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PubMed2006

Feasibility and validity of International Classification of Diseases based case mix indices.

BACKGROUND: Severity of illness is an omnipresent confounder in health services research. Resource consumption can be applied as a proxy of severity. The most commonly cited hospital resource consumption measure is the case mix index (CMI) and the best-known illustration of the CMI is the Diagnosis Related Group (DRG) CMI used by Medicare in the U.S. For countries that do not have DRG type CMIs, the adjustment for severity has been troublesome for either reimbursement or research purposes. The research objective of this study is to ascertain the construct validity of CMIs derived from International Classification of Diseases (ICD) in comparison with DRG CMI. METHODS: The study population included 551 acute care hospitals in Taiwan and 2,462,006 inpatient reimbursement claims. The 18th version of GROUPER, the Medicare DRG classification software, was applied to Taiwan's 1998 National Health Insurance (NHI) inpatient claim data to derive the Medicare DRG CMI. The same weighting principles were then applied to determine the ICD principal diagnoses and procedures based costliness and length of stay (LOS) CMIs. Further analyses were conducted based on stratifications according to teaching status, accreditation levels, and ownership categories. RESULTS: The best ICD-based substitute for the DRG costliness CMI (DRGCMI) is the ICD principal diagnosis costliness CMI (ICDCMI-DC) in general and in most categories with Spearman's correlation coefficients ranging from 0.938-0.462. The highest correlation appeared in the non-profit sector. ICD procedure costliness CMI (ICDCMI-PC) outperformed ICDCMI-DC only at the medical center level, which consists of tertiary care hospitals and is more procedure intensive. CONCLUSION: The results of our study indicate that an ICD-based CMI can quite fairly approximate the DRGCMI, especially ICDCMI-DC. Therefore, substituting ICDs for DRGs in computing the CMI ought to be feasible and valid in countries that have not implemented DRGs.

Diagnosis-Related Groups↗
PubMedDate not supplied

Percutaneous transluminal angioplasty in the treatment of renovascular hypertension: sequential prospective study.

OBJECTIVE: To evaluate the use of percutaneous transluminal renal angioplasty (PTRA) in the treatment of renal vascular hypertension. DESIGN: Sequential prospective PTRA treatment of severe arterial hypertension, screening by the captopril test, confirmed by renal arteriography, and the result evaluated by post-PTRA arteriography, blood pressure measurement and renal function. SITE: Vascular Surgery, angioradiology sector, and Nephrology outpatients department of the Federal University of São Paulo-Paulista School of Medicine, São Paulo, Brazil, a tertiary health-care institution. PARTICIPANTS: PTRA was employed on 32 patients screened by clinical examination, captopril test and renal arteriography. EVALUATION: PTRA results were evaluated by the criteria of the Cooperative Study of Renovascular Hypertension. RESULTS: After PTRA the completion arteriography showed no renal stenosis in 24 patients (75%), residual stenosis (20-50%) in 3 (9.4%) and no change in 5 (15.6%). The blood pressure results were: 3 patients (9.4%) were cured, 24 (75%) improved and 5 (15.6%) were unchanged. We observed normal renal function before and after PTRA in 25 patients (78%); altered pre- and improved post-PTRA in 2 (6.3%); post-PTRA remained unaltered in 2 (6.3%); and altered pre- and worsened post-PTRA in 3 (9.4%). Recurrence of stenosis occurred in one patient after 8 months. CONCLUSIONS: PTRA is a convenient procedure, relatively safe and an effective complementary method of medical therapy for controlling renovascular hypertension.

Aged↗
PubMed1992

Work-related mesothelioma in Québec, 1967-1990.

