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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 Mu ñoz Mexican Institute of Social Security. Background.

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slide2

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 MuñozMexican Institute of Social Security

background
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 have not impact in improving the quality of care they provide.
  • Physicians’ practices are not always in accordance with updated clinical evidence.
objective
Objective

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

methods
Methods

Design: Non-randomised prospective controlled Trial

Setting: Eight primary care facilities belonging to Mexican Institute of Social Security, in four different regions of Mexico

Study

population: Family physicians

methods1
Methods

Components

  • Formulation of evidence-based clinical guidelines
  • Training of selected clinical tutors from referral hospital
  • Educational intervention
educational intervention activities
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
Outcome measures

Appropriateness of physicians’ case-management 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
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
slide10

Percentage

P value

ARI

Appropriate prescription of antibiotics

Education to patients

Appropriate case-management

+32.7

+53.8

+37.7

<0.01

<0.001

<0.01

DM

Appropriate drug prescription

Appropriate case-management

+29.0

+26.9

<0.05

HT

Appropriate drug prescription

Diet recommendations

Appropriate case-management

+25.2

+21.4

+23.7

<0.01

<0.05

<0.005

Results

Impact of the intervention on the three causes of visit

slide11

70

Intervention

Control

%

P

H

Y

S

I

C

I

A

N

S

60

62.9

61.3

50

47.6

40

42.7

41.3

35.6

33.3

35.0

32.7

30

30.5

33.3

28.6

27.5

27.8

20

21.9

10

9.1

0

Base

line

Post-

workshop

Post-tutorial

Final

Base

line

Post-

workshop

Post-tutorial

Final

Appropriate prescription of antibiotics

Education to patient

Impact of the intervention on the treatment of

Acute Respiratory Infections

slide12

90

80

76.5

70

68.4

66.7

60

63.7

50

51.0

48.1

47.5

40

44.3

30

28.1

24.0

20

21.2

13.5

10

0

Follow-up

(six months)

Baseline

Final

(One year)

Follow-up

(six months)

Final

(One year)

Baseline

Appropriate case-management

Appropriate drug prescription

Intervention

Control

Impact of the intervention on the treatment of

Type 2 Diabetes

slide13

100

90

Intervention

Control

91.9

80

81.8

70

73.9

70.5

66.7

60

61.6

60.6

56.0

50

47.8

46.8

40

43.6

36.4

30

36.5

20

16.7

10

14.3

12.8

10.6

12.0

0

Follow-up

six months

Base

line

Follow-up

six months

Final

One year

Base

line

Final

One year

Base

line

Follow-up

six months

Final

One year

Appropriate drug prescription

Diet recommendations

Appropriate case-management

Impact of the intervention on the treatment of

Hypertension

methodological aspects strengths
Methodological aspectsStrengths

Design of the intervention

Multifaceted intervention:workshop and peer-review activities, reinforced by:

Clinical guidelines developed with the consensus and participation of the physicians and adapted to the local conditions

Individual tutorial activity. Clinical analytical skills can be learned at the moment of medical practice

methodological aspects strengths1
Methodological aspectsStrengths

Ascertainment of the impact of the intervention:

  • Baseline and at least two follow-up evaluations in experimental and control groups
  • Observation of actual physicians’ practices
methodological aspects weaknesses
Methodological aspectsWeaknesses
  • Non-randomised, Open-labeled study
  • Follow-up evaluations were made immediately after each stage
  • Lack of information regarding concurrent CME activities in which control group physicians participated during the study
slide17

QUESTIONS FOR THE FUTURE RESEARCH AGENDA

  • Analysis of organizational implications
  • Economic evaluation
  • Evaluation of sustainability of the intervention: CME Program
  • Impact on health outcomes
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