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 do not have impact in improving quality of care  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: Nonrandomised 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 1.Formulation of evidence-based clinical guidelines 2.Training of selected clinical tutors from referral hospital 3.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:  baseline evaluation  Follow-up at six and twelve months Evaluations consisted of:  Interviewing patients  Reviewing clinical records  Reviewing prescriptions

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

11. 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

12. 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 Lessons learned from the study

13. 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 Implications of this study to develop health policies and programs

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