Prior surveys of malignant mesothelioma in Québec have noted that almost all the excess in occupational exposure related mesothelioma was in the manufacture and industrial application of asbestos rather than in the mining and milling operations. To evaluate the current status of malignant pleural mesothelioma in the Québec workforce, we reviewed all cases of pleural mesothelioma seen and accepted by the Québec Workman's Compensation Board (CSST) for work related compensation of industrial disease. We identified 120 cases, 7 of whom were females. They were of an average age of 59 +/- 8.5 yrs (sd) (range 42-84); they were exposed to asbestos dust in the workplace for an average of 26 +/- 14.3 yrs (range 0.5-50). The cases were subdivided into 3 groups according to workplace asbestos exposures. There were 49 cases originating in the mines and mills of the Québec Eastern Township region (primary industry, group 1), 50 cases from the manufacture and industrial application sector (secondary industry, group 2), and 21 cases from industries where asbestos was not a major work material, often an "incidental" material (tertiary industry, group 3). Group 1 was of an average age of 62 +/- 8 years, exposed to asbestos dust 31 +/- 14 years and the distribution of exposure time was as follows: 15% cases with < or = 10 year-exposure and 77% > or = 25 year-exposure. In group 2, the age was significantly lower at 57 +/- 9 years; the exposure time was also significantly lower at 22 +/- 14 years, and the distribution of exposure time differed from the above (29% cases with < or = 10 year-exposure and 48% > or = 25 year-exposure). In group 3, the average age was 58 +/- 7 years, the exposure time was also significantly lower at 28 +/- 12 years and the distribution of exposure time differed from the above (33% cases with < or = 10 year-exposure and 62% > or = 25 year-exposure). Analyses of the yearly incidence of new cases in each group documented the general incremental trend in all groups, with the sharpest rises in group 3. In the mining towns of Thetford and Asbestos, the incidence of mesothelioma was proportional to the workforce, thus suggesting that the tremolite air contamination, which is 7.5 x higher in Thetford, may not be a significant determinant of the disease in these workers.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed2002

Clinical issues in aged care: managing the interface between acute, subacute, community and residential care.

Although there is considerable evidence for the use of geriatric assessment and rehabilitation in many clinical settings, there exists relatively poor access in various regions of Australia. There has been considerable growth of community support services to assist in personal care of older people. Unfortunately, a lack of uniform assessment has hindered prioritization of clients, with the resultant need, and delivery, of post-acute hospital care services. In addition, there has been considerable progress in the clinical management of the age dependent disabling problems, such as dementia, osteoporosis, incontinence and falls, but the appropriate mix of funding between primary, secondary and tertiary interventions has not been determined. The health care needs of older people in residential care have been totally neglected, placing the sector at considerable risk. There need to be a fundamental rethink in managing the interface between acute, subacute, community and residential care.

Aged↗
PubMed1992

Economic benefits of secondary and tertiary cardiac rehabilitation: a critical study.

At least seven criticisms have been advanced to those suggesting economic benefit from secondary and tertiary rehabilitation: (i) many existing data sets are weak, (ii) many analyses have been limited to self-selected exercise participants, (iii) the distribution of benefits between different sectors of the economy has been ignored, (iv) programme participation is not necessarily synonymous with economic benefit, (v) the discount rate has been neglected, (vi) opportunity costs have not been considered, and (viii) possible increases in pension costs could outweigh supposed benefits. Although there are limitations in the original calculations of economic benefit, there are also weaknesses in their critique. Cost-effectiveness analysis has some attractions over cost-benefit analysis, because areas of fiscal and ethical uncertainty are avoided. Given that patients who develop chronic diseases will require some form of treatment, exercise offers an attractive option for both secondary and tertiary prevention, particularly if programmes have low facility and opportunity costs, and attention is directed to high-risk segments of the population. The challenge to incorporate the lessons from such analyses into governmental and corporate-decision making.

Cardiac Rehabilitation↗
PubMed2001

1998 survey of cardiac pacing in South Africa--report of the working group on registries of the cardiac arrhythmia society of South Africa (CASSA).

BACKGROUND: Permanent pacemakers provide effective relief of symptoms and are life-saving in patients with symptomatic heart block. Since pacemakers are only implanted by cardiologists or cardiothoracic surgeons in tertiary hospitals, the rates of pacemaker implantation provide a readily auditable measure of tertiary health care. METHODS: A survey was conducted of pacemaker implantation in South Africa in 1998, using questionnaires completed by implanters and information on the total number of pacemakers sold during the period, supplied by pacemaker distributors. RESULTS: A total of 1,643 new pacemakers were implanted in 1998 by 112 doctors working in 31 institutions (9 public and 22 private). The annual implant rate per million population was 39, compared with 31/million in 1995, an increase of 25.8%. Public hospitals accounted for 31.7% of primary pacemaker implants in 1998 as opposed to 37% in 1995. Practice in the public sector differed from that in the private sector in that atrioventricular (AV) block was the major indication for pacing in 75.3% versus 45.3%, whereas sinus node dysfunction accounted for 34.9% of private patients, as opposed to 16.2% of public hospital patients. Simple VVI single-chamber pacemakers accounted for 49.5% of public hospital implants versus only 9.6% in private patients. The reverse was true for dual-chamber implants (12.1% v. 42.3%). Severe cost constraints in the public sector have resulted in increasing use of cheaper single-chamber pacemakers for more stringent indications (predominantly AV block). The overall implant rate remains low compared with a median of 283/million in Europe. Large discrepancies persist between race groups (232/million whites, as opposed to 8.8/million blacks) and regions (89.3/million in the Western Cape versus 10.8/million in the four provinces without pacemaker implanters). CONCLUSION: It is likely that socio-economic factors play a major role in the unequal distribution of this highly effective treatment for potentially lethal bradyarrhythmias. The changing trends in pacemaker implantations indicate a shift of tertiary health care resources from the public to the private sectors.

