Average Consultation Time Research Articles

Case management of malaria in under-fives at primary health care facilities in a Tanzanian district.

To study case management of malaria in children under 5 years of age at primary health care facilities in Kibaha district, Tanzania and to evaluate the accuracy of self-reported mothers'/guardians' information on chloroquine use in children. A random sample of 652 mothers/guardians with sick children under 5 years of age attending 10 primary health care facilities was observed and interviewed. Blood samples for determination of chloroquine levels were taken from all children and thick smears for detection of malaria parasites were taken from the children who were prescribed chloroquine. Information on diagnoses and prescriptions was collected from recording books. Fever and respiratory problems were the most common complaints and accounted for 75% and 46% of the presenting conditions, respectively (some complained of both). Fifty-four per cent of the children received medication at home, most commonly antipyretics and chloroquine, 20% had been taken to another health facility and 3% to traditional healers before coming to the health facilities. There was a significantly higher use of antipyretics among home treated children compared with those taken previously to health facilities (P <or= 0.001). Use of antibiotics was higher among children who had been taken to health facilities previously (P < 0.0001). Nine per cent had received injections. The average consultation time was 3.8 min. Thirty-nine per cent of the children were physically examined, with large interfacility variations. In 71% of the children malaria was diagnosed, either as a single condition or in combination with others, and with respiratory problems as the leading overlapping condition (29%). Malaria parasites were found in 38% of the cases given a malaria diagnosis. A total of 81% of the health facility prescriptions included analgesics, 71% chloroquine and 54% antibiotics. A fourth of all prescriptions were injections. The proportions of chloroquine and antibiotic injections in relation to the total number of prescriptions varied between the facilities. Of the 529 blood samples successfully analysed for chloroquine, 98% had detectable blood drug levels. Ninety-seven per cent of the children without history of prior chloroquine treatment had detectable drug levels in the blood, 11% had high levels (>or= 1000 nmol/l). Of those prescribed chloroquine, 16% already had high blood concentrations of the drug. Health care services, i.e. presumptive malaria diagnosis, consultation time and procedure for physical examination need to be improved.

An integrated nursing and telemedicine approach to vascular care.

We have developed a telemedicine approach to vascular care for patients being managed in primary care. District nurses visit patients in their homes. Clinical information and digital photographs can be sent by email to the vascular surgeon for assessment. Where appropriate a preliminary teleconsultation between the patient and a vascular surgeon, with the nurse in attendance, is held at the primary care centre and the management of the patient is agreed. This may include referral to surgery. Over eight months six patients with diabetes and peripheral ulcers participated in the vascular telemedicine clinic. The average consultation time was 12 min (SD 4), which included discussion of the case and negotiation of its management. Important outcomes of the new system were the ability to schedule patients for rapid referral and to have completed the management of the case during the teleconsultation.

Prescribing habits in church-owned primary health care facilities in Dar Es Salaam and other Tanzanian coast regions.

To assess prescribing practice of Primary Health Care (PHC) workers in church owned health care facilities using WHO drug use indicators. A cross-sectional study in which twenty primary health care facilities were randomly selected. Prescribing indicators were obtained by analysing outpatient records retrospectively for the past 14 months between January 1997 and February 1998. This period was chosen because of compete records of outpatient attendances. Patient care and facility indicators were recorded prospectively during the study period. The study was conducted in the Coast and Dar es Salaam regions of Tanzania. Six districts were randomly selected from both regions. The selected districts included Ilala, Temeke and Kinondoni in Dar es Salaam, Kibiti, Bagamoyo and Kisarawe in Coast region. Twenty primary health care facilities were randomly selected from the chosen districts. Patient registers were collected and patients' characteristics including age, sex, diagnosis, and drugs prescribed for the period January 1997 to February 1998 were recorded on data collection forms. Patient care indicators were measured by recording consultation time, dispensing time, per cent of drugs actually dispensed and adequately labelled whereas patients' knowledge of correct drug dosage was obtained using exit interviews. Verification of facility indicators was done by direct observation. The average number of drugs per prescription was 2.3 (range 1.8-2.8). Generic prescribing prevailed with a mean of 75.5% of all drugs. Antibiotic and injection encounters per prescription was 35.4 and 19%, respectively. Most drugs were prescribed according to the essential drug list of Tanzania (NEDLIT). Patient's average consultation time was 3.6 minutes whereas average dispensing time was 39.9 seconds. On average, 87% of all drugs dispensed were adequately labelled and patients' knowledge of correct dose was adequate. All facilities possessed drugs for treating important illnesses, all had reference educational materials. The study shows that there is an overuse of injections 19% +/- 1.7 (range 0.73%) compared to the recommended figure of 15%. The use of antibiotics appears appropriate when compared with the morbidity patterns in the study areas. A focus group discussion with prescribers in these facilities to address the question of overuse of injections is needed in order to plan an appropriate intervention.

Study of the quality of care at a diabetic clinic in Sri Lanka.

The aim was to study the quality of care at a diabetic clinic of a large hospital in Sri Lanka; a sample of 200 patients was randomly selected. A questionnaire was designed to assess patient knowledge of diabetic management and service provision. Clinic attendance records were also used. Measures of outcome were taken to be (i) the patient's level of understanding of their condition, (ii) the availability of diagnostic tests, (iii) the provision of regular screening and (iv) the length of consultation time. The average attendance at each four-hour clinic was 174 patients. With three doctors available, average consultation time was four minutes per patient. Procedures undertaken included measuring blood glucose levels, testing for proteinuria and screening for hyperlipidaemia, hypertension and eye disease. The average score for knowledge regarding management and complications, obtained from analysis of the questionnaire, was 5.3 out of a maximum of 9.0 points. The study showed that the quality of care of diabetic patients did not meet the standards that should be expected. Two of the principal problems were lack of good organisation and poor planning of resource utilisation. An increase in funding would, of course, assist in implementing the improvements suggested.

