Audit of therapeutic interventions in inpatient children using two scores: are they evidence-based in developing countries?

Improving the management of acute diarrhoea and dehydration in under-5 children in a paediatric referral facility in Lagos, Nigeria

BACKGROUND

Mortality from acute diarrhoea and dehydration (AD/D) in children is high despite existing management guidelines.

AIM

The aim of this study was to identify deficiencies in the management of AD/D by health staff and assess changes in management after a training intervention in a paediatric referral facility in Lagos, Nigeria.

METHODS

In a retrospective review of case notes, the management of AD/D was assessed using WHO guidelines as the standard. An e-learning module was developed that directly addressed deficiencies and was used to train health staff. Changes in the management of AD/D were assessed by re-auditing case notes.

RESULTS

There were learning needs among health staff in the management of AD/D. Altogether, 34 (97.1%) of 35 residents were trained. Training resulted in modest improvements in the number of children in whom nutritional status was assessed, use of oral rather than intravenous fluids for rehydration and reducing unnecessary laboratory tests. Training resulted in marked improvements in the correct volume of (pre- vs. post-training 6.3% vs. 94.1%, P<0.001) and follow-up of fluid therapy (8.1% vs. 98.0%; P<0.001), prescription of zinc (41.6% vs. 85.1%, P<0.001) and providing advice on when to return after discharge (77.6% vs. 96.0%, P<0.001). Although statistically significant, the minimal improvements in antibiotic use (43.8% vs. 56.6%, P = 0.03), re-starting feeds (10.6% vs. 38.6%, P<0.001) and counselling about feeding (11.8% vs. 33.7%, P<0.001) highlighted areas for further training.

CONCLUSIONS

In low-resource countries, clinical auditing and training can significantly improve the management of illnesses that contribute to child deaths and identify areas where further training is required.

An unsupported preference for intravenous antibiotics

Philip Bejon and colleagues reflect on the widespread belief in the superiority of intravenous antibiotics.

Is primary care evidence-based in Turkey? A cross-sectional survey of 375 primary care physicians

OBJECTIVE

Family medicine (also called general practice) is a specialty with a focus on primary care. In Turkey, not all primary care is provided by specialists. Efforts are underway to improve primary care by improving the provision of primary care, establishing referral chains, and having care provided by general practitioners after transition training or by family medicine specialists. We investigated the relationship between evidence-based medicine (EBM) and primary care in Turkey, to provide a snapshot of the current situation and baseline data to assess the effects of current and future reforms.

METHODS

A cross-sectional survey was done of 375 primary care physicians: 138 general practitioners (GPs), 121 family medicine (FM) trainees, and 116 FM specialists. They were asked 30 questions assessing general characteristics, knowledge, and training in EBM; general attitudes towards EBM; resources used to support clinical decisions; possible barriers to EBM practice; and opinions on future practice of EBM. Data were analyzed with SPSS 12.0.

RESULTS

Compared with the other physicians, FM specialists had significantly more Internet access, used the Internet for medical purposes more often and for longer hours, had published more scientific papers, searched MEDLINE or similar databases more often, and were more confident about conducting literature searches. FM specialists had significantly higher rates of training in EBM and critical appraisal. For all types of physicians surveyed, the main reported barrier to practicing EBM was lack of training in EBM.

CONCLUSIONS

Attitudes toward EBM differ significantly between GPs and FM specialists working in primary care in Turkey, which we believe results in variation in medical provision. The differences between these two groups of physicians should be investigated further, and means of improving the provision of care should be reported to policy makers.