Reduction In Consultations Research Articles

Mixed-method evaluation study of a targeted mass drug administration of long-acting anti-malarials among children aged 3 months to 15 years in the Bossangoa sub-prefecture, Ouham, Central African Republic, during the COVID-19 pandemic

BackgroundIn 2020, during the COVID-19 pandemic, Médecins Sans Frontières (MSF) initiated three cycles of dihydroartemisin-piperaquine (DHA-PQ) mass drug administration (MDA) for children aged three months to 15 years within Bossangoa sub-prefecture, Central African Republic. Coverage, clinical impact, and community members perspectives were evaluated to inform the use of MDAs in humanitarian emergencies.MethodsA household survey was undertaken after the MDA focusing on participation, recent illness among eligible children, and household satisfaction. Using routine surveillance data, the reduction during the MDA period compared to the same period of preceding two years in consultations, malaria diagnoses, malaria rapid diagnostic test (RDT) positivity in three MSF community healthcare facilities (HFs), and the reduction in severe malaria admissions at the regional hospital were estimated. Twenty-seven focus groups discussions (FGDs) with community members were conducted.ResultsOverall coverage based on the MDA card or verbal report was 94.3% (95% confidence interval (CI): 86.3–97.8%). Among participants of the household survey, 2.6% (95% CI 1.6–40.3%) of round 3 MDA participants experienced illness in the preceding four weeks compared to 30.6% (95% CI 22.1–40.8%) of MDA non-participants. One community HF experienced a 54.5% (95% CI 50.8–57.9) reduction in consultations, a 73.7% (95% CI 70.5–76.5) reduction in malaria diagnoses, and 42.9% (95% CI 36.0–49.0) reduction in the proportion of positive RDTs among children under five. A second community HF experienced an increase in consultations (+ 15.1% (− 23.3 to 7.5)) and stable malaria diagnoses (4.2% (3.9–11.6)). A third community HF experienced an increase in consultations (+ 41.1% (95% CI 51.2–31.8) and malaria diagnoses (+ 37.3% (95% CI 47.4–27.9)). There were a 25.2% (95% CI 2.0–42.8) reduction in hospital admissions with severe malaria among children under five from the MDA area. FGDs revealed community members perceived less illness among children because of the MDA, as well as fewer hospitalizations. Other indirect benefits such as reduced household expenditure on healthcare were also described.ConclusionThe MDA achieved high coverage and community acceptance. While some positive health impact was observed, it was resource intensive, particularly in this rural context. The priority for malaria control in humanitarian contexts should remain diagnosis and treatment. MDA may be additional tool where the context supports its implementation.

Qualidade da atenção primária à saúde da pessoa idosa durante a pandemia da covid-19: uma revisão sistemática

Abstract Objective To evaluate the quality of primary healthcare services for older adults during the COVID-19 pandemic through studies evaluating health services. Method A systematic literature review was conducted. The search for articles covered the databases Web of Science, Embase, Scopus, and Medline/Pubmed. Original scientific articles with a case-control or cross-sectional design, involving populations that included older adults, focusing on primary healthcare, and assessing the quality of health services were included. Exclusion criteria were studies without specific analysis for older adults, studies evaluating health access or economic evaluation of health. The risk of bias analysis was conducted according to JBI protocols, and data synthesis was performed using SWiM guidelines. Results Seven studies were included in the review. The primary care services evaluated were mostly outpatient, with diverse quality assessment parameters related to individual care. The evaluation of quality identified a decrease in in-person consultations and visits, and an increase in the use of telehealth, with good satisfaction ratings among older adults. Conclusion The studies highlighted the difficulties maintaining and accessing in-person services during the COVID-19 pandemic, which directly contributed to a reduction in consultations and exams, usage of and access to health services, and the quality of primary healthcare.

