cosas de casa

Soc. Sci. &led. Vol. 42, No. 8, pp. 1185-1194, 1996

Pergamon

0277-9536(95)00398-3

Copyright © 1996 ElsevierScienceLtd Printed in Great Britain. All rights reserved 0277-9536/96 $15.00 + 0.00

IMPROVING PHYSICIAN PRESCRIBING PATTERNS TO TREAT RHINOPHARYNGITIS. INTERVENTION STRATEGIES IN TWO HEALTH SYSTEMS OF MEXICO R I C A R D O PI~REZ-CUEVAS,* H E C T O R G U I S C A F R I ~ , O N O F R E M U l q O Z , H O R T E N S I A REYES, P A T R I C I A TOMI~, VITA L I B R E R O S and G O N Z A L O G U T I I ~ R R E Z Health Services Research lnterinstitutional Group: Secretaria de Salud, lnstituto Mexican, del Seguro Social, Ave. Cuauhtemol 330, CMN Siglo XXI, Blogue B Unidad de Congresos Col. Doctores 06726, Mexico DF, Mexico Abstract--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; (!II) 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*/0 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 ,16.2%, 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 (I 7.5%) 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. Key ,,ords---continuing medical education, antibiotics, appropriateness, educational research, quality of

care

BACKGROUND Inappropriate drug use to treat c o m m o n diseases, such as acute diarrhoea or acute upper respiratory infection, has been consistently reported in the literature [I,2]. Three problems are commonly noticed: overprescription, where excessive amounts o f antibiotics are prescribed without justification [3,4]; omission, where products that should be prescribed are not prescribed (for example, oral rehydration solution to prevent dehydration in acute diarrhoea) [3,4]; and inadequate use [5, 6] *Author for correspondence.

(for example, the use of inappropriate dosages). These problems highlight the use of poor clinicaltherapeutic criteria for diagnosis and the lack of appropriate prescribing practices among physicians. These deficiencies have been confronted in several ways, such as strengthening medical school curricula on the treatment of c o m m o n diseases [7], setting up guidelines (algorithms, critical paths) [8] and supporting activities designed to provide continuing medical education to practicing physicians [9, 10] who do not have access to educational activities. In a previous study, our work group carried out an interactive educational intervention [11, 12] with

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family physicians. They were taught to improve their prescribing practices to treat acute diarrhoea and encouraged to criticize their own clinical performance [9, 10]. The educational strategy took place in two family medicine clinics of the Mexican Social Security Institute (lnstituto Mexicano del Seguro Social, IMSS), obtaining successful results. The family physicians improved the appropriateness of diarrhoea treatments by (a) increasing the use of oral rehydration solutions, (b) reducing the inadequate prescription of antibiotics, and (c) reducing the use of restrictive diets. Senior researchers at the IMSS instructed family physicians in this study [9, 10]. The success of the previous study encouraged us to carry out a similar educational strategy to improve physicians' prescribing practices in the treatment of rhinopharyngitis. This disease is the leading cause of visits in primary care settings [13, 14]. It is self-limited [15, 16], with easy and inexpensive treatment [17-20] and clearly defined criteria. Nevertheless, inappropriate treatment, such as the excessive prescription of antibiotics and symptomatic medicines, remains a serious problem t3, 41. This study was carried out in primary care facilities of the two major health systems in the country. The Mexican Social Security Institute (IMSS) is a health system providing health care to workers and their families on a prepaid fee basis, covering almost 40% of the Mexican population. The other system, the Ministry of Health (SSA), is the governmental health system providing care to people with fewer resources and with no access to IMSS. It covers almost 30% of the Mexican population. The study aimed to improve the rational prescribing of primary care physicians because of the many consequences of inappropriate antibiotic prescription, such as increase in antibiotic resistance, waste of medicines, lack of compliance, toxicity, rising costs and inadequate patient education. In this paper we describe the methodology of the educational and managerial interventions and analyze the impact of the strategy on the prescribing practices of the physicians. We also discuss the relevance of continuing medical education for primary care physicians who provide services yet rarely participate in educational activities.

METHODS

This study was carried out from September 1990 to July 1992 in 18 primary care clinics located in the metropolitan area of Mexico City. It included four family medicine clinics of the IMSS and 14 health centres of the SSA.

