2. 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

3. 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.

4. 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

5. 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

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

7. 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

8. 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

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

10. Impact of the intervention on the three causes of visit
Results
Impact of the intervention on the three causes of visit
<0.01
<0.05
<0.005
+25.2
+21.4
+23.7 HT
<0.001
P value
+29.0
+26.9
+32.7
+53.8
+37.7
Percentage
Appropriate drug prescription
Diet recommendations
Appropriate case-management
Appropriate prescription of antibiotics
Education to patients DM
ARI

11. Impact of the intervention on the treatment of
Acute Respiratory Infections
Appropriate prescription of antibiotics
Education to patient
Intervention
Control
28.6
9.1
33.3
21.9
41.3
27.8
35.6
32.7
42.7
47.6
27.5
35.0
61.3
62.9
30.5 10 20 30 40 50 60 70
Base
line
Post-
workshop
Post-tutorial
Final % P H Y S I C A N

12. Impact of the intervention on the treatment of
Type 2 Diabetes 90
Appropriate drug prescription
Appropriate case-management
47.5
21.2
51.0
13.5
68.4
44.3
63.7
24.0
76.5
48.1
66.7
28.1 10 20 30 40 50 60 70 80
Baseline
Follow-up
(six months)
Final
(One year)
Intervention
Control

13. Impact of the intervention on the treatment of
Hypertension
36.4
70.5
12.8
43.6
60.6
10.6
46.8
81.8
14.3
47.8
73.9
12.0
61.6
91.9
36.5
56.0
66.7
16.7 10 20 30 40 50 60 70 80 90
100
Base
line
Follow-up
six months
Final
One year
Intervention
Control
Appropriate case-management
Appropriate drug prescription
Diet recommendations

14. Methodological aspects Strengths
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

15. Methodological aspects Strengths
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

16. Methodological aspects Weaknesses
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

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