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Background

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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  1. 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

  2. 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.

  3. 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

  4. 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

  5. Methods Components • Formulation of evidence-based clinical guidelines • Training of selected clinical tutors from referral hospital • Educational intervention

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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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