Changes to consultations and diagnosis of osteoarthritis in primary care during the COVID-19 pandemic

General practitioners (GP) are often the first medical professionals to treat musculoskeletal complaints. Yet the impact of COVID-19 on primary care utilisation for musculoskeletal complaints is largely unknown. This study quantifies the impact of the pandemic on primary care utilisation for musculoskeletal complaints and specifically osteoarthritis (OA) in the Netherlands. We extracted data on GP consultations in 2015-2020 from 118,756 patients over 45 years of age and estimated reductions in consultations in 2020 as compared to 5-year average. Outcomes were GP consultations for: any musculoskeletal complaints, knee and hip OA, knee and hip complaints, and newly diagnosed knee and hip OA/complaints. The relative reductions in consultations ranged from 46.7% (95% confidence intervals (CI): 43.9-49.3%) (all musculoskeletal consultations) to 61.6% (95% CI: 44.7-73.3%) (hip complaints) at the peak of the first wave, and from 9.3% (95% CI: 5.7-12.7%) (all musculoskeletal consultations) to 26.6% (95% CI: 11.5-39.1%) (knee OA) at the peak of the second wave. The reductions for new diagnoses were 87.0% (95% CI: 71.5-94.1%) for knee OA/complaints, and 70.5% (95% CI: 37.7-86.0%) for hip OA/complaints at the peak of the first wave, and not statistically significant at the peak of the second wave. We observed 47% reduction in GP consultations for musculoskeletal disorders during the first wave and 9% during the second wave. For hip and knee OA/complaints, the reductions were over 50% during the first, and 10% during the second wave. This disruption may lead to accumulation of patients with severe OA symptoms and more requests for arthroplasty surgery.

Effect of the COVID-19 pandemic on the mental health, daily and occupational activities among health professionals in Colombia: a national study

BackgroundThe COVID-19 pandemic has placed an unprecedented physical and mental burden on healthcare workers who are frequently at high risk of infection, particularly in low-income countries. This study aimed to assess the prevalence and associated factors of anxiety, depression, and stress, as well as changes in daily and occupational activities among healthcare professionals due to the COVID-19 pandemic in Colombia.MethodsAn observational, cross-sectional study was conducted between February and June 2021. The survey incorporated validated mental health tools such as the Generalized Anxiety Disorder–7, the Patient Health Questionnaire-9, and the Perceived Stress Scale-10. Multivariable ordinal logistic regression analysis was performed to determine the factors associated with severe mental health outcomes.ResultsAmong 1345 healthcare workers the prevalence of anxiety, depression, and stress were 75.61, 59.18, and 53.09%, respectively. Anxiety (OR:1.44; 95%CI:1.16–1.8), depression (OR:1.74; 95%CI:1.27–2.37), and stress (OR:1.51; 95%CI:1.18–1.94) were more frequent in women, and individuals who expressed fear of a negative outcome (death, sequelae) (OR:2.25; 95%CI:1.60–3.25), (OR:1.49; 95%CI:1.03–2.16) and (OR:2.36; 95%CI:1.69–3.29) respectively. Age was negatively associated with anxiety (OR:0.98; 95%CI:0.98–0.99), stress (OR:0.98; 95%CI:0.97–0.99), and depression (OR:0.97; 95% CI:0.96–0.98). Reduction in consultations and surgeries (OR:1.01; 95%CI:1.0–1.01) was positively associated with anxiety. Due to the pandemic, most specialists expected to incorporate drastic long-term (> 1 year) changes in their clinical setting and daily activities.ConclusionsThe prevalence of anxiety, depression, and stress is higher among Colombian healthcare workers compared to previous reports. Further research regarding these psychological outcomes is needed to achieve early mental health intervention strategies.Trial registrationHospital Universitario Fundación Santa Fe, Ethical Committee Registration ID: CCEI-12992-2021.

Mental health benefits of cohabitation and marriage: A longitudinal analysis of Norwegian register data

The aim is to examine how mental health is affected by cohabitation and marriage. Individual fixed-effects models are estimated from Norwegian register data containing information about consultations with a general practitioner because of mental health conditions in 2006–19. Mental health, as indicated by annual number of consultations, improves over several years before cohabitation. For those marrying their cohabiting partner, there is a weak further reduction in consultations until the wedding, but no decline afterwards. In other words, formalization of the union does not seem to confer additional mental health benefits. However, marriage may be considered a marker of favourable earlier development in mental health. In contrast, there is further improvement after direct marriage, as well as stronger improvement over the years just preceding direct marriage. Patterns are quite similar for women and men. Overall, the results suggest that the mental health benefits of cohabitation and marriage are similar. Supplementary material for this article is available at: https://dx.doi.org/10.1080/00324728.2022.2063933. Note: numbers in brackets refer to supplementary notes that can be found at the end of the supplementary material.