Data Collection↗
PubMed2005

Cost of curative pediatric services in a public sector setting.

OBJECTIVE: To estimate the cost of ambulatory (out-patient) and in-patient pediatric health services for the year 1999 provided by All India Institute of Medical Sciences (AIIMS) at all the three levels-primary, secondary and tertiary level. METHODS: The costing module developed by Children's Vaccines Initiative (CVI) was used. This rapid assessment tool focuses on collection of data at macro level by using key informants like doctors, nursing staff, accountant, store keeper, engineer etc. Cost per beneficiary was estimated separately for in-patients and out-patients and was calculated by dividing the total cost of the services by the number of beneficiaries for the year 1999. For the out-patient, the beneficiaries were the total out-patient attendees and for the in-patient, it was the total pediatric admissions multiplied by mean duration of stay in days. RESULTS: The cost per out-patient visit was INR.20.2 (US0.44 dollars@1US dollars=INR.46) at primary level, higher than INR14.5 (US0.31 dollars) at the secondary level, while at tertiary level it was INR 33.8 (US 0.73 dollars). At the primary and secondary level, non-physician cost was more than the physician cost, and for tertiary level, physician cost was much higher than the other costs. There were no in-patient services at primary level. The cost of in-patient services at secondary level was estimated as INR 419.30 (US 9.1 dollars) per patient per day with a bed occupancy rate of 60%. Two-fifths of the cost was due to nursing and other supportive staff and one fifth due to the doctor costs and overhead costs. The unit cost of INR 928 (US 20.2 dollars) per patient per day incurred at AIIMS with a bed occupancy rate of 100% was almost twice that of secondary level. In contrast to the secondary level, almost half the total costs at tertiary level was due to the doctors costs. CONCLUSIONS: Effective use of resources at lower level of care especially ambulatory care at primary level and inpatient care at secondary level can result in much higher savings for the system and also, the society. These would need to be appropriately strengthened.

Ambulatory Care↗
PubMed2004

Initial experience of a public sector antiretroviral treatment programme for HIV-infected children and their infected parents.

OBJECTIVE: To describe the initial experience of treating HIV-infected children and their infected parents with antiretroviral therapy. DESIGN: Prospective, cohort study. SETTING: Tertiary, referral hospital. PATIENTS: HIV-infected children and their parents. METHODS: This report focuses on the early response of children to highly active antiretroviral therapy (HAART). Children were followed up at 4-weekly intervals. Monitoring included initial and yearly viral load measurements, baseline and 6-monthly CD4 counts and 4-weekly adherence checks. RESULTS: Between August 2002 and June 2003, 80 children were enrolled in the programme, representing a follow-up period of 23.9 patient-years. Seventy-five children had severe clinical disease, severe immune suppression, or a combination of the two. The response of children who had received HAART for > or = 6 months (N = 17) was assessed. There was no change in mass z-score (p = 0.11) or length z-score (p = 0.37), but a significant increase in CD4 percentage (p < 0.0001) during the first 6 months of therapy. Six-month viral loads were available for 12 children. There was a significant drop in viral load (p = 0.001) and 9 achieved undetectable levels by 6 months. Most children achieved > or = 85% adherence. By June 2002, 67 children (84%) were relatively well, 1 had B-cell lymphoma, 7 (8.8%) had died, 4 (5%) were lost to follow-up and 1 was withdrawn from the programme. Of 57 children who completed 3 months of HAART, 12 were admitted a total of 17 times for infectious complications. There were no severe drug reactions. Three of 7 mothers on HAART received treatment through the programme. CONCLUSION: These initial results suggest that many HIV-infected children in the public sector will benefit from antiretroviral therapy. However, both ambulatory and inpatient facilities are required to manage children on HAART comprehensively.

Adult↗
PubMed1990

The use of two-dimensional Doppler sonography (color Doppler) in the diagnosis of hydranencephaly.

