicians registered could be biased in favour of
healthcare professionals with a pre-existing interest in PID, and
may not be representative of all GP. Bearing in mind this
limitation, the feedback was supportive, and many of the
comments consisted of positive comments such as “very
relevant” or “relevant”. Significant gaps remain in ensuring
PID in primary care. This project has demonstrated that
JANUARY 2014
E-learning trough e-mail invitations offering GPs relevant
teaching modules is one method of reinforcing and highlighting
clinical guidelines in an attempt to effect change in primary
care practice on PID. Web resources for general and paediatric
practicioner’s education in a variety of E-learning formats, such
as tutorials, self-directed learning modules, interactive case
studies, should be considered useful instruments for PID
awareness. Core components of the Jeffrey Modell Foundation
programme such as the 10 Warning Signs have been delivered
successfully to thousands of people across the word. There is a
great potential for further exploration on web based systems to
deliver and support medical education on PID.
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V. ACKNOWLEDGMENTS
ACKNOWLEDGMENTS
We are enormously grateful to Vicki and Fred Modell who
greatly support our work through the Jeffrey Modell
Foundation.
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Table 1.
Question
correct
answers
What routine examination may reveal a condition
of hypogammaglobulinemia?
97%
What tests are recommended to perform to
exclude hypogammaglobulinemias secondary to
lymphoproliferative disorders?
89%
Which of these symptoms can be considered an
adverse reaction to treatment with
immunoglobulins?
87%
Do you think there may be alternative therapies to
immunoglobulin administration in patients with
primary defects of humoral immunity?
84%
In an adult of thirty years with recurrent skin
abscesses is possible to assume a primary
immunodeficiency?
82%
In a child with growth retardation and oral
candidiasis is possible to assume a primary
immunodeficiency?
80%
What is the dose of immunoglobulin to be
administered as replacement therapy?
80%
When to get a vaccine response, you need to
convert a T-independent response in a Tdependent response?
30%
What is the immune defect in patients with SCID?
39%
Have been described reports of HBV transmission
in patients through immunoglobulins?
44%
Immunoglobulin for subcutaneous use causes
local reaction at the site of administration?
46%
What is the dose of immunoglobulin to be
administered as immunomodulatory therapy?
50%
What is the suspected diagnosis in a patient with
the following dosage of serum immunoglobulins:
IgG 320 mg/dl, IgA <4 mg/dl, IgM <8 mg/dl?
53%
What are the prevalent infections in patients with
antibody deficiencies?
55%
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Figure caption list
Fig.1. Total number of participants divided according to their
different clinical practices.
Fig.2. PID patient referral (upper part). Number of PID patients
and number of patients with other immunological disorders
diagnosed, treated, or referred in the last 5 years by participants
(lower part): 45% had 1-2 patients, 14% 3-4 patients, 28% more
than 4 patients and 13% had no PID patients attending their
clinics. 63% had less than 10 patients, 15% had 10-50 patients,
7% had 50-100 patients and 15% had more than 100 patients
affected by other immunological diseases.
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INTERNATIONAL TRENDS IN IMMUNITY
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Fig.3. Quality feedback. Educational quality, utility of the
update, relevance of topics, time spent for fruition declared by
participants.
JANUARY 2014
Supplementary Fig. 1. The 10 Warning Signs developed by the
Jeffrey Modell Foundation.
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