[Prescription of drugs in family medicine: on the trail of efficiency]. / Prescripción de medicamentos en medicina de familia: tras las pistas de la eficiencia.

OBJECTIVE: To analyse the effect of various factors on the efficiency of drug prescription by general practitioners (GPs). DESIGN: Descriptive, cross-sectional study. SETTING: Primary care in Murcia, Cartagena, and Lorca, in which 535 GPs work in the care of 921,281 people. Murcia Region (Spain).Participants. Prescriptions issued by the 288 GPs who were working constantly and continuously in May-June 1998 and who were away from work for no longer than 10% of the time (53.8%). MAIN MEASUREMENTS: We measured their efficiency with two general indicators--potential saving (PS) and prescription of generics (PG)--and 3 specific indicators: efficiency of prescription of omeprazole (EO), enalapril (EE), and ranitidine (ER). We analysed their relationship with structural-organisational factors and with the population attended, the doctor and his/her action. Bivariate and multivariate analyses (logistic regression) were used. RESULTS: There was an association with programmed consultation (PC); a weak inverse relationship with age of doctor, years qualified, pensioners allocated, case load and inter-consultations conducted; and a direct correlation with the length of the consultation. PG was related to rural environment, being non-permanent, specialist in family medicine, belonging to a primary care team. In the multivariate analysis PC was related to all the indicators: PS (OR=1.96), PG (OR=2.10), EO (OR=2.63), ER (OR=2.84), EE (OR=2.06); and the inter-consultations conducted with general efficiency of PS (OR=1.70), PG (OR=1.91). Rural environment was the worst for PS (OR=2.43). CONCLUSIONS: The main factors related to the efficiency of GPs prescription can be changed. The most important is the existence of PC. A lot of inter-consultations and working in a rural environment means worse general efficiency.

[Time spent waiting at primary care clinics: can this be improved?]. / La demora en la consulta de atención primaria: 'se puede mejorar?

OBJECTIVE: To analyse the factors that affect patients´ wait at a health centre before they enter the doctor´s consulting room (CD). DESIGN: Prospective full evaluative cycle of quality. SETTING: A teaching health centre in the Cartagena Health Area (Murcia). PARTICIPANTS: All those patients seen by the doctor during the weeks of the study (1st stage: 3823; 2nd stage: 4247). MAIN MEASUREMENTS: The dimensions evaluated were accessibility and patient satisfaction, through four criteria. Data were collected from the register of scheduled appointments and by telephone questionnaire. The intervention measures were: a) to create empty spaces without any appointments in the day´s diary in order to avoid delays; b) to create spaces at the end of the day for emergency patients, and c) to avoid interruptions during the consultation. RESULTS: 1st stage: on 48.3% of days there were patients with a delay greater than 20 minutes on entering the CD, with a mean waiting-time of 21.3 minutes per patient. 63.1% of the consulting rooms had over 5% «unavoidable¼ appointments per day, of which 61.3% were «emergencies¼. 72.6% of the consulting rooms had 5 or more interruptions per day. 46.7% of patients thought that the time they waited before going into the consulting room was «a lot or enough¼. 2nd stage: after putting the improvement criteria into practice, the number of consultations with waiting time over 20 minutes dropped (37.1%) (P<.05). The number of unavoidable consultations over 5% of the total fell by 35.7% (P=.001), as did the number of consultations with over 5 interruptions per day (by 58.6%) (P=.001). Fewer patients were dissatisfied with the time they had to wait before going into the CD (40.8%) (P<.05). CONCLUSIONS: Patients' waiting time at the clinic dropped. The number of «unavoidable¼ appointments and interruptions was reduced. Patients´ satisfaction improved with the time they had to wait at the clinic improved. The corrective measures introduced are the right ones for correcting the situation.

[Effectiveness of a personalized information system on the quality of family doctors' medical prescription]. / Efectividad de un sistema de información personalizada sobre la calidad de prescripción de medicamentos en médicos de familia.

OBJECTIVES: To evaluate the effectiveness of a system of personalised prescription information (PPI) to improve prescription habits of family doctors (FD); to examine how useful PPI is in maintaining these habits, and to analyse its influence through factors of the doctor and his/her environment. DESIGN: Cross-sectional, descriptive pilot study to analyse conditioning factors and possible confusion; quasi-experimental intervention study to assess the effectiveness of PPI, with two groups (experimental and control) and 4 determinations (before the PPI and after: short, medium and long-term).Setting. Family doctors in the Murcia Region. SUBJECTS OF STUDY: The prescriptions of all family doctors in the Murcia region which started before PPI and which continued until the end of the study and without absences of over 10% at each measurement.Intervention. The family doctors from the Murcia city area formed the experimental group: they received PPI with specific proposals for improvement. The FDs of Cartagena and Lorca, who did not receive PPI, made up the control group. Statistical analysis. Logistical regression to identify conditioning factors. Z comparison of proportions contrasted with one-tail hypothesis to check the effectiveness of PPI. LIMITATIONS OF THE DESIGN: Non-randomised allocation to groups made comparison difficult: conditioning factors for stratification or adjustment were studied. PRACTICAL APPLICATION: Confirmation of PPI s effectiveness justifies its dissemination. If there is no such confirmation, it will have to be perfected. Isolating the factors conditioning prescription that can be modified helps find ways to improve PPI.