Hydranencephaly, first described by Cruveilhier, may be defined as a rare condition in which the cerebral hemispheres are replaced by membranous sacs filled with cerebrospinal fluid. Cerebral angiography is especially useful in differentiating hydranencephaly and severe hydrocephalus, massive subdural hygromas and alobar holoprosencephaly, but it is no better than other neuroradiological diagnosis methods in the neonate. This report outlines the diagnostic use of two-dimensional Doppler (color Doppler) in a child with hydranencephaly. Color Doppler was performed using an SSA-270A (Toshiba) with a 3.75 MHz phase-array sector scanning probe and no sedation. In this study, color Doppler demonstrated the internal carotid artery in the proximal portion, but the secondary and tertiary branches were not observed. In summary, color Doppler permitted early, easy diagnosis of hydranencephaly. In addition, the use of color Doppler was beneficial in diagnosing other anomalies of the central nervous system in neonates.

Blood Flow Velocity↗
PubMed1997

Validation of outcomes through the analysis of the process-outcome relation: limitations.

Validation of outcomes of different levels of neonatal care through the analysis of the relationship between process and outcome of care was attempted as part of an effectiveness study and quality assurance programme. Adequacy rates and outcome measures were calculated for second- and third-level units and centres according to the babies' level of risk. Differences in adequacy rates were apparently influenced by the differential distribution of babies by care level sectors among maternity centres. The comparison of mortality rates for "treated" and "untreated" subgroups did not show higher mortality rates for the "untreated" subgroups. This finding could be related to the phenomenon of "confounding by indication". Consistency of differences in average rates of adequacy with differences in general outcomes was observed for most subgroups analysed; lack of consistency could be related to low effectiveness. Indications of low effectiveness related to secondary and more so to tertiary level technologies were observed. The study approach was found more useful for comparisons made at the level of maternity services as a whole, where "confounding by indication" does not operate than at the level of sectors.

Brazil↗
PubMed2004

Graduate entry to medical school? Testing some assumptions.

BACKGROUND: Debate abounds regarding the most appropriate candidates to admit to medical school. This paper examines whether there is any advantage to admitting 'graduate' entrants over secondary school leavers on selected medical school and practice outcomes. AIM: To compare the medical school experiences, research and academic achievements and practice outcomes of graduates who entered 1 medical school in Australia directly from high school (secondary school entry) to those of graduates who entered with tertiary level education (tertiary entry). DESIGN AND METHODS: Cross-sectional study using a mail-out survey to graduates from the first 16 graduating years (1983-98 inclusive) of the University of Newcastle Medical School. RESULTS: Secondary school entrants were, on average, 8 years younger than tertiary entrants and were less likely to have received rural-based schooling. However, there were no differences with respect to gender or type of secondary school attended (public or private). Motivations for studying medicine did not generally differ according to entry type, except that more secondary students were motivated by parental expectations and more tertiary entrants were motivated by the need for professional independence and the desire to prevent disease. A greater proportion of tertiary entrants experienced stress at medical school. However, secondary students experienced more stress due to doubts about being a doctor, while tertiary entrants experienced more stress due to lack of leisure time, finances and balancing commitments. There were no significant differences between the groups in terms of academic performance (as measured by the award of medical school honours) or research outcomes (as measured by completion of a research degree during or after medical school training, publication of scientific papers or holding career posts in the research sciences). There were no differences in career positions held by clinicians, choice of general practice or another specialty as a career, practice location (rural or urban) or employment sector (public or private). CONCLUSION: There is no clear advantage, at least on the outcomes measured in this study, to limiting medical school entry to either those candidates from secondary school or those with tertiary backgrounds. Medical schools could reasonably broaden their selection criteria to include more graduate entry candidates in addition to secondary school leavers without compromising medical school and practice outcomes.

Achievement↗
PubMed2001

Assessing community health among indigenous populations in Ecuador with a participatory approach: implications for health reform.

