A Multifaceted Continuing Medical Education Intervention to Improve

A Multifaceted Continuing Medical Education Intervention to Improve Primary Care Physicians’ Performance In Mexico Hortensia Reyes, Ricardo Perez-Cuevas, Sergio Flores, Patricia Tome, Juan A Trejo, Onofre Muñoz Mexican Institute of Social Security

Background § Inappropriate case management for common diseases in primary care level is a relevant problem in many countries. § Most of continuing medical education activities for primary care physicians in Mexico do not have impact in improving quality of care § Physicians’ practices are not always in accordance with updated clinical evidence.

Objective To evaluate the impact of a multifaceted educational intervention on primary care physicians, to improve case-management of acute respiratory infections, hypertension and type 2 diabetes

Methods Design: Setting: Nonrandomised prospective controlled Trial Eight primary care facilities belonging to Mexican Institute of Social Security, in four different regions of Mexico Study population: Family physicians

Methods Components 1. Formulation of evidence-based clinical guidelines 2. Training of selected clinical tutors from referral hospital 3. Educational intervention

Educational intervention activities The multifaceted strategy comprises three stages to be completed in a seven-month period: § Interactive workshops § In-service training through individual tutorial § Round-table Peer review sessions

Outcome measures Appropriateness of physicians’ casemanagement according to the clinical guideline: ARI: - Prescription of antibiotics - Patients’ education, including mother’s education whether the patient was a child, regarding the alarm signs HT: - Prescription of antihypertensive drugs DM: - Prescription of hypoglycemic drugs or insulin In both chronic illnesses dietary and exercise recommendations

Evaluation § § Acute respiratory infections: § baseline evaluation § follow-up evaluations after every intervention stage Hypertension and Type 2 diabetes: § baseline evaluation § Follow-up at six and twelve months Evaluations consisted of: § Interviewing patients § Reviewing clinical records § Reviewing prescriptions

Results Impact of the intervention on the three causes of visit ARI DM Percentage P value Appropriate prescription of antibiotics Education to patients Appropriate case-management +32. 7 <0. 01 +53. 8 +37. 7 <0. 001 <0. 01 Appropriate drug prescription Appropriate case-management +29. 0 <0. 05 +26. 9 HT Appropriate drug prescription Diet recommendations Appropriate case-management +25. 2 <0. 01 +21. 4 +23. 7 <0. 05 <0. 005

Lessons learned from the study Result: The educational intervention had a positive impact in improving case-management of the three causes of visit, although, positive changes in prescription of drugs were observed in less than 35% of physicians Comment: The intervention was conducted during routine working conditions of the clinic. The workload of family physicians places severe time restraints for academic activities. Modifying the organisation and process of care could improve the results, particularly to manage chronically ill patients

Lessons learned from the study Result: Changes varied in magnitude according to the outcome variables. Hypertension and type 2 diabetes treatments changed less than ARI treatments Comment: Chronically ill patients require long-term care and case management is a dynamic process that should change according to the particular conditions of each patient. The longer the intervention, the greater the opportunity to allow physicians and clinical tutors to provide appropriate case management, follow up patients, and ascertain health outcomes

Implications of this study to develop health policies and programs CME Programs based on this strategy can improve quality of care at primary health care settings through: § Promoting better coordination between primary and secondary care physicians § Encouraging participation of physicians to develop clinical guidelines thus facilitating acceptance and utilisation § Supporting tutorial activities to allow physicians to enhance their clinical analytical skills during actual medical practice

QUESTIONS FOR THE FUTURE RESEARCH AGENDA § Analysis of organisational implications § Economic evaluation § Evaluation of sustainability of the intervention: CME Program § Impact on health outcomes