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

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. 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. Objective

4. Design: Nonrandomized 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 working in selected clinics. Methods

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

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

7. Methods 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. Methods 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. Results Impact of the intervention on the three causes of visit <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+37.7Percentage 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 ARIOutcome

10. Results Impact of the intervention to improve 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 30.533.3 0 10 20 30 40 50 60 70 Post- workshop Post- tutorial FinalBase line Post- workshop Post- tutorial Final % P H Y S I C I A N S Base line

11. 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 0 10 20 30 40 50 60 70 80 BaselineFollow-up (six months) Final (One year) BaselineFollow-up (six months) Final (One year) InterventionControl Results Impact of the intervention to improve treatment of Type 2 Diabetes

12. Results Impact of the intervention to improve 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 0 10 20 30 40 50 60 70 80 90 100 Base line Follow-up six months Final One year Base line Follow-up six months Final One year Base line Follow-up six months Final One year InterventionControl Appropriate case- management Appropriate drug prescription Diet recommendations

13. Conclusions  A positive impact was demons- trated on case-management plus the feasibility of reinfor- cing continuity and coordina- tion of care between primary and secondary care physicians.  Further studies are needed to analyze organizational implica- tions, cost, sustainability and effectiveness of continuing medical education intervention studies.