Health reform is an important movement in countries throughout the region of the Americas, which could profoundly influence how basic health services are provided and who receives them. Goals of health sector reform include to improve quality, correct inefficiencies, and reduce inequities in current systems. The latter may be especially important in countries with indigenous populations, which are thought to suffer from excess mortality and morbidity related to poverty. The purpose of this paper is to report the results of a community health assessment conducted in 26 indigenous communities in the Province of Cotopaxi in rural Ecuador. It is hoped that this information will inform the health reform movement by adding to the current understanding of the health and socioeconomic situation of indigenous populations in the region while emphasizing a participatory approach toward understanding the social forces impacting upon health. This approach may serve as a model for empowering people through collective action. Recommended health reform strategies include: 1) Develop a comprehensive plan for health improvement in conjunction with stakeholders in the general population, including representatives of minority groups; 2) Conduct research on the appropriate mix between traditional medicine, primary health care strategies, and high technology medical services in relation to the needs of the general population; 3) Train local health personnel and traditional healers in primary health care techniques; 4) Improve access to secondary and tertiary health services for indigenous populations in times of emergency; and 5) Advocate for intersectoral collaboration among government institutions as well as non-governmental organizations and the private sector.

Community Health Planning↗
PubMed1999

The economic consequences of reorganizing hospital services in Bishkek, Kyrgyzstan.

Kyrgyzstan gained independence from the Soviet Union in 1991 and has since been thrown into severe financial crisis. All public sector funding has been significantly reduced and international aid agencies are supporting the government in rebuilding the economy. The health sector requires a radical overhaul and a major part of this process involves rationalization of existing facilities, particularly in the capital Bishkek, where 26 secondary and tertiary hospitals support a population of approximately 800000 people. This paper describes the development of a plan for rationalization with particular emphasis on the economic aspects of the process. This involved calculating future hospital requirements by modelling a variety of policy options, ranging from changes to clinical practice to hospital closures. The model generates estimates of resource requirements at each hospital, from which the costs falling on the health budget and patients are derived.

Adult↗
PubMed2006

Why we need a population-based approach to clinical indicators for cancer: a case study using microscopic confirmation of lung cancer in Queensland.

An important function of clinical cancer registries is to provide feedback to clinicians on various performance measures. To date, most clinical cancer registries in Australia are located in tertiary academic hospitals, where adherence to guidelines is probably already high. Microscopic confirmation is an important process measure for lung cancer care. We found that the proportion of patients with lung cancer without microscopic confirmation was much higher in regional public hospitals (27.1%) than in tertiary hospitals (7.5%), and this disparity remained after adjusting for age, sex and comorbidities. The percentage was also higher in the private than in the public sector. This case study shows that we need a population-based approach to measuring clinical indicators that includes regional public hospitals as a matter of priority and should ideally include the private sector.

Academic Medical Centers↗
PubMed2002

Stethoscope: a friend or an enemy?

CONTEXT: The stethoscope is a universal tool in the hospital that is in direct contact with many patients and can therefore be a vector in the dissemination of bacterial infections. OBJECTIVE: To research the presence of bacteria, fungi and yeast on the stethoscope diaphragm and the resistance of bacteria to antimicrobial drugs. DESIGN: Descriptive, prospective, non-controlled. SETTING: A tertiary care hospital. SAMPLE: Samples were taken randomly from 300 stethoscopes employed by medical staff (medical residents, medical students, nurses and nursing school students) and other sectors of the hospital. MAIN MEASUREMENTS: Three hundred stethoscope diaphragms used in several sectors of the hospital facilities by medical doctors (63 samples), medical residents (54 samples), medical students (106 samples), nursing school students (33 samples) and specific sectors (36 samples) were analyzed. Material was collected randomly. It was collected with the aid of a sterile swab moistened in physiological solution, inoculated into Brain Heart Infusion media and incubated in an oven for 24 to 48 hours. After this period, the samples were inoculated into blood agar, MacConkey agar and Sabouraud media and identified by Gram staining and biochemical assays. An assay to test bacteria sensitivity to antibiotics was also carried out by the Kirby-Bauer method. RESULTS: Eighty-seven percent of the analyzed stethoscopes were contaminated. Gram-positive cocci, yeasts, fungi and Gram-positive and negative bacilli were isolated. There was no significant association between the most predominant microorganisms and professional category. Staphylococcus aureus, Staphylococcus negative coagulase and Bacillus were significantly more frequent in relation to the presence of more than one microorganism on the stethoscope diaphragm. CONCLUSION: Stethoscopes presented a high rate of contamination and their use without precautions can spread nosocomial infections.

Chi-Square Distribution↗
PubMed1993

Preoperative autologous blood donation. Linkage of the public and private hospital sectors.

