1、,From Concept to Preliminary ResultsAMEE 2009 Malaga, Spain,Pablo Pulido M, MD, PresidentAlberto Oriol I Bosh, MD, Vice President,Toward Leadership and Innovation in Professional Development,To promote life long learning through continuing professional development among family physicians and general
2、 practitioners in mid and lower income countries by developing programs, standards, resources and partnerships that foster higher quality care for patients and communities,Our MissionShift of Emphasis from Live long Learning to the Quality of Primary Health Care Services,To increase the quality of h
3、ealth care in mid- and lower-income countries by engaging primary care physicians in robust continuing professional development and practice improvement programs designed to meet country specific public health priorities,2005,2009,A Four-Year Journey from Concept to Implementation & Results,Initial
4、Steering Committee, MD, co-chairs),Rashid Bashshur, PhD Professor of Telemedicine/U. of Michigan (USA)Yank D. Coble, President, World Medical Assn.Alejandro Cravioto, MD President, PAFAMS (Mexico)Mark Evans, PhDG President, Global Alliance CAME (USA)Christina Fabian, MD President, UEMO (Sweden)James
5、 Hallock, MD President, Educ. Commission for Foreign Medical Graduates ECFMG (USA)Hans Karle, MD President,World Federation for Medical Education , WFME (Denmark)Salah Mandil, PhD International e-Health Association, (Switzerland and Sudan ),Lewis A. Miller, MS Editorial Director, J. of Family Practi
6、ceAlberto Oriol I Bosch, MD President, Medical Education Foundation (Spain) M. Roy Schwarz, MD President, China Medical Board of NY and IIMEHonorio Silva, MD Pfizer Medical Humanities Initiative David Stern, MD, PhD Director, Global REACH, U. of Michigan & International Institute for Med. Education
7、Amando Martin Zurro, MD Coordinator General, Programa de Medicina de Familia i Communitaria de Catalonia,(Spain) Observer Members: Daniel J. Ostergaard, MD Vice-President, American Academy of Family Physicians (USA)Bruce L. W. Sparks, MD President-Elect, WONCA (South Africa),Pablo Pulido M, MD and D
8、ennis Wentz, MD Co-Chairs,Board of Directors 2008-2009,Involve a significant number of primary care physicians in participating countries Improve at least three morbidity or mortality measures in served populations by measuring bio-markers Improve measured knowledge levels in curriculum areas amongs
9、t participating physicians Build a core curriculum for physicians working in primary health care services Identify and test Global CME/CPD standards to be accepted and published Expand life-long medical learning to non-physician health providers and patients,Goals,Pilot Educational Program: Cardiova
10、scular Disease Risk FactorsWhy? Cardiovascular Disease (CVD) accounts for 29.2% of total global deaths; Approximately 80 % of these deaths are in emerging countries; Economic burden on the health systems Availability of surrogate measures,Educational Intervention,2004 2030 Disease or Injury Deaths R
11、ank Rank Deaths Disease or injury (%) (%) Ischaemic heart disease 12.2 1 1 14.2 Ischaemic heart disease Cerebrovascular disease 9.7 2 2 12.1 Cerebrovascular disease Lower respiratory infections 7.0 3 3 8.6 Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease 5.1 4 4 3.8 Lower
12、respiratory infections Diarrheal diseases 3.6 5 5 3.6 Road traffic accidents HIV/AIDS 3.5 6 6 3.4 Trachea, bronchus, lung cancers Tuberculosis 2.5 7 7 3.3 Diabetes mellitus Trachea, bronchus, lung cancers 2.3 8 8 2.1 Hypertensive heart disease Road traffic accidents 2.2 9 9 1.9 Stomach cancer Premat
13、urity and low birth weight 2.0 10 10 1.8 HIV/AIDS Neonatal infections and other* 1.9 11 11 1.6 Nephritis and nephrosis Diabetes mellitus 1.9 12 12 1.5 Self-inflicted injuries Malaria 1.7 13 13 1.4 Liver cancer Hypertensive heart disease 1.7 14 14 1.4 Colon and rectum cancers Birth asphyxia and birth
