Pérez-Cuevas R, Guiscafré H, Muñoz O, Reyes H, Tomé P, Libreros V, Gutiérrez G
Health Services Research Interinstitutional Group, Instituto Mexicano del Seguro Social, Mexico DF, Mexico.
Soc Sci Med. 1996 Apr;42(8):1185-94. doi: 10.1016/0277-9536(95)00398-3.
To improve prescribing practices for rhinopharyngitis, an interactive educational intervention and a managerial intervention were carried out in 18 primary care facilities in metropolitan Mexico City. Four family medicine clinics of the Mexican Social Security Institute (IMSS) and 14 health centres of the Ministry of Health (SSA) were included. A quasi-experimental design was employed. One hundred and nineteen physicians (IMSS 68, SSA 51) participated. Sixty-five physicians (IMSS 32, SSA 33) were in the study group, while 54 were in the control group (IMSS 36, SSA 18). The study had four stages: (I) baseline, to evaluate the physicians' prescribing behaviour for rhinopharyngitis; (II) intervention, using an interactive educational workshop and a managerial peer review committee; (III) post-intervention evaluation of short-term impact; and (IV) follow-up evaluation of long-term effect 18 months after the workshop. The control group did not receive any intervention but was evaluated at the same time as the study group. At baseline, most patients in both institutions received antibiotic prescriptions (IMSS 85.2%, SSA 68.8%). After the workshop, the percentage of patients receiving antibiotic prescriptions in the IMSS went from 85.2% to 48.1%, while in the SSA it went from 68.8% to 49.1%. Appropriateness of treatment was analyzed using the physician as the unit of analysis. At baseline, 30% of IMSS physicians in the study group treated their patients appropriately. After the intervention, this percentage increased to 57.7%, and at the 18-month follow-up it was 54.2%. The SSA study group increased the appropriate use of antibiotics from 35.7% to 46.2%, with this percentage falling to 40.9% after the 18-month follow-up period. In the control group there were no significant changes in prescribing patterns with respect to either the prescribing of antibiotics or the appropriateness of treatment. The intervention strategies were successful in both institutions. Forty per cent of physicians improved their prescribing practices after the workshop, with this change remaining in 27.5% of them throughout the follow-up period. On the other hand, 42.5% of the physicians did not change their prescribing practices after the intervention. The rest (17.5%) showed appropriate prescribing practices during all the stages of the study. We conclude that it is possible to improve the physicians' prescribing practices through interactive educational strategies and managerial interventions. This type of intervention can be an affordable way to provide continuing medical education to primary care physicians who do not have access to continuing educational activities, and to improve the quality of care they provide.
为改善鼻咽炎的处方开具行为，在墨西哥城大都市区的18个初级保健机构开展了一项互动式教育干预和管理干预。其中包括墨西哥社会保障局（IMSS）的4家家庭医学诊所和卫生部（SSA）的14个健康中心。采用了准实验设计。119名医生（IMSS 68名，SSA 51名）参与其中。65名医生（IMSS 32名，SSA 33名）在研究组，54名在对照组（IMSS 36名，SSA 18名）。该研究有四个阶段：（I）基线阶段，评估医生对鼻咽炎的处方开具行为；（II）干预阶段，采用互动式教育工作坊和管理同行评审委员会；（III）干预后短期影响评估；（IV）工作坊18个月后的长期效果随访评估。对照组未接受任何干预，但与研究组同时进行评估。在基线阶段，两个机构的大多数患者都接受了抗生素处方（IMSS为85.2%，SSA为68.8%）。工作坊后，IMSS接受抗生素处方的患者比例从85.2%降至48.1%，而SSA则从68.8%降至49.1%。以医生为分析单位分析治疗的适宜性。在基线阶段，研究组中30%的IMSS医生对患者的治疗是恰当的。干预后，这一比例增至57.7%，在18个月的随访中为54.2%。SSA研究组抗生素的合理使用率从35.7%增至46.2%，在18个月的随访期后这一比例降至40.9%。对照组在抗生素处方开具或治疗适宜性方面的处方模式没有显著变化。干预策略在两个机构均取得成功。40%的医生在工作坊后改善了他们的处方开具行为，在整个随访期内，27.5%的医生保持了这一变化。另一方面，42.5%的医生在干预后没有改变他们的处方开具行为。其余（17.5%）在研究的所有阶段都表现出恰当的处方开具行为。我们得出结论，通过互动式教育策略和管理干预可以改善医生的处方开具行为。这种干预类型可以成为一种经济实惠的方式，为无法参加继续医学教育活动的初级保健医生提供继续医学教育，并提高他们提供的医疗服务质量。