Characteristics of the clinics All of the clinics provide primary care services. Family medicine clinics of the IMSS have approxi-

mately 27 examining rooms each, and all these clinics have a clinical laboratory, X-ray laboratory and pharmacy. Health centres of the SSA are smaller clinics. There are one to twelve examining rooms in each, and only three of the fourteen clinics have a laboratory, X-ray lab and pharmacy. Both institutions share an essential drug list regulated by the SSA. The observance of this list, however, is quite different between these two institutions. The IMSS strictly requires all physicians to use the essential drug list; it is a prepaid fee system facility in which patients receive medicines at no extra charge. On the other hand, the SSA is more flexible in the use of the essential drug list, but patients can buy drugs either in the clinic's pharmacy or elsewhere. Thus, the SSA physicians are less restricted to prescribing drugs included in the essential list. Patients' demographic characteristics differ between the two health systems. The IMSS provides care to its enrollees and their families, and most of the services are provided to adults. The SSA provides services to people with scarce resources, mainly children.

Allocation of the physicians and the clinics T o carry out the study, a quasi-experimental design using a control group and a study group was employed [21,22]. One hundred and nineteen physicians (IMSS 68, SSA 51) participated in the study. The study group consisted of 65 physicians, 32 working in two IMSS family medicine clinics and 33 working in nine SSA health centres. The control group consisted of 54 physicians, 36 working in two IMSS family medicine clinics and 18 working in five SSA health centres. Only physicians with permanent contracts working during the morning shift were included in the study.

Stages of the study (I) Baseline stage. The baseline stage was carried out from September to December 1990. Physicians' prescribing practices were evaluated through a survey of patients with illness less than 21 days in duration, in whom the physicians had made a diagnosis of rhinopharyngitis. By rhinopharyngitis we mean the clinical picture characterized by runny nose and cough, with or without fever and with no concurrent infection. Between 8 and 15 patients were assessed for each physician. To evaluate the physicians' prescribing practices, the information was gathered from several sources. Trained nurses interviewed patients, reviewed clinical records and reviewed prescriptions given by the physicians. These data were recorded in a questionnaire which included information on duration of illness, clinical picture, length of visit, diagnosis and treatment given to the patient. (II) Intervention strategies. The interactive educational intervention consisted of two phases: training of the instructors, and a workshop. The

Prescribing patterns to treat rhinopharyngitis managerial intervention consisted of the development of a peer review committee. Training of the instructors. The instructors were four physicians from the staff of the study group clinics and four junior researchers from our work group (HR, PT, VL, RP). Those physicians were selected by the medical director of each clinic. They were chosen because of their interest and ability to participate in educational activities. The training period lasted 40 hours. During this time the research project and current bibliography were reviewed and analyzed [16, 18, 20, 23, 24]. Findings of the baseline stage and an algorithm to treat rhinopharyngitis [8] were discussed. Workshop. The workshop was carried out with the study group using interactive educational techniques [11, 12]. The study group was allocated to four sites; at each site there were one physician and one researcher as instructors. The workshop consisted of five daily 2-hour sessions over one week. The following is a brief description of the activities in the five sessions: (A) Presentation of the research project. The instructors assembled the clinic's physicians to inform them of and to discuss with them the purpose of the research. All of the clinic's physicians were invited to participate in the study. Most of them agreed to participate when they learned that it was an educational research project. (B) Bibliographic review. Participating physicians received a current bibliography related to the appropriate treatment of rhinopharyngitis [16, 18,20,23,24]. At this time round-table discussions analyzing the appropriateness and applicability of the recommended treatments were organized. (C) Baseline analysis. Data describing physicians' prescribing practices were presented to them. The results showed inappropriate prescribing practices. However, the group of physicians agreed with the findings and a discussion was carried out with them to analyze the results. (D) Proposing the rhinopharyngitis therapeutic scheme. After the analysis of the physicians' prescribing practices, a therapeutic scheme for rhinopharyngitis, based on an algorithm previously published by our research group [8], was proposed. The former algorithm was more complex, including criteria to treat other acute respiratory infections (tonsillitis, sinusitis, acute otitis media and bronchitis) besides rhinopharyngitis. After discussion with the physicians, the scheme was modified to make it simpler and more appropriate. Opinions and suggestions of the physicians to standardize the treatment criteria were considered. As a reinforcement strategy, the scheme was printed and posted in all the examining

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rooms. All physicians were asked to use it voluntarily, but their decision to use it or not w a s respected. (E) Discussion of clinical cases. To reinforce the use of the therapeutic scheme, eight scenarios illustrating common clinical situations were presented to the physicians. The group worked out the scenarios in round-table discussions using the proposed therapeutic scheme.