Efectividad de un sistema de información personalizada sobre la calidad de prescripción de medicamentos en médicos de familia / Effectiveness of a personalised information system on the quality of family doctors' medical prescription

Objetivo. Evaluar la efectividad de un sistema de información personalizada de prescripción (IPP) en la mejora de los hábitos de prescripción de los médicos de familia (MF); conocer su utilidad para mantener estos hábitos, y analizar su influencia por factores del médico y su entorno. Diseño. Estudio descriptivo, transversal, previo para analizar factores condicionantes y de confusión; estudio de intervención cuasiexperimental para valorar la efectividad del IPP, con 2 grupos (experimental y control) y 4 determinaciones (antes del IPP y después: corto, medio y largo plazo).Emplazamiento. MF de la Región de Murcia. Sujetos de estudio. Prescripciones de todos los MF de la Región de Murcia existentes antes del IPP, que continúan hasta finalizar el estudio y sin ausencias superiores al 10 por ciento en cada medición. Formación de los grupos. Intervención: los MF de la Gerencia de Murcia formarán el grupo experimental; reciben el IPP con propuestas específicas de mejora. Los MF de Cartagena y Lorca no reciben el IPP y constituyen el grupo control. Análisis estadístico. Regresión logística para identificar factores condicionantes. Z de comparación de proporciones con contraste de hipótesis unilateral para comprobar la efectividad del IPP. Limitaciones del diseño. La no asignación aleatoria de los grupos dificulta su comparabilidad: se estudian factores condicionantes para estratificación o ajuste. Aplicabilidad práctica. Confirmar la efectividad del IPP justifica su difusión. No hacerlo obligará a perfeccionarlo. Aislar factores modificables condicionantes de la prescripción ayuda a actuar para mejorar (AU)

[Episodes of sickness attended by general/family physicians according to demographic context. 2. Utilization]. / Episodios de enfermedad atendidos en medicina general/de familia, según medio demográfico (y II): Utilización.

OBJECTIVES: To describe the use of consultations, the place where care is given and referral demand, in function of episodes of illness and the demographic context. DESIGN: An observational, prospective study based on a year-long record. SETTING: 43 practices spread over 10 Autonomous Communities. INTERVENTIONS: Identification, date of birth and sex of each patient attended, date of their first consultation and the number of consultations per episode, the health problem, place of consultation and existence or otherwise of referral, were all recorded. RESULTS: 74.57% in the rural areas, 56.21% in the urban and 56.74% in the mixed saw the doctor over the year. In the rural context there were 2.26 consultations per episode and 5.41 consultations per person, against 1.88 and 4.55 in the urban context. Figures for the mixed context were in between. In all the illness groups (except that for accidents) the number of consultations per episode in the urban context: 13.90% against 10.74 in the rural. CONCLUSIONS: Greater use of the doctor in rural areas could be because of the lower population/doctor ratio and easier access. Higher referral rates in urban areas could be due to the closeness of the second care level. A low percentage of home consultations was observed.

[Episodes of disease taken care of in general practice/family medicine according to demographic context (I): morbidity]. / Episodios de enfermedad atendidos en medicina general/de familia, según medio demográfico (I): morbilidad.

OBJECTIVES: To identify the population seen at general/family medical practices and quantity the episodes of illnesses attended, in function of the demographic context. DESIGN: An observational, prospective study based on a year-long record. SETTING: 43 practices spread over 10 autonomous communities. INTERVENTIONS: Identification, sex and date of birth of each patient attended, the type of episode, health problem and date of their first consultation, were all recorded. Standardisation by the indirect method was used to compare morbidity rates. RESULTS: 2.39 episodes per person seen were attended in rural areas, 2.42 in urban ones, and 2.45 in mixed areas. The rural context had rates below 15% of the standard rate for neoplasias, endocrine diseases, neurological illness and additional categories; and over 15% for digestive tract diseases, traumas and side-effects. The urban context had higher rates for neoplasias, endocrine, blood and neurological diseases, and additional categories; and lower for respiratory system illnesses. In the mixed areas, rates were higher for contagious, neurological, respiratory system and congenital diseases. CONCLUSIONS: The morbidity attended varies in function of context. Some differences could be due to age distribution (younger in the mixed areas) or accidents (greater in rural areas). Others could be affected by use or problem-solving criteria varying according to the demographic context.

Creatine kinase BB and neuron-specific enolase in cerebrospinal fluid in the diagnosis of brain insult.

Cerebrospinal fluid (CSF) markers provide useful information about the extent of brain damage. These biochemical indices may also be used when postmortem histopathological examination does not confirm antemortem brain insult. Seven biochemical parameters--creatine kinase (CK), creatine kinase BB isoenzyme (CK-BB), lactate dehydrogenase (LDH), gamma-glutamyltransferase, aldolase, leucine aminopeptidase (LAP), and neuron-specific enolase (NSE)--were analyzed in CSF from 82 cadavers. Case studies were categorized into one of four diagnostic groups. There were 15 cases of head trauma, 23 of hypoxia (hangings, carbon monoxide, and drug poisonings), 23 sudden cardiac death, and 21 miscellaneous cases. The degree of craniocerebral trauma was graded. In CSF there was a statistically significant correlation between the severity of craniocerebral trauma and levels of CK, CK-BB, aldolase, LDH, and LAP. CSF CK-BB [median U/L (range)] for the groupings of head trauma, hypoxia, sudden cardiac death, and miscellaneous were, respectively, 873 (1-12,100), 26 (2-2,780), 16 (1-42), and 18 (0-2,780). Corresponding CSF CK levels were 9,370 (28-67,842), 101 (18-36,840), 180 (10-29,622), and 264 (17-26,556). There were no statistical significant differences among the NSE concentrations in the four diagnostic groups. The testing of biochemical markers could be a reliable indicator of the degree of brain insult in support of morphological studies.