Online continuing medical education as a key link for successful noncommunicable disease self-management: the CASALUD™ Model

Abstract

Purpose

The purpose of this study is to evaluate how the benefits of online continuing medical education (CME) provided to health care professionals traveled along a patient “educational chain”. In this study, the educational chain begins with the influence that CME can have on the quality of health care, with subsequent influence on patient knowledge, disease self-management, and disease biomarkers.

Methods

A total of 422 patients with at least one noncommunicable disease (NCD) treated in eight different Mexican public health clinics were followed over 3 years. All clinics were participants in the CASALUD Model, an NCD care model for primary care, where all clinic staff were offered CME. Data were collected through a questionnaire on health care, patient disease knowledge, and self-management behaviors; blood samples and anthropometric measurements were collected to measure patient disease biomarkers.

Results

Between 2013 and 2015, the indexes measuring quality of health care, patient health knowledge, and diabetes self-management activities rose moderately but significantly (from 0.54 to 0.64, 0.80 to 0.84, and 0.62 to 0.67, respectively). Performing self-care activities – including owning and using a glucometer and belonging to a disease support group – saw the highest increase (from 0.65 to 0.75). A1C levels increased between 2013 and 2015 from 7.95 to 8.41% (63–68 mmol/mol) (P<0.001), and blood pressure decreased between 2014 and 2015 from 143.7/76.8 to 137.5/74.4 (systolic/diastolic reported in mmHg) (P<0.001). The mean levels of other disease biomarkers remained statistically unchanged, despite the improvements seen in the previous “links” of the educational chain.

Conclusion

Online CME can effect certain changes in the educational chain linking quality of health care, patient knowledge, and self-management behaviors. However, in order to assure adequate NCD control, the entire health care system must be improved in tandem. Online CME programs, such as CASALUD’s, are feasible strategies for impacting changes in disease self-management at a clinic level throughout a country.

Keywords:

• chronic disease
• health education
• type 2 diabetes mellitus
• Mexico
• continuing medical education
• primary care

Supplementary materials

Index construction with three evaluated groups and their nine subgroups

Variables were dichotomous dummy variables; the aggregated sum was obtained for each of the three groups and the corresponding nine subgroups using the following formula:

$\frac{{\displaystyle {\sum }_{\mathrm{i}=1}^{\mathrm{n}}{\mathrm{d}}_{\mathrm{i}}-\text{Min}\left({\displaystyle {\sum }_{\mathrm{i}=1}^{\mathrm{n}}{\mathrm{d}}_{\mathrm{i}}}\right)}}{\text{Max}\left({\displaystyle {\sum }_{\mathrm{i}=1}^{\mathrm{n}}{\mathrm{d}}_{\mathrm{i}}}\right)-\text{Min}\left({\displaystyle {\sum }_{\mathrm{i}=1}^{\mathrm{n}}{\mathrm{d}}_{\mathrm{i}}}\right)},$

where d is dummy. Values were normalized with unidimensional distance in function of the operationalization.

Table S1 Criteria to define diagnosis of NCD

Table S2 Patient health knowledge

Table S3 Disease self-management activities

Table S4 Perception of quality of medical care

Table S5 The IDF consensus worldwide definition of the metabolic syndrome

Acknowledgments

At the national level, Jesús Felipe González-Roldán, General Director at CENAPRECE, and Gabriela Ortíz, Director at CENAPRECE, were key allies in supporting the implementation and evaluation of CASALUD. And, although we cannot enlist everyone by name here, we appreciate the support shown by the Mexican public health system staff along the way. At the state level, Martina Pérez, Director of Health Services, Jorge Octavio García, Director of Health Policy and Quality, and Jurisdiction Program Directors Ma. de la Paz Herrera and Violeta Nidia Acosta proved invaluable in coordinating with clinics and local authorities. Implementation of the CASALUD Model at health care clinics was made possible with the support of their directors, Carlos Castellanos, Miguel Ramírez, Alma Martell, María González, Tania Alomia del Río, Juana Martínez, Juan Saldaña, Georgina Sánchez, and Gloria Vázquez. We are indebted to the patients and health care workers who so graciously participated in tracing studies and interviews at their health care clinics. We would like to acknowledge the significant contribution of Vicente Sotelo and Micaela Mussini to the analysis of the data used in this study and Craig Waugh for his valuable comments on this document. Finally, many thanks go out to our field research team, Christian García, Rayénari Gurrola, Ana Laura Islas, América Ruiz, and Víctor Nolasco, whose tireless data collection efforts made this study possible. The research on the CASALUD Model reported in this publication was supported by the NCD Partnership of Eli Lilly.

Author contributions

RT-C and RM-R designed the CASALUD Model and its innovations, conceived the study, and helped to draft the manuscript. HG-R designed the CASALUD Model and its innovations, conceived the study, participated in its design and coordination, and helped to draft the manuscript. RS-M designed the CASALUD Model and its innovations, conceived the study, participated in its design and coordination, and drafted the manuscript. EL and AI performed critical revision of the manuscript and provided valuable feedback during the study design. PK-M supervised the study execution and provided administrative and technical support. BT-B helped to design the study, designed the logistics for data acquisition, provided supervision, and helped to draft the manuscript. UQ-G helped to design the study, designed the logistics for data acquisition, coordinated the study, designed the statistical analysis plan, and helped to draft the manuscript. ERA helped to design the study, participated in the analysis and interpretation of data, and drafted the manuscript. All authors contributed toward data analysis, drafting and critically revising the paper and agree to be accountable for all aspects of the work.

Disclosure

RT-C, HG-R, RS-M, and RM-R are employed full time by the Fundación Carlos Slim. PK-M currently serves as Deputy Secretary for Prevention and Health Promotion at the Mexi-can Ministry of Health. EL and AI are employed full time by the Lilly Global Health, of Eli Lilly and Company. BT-B, UQ-G, and ERA are employed full time by C230 Consultores. The authors report no other conflicts of interest in this work.