Peer review committee. The peer review committee was assembled to (a) strengthen and promote the use of the therapeutic scheme among the physicians, (b) evaluate how it was used in daily practice and (c) encourage the physicians to criticize their own clinical performance. It was formed by the instructors and two or three rotating physicians of the clinics. Every physician went to the meetings at least three times. The peer review committee met once a week and finished when all the medical staff had participated. In each session the members of the peer review committee reviewed clinical records of patients with rhinopharyngitis and evaluated the adherence of the physicians to the therapeutic scheme. With the peer review committee we encouraged a more participatory activity than with the workshop. The physicians reviewed clinical records, identified failures in the treatments, them and proposed improvement alternatives. (IIl) Post-workshop evaluation. This evaluation was carried out over 3 months (April-June 1991), using the same data collection procedures as those used in the baseline stage. The group of nurses who had interviewed patients in the first stage served as interviewers for this stage as well. All the physicians in the baseline stage group were evaluated again, (IV) Follow-up stage. This stage began between 12 and 18 months after the educational strategy had finished. The same criteria for data collection were followed. During the baseline and post-workshop stages, 119 physicians were evaluated, but in this stage only 79 of them (66.3% of the initial sample) remained. Twenty-five physicians (38.5%) from the study group and 15 physicians from the control group (27%) did not continue because of attrition, illness, changes of responsibilities in the clinics, etc. It is important to mention that none of the physicians refused to be evaluated at any stage. Analysis Some academic and professional characteristics of the physicians (Table 1) were analyzed using the chi-square and Mann-Whitney U tests [25]. The study and control groups of each institution were compared. Drugs prescribed during the baseline stage were analyzed (Table 2), comparing both institutions. The mean number of medicines per patient w a s calculated using the number of drugs divided by the number of patients. The chi-square test was used to make the comparisons between institutions.

Ricardo P~rez-Cuevas et

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al.

Table I. Study and control group physicians"characteristics Ministry of Health (SSA)

Characteristics Age (years) Median Interval Postgraduate training None Family medicine Other spectahy Years of practice Median lnte[val Private practice Work for other institution Contact with pharmaceutical company representative Non-medical remunerated activities

Mexican Institute of Social Security (IMSS)

Control group n=18

Study group n=33

Control group n=36

Study group n =32

P value comparing both institutions

36 (29-58)

35 (28-68)

43 (31-M)

43 (31-58)

< 0.0 I

88.8 0.0 I I. I

84.8 0.0 15. I

33.3 44.4 22.2

40.6 34.3 25.0

0.05) during the three stages of the study.

Analysis of changes in prescribing practices according to physicians' characteristics At the end of the follow-up stage, the characteristics of the physicians who maintained stable positive change and those with persistent negative behaviour were compared (Table 6). The analyzed physicians' characteristics were similar to those shown in Table 1. This analysis was performed to find associations between the physicians' academic and professional characteristics and their prescribing behaviour and to obtain a profile of a physician who might respond positively to continuing medical education activities. The analysis showed no associations between physician characteristics and their prescribing practices. However, when we analyzed by the institutions where the physicians worked, we found that 11 SSA physicians but only 6 IMSS physicians maintained negative behaviour. Among the 10 physicians who exhibited a persistent positive change, 9 of them were from the

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IMSS staff and only one from the SSA staff (P < 0.01). DISCUSSION

This study was carried out in two health institutions that are quite different in their organization, procedures of providing services and type of population served. Nevertheless, these institutions share a severe deficiency in providing continuing medical education activities or research activities related to health services at the primary care level. We were encouraged to set up an interactive educational technique and a managerial intervention for primary care physicians for several reasons. Previous works have highlighted inappropriate prescribing practices to treat common diseases such as acute diarrhoea [3,5,6] or acute upper respiratory infections [3, 4]. This inappropriateness is reflected not only in high rates of antibiotic prescribing but also in the incorrect way the antibiotics are used; mistakes in dosage, selection and duration of use are frequently reported

[27}. Several factors have been considered to influence physicians to prescribe medicines inappropriately: (a) Shortcomings in medical education during both the undergraduate and the postgraduate training periods. The predominant educational trend supports prescribing drugs to all patients [6, 28]. (b) Lack of

trustworthy clinical and pharmacological judgement. This problem has been stressed given the inappropriate prescribing practices that have been observed even for the treatment of mild and self-limited diseases. (c) Unreliable sources of pharmacological

Table 6. Relation between behaviour changes and some selected characteristics of physicians study group Comparison between the physicians who changed and those who did not

Selected characteristics

Stable positive change n = 10

Persistent negative behaviour n = 17

6 4

7 10

43 (40-54)

36 (31-44)

6 0 4 4

II 4 2 4

8 I 3

14 0 3

ns ns ns

I 9

11 6