In fl uence of Contextual Factors and Continuous Medical Education on Healthcare Outcomes in the Republic of Serbia A

Introduction: The basic purpose of the professional continuing education is facilitating the successful conduct of practitioners in the fi eld of practical characteristics of their professional work. Topic: In the Republic of Serbia (RS), the current Ordinance on Closer Conditions for Continuing Education for Healthcare Workers and Healthcare Associates implies that there is a connection between continuing medical education (CME) and the improvement of quality of healthcare workers and healthcare associates. However, such connectivity is diffi cult to prove. In order for the CME programs to be eff ective in improving the quality of work of healthcare professionals, it is essential that the well-known criteria for assessing the effectiveness of the CME programs be implemented in the Ordinance of the RS. Conclusions: Strong application of the criteria for assessing the eff ectiveness of the CME program can lead to improvement of the performance of the healthcare professionals, patient outcomes and the population’s health in the RS.


INTRODUCTION
In the 1980s, Houle defi ned the basic purpose of continuing education to "facilitate the success ful conduct of practitioners in the fi eld of the various, practical characteristics of their professional work" [1].On the other hand, in the Republic of Serbia, the current Ordinance of Closer Conditions for Continuing Education for Health Care Workers and Health Associates defi nes that "health workers and healthcare workers have the right and duty to constantly monitor the development of medical, dental, pharmaceutical science and other corresponding doctrine, and do advanced training in order to maintain and improve the quality of their work" [2].Since the distinction is clear between the attempt to defi ne the "purpose" of education and to defi ne the "rights and duties" of healthcare workers, [3] it could be expected that the basically forgotten "purpose" brought up new proposal of the Serbian Medical Council on amendments to the current Ordinance.Th ese "new proposals" contained about ten amendments, which concerned the quality control of the implementa-tion of individual continuing medical education (CME) programs [4].

TOPIC
Th e proposed amendments included the penal provisions that included Article 20: "If any irregularity is found in the performance of an accredited continuing education program or if there is any discrepancy in the execution of the accredited program, the Health Council shall take a decision on the prohibition of the implementation of accredited continuing education and prohibition of the registration of all new continuing education programs within a period of 12 months from the date of the decision".Th us, in the amendments, the phrase "monitoring and evaluation of the quality of the CME program", actually referred to "monitoring and evaluating the regularity of the CME implementation".Fortunately, the mentioned amendments were not adopted because their adoption could produce a legal absurdity situation that seriously undermines the rights of those who have been granted these rights.On the other hand, without any scientifi c evidence, the proposed amendments set the premise that the methodology of a simple and easy way "the quality of individual CME programs" can be related to "improving the quality of work" of healthcare workers and healthcare associates.Namely, terms such as "CME quality" and "improvement of work quality" are too general and indefi nite, and as such are not commonly applicable in the scientifi c assessment of the eff ects or eff ectiveness of the CME program.Th e quality assessment of the CME program, above all, must relate to the assessment of the eff ectiveness of CME in improving the working characteristics of the healthcare workers and healthcare associates.However, the proposed amendments were supposed to rate the CME on the basis of: 1) the assessment of the quality of the accredited continuing education program (bad, good, very good, excellent, exceptional), 2) the prices of the accredited continuing education program (low, appropriate, high) and 3) the organization of accredited continuing education program such as respect of the hours, the adequacy of the space, completeness of the participants' meeting data (appropriategood, very good, excellent or inadequate).
However, according to the latest synthesis of systematic review studies (Carvero and Gaines, 2015), in terms of improving effectiveness, the following strategies should be included in the design of the teaching model, both for planning and evaluation of the CME programs [5]: A) CME has a more reliable positive impact on the performance of the physician compared to the health outcomes of patients.B) CME leads to a greater improvement of the physician's performance and the patient outcomes if education is: (1) interactive, (2) uses or combines multiple learning methods, (3) covers multiple exposures, if (4) longer and ( 5) focused on outcomes that are considered important to the physician.
Unfortunately, in the current Ordinance of the Republic of Serbia, in evaluating and awarding points for accredited CME programs, the length of the education is disproportionately evaluated in relation to the other three criteria mentioned above.Likewise, it is losing sight of the fact that in reviewed studies of the Cochrane group, the term "meeting" (or expert meeting) synchronously refers to a whole group of educations such as: courses, conferences, lectures, workshops, seminars and symposiums and essentially (at least in terms of considering their eff ectiveness) expert meetings just diff er only in terms of length (short -up to 6 hours, medium length -up to one day and longer -for a few days) [6].Th e next criteria that should be included in the CME evaluation are certainly the explanation of the proposer (CME organizer) of the chosen evaluation framework, as well as the design of the CME eff ectiveness assessment.With regard to design, the advantage must have a randomized but also quasi-experimental design.Selection and explanation of the multi-level assessment framework of eff ectiveness, e.g.Moore's seven-level assessment framework or Kirkpatrick's four-level assessment framework should also take precedence [7,8].Regardless of whether all the levels of assessment of the eff ectiveness of the CME program are ultimately carried out under the above mentioned frameworks, performing multiple levels of assessment is crucial for better evaluation of training in its application for approval to the competent Chamber and the Serbian Medical Council.More levels of the CME assessment imply serious planning, prior consideration of the context and the need for education [5,8], determination of the motivation of the physician, setting a clear educational goal, target group analysis to which the planned activities are addressed, careful planning of activities, choice of tracing of the target characteristics of the physician that education can potentially improve (clinical decision, economic behavior, skills and competence), [9] choice of variables related to patient outcomes, choice and implementation of analytical methods for assessing the CME listening response (e.g.satisfaction and motivation), assessment of declarative and practical knowledge of the listener, patient outcomes important for the physician (clinically -objective or subjectively expressed by the patient), as well as analytical methods for assessing population health.
To give a suggestion in this regard, we are also encouraged by the results of our case study, which showed the high eff ectiveness of didactic CME in reducing the cost of quality and reducing the irrational use of human albumin solution on the surgical department and reducing the mortality of patients with severe sepsis and septic shock, [10,11] which also studied contextual eff ects such as the intervention of the Serbian Republican Health Insurance Fund (SRHIF) in determining and changing criteria for prescribing human albumin solutions.Namely, despite the above-mentioned intervention by the SRHIF to achieve certain economic eff ects during the pre-education period, unlike education interventions, there was no impact of the SRHIF intervention in terms of improving the health outcomes of patients.In our follow-up reports, we have also shown that the accreditation of health institutions in the Republic of Serbia has no impact on the most important health outcomes, such as total hospital mortality or mortality in surgical departments [12].It is well known that the eff ects of CME are not immune to the infl uence of contextual factors (political, economic, social).For CME reform, lack of knowledge is less of a problem, while the greater the problem has political nature, which is refl ected in the change of system in which CME should become an important constituent element [13][14][15][16][17].

CONCLUSION
By adopting the aforementioned additional criteria for assessing the eff ectiveness of CME, as well as by defi ning a CME validation strategy, it would be a serious step in reforming the health system of the Republic of Serbia.Th e