14、 trauma 1.5 15 15 1.3 Oesophagus cancer Self-inflicted injuries 1.4 16 16 1.2 Violence Stomach cancer 1.4 17 17 1.2 Alzheimer and other dementias Cirrhosis of the liver 1.3 18 18 1.2 Cirrhosis of the liver Nephritis and nephrosis 1.3 19 19 1.1 Breast cancer Colon and rectum cancers 1.1 20 20 1.0 Tub
15、erculosis Violence 1.0 22 21 1.0 Neonatal infections and other* Breast cancer 0.9 23 22 0.9 Prematurity and low birth weight Oesophagus cancer 0.9 24 23 0.9 Diarrheal diseases Alzheimer and other dementias 0.8 25 29 0.7 Birth asphyxia and birth trauma41 0.4 Malaria* Comprises severe neonatal infecti
16、ons and other, noninfectious causes arising in the perinatal period.,about the same large increase large decrease,Adapted from WHO 2008 World Health Report Page 30,Projected Leading Causes of Death 2030,Blended learning approach: Standard tool: Online self directed learning activity Reinforcement to
17、ols: facilitated face-to-face discussions, self assessment exercises, online discussion board, reminders Enabling tools: reference lists, best practice guidelines, patient education materials and tools Alternating Methods: In-country orientation, online didactic, in-country clinic, online didactice
18、etc. etc. Focus on Practice Improvement: Physicians assess CV risk level of cohort of patients Physicians establish treatment goals In-country sessions aimed at practice improvement planning and problem solving Data on patient progress provided to physicians,Pilot course design,Inclusion Criteria Pr
19、imary Care Physicians Hospitals/ Private Practices Attending 100 patients with CV RF/month Practicing in the Project GLOBE pilot country Internet Connection Access to computer Working knowledge of English Consenting to the protocol,Study participants,Exclusion Medical Students Non Primary Care PCPs
20、not interested in participation,% of Patients with controlled Cholesterol level ( goal 200 mg/dL 6.2 mMol/L % of Patients with controlled hypertension ( goal 140/90 mm Hg),Primary endpoints:,Bio Markers of CV health care,Physicians knowledge (tests) Physicians satisfaction (tests, interviews) Attitu
21、des (interviews) Additional secondary endpoints % of Patients with smoking behavior % of Diabetic patients with controlled blood glucose ( 110 mg/dL) Mean BMI (lean, 25; overweight, 25-29; and obese, 30) or weight in the total patient population / waist circunference Changes in Risk Factor Score (Fr
22、amingham),Secondary enpoints:,Traditional Metrics,Evaluation,Sponsors,Partners,Li Ka Shing Knowledge Institute at The University of Toronto,Support, Partners and Participating Countries,Participating Countries:ColombiaRussiaTurkeyVenezuela,Partners:,*,*,*Exploratory Relationship,o,Project Timeline,F
23、elix Vartanyan, MD,Project Globe in the Russian Federation,Project Globe in the Russian Federation,Project Globe in the Russian Federation,Administrative Structure of Project Globe in Moscow,Ministry of Heath and Social Development,Russian Academy of Advanced Medical Studies,Comprehensive Training P
24、rogram Improvement of training quality of primary health care staff for prevention and treatment of cardiovascular pathology,Main Components of Comprehensive Training Program,Selected issues of management From obesity to metabolic syndrome Ischemic Heart Disease Tactic of management of patients with
25、 hypertension School for outpatients of district polyclinics To promote continuing professional development and PHC physicians,“Hypertension Prevention”,Formation Process of Competention,Effective Training Programs,Biomedical Advances,Training Technologies,Educational Programs Development,Improvemen
26、t of Health Quality,Educational Intervention,Model of Project Globe Development,e-learning,11 modules,CD/DVD, Internet,Training Physicians,Patient Education,Clinical Observations,Efficacy of Educational Intervention,Moscow Polyclinics Involved in Project Globe Study*,Polyclinic No Involved ExpectedN
