The pediatric walk-in clinic: competition for the private practitioner

In an affluent city with many pediatricians a 20% increase in patients seen in a hospital-based walk-in clinic in 1982 prompted a study to determine the characteristics of clinic users and their reasons for using the clinic. It was found that users of the clinic were middle-class, that they had a higher employment rate than the average for the region, and that in 54% of the families both parents worked outside the home. The children of 85% of the families were patients of pediatricians in private practice; most of the others were patients of a family physician in private practice. Most of the children seen at the clinic had had symptoms for more than 24 hours, but few parents had attempted to contact their own physicians. In the previous 12 months 95% of the children had been seen at the clinic, 43% in the month preceding the study. They came to the clinic for two main reasons: the broad range of services offered --laboratory, radiology and pharmacy as well as medical--and the convenient hours, with 71% coming outside of their physicians' office hours. Given the reality of social trends pediatricians will either have to share their patients with facilities that offer services outside of regular office hours or devise another system for the treatment of their patients.     

Patients' evaluation of outpatient medical care

150 patients attending an outpatient clinic at the University of Oklahoma Hospital over a 5-week period were asked whether the clinic care they were receiving was better than, as good as, or worse than the care they had received from local physicians. The patients were drawn from the general medicine, cardiology, and oncology-hematology units and tended to be elderly and chronically ill. Most of the patients viewed favorably the care they received in the medical outpatient clinics. 65% reported they had experienced pain or discomfort in the week prior to their visit, but there was no association between these factors and degree of satisfaction with clinic care. Patients averaged about 30 minutes with the physician, and 80% felt the doctor adequately explained their medical condition to them. Patients who rated the clinic care as being worse than the care of private practitioners felt that their condition was not adequately explained. When asked to define a "good doctor," patient responses were "interest in the patient," "skilled and thorough," and "explains things to you." Characteristics identified as being most important in a "good clinic" were; good doctors, well-trained staff, and information from doctors. Of all the factors examined, the one associated most directly with patient satisfaction was personal interest on the part of the physician in the patients.     

A delay-scheduling model for patients using a walk-in clinic

Clinics receiving unscheduled visits experience wide fluctuations in the number of patients present at any one time, due to random arrival of patients and variations in the time needed for the evaluation and treatment. This can cause periods of congestion and long patient waiting times. Using a flexible technique for “delay scheduling,” a study was conducted to determine the most efficient use of limited physician resources in the management of patients using a walk-in clinic. Delay scheduling makes it possible to shift work load from periods of high congestion to other times without compromising the walk-in nature of the clinic. A computer simulation model was used to evaluate the clinic performance with different physician staffing patterns and different rules for delay scheduling. The model was validated using actual data from the walk-in clinic and the results implemented. The delay scheduling and staffing changes resulted in reduction of manpower by 10% while significantly reducing the clinicaccountable waiting time.     

Patient care and professional staffing patterns in McKinney Act clinics providing primary care to the homeless.

OBJECTIVE--To describe the patient care and staffing patterns of the 157 clinics that receive federal funding to provide health care to the homeless. DATA SOURCES--Telephone interviews with clinic medical directors. RESULTS--Clinics treated a mean of 96 homeless patients per week, approximately 50% of the estimated homeless population. Three quarters treated homeless patients only, the others integrated homeless patients into an existing setting. One third of the clinics had no physician more than 5 hours per week, 10% had no physician staff at all, and 80% employed a nurse practitioner. The proportion of patients initially examined by a nurse practitioner and the proportion subsequently referred to a physician ranged between 10% and 100%. Clinic directors reported that in over 50% of clinics, physician recruitment was hampered by poor working conditions, inadequate salaries, physician biases against working with the homeless, and the lack of respect this work receives from the medical profession. CONCLUSIONS--Current financial constraints may be impeding the ability of clinics serving the homeless to ensure adequate access to high quality care. Additional research should evaluate the impact various staffing patterns have on access and quality of care and develop methods to improve physician recruitment.     

