Paediatric utilisation of a teaching hospital and a community health centre. Predictors of level of care used by children from Khayelitsha, Cape Town.

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.

Repeatability and validity of a field kit for estimation of cholinesterase in whole blood.

OBJECTIVES: To evaluate a spectrophotometric field kit (Test-Mate-OP) for repeatability and validity in comparison with reference laboratory methods and to model its anticipated sensitivity and specificity based on these findings. METHODS: 76 farm workers between the age of 20 and 55, of whom 30 were pesticide applicators exposed to a range of organophosphates in the preceding 10 days, had blood taken for plasma cholinesterase (PCE) and erythrocyte cholinesterase (ECE) measurement by field kit or laboratory methods. Paired blinded duplicate samples were taken from subgroups in the sample to assess repeatability of laboratory and field kit methods. Field kits were also used to test venous blood in one subgroup. The variance obtained for the field kit tests was then applied to two hypothetical scenarios that used published action guidelines to model the kit's sensitivity and specificity. RESULTS: Repeatability for PCE was much poorer and for ECE slightly poorer than that of laboratory measures. A substantial upward bias for field kit ECE relative to laboratory measurements was found. Sensitivity of the kit to a 40% drop in PCE was 67%, whereas that for ECE was 89%. Specificity of the kit with no change in mean of the population was 100% for ECE and 91% for PCE. CONCLUSION: Field kit ECE estimation seems to be sufficiently repeatable for surveillance activities, whereas PCE does not. Repeatability of both tests seems to be too low for use in epidemiological dose-response investigations. Further research is indicated to characterise the upward bias in ECE estimation on the kit.

Levels of care needed by medical inpatients in a teaching hospital.

Medical inpatients in a teaching hospital ward were studied daily for 2 weeks. The registrar responsible for each patient decided each day what level of care would be most appropriate, and what elements of care were needed for the patient on that day. From their documented assessments on 308 of 458 recorded days registrars considered that 54.5% of patient-days (168 of 308 days) could appropriately have been spent at a lower of level of care than the academic hospital, had such beds been available. The assessments of the registrars in the study ward were similar to assessments of all medical registrars in all other general medical wards in the hospital. Professional staff in the study ward recorded task duration each time any work was done for a patient. Nurses spent 23.9% more time per patient on those whom registrars thought could be treated at lower levels. Doctors spent 15.0% more time per patient on those whose presence in the hospital registrars considered appropriate. Health care could be provided more economically if more lower-level facilities were available. This could perhaps also be achieved with reorganisation of care within a teaching hospital but steps would have to be taken to ensure maintenance of continuity of care and staff-patient relationships.

Compensating for occupational lung disease.

Workers' compensation for occupational lung disease in South Africa and in other countries is reviewed. Compensation legislation in South Africa has a long history of evolution, with important changes expected in the near future. The South African system is similar to that in other countries, but has some unique features. Problems for workers disabled by occupational lung disease include a limited range of compensable conditions, difficulty in establishing a diagnosis, delays in obtaining payment, and small amounts paid. International experience suggests that certain changes would be especially useful. Racial inequalities should be removed, the schedule of compensable occupational diseases needs to be extended, and presumptive standards should be developed for diagnosis and disability assessment.