We designed a controlled interventional study on family doctors in a rural health area. A before-and-after study was performed with a control group in order to evaluate the educational intervention.
We pursued this study in a BZH in the province of Burgos, with 5700 inhabitants affiliated with our public health system, and eight doctors – seven of them primary care physicians and one paediatric specialist – who care for patients in three different doctors' offices, located in the larger towns of this rural area: a central office and two peripheral doctors' offices. This BZH is located more than 100 km from their reference center, the General Yagüe Hospital, and the road has three mountain passes. A control group was used: an adjacent BZH, with a population of 4378 affiliated to the public health system, five doctors and a similar environment, nutritional habits, etc. The centers of these areas are 7.5 km apart, and they have the same kind of population.
The intervention consisted of the establishment of a local area network (LAN) with free access to the Internet, and access to the UniNet network. Computer equipment was installed at the offices of every rural doctor. These doctors continuously used different services available on the Internet to retrieve information, perform searches in bibliographic databases, etc. The different services used were:
-
1.
The World Wide Web, which was used as a complex entity with information from a variety of source types, including databases accessible on the Web and from the hospital library's collection of Web-based e-journals and databases. Also, at the UniNet site the doctors could find relevant information including courses, a doctoral program, and congresses organized on the network, such as the 3rd Congress of Nephrology on the Internet (CIN2003), organized by us during the the study. In addition, search engines were used to retrieve and store specific information related to the required health field.
-
2.
Electronic mail (e-mail) was used as a tool of private communication by the rural and specialized doctors. We included the use of a mailing list to transmit information to the participants in this study, and tried to encourage their participation in other meetings, such as the online congress.
-
3.
Chat sessions, or text conferencing, was the most relevant tool. Sessions of continuing medical education were planned as updates on diverse medical subjects as requested by the rural doctors. These sessions were provided by means of the simultaneous connection of the specialized doctors involved and the rural doctors in a private channel of text-conferencing.
All these interventions, including the initial training in Internet tools, occurred during a 12-month period. The global coordination of the project was made by the Research Unit of the General Yagüe Hospital. The educational activities were conducted by specialists from diverse medical departments: nephrology, haematology, rheumatology, neurology, gynaecology, etc. The specialists from the Department of Nephrology led the communication with the BZH and took the lead role in coordinating the educational activities.
For these purposes, each doctor had a personal computer installed in his or her office. In addition, these doctors had access to the databases at the hospital's library, as well as other existing ones freely available via the Internet (Pubmed, Embase, etc).
It took nine months to make the site operational. The first three months of the project were spent on administrative efforts, including equipment orders and installation. During the next three months the software was installed and the network and computers were configured. Afterwards, another six months was used for scheduling and training.
The work plan began with the installation of the local area network (LAN) and the computing equipment. Next, an Introduction to Internet course was delivered, and in the following months, the doctors were trained in computer operation and how to use the diverse services available via the Internet: Web, electronic mail, online databases and text conferencing.
Between January and June 2001, when it was agreed that the doctors had had enough training, we launched the first steps of the continuing medical education program, including clinical sessions, bibliographic reviews, conferences to maintain currency, debate, etc., using live communication by text conferencing, hosted on the UniNet network.
Generally we planned and ran a weekly conference session with the hospital's doctors along with those in the BZH location. A program of subjects of interest presented by the rural doctors was developed. The procedure was as follows: a written document related to the item was sent to the participants before the conference via e-mail, so that it could be read by the rural doctors in advance. Later, at a text conference, all the doctors could discuss the subject more effectively. Every session included bibliographic directions and practical questions. In addition, there was continuous interaction between the specialists and the primary care doctors during the week via e-mail, etc.
In order to measure the effectiveness of these procedures with regard to the effect on the patients, the variation of four parameters, corresponding to the years 2000 (before the intervention) and 2001 (the year of the intervention), was compared.
-
1.
Referral to a hospital specialist. This was defined as every consultation of the patients from the Basics Zone of Health (the BZH of the study and BZH control), requested by their family doctor, to the departments of the hospital that corresponded to any of the CIE-10 codes.
-
2.
Number of hospital stays. This means the number of nights that the patient of the BZH stayed in the hospital, occupying a bed.
-
3.
The proportion of prescriptions of drugs of low therapeutic utility (UTB) with regard to the total of prescribed drugs. One considers the crude rate and the standardized rate, adjusted for the active population versus retired persons; the Spanish population census and the direct method of standardization were used to adjust the rate. The UTB drugs are found in a list of UTB, described annually by the Directorate of Public Health (INSALUD)
-
4.
Generic drug prescription: the proportion of prescribed generic medicines relative to the total.
All these data were gathered through a blind and independent method with respect to this study by the Directorate of Public Health in Burgos. The doctors of the BZH of the study did not know the evaluation parameters, and the BZH control remained isolated from this investigation.