Wilf-Miron Rachel, Galai Noya, Gabali Amal, Lewinhoff Irene, Tov Orna Shem, Lernau Omri, Shemer Joshua
Department for Quality Promotion in Health Care, Maccabi Healthcare Services, Tel Aviv 68125, Israel.
Qual Saf Health Care. 2010 Oct;19(5):e36. doi: 10.1136/qshc.2008.029645. Epub 2010 Jun 17.
(1) To improve quality and equity by increasing utilisation of mammography screening among Israeli Arab women. (2) To explore effectiveness of designing interventions with a combined top-down and bottom-up approach.
Retrospective study at two periods of time: 2004--intervention's preliminary stages; 2005--intervention's implementation.
Maccabi Healthcare Services (MHS), an Israeli health plan serving 1.7 million members at study period; 7% of them are Arabs by 139 branches, 13 of which serve Arabs exclusively. MACRO-ORGANISATIONAL INTERVENTION (TOP DOWN): Development of a computerised Mammography Promotion System, phone contacts with non-respondents and intraorganisational reporting of screening rates. INTENSIVE INTERVENTION (BOTTOM UP): A local analysis of barriers to care and implementation of tailored solutions. This intervention was initiated and documented in three Arab branches, with spillover to the entire Arab sector. MEASURE DEFINITION: Biennial breast cancer (BC) screening of eligible women. Improvement measures Changes in BC screening rates in Arabs and comparisons with overall MHS BC screening rates for 2004 and 2005.
In 2005, average BC screening rates in Arab branches increased from 26.7% to 46.2% (73% improvement), while overall MHS screening rates increased from 49.0% to 63.1% (29% improvement). Analysis of the relative differences between 2004 and 2005 BC screening rates indicated statistically significant differences (p<0.006) in rates between the Arab and other branches. These results did not change after adjustment for branch size, region and branch average age.
Combined top-down interventions and bottom-up initiatives are effective for formulating programmes to reduce inequality.
（1）通过提高以色列阿拉伯女性乳腺钼靶筛查的利用率来改善质量和公平性。（2）探索采用自上而下与自下而上相结合的方法设计干预措施的有效性。
在两个时间段进行回顾性研究：2004年——干预的初步阶段；2005年——干预的实施阶段。
马卡比医疗服务公司（MHS），以色列的一项健康计划，在研究期间为170万成员提供服务；其中7%为阿拉伯人，分布在139个分支机构，其中13个专门为阿拉伯人服务。宏观组织干预（自上而下）：开发计算机化的乳腺钼靶推广系统，与未回应者进行电话联系，并在组织内部报告筛查率。强化干预（自下而上）：对护理障碍进行局部分析，并实施量身定制的解决方案。该干预措施在三个阿拉伯分支机构启动并记录，随后扩展到整个阿拉伯部门。测量定义：对符合条件的女性进行两年一次的乳腺癌（BC）筛查。改进措施：阿拉伯人乳腺癌筛查率的变化，并与2004年和2005年MHS整体乳腺癌筛查率进行比较。
2005年，阿拉伯分支机构乳腺癌平均筛查率从26.7%提高到46.2%（提高了73%），而MHS整体筛查率从49.0%提高到63.1%（提高了29%）。对2004年和2005年乳腺癌筛查率的相对差异分析表明，阿拉伯分支机构与其他分支机构的筛查率存在统计学上的显著差异（p<0.006）。在对分支机构规模、地区和分支机构平均年龄进行调整后，这些结果没有改变。
自上而下的干预措施与自下而上的举措相结合，对于制定减少不平等的计划是有效的。
