Elford R W, Jennett P, Bell N, Szafran O, Meadows L
University of Calgary, Alberta.
Health Rep. 1994;6(1):142-53.
In primary medical care settings, disease prevention services are delivered at lower rates than recommended. Furthermore, practitioners tend to overestimate the rate at which they perform them. There are essentially two steps in delivering evidence-based preventive services: (1) knowing what the evidence is for performing various detection and intervention manoeuvres, and (2) integrating the preventive services into daily practice. The first is a scientific process and is carried out in Canada by the Canadian Task Force on the Periodic Health Examination. However, after a decade of experience with evidence-based guidelines, we now know that guidelines are not enough. Integrating clinical prevention into busy practices is a political and logistical process. This truth is best captured by the quip, "An ounce of prevention requires a pound of office system change". A number of studies have demonstrated that continuing medical education (CME) courses and workshops for physicians are not enough to ensure that clinical preventive services are incorporated into practice. According to Lomas, the traditional CME educational approaches need to be complemented by strategies from such paradigms as the social influence model, the diffusion of innovation model and the adult learning model. Battista, in "From Science to Practice," points out the complexity of the communication process required for the diffusion of innovation into practice. Walsh's Systems Model of Clinical Preventive care best captures the interacting factors that mediate between practitioners' intentions and their actions when it comes to delivering clinical prevention services. This paper reports on a practical example of helping family practitioners develop a "sustaining office system in prevention" that minimizes barriers, focuses energy and integrates clinical prevention into office routines. The key components are (i) a practice coordinator for prevention, (ii) clear clinical prevention-related job descriptions for all persons who deal with patients, (iii) an information management system that reinforces prevention, and (iv) a practice feedback and problem solving strategy.
在基层医疗环境中，疾病预防服务的提供率低于推荐水平。此外，从业者往往高估了他们提供这些服务的比率。提供循证预防服务基本上有两个步骤：（1）了解进行各种检测和干预措施的证据是什么，以及（2）将预防服务纳入日常实践。第一步是一个科学过程，在加拿大由加拿大定期健康检查特别工作组开展。然而，在经历了十年的循证指南实践后，我们现在知道仅有指南是不够的。将临床预防纳入繁忙的医疗实践是一个政治和后勤过程。“一盎司的预防需要一磅的办公系统变革”这句俏皮话最能体现这一事实。多项研究表明，为医生提供的继续医学教育（CME）课程和研讨会不足以确保临床预防服务纳入实践。根据洛马斯的观点，传统的CME教育方法需要辅之以社会影响模型、创新扩散模型和成人学习模型等范式的策略。巴蒂斯塔在《从科学到实践》中指出了将创新扩散到实践所需的沟通过程的复杂性。沃尔什的临床预防护理系统模型最能体现当涉及提供临床预防服务时，在从业者意图和行动之间起中介作用的相互作用因素。本文报告了一个帮助家庭医生建立“预防持续办公系统”的实际例子，该系统可最大限度地减少障碍、集中精力并将临床预防纳入办公日常。关键组成部分包括：（i）一名预防实践协调员，（ii）为所有与患者打交道的人员制定明确的与临床预防相关的工作职责描述，（iii）一个强化预防的信息管理系统，以及（iv）一个实践反馈和问题解决策略。
