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Review | Clinician's Corner

Internet-Based Learning in the Health Professions: A Meta-analysis

David A. Cook, MD, MHPE; Anthony J. Levinson, MD, MSc; Sarah Garside, MD, PhD; Denise M. Dupras, MD, PhD; Patricia J. Erwin, MLS; Victor M. Montori, MD, MSc
JAMA. 2008;300(10):1181-1196. doi:10.1001/jama.300.10.1181.
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Published online

Context The increasing use of Internet-based learning in health professions education may be informed by a timely, comprehensive synthesis of evidence of effectiveness.

Objectives To summarize the effect of Internet-based instruction for health professions learners compared with no intervention and with non-Internet interventions.

Data Sources Systematic search of MEDLINE, Scopus, CINAHL, EMBASE, ERIC, TimeLit, Web of Science, Dissertation Abstracts, and the University of Toronto Research and Development Resource Base from 1990 through 2007.

Study Selection Studies in any language quantifying the association of Internet-based instruction and educational outcomes for practicing and student physicians, nurses, pharmacists, dentists, and other health care professionals compared with a no-intervention or non-Internet control group or a preintervention assessment.

Data Extraction Two reviewers independently evaluated study quality and abstracted information including characteristics of learners, learning setting, and intervention (including level of interactivity, practice exercises, online discussion, and duration).

Data Synthesis There were 201 eligible studies. Heterogeneity in results across studies was large (I≥ 79%) in all analyses. Effect sizes were pooled using a random effects model. The pooled effect size in comparison to no intervention favored Internet-based interventions and was 1.00 (95% confidence interval [CI], 0.90-1.10; P  < .001; n = 126 studies) for knowledge outcomes, 0.85 (95% CI, 0.49-1.20; P  < .001; n = 16) for skills, and 0.82 (95% CI, 0.63-1.02; P  < .001; n = 32) for learner behaviors and patient effects. Compared with non-Internet formats, the pooled effect sizes (positive numbers favoring Internet) were 0.10 (95% CI, −0.12 to 0.32; P = .37; n = 43) for satisfaction, 0.12 (95% CI, 0.003 to 0.24; P = .045; n = 63) for knowledge, 0.09 (95% CI, −0.26 to 0.44; P = .61; n = 12) for skills, and 0.51 (95% CI, −0.24 to 1.25; P = .18; n = 6) for behaviors or patient effects. No important treatment-subgroup interactions were identified.

Conclusions Internet-based learning is associated with large positive effects compared with no intervention. In contrast, effects compared with non-Internet instructional methods are heterogeneous and generally small, suggesting effectiveness similar to traditional methods. Future research should directly compare different Internet-based interventions.

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Figures

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Figure 1. Trial Flow
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Five studies compared the Internet-based intervention with both no intervention and a non-Internet comparison intervention.

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Figure 2. Random-Effects Meta-analysis of Internet-Based Learning vs No Intervention: Knowledge Outcomes
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Boxes represent the pooled effect size (Hedges g). P values reflect paired or 3-way comparisons among bracketed subgroups. Participant groups are not mutually exclusive; thus, no statistical comparison is made. There are 126 interventions because the report by Curran et al39 contributed 10 separate interventions to this analysis. I2 for pooling all interventions is 93.6%.

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Figure 3. Random-Effects Meta-analysis of Internet-Based Learning vs No Intervention: Skills Outcomes
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For a definition of figure elements, see the legend to Figure 2. All interventions were tutorials; hence, no contrast is reported for this characteristic. I2 for pooling all interventions is 92.7%.

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Figure 4. Random-Effects Meta-analysis of Internet-Based Learning vs No Intervention: Behaviors in Practice and Effects on Patients
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For a definition of figure elements, see the legend to Figure 2. All interventions occurred in a practice setting; hence, no contrast is reported for this characteristic. There are 32 interventions because the report by Curran et al39 contributed 14 separate interventions to this analysis. I2 for pooling all interventions is 79.1%.

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Figure 5. Random-Effects Meta-analysis of Internet-Based Learning vs Alternate Instructional Media: Satisfaction Outcomes
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Studies are classified according to relative between-intervention differences in key instructional methods; namely, did the comparison intervention have more (comparison >Internet), less (comparison <Internet), or the same (equal) amount of interactivity, practice exercises, discussion (face-to-face and Internet-based discussion combined), and repetition. Boxes represent the pooled effect size (Hedges g). P values reflect paired or 3-way comparisons among bracketed subgroups. Participant groups are not mutually exclusive; thus, no statistical comparison is made. All outcomes were subjectively determined; hence, no contrast is reported for this characteristic. Crossover studies assessed participant preference after exposure to Internet-based and non−Internet-based interventions. I2 for pooling all interventions is 92.2%.

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Figure 6. Random-Effects Meta-analysis of Internet-Based Learning vs Alternate Instructional Media: Knowledge Outcomes
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For a definition of figure elements and study parameters, see the legend to Figure 5. I2 for pooling all interventions is 88.1%.

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Figure 7. Random-Effects Meta-analysis of Internet-Based Learning vs Alternate Instructional Media: Skills Outcomes
Graphic Jump Location

For a definition of figure elements and study parameters, see the legend to Figure 5. All interventions were tutorials, and all outcomes were objectively determined except for 1 study in which the method of assessment could not be determined; hence, no contrasts are reported for these characteristics. I2 for pooling all interventions is 89.3%.

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Figure 8. Random-Effects Meta-analysis of Internet-Based Learning vs Alternate Instructional Media: Behaviors in Practice and Effects on Patients
Graphic Jump Location

For a definition of figure elements and study parameters, see the legend to Figure 5. I2 for pooling all interventions is 94.6%.

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