PubMed · 5210165
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T Stapleton. 1971. Perspective in paediatrics.. https://doi.org/10.1093/tropej%2F17.2.71
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RATIONALE: Inappropriate utilisation of hospital services for primary curative care aggravates inefficiencies and inadequacies in health care delivery. Identification of reasons for such malutilisation may assist the development of appropriate strategies for development of rationally organised primary and secondary care services that will provide improved quality of care. SUBJECTS: Children under 6 years of age living in Khayelitsha. OBJECTIVES: To ascertain: (i) the proportion of visits made to Red Cross Children's Hospital (RXH) that could be more appropriately handled at primary care level; (ii) reasons for attendance at RXH, compared with attendance at a large community health centre (Site B day hospital) in Khayelitsha; (iii) predictors of inappropriate attendance at the teaching hospital for primary care problems. METHODS: A case-referent study design was used to compare children attending RXH with children attending Site B day hospital. All care-givers attending the respective outpatient departments on 2 randomly selected days were included in the study sample. Data were collected by semi-structured interview and record review, on reasons for attendance, demographic and social variables relating to the child and care-giver, as well as clinical data on the final diagnosis contained in the patients' folders. Criteria for determining appropriateness of attendance by level of care were developed a priori via a modification of published measures. MAIN OUTCOME MEASURES: Reasons for attendance at the facility, appropriateness of the visit by level of care and predictors of inappropriate attendance at the teaching hospital. RESULTS: Sixty-nine per cent of RXH visits were identified as inappropriate for a tertiary institution. The main reasons given by care-givers for attending Site B were convenience and the prohibitive cost of travel to RXH. Mothers interviewed at RXH reported problems with failure of treatment at primary care clinics, and being turned away at Site B because of overcrowding as the main reasons for attending RXH. Attendance at RXH was predicted by: (i) children who were infants; (ii) no other domestic child care responsibilities for the care-giver; and (iii) no previous attendance documented in the hospital folder. CONCLUSION: Appropriate service utilisation by level of care needs to be improved. Users' choice of service appears to be a rational decision based on the accessibility of local primary care services and perceptions of the quality of these services. More appropriate use of primary care facilities therefore requires better access and perceived quality.
OBJECTIVES: (i) To ascertain what proportion of patients attending the general medical outpatient service at Red Cross War Memorial Children's Hospital (RXH) could safely be managed at peripheral primary care facilities; and (ii) to measure the effect of the introduction of free health care for children under 6 years of age on requirements for levels of care ranging from home to super-specialist referral centres. DESIGN: Prospective survey of patients attending on a stratified, randomised sample of 7 days in March 1994 (N = 1 962) and again in November 1994 (N = 1 404)-before and after the introduction on 6 June 1994 of free care for children under 6 years of age. SETTING: The general outpatient department of an academic/referral children's hospital. PATIENT SELECTION: All patients attending the outpatient department on the study days (7h00 to 6h59 the following day), excluding those who were referred, returning for follow-up, attending a specialist clinic or attending the surgical outpatient department. QUESTIONNAIRE: The questionnaire completed by medical officers recorded the following: patient's name, folder number, date and time of arrival, whether referred, clinic, treating doctor, disposal, diagnoses, home suburb and the level of care required: (i) home: (ii) clinic without a doctor; (iii) clinic with a doctor; (iv) hospital with non-specialists; (v) hospital with general paediatricians; or (vi) super-specialist hospital. MAIN RESULTS: In March 1994 the percentages of unreferred patients requiring the 6 levels of care defined for the study were 0.3, 25, 62, 8, 3 and 1, respectively. In November 1994 the percentages were 4, 41, 43, 8, 4 and 1. The graph of the number of patients seen at the outpatient department each month shows a large month-to-month variation but the trend is clearly towards an increase. CONCLUSIONS: The general medical outpatient department at RXH provides care to a large number of children, 48% of whom are unreferred. Of the unreferred patients 95% could be treated (more appropriately for the health services and more conveniently for their families) at a local primary health care facility. The situation has been aggravated by the introduction of free care for children under 6 years of age, who constitute 83% of the unreferred workload.
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