Self-referral in point-of-service health plans

CONTEXT: Most health maintenance organizations offer products with loosened restrictions on patients' access to specialty care. One such product is the point-of-service (POS) plan, which combines "gatekeeping" arrangements with the ability to self-refer at increased out-of-pocket costs. Few data are available from formal evaluations of this new type of plan. OBJECTIVES: To comprehensively describe the self-referral process in POS plans by quantifying rates of self-referral, identifying patients most likely to self-refer, characterizing patients' reasons for self-referral, and assessing satisfaction with specialty care. DESIGN: Retrospective cohort analysis using administrative databases composed of members aged 0 to 64 years who were enrolled in 3 POS health plans in the Midwest (n = 265 843), Northeast (n = 80 292), and mid-Atlantic (n = 39 888) regions for 6 to 12 months in 1996, and a 1997 telephone survey of specialty care users (n = 606) in the midwestern plan. MAIN OUTCOME MEASURES: Self-referred service use and charges, reasons for self-referral, and satisfaction with specialty care. RESULTS: Overall, 8.8% of enrollees in the midwestern POS plan, 16.7% in the northeastern plan, and 17.3% in the mid-Atlantic plan self-referred for at least 1 physician or nonphysician clinician visit. The proportions of enrollees self-referring to generalists (4.7%-8.5%) were slightly higher than the proportions self-referring to specialists (3.7%-7.2%) across all 3 plans. Nine percent to 16% of total charges were due to self-referral. The chances of self-referral to a specialist were increased for patients with chronic and orthopedic conditions, higher cost sharing for physician-approved services, and less continuity with their regular physician. Patients who self-referred to specialists preferred to access specialty care directly (38%), reported relationship problems with their regular physicians (28%), had an ongoing relationship with a specialist (23%), were confused about insurance rules (8%), and did not have a regular physician (3%). Compared with those referred to specialists by a physician, patients who self-referred were more satisfied with the specialty care they received. CONCLUSIONS: Having the option to self-refer is enough for most POS plan enrollees; 93% to 96% of enrollees did not exercise their POS option to obtain specialty care via self-referral during a 1-year interval. The potential downside of uncoordinated, self-referred service use in POS health plans is limited and counterbalanced by higher patient satisfaction with specialist services.     

Patients who leave a public hospital emergency department without being seen by a physician. Causes and consequences

OBJECTIVE: To determine whether patients who sought care at a public hospital emergency department and left without being seen by a physician needed immediate medical attention and whether they obtained care after leaving. DESIGN: Follow-up study of patients who left without being seen and of patients who waited to be seen by a physician. SETTING: A public hospital's emergency department in Torrance, Calif. PATIENTS: All patients who registered for care and left without being seen (n = 186) and a 20% random sample of patients who waited until they were seen (n = 211) in a 2-week period during spring 1990. MAIN OUTCOME MEASURES: At time of presentation: triage nurse urgency assessment, clinical acuity rating, and self-reported health status. At follow-up: hospitalization rates. RESULTS: Patients who left reported that they had waited 6.4 hours before leaving; those who stayed reported a 6.2-hour wait before being seen. There were no differences between those who left and those who stayed in chief complaint, triage nurse assessment, acuity ratings, or self-reported health status. Forty-six percent of those who left were judged to need immediate medical attention, and 29% needed care within 24 to 48 hours. Eleven percent of those who left were hospitalized within the next week, and three patients required emergency surgery. Nine percent of those who waited to be seen were hospitalized. Forty-nine percent of patients who left did not see a physician during the 1-week follow-up period. CONCLUSION: Overcrowding in this public hospital's emergency department restricts access to needed ambulatory medical care for the poor and uninsured.     

Situation of seven-day service among family medicine clinics in Taiwan: A nationwide survey

Background

General medicine practices in England are required to provide services from 8am to 8pm on weekdays and to also open on Saturdays and Sundays. Internationally, however, the literature regarding the temporal availability of primary health care on national levels is scarce.

A randomized controlled trial of academic group practice. Improving the operation of the medicine clinic

We conducted a controlled trial of the adoption of a group-practice model within an academic department of medicine. Ongoing randomization yielded similar groups of patients and residents. To determine the effect of the intervention on medicine-clinic operation, we monitored the hospital outpatient activity of 28 residents and 2299 patients during an 11-month study period. The group-practice clinics generated 20% more patient encounters per month than did the traditional, control clinics (328 vs 273 encounters), primarily because twice as many voluntary, overflow clinic sessions were scheduled (20.2 vs 9.7 sessions). Yet, because group-practice registration was decentralized, patients spent 15% less time in completing scheduled visits (93.2 vs 109.9 minutes). Regular utilizers of the group practices made 7% more scheduled clinic visits on average (3.27 vs 3.05 visits), but 39% fewer walk-in visits (0.14 vs 0.23 visits). Hospital-wide, continuity of care was not affected. We conclude that adoption of a group-practice model at our institution improved clinic productivity, enhanced patient flow, and decreased unscheduled clinic visits.     