Proctologic emergency consultation during COVID-19: Comparative cross-sectional cohort study

IntroductionProctologic issues entail a frequent reason for consultation in the emergency department (ED). We aim to analyze how the SARS-COV-2 pandemic has impacted in the demand for proctological consultations. Material and methodDescriptive comparative retrospective study of cross-sectional cohorts of patients attending the ED for proctological complaints from March to April in 2020 and 2019. Demographic variables, comorbidities, reasons for consultation and diagnosis, treatment and readmission were included. Four periods were analyzed according to the different stages of the pandemic derived limitations. ResultsA total of 191 patients were reviewed, 58 in 2020 and 133 in 2019 with an average age of 48 years (SD 20.1) and 112 (58.6%) males. The average number of daily consultations was 2.18 patients in 2019 versus 0.95 in 2020 (p=0.025) meaning a 56% reduction in consultations for proctological reasons. This difference in average consultations was significant in both periods of lockout (p=0.001) and previous de-escalation (p=0.014). The diagnosis distribution was similar between both periods; however, perianal abscesses doubled their rate in 2020, 22.4% versus 11.3% (p=0.045). There was an increasing need for surgery, 31% vs 15% (p=0.011) with no difference in outpatients regimen after emergency surgery (12.5% vs 7.5%, p=0.201). Three patients in 2020 required readmission to the ED (5.2% vs 12.9%, p=0.086). ConclusionThere was a decrease of a 56% in proctologic emergency consultation, however, the need for surgery was twice more frequent during the study period. Reflection on the use of emergencies for proctological reasons is warranted.

Small animal disease surveillance 2020/21: SARS-CoV-2, syndromic surveillance and an outbreak of acute vomiting in UK dogs.

Small animal disease surveillance 2020/21: SARS-CoV-2, syndromic surveillance and an outbreak of acute vomiting in UK dogs.

COVID-19 Concerns Among Old Age Psychiatric In- and Out-Patients and the Employees Caring for Them, a Preliminary Study.

A questionnaire was administered to 14 patients admitted at the Department of Old Age Psychiatric 24-h unit at Oslo University Hospital with questions about experiences and fears regarding COVID-19. A similar adjusted questionnaire was administered to 19 outpatients. The purpose was to investigate if the patients had fears, anxieties, and quality of life issues related to COVID-19 that could affect their treatment. A quest back questionnaire with similar questions about patient care and work conditions was sent to the personnel working with these patients, and 46 of 81 responded. Most patients welcomed the strict measures that were applied, including a visitation ban for inpatients and a reduction in consultations for the outpatients. Most patients reported that they were not very scared of getting COVID-19, nor did many believe that they would die if they were infected. A minority of patients reported being very worried. The patients also differed on other issues related to the COVID-19 situation. A minority were negative to the interventions, rules, and regulations, and/or considered the risk of infection to be elevated at the clinic, and/or that the quality of their daily life was negatively impacted. Employees more often than patients were concerned about the COVID-19 influence on their health. They were also concerned about being at work amid the crisis. About half of their comments were related to the fear of inadvertently infecting patients with COVID-19. Also, a majority complained about aspects related to the implemented COVID-19 guidelines. This study is explorative in nature, mainly due to its small sample size, which makes it difficult to draw conclusions from the results. However, the results imply a need for addressing the COVID-19 concerns of both patients and employees, to prevent potential negative effects on treatment and overall life quality. Future research should investigate the self-reported effects of the pandemic situation on a larger sample size of elderly psychiatric patients.

Proctologic emergency consultation during COVID-19: Comparative cross-sectional cohort study

IntroductionProctologic issues entail a frequent reason for consultation in the emergency department (ED). We aim to analyze how the SARS-COV-2 pandemic has impacted in the demand for proctological consultations. Material and methodDescriptive comparative retrospective study of cross-sectional cohorts of patients attending the ED for proctological complaints from March to April in 2020 and 2019. Demographic variables, comorbidities, reasons for consultation and diagnosis, treatment and readmission were included. Four periods were analyzed according to the different stages of the pandemic derived limitations. ResultsA total of 191 patients were reviewed, 58 in 2020 and 133 in 2019 with an average age of 48 years (SD 20.1) and 112 (58.6%) males. The average number of daily consultations was 2.18 patients in 2019 versus 0.95 in 2020 (p=0.025) meaning a 56% reduction in consultations for proctological reasons. This difference in average consultations was significant in both periods of lockout (p=0.001) and previous de-escalation (p=0.014). The diagnosis distribution was similar between both periods; however, perianal abscesses doubled their rate in 2020, 22.4% versus 11.3% (p=0.045). There was an increasing need for surgery, 31% vs 15% (p=0.011) with no difference in outpatients regimen after emergency surgery (12.5% vs 7.5%, p=0.201). Three patients in 2020 required readmission to the ED (5.2% vs 12.9%, p=0.086). ConclusionThere was a decrease of a 56% in proctologic emergency consultation, however, the need for surgery was twice more frequent during the study period. Reflection on the use of emergencies for proctological reasons is warranted.