An analysis of the teaching techniques used in diabetic specialist consultations

We attempted to explore the teaching practices of 11 senior diabetic specialists consulting in a out-patient hospital setting and known to have a strong commitment to patient education. The survey consisted of a questionnaire dealing with the duration and distribution of speaking time, the classification of questions, the type of oral questions asked of patients, written materials, teaching aids, demonstrations, if any, care techniques used, and whether or not information was summarized. Our study of 44 consultations showed an average consultation time of 26±10 min and a balanced sharing of speaking time. The percentage of consultations during which no questions were asked depended on the type and classification of test questions, i.e. oral questions to check knowledge (13.6%), open-ended problem-solving questions (27.3%) or problems involving written materials (54.5%). One to two problems involving open-ended questions were set during 36.4% of the consultations and one to two problems involving written materials were set in 20.5% of the cases; visual aids prepared in advance took a back seat to sketches made during the consultation itself. Information was summed up by the caregiver 75% of the time, and 50% with the patient’s help. Our results indicate a patient education orientation during consultations and help to design a standard model formation combined teaching/treatment consultations.

Do minutes count? Consultation lengths in general practice.

To document the variability in consultation length and to examine the relative weight of different kinds of characteristics (of the patients, of the general practitioner (GP), or of the practice) in affecting consultation length, and, thus, to assess whether consultation length can legitimately be used as a quality marker. A multilevel statistical analysis of 836 consultations across 51 GPs in ten practices. Ten general practices across four regions in England with varying list sizes, number of partners and fundholding status. Length of time face-to-face with patients in consultation measured in minutes and fractions of minutes. There is substantial inter-practice variation in consultation length, from a mean of 5.7 minutes to one of 8.5 minutes. In some practices the longest average GP consultation time is about twice that of the shortest. Trainees and new partners spend, on average, about 1 minute less than their longer-serving colleagues. Consultation lengths for individual GPs range from a mean of 4.4 minutes to 11 minutes. Late middle-aged women (55-64 years) receive the longest consultations, followed by elderly people, with children receiving the shortest consultations. The number of topics raised affects the length of the consultation by about 1 minute per additional topic. When female patients consult female GPs, approximately 1 minute is added to the average consultation. A significant fraction of the variability in consultation lengths can be explained in terms of characteristics of patients, of GPs and of practices. The fact that there is little unexplained variation in GP consultation lengths that might be attributable to variations in quality (i.e. GP-related) throws doubt on the proposition that length of consultation can be used as a marker for quality of consultation in general practice.

Quality of life assessment in daily clinical oncology practice: a feasibility study

Quality of life (QL) assessments are increasingly being included in clinical trials, but their use in clinical practice is still uncommon. The objectives of this study were to investigate the feasibility of introducing individual QL assessments into the daily routine of an out-patient oncology clinic, and the potential impact of such assessments on doctor–patient communication. The study sample included six physicians and 18 of their patients from the out-patient clinic of the Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital in Amsterdam, The Netherlands. For each patient, three follow-up consultations were observed. The first visit was employed for the purpose of a baseline measurement. At the two subsequent visits, the patients were asked to complete the EORTC QLQ-C30, a standardised cancer-specific QL questionnaire. The patients’ responses were computer-scored and transformed into a graphic summary. The summary included current scores as well as those elicited at the previous visit. Both the physicians and the patients received a copy of the summary just prior to the medical consultation. Completing, scoring and printing the QL data could be done during waiting room time. The availability of the summary did not lengthen the average consultation time. A small increase was noted in the average number of QL issues discussed per consultation. However, the most notable trend was the increased responsibility taken by the physicians in raising specific QL issues for discussion. When the QL summary was available, the physicians raised three times as many topics than was the case prior to its use ( P<0.05). All six physicians and the majority of patients believed that the QL summary facilitated communication, and expressed interest in continued use of the procedure. The introduction of individual QL assessments in routine out-patient oncology practice is feasible and appears to stimulate physicians to inquire into specific aspects of the health and well-being of their patients. However, given the methodological limitations of this pilot study, the results should be interpreted with caution.

Drug utilization and antibiotic use in the primary health care centres in Sharjah

Drugutilization and antibiotic use in the primary health care centres in Sharjah were studied before and after an intervention by the Antibiotics Control Committee. Prescriptions and patient records were reviewed and analysed based on World Health Organization methodology. Before intervention, the average number of drugs per prescription was 2.8, the average consultation time was 10.8 minutes, the average dispensing time was 89 seconds and 92% of visits resulted in a prescription, of which antibiotics constituted 45%. Following intervention, the percentage of prescriptions with antibiotics and the percentage of visits resulting in a prescription were significantly reduced

A Study of Queues and Appointment Systems in Hospital Out-Patient Departments, with Special Reference to Waiting-Times

Summary An investigation, based on the use of random numbers, has been made into the kind of queueing process occurring in hospital out-patient departments. Special attention has been paid to the patients’ waiting time and also to the time which a consultant may waste waiting for the next patient. As compared with many appointment systems at present in use, it is concluded that by suitable choice of the system to be adopted a substantial amount of the patients’ waiting time may be eliminated without appreciably affecting the consultant. A recommended procedure is to give patients appointments at regular intervals, each equal to the average consultation time; the consultant commencing work when the second patient arrives. The effect of variations in the appointment interval, the number of patients attending the clinics, and the distribution of queue-size are discussed. The precision of the results obtained is also considered.