OBJECTIVE: To evaluate the safety and efficacy of a preoperative autologous blood donation (PABD) program with liberal patient exclusion criteria. DESIGN: Prospective patient accrual from September 1990 to May 1992. SETTING: A PABD program in a public tertiary care hospital linked with a specialist orthopaedic practice in a private hospital. PATIENTS: One hundred and twenty patients consecutively scheduled for orthopaedic surgery were referred for PABD. There were 77 women (median age, 63 years) and 43 men (median age, 62 years). One-third of patients were 70 or more years old. Coexistent medical disease, mainly cardiovascular, was present in 46% of patients and 3% were excluded because of coexisting morbidity. Total hip or total knee replacement was performed in a private hospital with intraoperative or postoperative blood salvage in 37% of the patients. OUTCOME MEASURES: Adverse effects of PABD, autologous blood collected and used and homologous blood transfused. RESULTS: One hundred and sixteen patients donated 267 units of autologous blood. In 70 patients undergoing total hip replacement, 78% donated three and 20% donated two units, with 95% of autologous blood being used. In 38 patients undergoing total knee replacement, 42% donated two units and 55% donated one unit, with 87% of autologous blood being transfused. Seventy-eight per cent of all patients only received autologous blood. In the remaining patients, homologous blood use was confined to two units or less in 80%. Hypotensive episodes associated with phlebotomy occurred in 3% of patients, and 13% of patients had preoperative haemoglobin levels ranging from 85-100 g/L without adverse clinical effects. CONCLUSION: A hospital-based PABD program with less strict patient exclusion criteria does not prejudice the clinical status of the donors. Its linkage to private hospitals can significantly reduce the use of homologous blood in selected elective surgery.

Adult↗
PubMed1983

Training doctors for family practice in primary health care work in Sri Lanka.

Over one-third of the doctors in Sri Lanka are involved in the delivery of PHC. They form one of seven categories of PHC workers--others being the ayurveda physician, the assistant medical practitioner, nurse, midwife, traditional healer and unqualified practitioner. PHC workers function either in the government or private sector. Their functions in the PHC system are not defined and are dependent on state health policies and people's expectations of health care. The secondary and tertiary levels of the health system are managed by the government through a network of hospitals. These hospitals provide Western type health care facilities free to the people. Government PHC workers have access to referral facilities and back up services provided through this hospital system. Doctors functioning within the PHC system had neither undergraduate nor postgraduate training in PHC. Private general practitioners were the first to realise the need for training doctors in PHC. They sought and got government and university approval for postgraduate training in family practice. The family practice training programme is conducted by the Postgraduate Institute of Medicine of the University of Colombo. The course consists of educational and clinical components which could be completed in a minimum of 1 year or maximum of 4 years. Nine private general practitioners and 19 government medical officers registered for the course. Fifteen completed the course in 1 year. Family practice trained doctors will function in a PHC system in which the services provided are not coordinated. Changes in the PHC system are being considered.(ABSTRACT TRUNCATED AT 250 WORDS)

Curriculum↗
PubMed1995

Is HIV/AIDS a primary-care disease? Appropriate levels of outpatient care for patients with HIV/AIDS.

OBJECTIVE: To estimate the proportion of outpatient visits that could be managed at a primary-care level, by World Health Organization (WHO) clinical staging. DESIGN: Prospective, descriptive study. Six medical doctors in a tertiary hospital HIV ambulatory clinic recorded clinical diagnoses, WHO clinical staging and their recommendation regarding the appropriate level of care for each outpatient seen. SETTING AND STUDY POPULATION: All HIV-infected patients attending a public-sector, urban, South African, referral and teaching hospital HIV outpatient clinic between September and November 1992. PARTICIPANTS: There were 238 visits by 148 patients during the study period. RESULTS: Of 238 visits, 165 (69.3%) were deemed suitable for treatment at the primary-care level. After allowing for contradictory responses, at least 141 visits (59.2%) could be appropriately treated at the primary-care level. Although all six doctors assessed more than half of their visits as suitable for primary care, there were significant differences among them. In total, 83 visits (34.8%) needed a medical specialist, and 45 (18.9%) required tertiary-care facilities. Of all the visits, 58 (24.9%), 51 (21.9%), 60 (25.8%) and 64 (27.4%) were classified as WHO stages 1, 2, 3 and 4, respectively. For these stages, 55 (94.8%), 38 (74.5%), 42 (70.0%) and 26 (40.5%) visits, respectively, were suitable for treatment at a primary-care facility. CONCLUSIONS: Many of the outpatient visits to this outpatient specialist clinic could have been safely cared for at a primary-care level. As the severity of the disease increases, there is a decrease in the proportion of patients that can be treated at a primary-care level.

Acquired Immunodeficiency Syndrome↗