Satisfaction with care and adherence to treatment when using patient reported outcomes to individualize follow-up care for women with early breast cancer – a pilot randomized controlled trial

Background: The population of breast cancer survivors is increasing as a positive consequence of early detection and enhanced treatment. The disease and treatment associated side-effects or late-effects often impact on quality of life and daily life functions during survivorship. This calls for optimization of follow-up care. We aimed to evaluate the patients’ satisfaction with the care provided, when using electronic patient reported outcomes (ePROs) to individualize follow-up care in women with early breast cancer receiving adjuvant endocrine therapy.Material and methods: Postmenopausal women treated for hormone receptor positive early breast cancer were included in a pilot randomized controlled trial and randomized to receive standard follow-up care with prescheduled consultations every six months or individualized follow-up care with the active use of ePROs to screen for the need of consultations. ePROs were distributed every third month over a two-year period. Primary outcomes were satisfaction with the assigned follow-up care and unmet needs. Secondary outcomes were use of consultations, adherence to treatment and quality of life.Results: Of the 207 consecutive patients who were potentially eligible for the study, 134 women were enrolled (65%). In total 64 women in standard care and 60 women in individualized care were analyzed. No statistically significant differences were reported in relation to satisfaction, unmet needs, adherence to treatment or quality of life. Women in standard care attended twice as many consultations during the two year follow-up period as women in individualized care; 4.3 (95% CI 3.9–4.7) versus 2.1 (95% CI: 1.6–2.6), p < .001.Conclusion: A significant reduction in consultations was observed for the group attending individualized care without compromising the patients’ satisfaction, quality of life or adherence to treatment. For the majority of postmenopausal women treated for early breast cancer, implementation of ePROs to individualize follow-up care was feasible.

A study on reduction in consultations of patients with mild symptoms in outpatient sections of large hospitals：The influence of hospital functions and regional medical systems

A study on reduction in consultations of patients with mild symptoms in outpatient sections of large hospitals：The influence of hospital functions and regional medical systems

Reduced neonatal lung function and wheezing illnesses during the first 5 years of life

Studies of reduced neonatal lung function and wheezing illnesses during childhood show conflicting results. The aim of our study was to assess the association between resistance (Rrs) and compliance (Crs) of the respiratory system by using the single occlusion technique (SOT) and prospectively collected wheezing illnesses during the first 5 years of life in a large birth cohort. SOT was performed during natural sleep before the age of 2 months. Information about wheezing illnesses was collected from the electronic patient file. 549 infants had a successful SOT measurement and complete medical records. Every kPa·L(-1)·s(-1) increase in Rrs was associated with 10% more consultations in the first 3 years of life. Every 10 mL·kPa(-1) increase in Crs was associated with a 14% reduction in consultations in the first 3 years of life, 27% in the fourth to fifth years of life, and a lower probability of having asthma at the age of 5 years (OR 0.66). Children with late-onset or persistent wheezing had significant lower Crs values than their peers. An increased neonatal resistance is associated with more wheezing illnesses during infancy, while a reduced neonatal compliance is associated with more wheezing illnesses during the first 5 years of life, a late-onset or persistent wheezing phenotype, and asthma.

Contaminación del aire en la Florida (Talca, Chile): Beneficios económicos en salud por la reducción de los niveles PM10

Environmental air pollution is associated with a higher incidence of respiratory diseases, absenteeism and costs.To model the health related economic benefits associated to a reduction in air pollution and the resulting lower prevalence of respiratory diseases, in a Chilean city.A time series model for year 2006 was elaborated. The dependent variable was the number of consultations for respiratory disease. The independent variables were air pollution expressed as particulate matter of 10 micrometers or less (PM₁₀), minimum and maximum environmental temperatures, environmental humidity and number of consultations for chronic diseases.The variables that best explained the number of consultations for respiratory diseases were PM₁₀, minimal environmental temperatures and preexisting respiratory diseases. In a hypothetical scenery of a 67% reduction in PM₁₀, 69% of medical consultations for respiratory diseases would be avoided. This would result in a net saving of US$ 345,000 per year.The reduction in PM₁₀ emissions would result in an important reduction in consultations for respiratory diseases and monetary savings.

