Patterns of Medical Care: A Hospital's Outpatients

Closing the clinics: would it close the teaching hospital?

To improve their overall financial position, many teaching hospitals have considered decreasing the size of their clinics. To assess the effect this would have on the inpatient service, the medical ward service of The New York Hospital was studied during the 1981 to 1982 academic year. In 50 percent of hospitalizations, patients were enrolled in the clinic system before admission. In an additional 19 percent of hospitalizations, patients had either been previously seen in the emergency room or hospitalized at this institution, but never seen in a clinic. In the remaining 31 percent of hospitalizations, the patient's admission was the first contact with the institution. This group of "new" patients simply replaced the patients who died (14 percent) or were lost to the system through transfer to chronic-care facilities (11 percent) or referral to community physicians (7 percent). Twenty percent of patients discharged to a clinic were readmitted during the study year as opposed to only 3 percent of patients who were transferred to chronic-care facilities or referred to community physicians. The clinic system is the principal source of referral into the ward service and the most effective mechanism for insuring that a patient needing rehospitalization returns to the hospital. It is concluded that major reduction of clinic size will result in severe contraction of the inpatient service.

Affiliations with medical care providers

Two analytical techniques are applied to a household survey of Rhode Island residents to develop the concept of an affiliation with medical care provider. A modification of a deviant case analysis is used to examine those people who are extreme in terms of the numbers of affiliations that they have with medical care providers. Overall, 4.1% of the sample have no affiliations and 7.3% have four or more affiliations. One of the most important variables in distinguishing those people with an unusual number of affiliations is a subjective variable of health status--whether they worry about their health. Nonparticipants rarely worry about their health and are generally in good health, while those with a high number of affiliations worry a great deal, regardless of their actual health status. A multiple regression analysis reveals that the variables of number of health conditions, sex, insurance, worry about health, income, disability days, and family structure are significantly related to mean number of affiliations with an R2 of 19.5%. Discussion includes the study's implications both for greater understanding of how and why people seek care and for application in the further development of a social psychological model of health behavior.

Primary health care in an academic medical center

In 1975-76 a one-year longitudinal study of the delivery of primary care services was carried out at all ambulatory institutional facilities in Durham County, North Carolina and in 47 of 50 community private practices covering the broad fields of surgery (including urology and orthopedics), medicine, pediatrics, and ob/gyn. The present paper focuses on the private and public clinics of Duke University Medical Center. Data were analyzed to document differentials in sociodemographic characteristics of patients attending these two systems of care. Results showed that patients attending the private clinics are predominantly white and covered by private insurance, while patients attending the public clinics are predominantly black and heavily dependent on Medicaid coverage. The potentially detrimental effects of a two-class system of care on the health of patients, as well as on the education of students, is discussed in the context of a scant medical literature on this subject.

The teaching hospital and primary care. Closing down the clinics

Hospitals have become major providers of primary medical care by default rather than design because of the decreasing availability of primary physicians in community practice. In 1972, Beth Israel Hospital in Boston closed its traditional general clincs and estblished a primary-care group practice--Beth Israel Ambulatory Care. The practice is staffed by teams of full-time salaried physicians, other health professionals and paraprofessionals, house staff and medical students. More than 25 per cent of patient visits are managed by nonphysicians. Subspecialty clinics have been relieved of primary-care case loads and limited to referral and consultative functions. In 1973-74, the cost per visit was $20.32. Patient-visit volume in primary care has increased from a figure of 29,144 in 1971-72 to 41,650 in 1973-74. Broken appointments have declined by one third.