Transcript From Drug Prescribing Practices Research to a Continuing Medical

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
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
To evaluate the impact of a multifaceted educational intervention
on primary care physicians, to
improve case-management of
acute respiratory infections,
hypertension and type 2
diabetes.
Methods
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
Components
1. Formulation of evidence-based
clinical guidelines
2. Training of selected clinical
tutors from referral hospital
3. Educational intervention
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
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
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
Results
Impact of the intervention on the three
causes of visit
Outcome
Percentage
P value
ARI Appropriate prescription of
antibiotics
Education to patients
Appropriate casemanagement
+32.7
<0.01
+53.8
+37.7
<0.001
<0.01
DM Appropriate drug
prescription
Appropriate casemanagement
+29.0
HT
+25.2
<0.01
+21.4
+23.7
<0.05
<0.005
Appropriate drug
prescription
Diet recommendations
Appropriate casemanagement
<0.05
+26.9
Results
Impact of the intervention to improve
treatment of
Acute Respiratory Infections
70
Intervention
60
62.9
61.3
%
P
H
Y
S
I
C
I
A
N
S
Control
50
47.6
40
42.7
41.3
33.3
30
35.6
32.7
35.0
30.5
28.6
33.3
27.5
27.8
20
21.9
10
9.1
0
Base
line
Postworkshop
Posttutorial
Final
Appropriate prescription of
antibiotics
Base
line
Postworkshop
Posttutorial
Education to patient
Final
Results
Impact of the intervention to
improve treatment of
Type 2 Diabetes
90
80
76.5
Intervention
70
68.4
Control
66.7
63.7
60
50
51.0
48.1
47.5
44.3
40
30
28.1
24.0
20
21.2
10
13.5
0
Baseline
Follow-up
(six months)
Final
(One year)
Appropriate drug prescription
Baseline
Follow-up
(six months)
Final
(One year)
Appropriate case-management
Results
Impact of the intervention to improve
treatment of hypertension
100
90
Intervention
91.9
80
Control
81.8
73.9
70
70.5
66.7
60
61.6
60.6
56.0
50
46.8 47.8
43.6
40
36.4
36.5
30
20
16.7
10
14.3
12.8
10.6
12.0
0
Base
line
Follow-up
Final
six months One year
Appropriate
drug
prescription
Base
line
Follow-up
Final
six months One year
Diet
recommendations
Base Follow-up
Final
line six months One year
Appropriate
casemanagement
Conclusions
A positive impact was demonstrated on case-management
plus the feasibility of reinforcing continuity and coordination of care between primary
and secondary care physicians.
Further studies are needed to
analyze organizational implications, cost, sustainability and
effectiveness of continuing
medical education intervention
studies.