Hypothetical health and economic benefits associated with a reduction in air pollution in a Chilean city (Talca)

Environmental air pollution is associated with a higher incidence of respiratory diseases, absenteeism and costs. To model the health related economic benefits associated to a reduction in air pollution and the resulting lower prevalence of respiratory diseases, in a Chilean city. A time series model for year 2006 was elaborated. The dependent variable was the number of consultations for respiratory disease. The independent variables were air pollution expressed as particulate matter of 10 micrometers or less (PM₁₀), minimum and maximum environmental temperatures, environmental humidity and number of consultations for chronic diseases. The variables that best explained the number of consultations for respiratory diseases were PM₁₀, minimal environmental temperatures and preexisting respiratory diseases. In a hypothetical scenery of a 67% reduction in PM₁₀, 69% of medical consultations for respiratory diseases would be avoided. This would result in a net saving of US$ 345,000 per year. The reduction in PM₁₀ emissions would result in an important reduction in consultations for respiratory diseases and monetary savings.

Descripción de los tres primeros brotes de gripe A (H1N1) 2009 notificados en prisiones de España

This study describes three reported outbreaks of influenza H1N1 2009 in Spanish prisons between july and september 2009. An outbreak was defined as the appearance of three or more cases with influenza symptoms and with an epidemiological link in the same module of a prison. The outbreaks were reported using a specific questionnaire. The analysis, which used variables of gender, age, date of notification, duration of outbreak, risk factors and clinical features are presented as absolute numbers, percentages and attack rates, while study of the diffusion of the illness is expressed as epidemic curves. Three outbreaks were reported at the prisons of Alcala-Meco (85 affected males), Pamplona (18 affected males) and Jaen (12 affected females) with an overall attack rate that ranged from 7.1% to 17.9%. Duration of the outbreaks was between 8 and 35 days, and the average duration of the illness itself was 3 days. Only 4 inmates were admitted who were later given discharges for recovery. The men were younger (p<0.001). The epidemiological curves of the outbreaks did not show any clear propagation patterns. The attack rates are highly variable although they are lower than other community outbreaks. Symptoms were slight and lethality was zero. The women's age was significantly greater that that of the men, although it is practically the same amongst the prison population. Low morbidity was very probably the cause of the reduction in consultations of the persons affected and the consequent underestimation of the rates.

Effect of antibiotic prescribing strategies and an information leaflet on longer-term reconsultation for acute lower respiratory tract infection.

Limited evidence suggests that delayed prescribing may influence future consultation behaviour. To assess the effects of antibiotic prescribing strategy on reconsultation in the year following presentation with acute lower respiratory tract infection (LRTI). Balanced factorial randomised trial. Primary care. Eight hundred and seven subjects, aged>or=3 years, had acute illness presenting with cough as the main symptom, plus at least one symptom or sign from sputum, chest pain, dyspnoea or wheeze. The subjects were randomised to one of three prescribing strategies (antibiotics, delayed antibiotic, no antibiotic) and a leaflet. Prior antibiotic use and reconsultation were assessed by medical record review. Patients who had been prescribed antibiotic for cough in the previous 2 years were much more likely to reconsult (incidence rate ratio [IRR]=2.55, 95% confidence interval [CI]=1.62 to 4.01) and use of a delayed prescription strategy is associated with reduced reconsultation in this group. In those with prior antibiotic exposure, there was a 34% reduction in consultation rate in the no antibiotic group (IRR=0.66, 0.30 to 1.44, P=0.295) and a 78% reduction for the delayed antibiotic group (IRR=0.22, 0.10 to 0.49, P<0.001) when compared with those given immediate antibiotics. This effect was not observed in patients who had not been prescribed antibiotics in the previous 2 years; there was no reduction in consultations in the no antibiotic group (IRR=1.23, 0.79 to 1.92, P=0.358) or the delayed antibiotic group (1.19, 0.78 to 1.80, P=0.426). There was an increase in consultation rate with an information leaflet (IRR=1.27, 0.86 to 1.87, P=0.229). Past attendance with cough, or past attendance with other respiratory illness and smoking, also predicted reconsultation with cough. Delayed antibiotic prescribing for LRTI appears effective in modifying reconsultation behaviour, particularly in those with a prior history of antibiotic prescription for LRTI.

