ORS is never enough: physician rationales for altering standard treatment guidelines when managing childhood diarrhoea in Thailand
ORS is never enough: physician rationales for altering standard treatment guidelines when managing childhood diarrhoea in Thailand
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DOI：
10.1016/s0277-9536(02)00478-1
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发表时间：
2003-09-01
影响因子：
5.4
通讯作者：
Dibley, MJ
中科院分区：
文献类型：
--
作者：
Howteerakul, N;Higginbotham, N;Dibley, MJ
这项研究探索了泰国医生关于他们在泰国中部公立医院系统内治疗儿童腹泻的处方做法的理由。首先介绍了一项前瞻性临床审计的结果和对38名医生治疗的424例病例的观察，根据泰国政府和世卫组织的治疗指南，这些医生用来估计次优处方做法的流行率。第二，定性访谈数据被用来确定影响医生病例管理实践的个人、个人间、社会文化和组织因素。重要的是，我们说明了医生如何在相互竞争的优先事项之间进行谈判，例如看护人感受到为孩子开过多处方的压力，以及卫生当局要求公共卫生系统的医生充当卫生资源看门人。泰国医生提出的坚持或不遵守儿童腹泻标准治疗指南的理由，是根据目前关于循证指南的临床、伦理和哲学辩论而提出的。我们认为，关于临床自主性、最佳护理和最佳效率的定义以及以患者为中心和整个社区的健康目标之间的紧张关系的不同观点决定了泰国儿童腹泻的标准实践指南是如何实施的。(C)2003爱思唯尔科学有限公司。保留所有权利。
This study explores Thai physicians' rationales about their prescribing practices for treating childhood diarrhoea within the public hospital system in central Thailand. Presented first are findings of a prospective clinical audit and observations of 424 cases treated by 38 physicians used to estimate the prevalence of sub-optimal prescribing practices according to Thai government and WHO treatment guidelines. Second, qualitative interview data are used to identify individual, inter-personal, socio-cultural and organisational factors influencing physicians' case management practices. Importantly, we illustrate how physicians negotiate between competing priorities, such as perceived pressure by caretakers to over-prescribe for their child and the requirement of health authorities that physicians in the public health system act as health resource gatekeepers. The rationales offered by Thai physicians for adhering or not adhering to standard treatment guidelines for childhood diarrhoea are contextualised in the light of current clinical, ethical and philosophical debates about evidence-based guidelines. We argue that differing views about clinical autonomy, definitions of optimal care and optimal efficiency, and tensions between patient-oriented and community-wide health objectives determine how standard practice guidelines for childhood diarrhoea in Thailand are implemented. (C) 2003 Elsevier Science Ltd. All rights reserved.