27、o Physicians Patients Patients97 9 100 27081 15 212 300146 12 196 260 151 11 100 300Total: 47 608 1130,*Time of observation: 1 year,Tripartite System,Interaction Between Training and Practice,Training Effectiveness,Improvement of health indicators,HEALTH Outcomes,Population,Data Entry Forms,Demograp
28、hic Breakdown,Age Distribution (n =574),Age Group,Gender,Female,Male,Hypertension mm Hg,Normal 25,Pre 83,Grade 1 286,Grade 2 180,Cholesterol mg/dL,200 154,200-220 110,220-300 127,300-400 69,400+ 114,Risk Factors: Preliminary Results* % Change from Initial Visit to 3 Months n=574,Parameter Baseline 3
29、 mos. D % change* Total Cholesterol (mg/dl) 270.9 264.5 -6.4 -2.4% LDL (mg/dl) 176.5 171.2 -5.3 -3.0% Systolic (mmHg) 146.7 141.6 -5.1 -3.5% Diastolic (mmHg) 88.1 84.2 -3.9 -4.4% Triglycerides (mg/dl) 240.0 234.0 -6.0 -2.5% Plasma Glucose (mg/dl) 99.9 96.3 -3.6 -3.6% Weight (kg) 80.9 79.5 -1.4 -1.7%
30、 Waistline (cm) 89.5 88.3 -1.2 -1.3% Cigarettes (per day) 6.3 4.8 -1.5 -23.8% Exercise hours (per week) 2.6 3.2 0.6 +23.1%,*p0.05,Preliminary Results by Gender* % Change from Initial Visit to 3 Months n=574,Measure Female Male Total Cholesterol (mg/dl) -2.4% -2.4% LDL (mg/dl) -2.9% -3.4% Systolic (m
31、mHg) -3.3% -4.0% Diastolic (mmHg) -4.5% -4.0% Triglycerides (mg/dl) -2.4% -3.4% Plasma Glucose (mg/dl) -3.2% -5.2% Weight (kg) -1.6% -2.4% Waistline (cm) -1.3% -1.9% Cigarettes (per day) -24.1% -24.4% Exercise hours (per week) 25.5% 26.3%,*p0.05,Preliminary Results for Hypertension by Grade* % Chang
32、e from Initial Visit to 3 Months n=549,Pre Hypertension Hypertension Measure Hypertension Grade 1 Grade 2 Total Cholesterol (mg/dl) -2.2% -2.6% -2.0% LDL (mg/dl) -6.1% -2.5% -1.9% Systolic (mmHg) -2.1% -2.9% -5.6% Diastolic (mmHg) -4.5% -4.1% -5.7% Triglycerides (mg/dl) -0.3% -2.3% -3.2% Plasma Gluc
33、ose (mg/dl) -4.4% -3.7% -3.9% Weight (kg) -0.9% -1.8% -2.3% Waistline (cm) -0.8% -1.4% -1.8% Cigarettes (per day) -20.8% -24.4% -26.2% Exercise hours (per week) 19.9% 26.8% 32.3%,83,286,180,*p0.05,Preliminary Results for High Total Cholesterol subjects* % Change from Initial Visit to 3 Months n=420,
34、TOTAL Measure 200+ 200-220 220-300 300-400 400+ n 420 110 127 69 114 Total Cholesterol (mg/dl) -2.6% -0.9% -2.3% -3.8% -3.1% LDL (mg/dl) -3.4% -1.4% -1.6% -5.6% -4.8% Systolic (mmHg) -3.1% -3.9% -3.7% -2.4% -1.8% Diastolic (mmHg) -4.4% -4.7% -3.9% -6.3% -3.7% Triglycerides (mg/dl) -3.7% -3.7% -2.9%
35、-2.0% - 2.4% Plasma Glucose (mg/dl) -3.6% -3.5% -4.6% -3.8% -3.0% Weight (kg) -1.3% -1.5% -1.9% -1.1% -0.4% Waistline (cm) -1.1% -1.3% -1.5% -0.7% -0.3% Cigarettes (per day) -23.9% -27.8% -28.7% -18.8% -19.2% Exercise hours (per week) -24.4% 34.3% 31.1% 17.9% 20.3%,*p0.05,Project Globe VenezuelaAda
36、Vedilei, MD,Development of Project Globe Venezuela,Building Pilot Relationships between PGC and local leaders,Venezuelan Coordinating Team established with local leaders,Identifying Needs & Priority Diseases,Systems Level,Organizational Level,Individual Level,Existing Data,Interviews,Online Question
37、naires,Data Sources,Focus Group,Pilot Studies Proof of Concept,Selection of Ambulatories,Selection of Patients,Selection of Physicians,Data Management Training,Computation Training,Pilot Studies Proof of Concept,Course Design,FSFB Meeting,Humana Group Teachers Meeting,Making Videos,Pilot Studies - P
38、roof of Concept,Pilot Studies Proof of Concept,Course Design,IM-Cardio: Blended Learning Problem Based Learning (PBL) Online Unit I Introduction & Generalities Unit II Therapeutic Management Unit III Therapeutic Education Workshop face to face Behavior Change,Pilot Studies Proof of Concept,Course Im
39、plementation,Behavior Change Workshops,Objetivos Justificacin Descripcin,Introduccin a la Metodologa,Sobre este Curso,Mi curso,Manual del Usuario,1. Generalidades 2. Manejo Teraputico 3. Educacin del Paciente,Objetivos Justificacin Descripcin,Introduccin a la Metodologa,Sobre este Curso,Mi curso,1.