Age-related changes in consultations and antibiotic prescribing for acute respiratory infections, 1995–2000. Data from the UK General Practice Research Database

International studies using data aggregated for all ages have shown decreasing rates of general practice consultations for acute respiratory infections with fewer antibiotic prescriptions issued per consultation. The occurrence of different respiratory infections varies widely at different ages but we do not know whether prescribing has reduced equally in all age groups. We aimed to determine how reductions in consultation rates and antibiotic prescribing varied with age for different respiratory infections. Data were abstracted from the General Practice Research Database for 108 general practices in the UK (mean registered population 642 685). We estimated age-specific changes between 1995 and 2000 in consultation rates, and the proportion of consultations resulting in an antibiotic prescription for 'all respiratory infections' and for 'sore throat', 'ear infection', 'bronchitis' and 'chest infection'. Consultation rates for 'all respiratory infections' declined in all age groups with the greatest decreases in children aged 1-4 years (41%), 5-10 year olds (53%) and 11-16 year olds (54%), whereas at 75-84 years the reduction was 28%. The pattern of greater reductions in children held for each separate condition even though the age of peak incidence varied. The relative reduction in antibiotic prescribing was greatest at 1-4 years (18%), 5-10 years (17%) and 11-16 years (17%), compared with 5% at 75-84 years. Antibiotic prescribing decreased most for sore throat and this was observed at all ages particularly in 5-10 year olds (relative reduction, 32%). School age children account for the greatest reduction in consultations for acute respiratory infection. School age and preschool children account for the greatest reductions in antibiotic prescribing during the consultation. The rapid changes in consultation rates are unexplained.

Decreasing the number of consultations for minor illnesses of Turkish and Dutch inhabitants of a deprived area in The Netherlands: an intervention study

The purpose of this study was to assess the effectiveness of GPs personally handing out to their patients booklets about minor ailments and self-limiting health problems (minor illnesses). The study was a pre-test-post-test, control group design and took place in seven general practices. The participants were 162 patients (72 Turkish, 70 Dutch and 20 of other nationality) who frequently visit their GP (>5 times a year), living in deprived areas of The Hague. They were recruited in the waiting rooms of participating general practices. GPs personally handed out booklets to their patients about 12 of the most common minor illnesses and explained how to use them. The main outcome measures were consultations for the 12 minor illnesses listed in the booklet, reported by the patients themselves as well as registered in the general practice medical records, and the number of self-reported illnesses the patients suffered from. The results of both the self-report and the medical records show a significant decrease in number of consultations for minor illnesses in the entire research population, Turkish as well as Dutch. The number of self-reported self-limiting health problems of the Dutch increased. Due to the non-randomization procedure, some caution with regard to generalization must be taken. The results indicate that distribution by the GP of booklets with tailored information when a patient is ill leads to a reduction in consultations for minor illnesses.

The influence of SCUD missile attacks on the utilization of ambulatory services in a family practice.

The consulting load in a family practice exposed to SCUD missile attacks during the 1991 Gulf War was compared with the equivalent period in 1990. The rate of visits was cut by half, with a relative and absolute increase in psychological consultations, and a decrease in consultations for infectious and respiratory conditions. There were more urgent consultations and fewer planned appointments. It is suggested that the stress of the SCUD missile attacks led to a reduction in consultations for trivial disorders, but an increase in the anxiety level of the population.

New programme of antenatal care in general practice.

The conclusions from recent analyses of the clinical worth of routine antenatal attendances have been used in the setting of a modern primary health care team. As a result the number of times a low risk nulliparous woman is seen by her general practitioner has been reduced from 15 to eight and a low risk multiparous woman from 15 to six. The number of consultations with a midwife has also been considerably reduced. The time saved is used in longer, more structured consultations and for more intensive care of high risk, usually socially deprived, women. Despite these reductions in consultations organised, well recorded care of this type renders antenatal attendances at a hospital virtually unnecessary for low risk women.