Gutiérrez G, Guiscafré H, Bronfman M, Walsh J, Martínez H, Muñoz O
Department of Technical Services and Special Projects, Ministry of Health, Mexico City, Mexico.
Med Care. 1994 May;32(5):436-46.
This paper presents the results of an intervention strategy designed to decrease drug prescription and increase the use of oral rehydration therapy (ORT) in the treatment of acute diarrhea aimed at family medicine practitioners in two primary health care units of the Mexican Social Security Institute. The intervention consisted of six successive stages: 1) Baseline study of prescribing practices by all 69 physicians in both clinics; 2) Training workshop attended by 36 physicians, including a critical analysis of relevant up-to-date literature, review of results of stage I, discussion of a previously designed treatment algorithm for acute diarrhea, and modification of it according to participant's experience; 3) Post-workshop evaluation; 4) Establishment of a peer review committee to discuss the treatment behavior of participating physicians; 5) Mid-term evaluation for 2 months after the committee stopped functioning; 6) Long-term evaluation at 6, 12 and 18 months, of 20 physicians who received the complete intervention (study group) and 20 physicians who received none (control group). The treatment behaviors of the study and control groups were similar on baseline, but differed significantly (P < 0.01) in the post-workshop evaluation. The study group showed a reduction in the use of antibiotics (from 78.8% to 39.3%) and restrictive diets (47.3% to 12.4%), and increased the use of ORT (31.4% to 58.4%) for children younger than 5 years old with acute diarrhea. In the mid-term evaluation, the use of antibiotics by the study group decreased to 27.6%, prescription of restrictive diets decreased to 6.4%, and use of ORT increased to 73.8% (P < 0.01, in all cases). In the long-term evaluation, persistent positive prescribing behavior was still present in the study group, with a significant difference (P < 0.05) compared to the control group, where no modification was found in the prescribing behavior throughout the study. The average proportion of cases treated according to the algorithm by the study group increased in 29.2% (31.3 to 60.5%) after the workshop, and 45.2% (31.3 to 76.5%) after peer review committee. This behavior was maintained during 18 months after the intervention (74%). The control group showed no significant modification in the average proportion of cases treated according to the algorithm during the study (2 years 7 months). The active participation of physicians in the workshop and in the peer review committee was identified as the key to the short and long-term success of the educational strategy.
本文介绍了一项干预策略的结果。该策略旨在减少墨西哥社会保障局两个初级卫生保健单位的家庭医生在治疗急性腹泻时的药物处方，并增加口服补液疗法（ORT）的使用。干预包括六个连续阶段：1）对两家诊所的所有69名医生的处方行为进行基线研究；2）36名医生参加的培训研讨会，包括对相关最新文献的批判性分析、第一阶段结果的回顾、对先前设计的急性腹泻治疗算法的讨论以及根据参与者的经验对其进行修改；3）研讨会后评估；4）成立同行评审委员会，讨论参与医生的治疗行为；5）委员会停止运作2个月后的中期评估；6）对接受完整干预的20名医生（研究组）和未接受任何干预的20名医生（对照组）在6个月、12个月和18个月时进行长期评估。研究组和对照组的治疗行为在基线时相似，但在研讨会后评估中存在显著差异（P < 0.01）。研究组中，5岁以下急性腹泻儿童使用抗生素的比例（从78.8%降至39.3%）和限制性饮食的比例（从47.3%降至12.4%）降低，而ORT的使用比例（从31.4%增至58.4%）增加。在中期评估中，研究组抗生素的使用比例降至27.6%，限制性饮食的处方比例降至6.4%，ORT的使用比例增至73.8%（在所有情况下，P < 0.01）。在长期评估中，研究组仍存在持续的积极处方行为，与对照组相比存在显著差异（P < 0.05），对照组在整个研究过程中处方行为未发现变化。研讨会后，研究组按照算法治疗的病例平均比例增加了29.2%（从31.3%增至60.5%），同行评审委员会成立后增加了45.2%（从31.3%增至76.5%）。这种行为在干预后的18个月内保持（74%）。在研究期间（2年7个月），对照组按照算法治疗的病例平均比例没有显著变化。医生在研讨会和同行评审委员会中的积极参与被确定为教育策略短期和长期成功的关键。