Patient-reported outcome measures: an on-line system empowering patient choice

An innovative web-based system was developed to allow patient-reported outcome measures (PROMs) to be easily administered. Stakeholders guided the design and implementation. The software gives patients access to their current and previous scores. This pilot study focused on patients undergoing arthroscopic subacromial decompression, evaluated using the Oxford shoulder score (OSS). Patients showing good improvement in their OSS were offered the choice to return for routine follow-up clinic appointments, or continue rehabilitation, reassured by their improved score. Thirty-six of 117 patients were eligible. Thirty of these (83%) were opted to avoid further clinics. PROMs 2.0 can be used for any medical intervention with a validated PROM. Evolution and refinement is ongoing. Funding has been granted for 12 primary and secondary healthcare trusts to implement PROMs 2.0. Further work is needed to assess economic impact, patient views and satisfaction with the process.     

An Evaluation of Patients’ Opinions of Primary Care Physicians: the Use of EUROPEP in Gaza Strip-Palestine

The objective of this paper is to identify the level of patients' satisfaction with primary care physicians. Data were gathered from an exit interview using a standardized questionnaire (EUROPEP) and background variables. A total of 956 patients in fifteen primary health care clinics in Gaza Strip participated. Outcome measures is positive patient satisfaction (good and excellent ratings in the EUROPEP Index). As a results, the mean percentage of positive satisfaction with medical services was poor (41.8%). The poorest performance was recorded for: getting through to the clinic on the phone, being able to speak to physician on the telephone, time spent in waiting rooms and helping the patient deal with emotional problems. The comparison between clinical behaviour dimension and organization of care showed that clinical behaviour was evaluated higher. In conclusion, Palestinian patients expressed overall dissatisfaction with services provided by primary care physicians. These findings present a real challenge for Palestinian authority policy makers and administrators in terms of designing appropriate quality improvement strategies.     

Patient satisfaction and quality of life among persons attending chronic disease clinics in South Trinidad, West Indies

OBJECTIVE: Patient satisfaction and quality of life are increasingly being recognized as central elements in the monitoring and evaluation of healthcare. In this survey, the level of patient satisfaction and quality of life were investigated in regular attendees at public health chronic disease facilities in South Trinidad. METHOD: A random sample of 200 clients attending the three public chronic disease clinics during the period August 12, 2002 to December 31, 2002, completed self-administered questionnaires consisting of socio-demographic, quality of life (SF 12) and health service items. RESULTS: Participants had an average of four annual visits and 75% of them were 50 years and older. Approximately two-thirds of participants gave health and support staff a rating of good to excellent. Overall clinic experience was rated as poor to fair by 41.5%. Forty-five and a half per cent gave a rating of the explanations given by doctors and nurses about their illnesses. Fifty-three and a half per cent and 58% gave a poor to fair rating for the length of the waiting time and explanation offered when there was a significant delay in the starting times of clinics respectively. In regression analyses controlling for age, gender and number of illnesses, ratings of clinic experience and all categories of clinic staff were significantly associated with SF-12 mental and physical component summary scores. CONCLUSION: The findings suggest that in this population of regular clinic attendees, levels of client satisfaction and numbers of illnesses are associated with subjective quality of life.     

Patients' views of the medical education setting

The results of a survey of 1,334 patients at three community health centers operated by the University of Illinois College of Medicine at Rockford are presented and discussed. The research was designed to begin to obtain a better understanding of the patient's views on the quality of care and medical students in the medical education setting. Patients in the study reported being attracted to the educational site for the same reasons they would go to a private physician, that is, location, advice of a friend, or dissatisfaction with their previous doctor. They also reported satisfaction with care in general and with the specific components of care at the health centers. However, the patients expressed different views of the medical student's role, and there were differences in the patients' preferences for a student or a faculty physician depending on their medical problem or condition. These views of the student's role and the patients' preferences of physicians were found to be related significantly to the patient's age, the patient's perception of his primary source of medical care, the patient's evaluation of the effect of medical schools on health care, and the patient's level of satisfaction with the care received.     

Patterns of admission and discharge in an acute geriatric medical ward.

Patients admitted to a 30 bedded acute geriatric medical ward in 1993 were followed up to discharge. The admission rate on weekend days was half that for weekdays. Six percent of ward discharges occurred at weekends, over half being due to death. Respiratory, cardiovascular and central nervous systems disorders were the commonest reasons for admission (56%) and death (73%). Greater emphasis should be placed on discharging patients at weekends.     

