Outcome-based continuing medical education : An intervention to improve rational prescribing

Background: Continuing medical education (CME) for doctors has been compulsory in Iran since 1991. Conventional CME programmes are often unsuccessful in improving medical professionals’ performance. Modifications of CME elements are necessary to improve the effectiveness of the programmes. It has been proposed that the concept of outcome-based education (OBE) could be more effective than traditional methods as an overarching approach that can influence the entire process of education: decisions about the content, formulation of aims, educational strategies, teaching methods, assessment procedures, and the educational environment. We have therefore evaluated the effectiveness of OBE in CME and how it impacts the prescribing practices of general physicians in primary care (GPs) in the East Azerbaijan Province of Iran. The topic was chosen since the field of rational prescribing has been recognized as a high-priority issue. Methods: Cluster randomized controlled design. First, outcome-based educational indicators regarding rational prescribing were identified using a two-round Delphi consensus process. In the second phase the agreed indicators were submitted to panels of experts for assessment and determination of the content of a CME programme for GPs. All GPs working in six cities in the East Azerbaijan province in Iran were invited to participate in the educational programme and 159 agreed to take part. The cities were matched and randomly divided into an intervention arm for education within an OBE programme on rational prescribing, and a control arm for a traditional programme on the same subject. The GPs’ knowledge and skills were assessed using a preand post-test and their prescribing behaviour was assessed through collecting 10% of their prescriptions, nine months before, and three months after the CME programmes. All nine trainers and 12 GPs (out of 58) in the intervention arm were invited to individual interviews four months after participation in the CME programme. A semi-structured open-ended guideline was used in the interviews. Qualitative content analysis was applied to explore the text and to interpret meaning and intention. Results: Twenty-one learning outcomes were identified through a modified Delphi process. The OBE indicators were used by expert panels to determine six educational topics for the CME programme and define the curricular content for each topic. The six topics were 1) Principles of prescription writing, 2) Adverse drug reactions, 3) Drug interactions, 4) Injections, 5) Antibiotic therapy, and 6) Therapy with anti-inflammatory agents. In total, 112 GPs participated in the programme. There were significant improvements in knowledge and prescribing skills after the training in the intervention arm as well as in comparison with the changes in the control arm, with an overall intervention effect of 26 percentage units. The GPs in the intervention arm significantly reduced the total number of prescribed drugs and the number of injections per prescription. They increased their compliance with specific requirements for a correct prescription, in particular significantly improved information to the patient. Compared with the control arm, there was no significant improvement regarding prescribing antibiotics and antiinflammatory agents and some other indicators. Interviews showed that the participants themselves stated improved knowledge and skills to a higher extent than previously attended programmes. Trainers emphasized the effect of outcomebased education on their educational planning, teaching and assessment methods, while the GPs’ challenge was how to adapt their learning in the real work environment considering social and economical barriers. Self-described attitudes changed towards more rational prescribing. Conclusion: The introduction of an outcome-based approach in CME appears to be attractive and effective when creating programmes to improve GPs’ knowledge, skills, attitude and performance. The results strongly suggest that CME programmes could be more effective through the use of an OBE approach.