40、Generalidades 2. Manejo Teraputico 3. Educacin del Paciente,Caso 1,2. MANEJO TERAPUTICO,a. Nombre los FRCV que tiene este paciente:,Objetivos Justificacin Descripcin,Introduccin a la Metodologa,Sobre este Curso,Mi curso,Manual del Usuario,1. Generalidades 2. Manejo Teraputico 3. Educacin del Pacient
41、e,Objetivos Justificacin Descripcin,Introduccin a la Metodologa,Sobre este Curso,Mi curso,1. Generalidades 2. Manejo Teraputico 3. Educacin del Paciente,Caso 1,Muy bien! Lo invitamos a continuarAceptar,2. MANEJO TERAPUTICO,Problemas sicolgicos (depresin) Impedimentos cognitivos Tratamiento de condic
42、iones asintomticas Seguimiento inadecuado Reacciones adversas Falta de confianza en el tratamiento Incomprensin de la enfermedad Mala relacin mdico-paciente Barreras al cuidado o la medicacin Consultas fallidas Complejidad del tratamiento Mltiples medicaciones Fumadores Costos,c. Detecte tres predic
43、tores de baja adhesion en este paciente,Tratamiento de condiciones asintomticas,Seguimiento inadecuado,Fumadores,Data Review and Impact - Demographic Breakdown n=245,Age Distribution,Age Group,Gender,Female 173,Male 71,Hypertension,Normal 11,Pre 61,Grade 1 114,Grade 2 59,Cholesterol Range,200 80,200
44、-220 45,220-240 41,240-260 39,0,50,100,150,30,30,-,34,35,-,39,40,-,44,45,-,49,50,-,54,55,-,59,60+,6,6,9,18,25,38,49,89,260+ 40,Risk Factors: Preliminary Results % Change from Initial Visit to 3 Months n=245,Parameter Baseline 3 mos. D % change* Total Cholesterol (mg/dl) 218.7 198.9 -19.8 -9.1% LDL 1
45、37.0 122.2 -14.8 -10.8% HDL 45.0 46.9 1.9 +4.1% Systolic (mmHg) 142.7 137.6 -5.1 -3.6% Diastolic (mmHg) 87.8 80.7 -7.1 -8.1% Triglycerides (mg/dl) 182.9 163.1 -19.7 -10.8% Plasma Glucose (mg/dl) 104.4 105.2 0.8 0.7% BMI 30.0 28.9 -1.1 -0.4%,*p0.05,Preliminary Results by Gender % Change from Initial
46、Visit to 3 Months n=245,Measure Female Male Total Cholesterol (mg/dl) -6.5% -11.3% LDL (mg/dl) -10.4% -12.2% HDL (mg/dl) +1.5% +10.5% Systolic (mmHg) -2.8% -5.0% Diastolic (mmHg) -8.9% -6.0% Triglycerides (mg/dl) 4.9% 3.4% Plasma Glucose (mg/dl) -12.1% -27.6% BMI -0.1% -1.0%,*p0.05,173,71,Preliminar
47、y Results for Hypertension by Grade % Change from Initial Visit to 3 Months n=245,Pre Hypertension Hypertension Measure Hypertension Grade 1 Grade 2 Total Cholesterol (mg/dl) -7.8% -5.8% -7.4% LDL (mg/dl) -7.6% -8.7% -16.2% HDL (mg/dl) +6.1% +0.7% +10.5% Systolic (mmHg) -0.1% 0.5% -12.0% Diastolic (
48、mmHg) -2.4% -7.4% -14.2% Triglycerides (mg/dl) -8.4% -5.9% -22.3% Plasma Glucose (mg/dl) 0.1% 3.6% 1.0% BMI -0.4% -0.4% -0.3%,61,114,59,*p0.05,Preliminary Results for Smoking and Weight Change from Initial Visit to 3 Months,Average Average % Measure n 0 months 3 moths change Cigarettes (per day) 22
49、9.6 9.0 -6.25% Weight kg) 245 74.3 73.9 -0.9%,Course Satisfaction Feedback n=64,1 Strongly disagree 2 Disagree 3 Neutral 4 Agree 5 Totally agree 6 Not Applicable,Items,Knowledge Evaluation of Physicians,Baseline,SCORE,3 MONTHS,SCORE,Knowledge Assessment % Change from Baseline to 3 Months n=64*,127 %,P=0.000000,*p0.05,Next Steps,