Career and parenting satisfaction among medical students, residents and physician teachers at a Canadian medical school

BACKGROUND: Studies of career and parenting satisfaction have focused separately on medical students, residents and practising physicians. The objective of this study was to compare satisfaction across a spectrum of stages of medical career. METHODS: A survey of incoming medical students, current medical students, residents and physician teachers at the University of Saskatchewan was conducted in the spring of 1997. Response rates were 77% (43/56), 81% (177/218), 65% (134/206) and 39% (215/554) respectively. Factors assessed in the stepwise regression analysis were the effect of sex, parenting and level of training on the likelihood of recommending parenting to medical students or residents, and on parenting dissatisfaction, job dissatisfaction, career dissatisfaction and the importance of flexibility within the college program to accommodate family obligations. RESULTS: More male than female physician teachers had partners (92% v. 81%, p < 0.01) and were parents (94% v. 72%, p < 0.01). Female physician teachers spent equal hours per week at work compared with their male counterparts (mean 52 and 58 hours respectively) and more than double the weekly time on family and household work (36 v. 14 hours, p < 0.01). Physician teachers were the most likely respondents to recommend parenting to residents and their peers. Residents were the most dissatisfied with their parenting time. At all career stages women were less likely than men to recommend parenting, were more dissatisfied with the amount of time spent as parents and were more likely to regard flexibility within the college program as beneficial. There were no sex-related differences in job dissatisfaction and career dissatisfaction. However, married women were more dissatisfied with their jobs than were married men. Job dissatisfaction was greatest among medical students, and career dissatisfaction was greatest among residents. INTERPRETATION: The optimal timing of parenthood appears to be upon completion of medical training. Women were less likely to recommend parenting, less satisfied with the time available for parenting and more likely to value flexibility within the college program to accommodate family needs. These differences did not translate into women experiencing more job or career dissatisfaction.     

“医药分开”政策对于临床医师服务行为的影响研究简

目的：了解“医药分开”政策对临床医师服务行为的影响。方法：以北京市试行“医药分开”政策的部分医院为研究现场,随机抽取800名临床医师进行问卷调查,分析该政策对临床医师服务行为的影响。结果：临床医师对“医药分开”政策的知晓率为99.5%;92.1%的临床医师更加重视规范诊疗;85.0%的临床医师提高了服务意识,服务更周到;86.8%的临床医师更加重视患者满意度。结论：试点医院临床医师对政策的知晓和掌握情况良好。大多数临床医师优化了服务行为,并对政策的进一步完善提出有益建议,如应加强宣传,正确舆论导向;提高医疗服务收费标准;提高医务人员待遇,建立完善激励机制和考核机制;提高医师积极性等。     

The ethical problem of false positives: a prospective evaluation of physician reporting in the medical record

OBJECTIVE: To determine if the medical record might overestimate the quality of care through false, and potentially unethical, documentation by physicians. DESIGN: Prospective trial comparing two methods for measuring the quality of care for four common outpatient conditions: (1) structured reports by standardised patients (SPs) who presented unannounced to the physicians' clinics, and (2) abstraction of the medical records generated during these visits. SETTING: The general medicine clinics of two veterans affairs medical centres. PARTICIPANTS: Twenty randomly selected physicians (10 at each site) from among eligible second and third year internal medicine residents and attending physicians. Main measurements: Explicit criteria were used to score the medical records of physicians and the reports of SPs generated during 160 visits (8 cases x 20 physicians). Individual scoring items were categorised into four domains of clinical performance: history, physical examination, treatment, and diagnosis. To determine the false positive rate, physician entries were classified as false positive (documented in the record but not reported by the SP), false negative, true positive, and true negative. RESULTS: False positives were identified in the medical record for 6.4% of measured items. The false positive rate was higher for physical examination (0.330) and diagnosis (0.304) than for history (0.166) and treatment (0.082). For individual physician subjects, the false positive rate ranged from 0.098 to 0.397. CONCLUSIONS: These data indicate that the medical record falsely overestimates the quality of important dimensions of care such as the physical examination. Though it is doubtful that most subjects in our study participated in regular, intentional falsification, we cannot exclude the possibility that false positives were in some instances intentional, and therefore fraudulent, misrepresentations. Further research is needed to explore the questions raised but incompletely answered by this research.     

Who undertakes the consultations in the outpatient department?

In a study of all 4275 outpatient consultations over one month in a district general hospital it was found that the clinics in surgical specialties had the largest numbers of patients. In general surgery less than half of new patients and only one third of all patients attending the clinic were seen by a consultant. (Nine months later about a third of all new patients had still not seen a consultant in the clinic.) In the medical clinics just over a quarter of patients were seen by doctors who had less than six months' experience in their present specialty after registration. Overall, doctors had been on continuous duty for at least 24 hours before a third of consultations. Doctors in training had actually worked during the previous night before attending a quarter of the clinics. Much of the large volume of work is performed by tired, incompletely trained doctors. It is suggested that a greater proportion of the work should be performed by fully trained staff. The workload might be reduced by modifying the pattern of the consultation.     

Evaluation of the Medical Records System in an Upcoming Teaching Hospital—A Project for Improvisation

The medical records system of an upcoming teaching hospital in a developing nation was evaluated for its accessibility, completeness, physician satisfaction, presence of any lacunae, suggestion of necessary steps for improvisation and to emphasize the importance of Medical records system in education and research work. The salient aspects of the medical records department were evaluated based on a questionnaire which was evaluated by a team of 40 participants—30 doctors, 5 personnel from Medical Records Department and 5 from staff of Hospital administration. Most of the physicians (65%) were partly satisfied with the existing medical record system. 92.5% were of the opinion that upgradation of the present system is necessary. The need of the hour in the present teaching hospital is the implementation of a hospital-wide patient registration and medical records re-engineering process in the form of electronic medical records system and regular review by the audit commission.     

农村卫生室5岁以下儿童静脉用抗生素情况的调查分析

目的:了解农村卫生室5岁以下小儿静脉使用抗生素情况。方法:采用多级抽样的方法分别抽取南宁市邕宁县和武鸣县的1个乡的1个村，对这2个村的所有卫生室进行回顾性调查，翻阅各诊室一年内5岁以下儿童的处方，记录其静脉使用抗生素情况，输入数据库并进行统计。结果:6个诊室的10名村医一年内共对6219名5岁以下患儿进行了抗生素的静脉输液，占所有使用抗生素的90．0％，其中82．8％为发热儿童；72．9％为急性呼吸道感染的患儿，以咳嗽为主诉就诊的最多(45．8％)，此外冬、春季节以上呼吸道感染(URI)较多，夏、秋季节则以发热为主诉的较多；静脉用抗生素以青霉素为主，庆大霉素、丁胺卡那等耳毒性抗生素占29.6％，用抗生素二联治疗的患儿有1．4％；6个诊室患儿就诊的平均费用在4．8～13．5元之间，平均为8．2元。结论：村卫生室抗生素的使用以经验用药为主，缺乏规范的用药知识和经验；应加强对乡村医生诊疗和用药的培训，对其抗生素使用和输液条件进行管理以及对群众开展正确认识抗生素的广泛宣传。     

Regular outpatient medical and drug abuse care and subsequent hospitalization of persons who use illicit drugs

CONTEXT: Patients and the public could benefit from identification of factors that prevent drug users' heavy reliance on inpatient care; however, optimal health care delivery models for illicit drug users remain ill-defined. OBJECTIVE: To evaluate associations of outpatient medical and drug abuse care with drug users' subsequent hospitalization rates. DESIGN AND SETTING: Retrospective cohort study of data from longitudinally linked claims for all ambulatory physician/clinic services and drug abuse services covered by the New York State Medicaid program. SUBJECTS: A total of 11 556 human immunodeficiency virus (HIV)-positive and 46 687 HIV-negative drug users. MAIN OUTCOME MEASURES: Hospitalization in federal fiscal year (FFY) 1997 compared by 4 patterns of care in FFY 1996: regular drug abuse care (>/=6 months in 1 program), regular medical care (>35% of care from 1 clinic, group practice, or individual physician), both, or neither. RESULTS: Hospitalization occurred in 55.6% of HIV-positive and 37.5% of HIV-negative drug users, with a mean of 27.5 and 24.5 inpatient days, respectively. In HIV-positive drug users, the adjusted odds ratio (AOR) for hospitalization was lowest among those with both regular medical and drug abuse care (AOR, 0.76; 95% confidence interval [CI], 0.67-0.85) followed by those with regular medical care alone (AOR, 0.82; 95% CI, 0.74-0.91) and regular drug abuse care alone (AOR, 0.85; 95% CI, 0.76-0.96) vs those with neither. In HIV-negative drug users, the AOR of hospitalization was lower for those with regular medical and drug abuse care (AOR, 0.73; 95% CI, 0.68-0.79), regular drug abuse care alone (AOR, 0.71; 95% CI, 0.66-0.76), and regular medical care (AOR, 0.91; 95% CI, 0.86-0.95) vs those with neither. Both types of care showed favorable effects for all but drug abuse-related hospitalizations. CONCLUSION: Our data indicate that regular drug abuse care with regular medical care for drug users is associated with less subsequent hospitalization.