Using simulation to improve the operational efficiency of a multi-disciplinary clinic

A recent trend in health care is to provide patients with the benefits of multi-disciplinary care during a single clinic visit. The University of Michigan Breast Care Center is a leading example of a multi-disciplinary clinic which has served the Midwest United States since 1985. A hallmark of the Breast Care Center operation is a patient care conference immediately following the clinical evaluation sessions, where each case is discussed by a group of experts for immediate evaluation and generation of recommendations. The Center has experienced significant increases in the number of patient visits over the nine years since its inception. The patient mix, initially all new patients, has matured, and returning patients are now a significant portion of the clinic load. Unfortunately, the success of the Breast Care Center strained its smooth operation. Physicians were unable to attend the patient care conference because the clinical evaluation sessions were too busy, and this undermined the quality of the care recommendations generated. Patients were complaining about long waits in the Breast Care Center and delays in getting their next appointment. To examine these operational problems and to suggest corrective actions, a simulation study was conducted. This paper reports the results of this study. Our findings provide interesting insights into the operation and management of multi-disciplinary clinics.

Pap test coverage in São Paulo municipality and characteristics of the women tested

Interview data collected in March-September 1987 as part of an international multi-center study were used to assess Pap test coverage in the municipality of São Paulo and determine characteristics that made study subjects more likely or less likely to have been tested. The data analyzed came from interviews with 967 women. Information gathered during the interviews included demographic and socioeconomic data as well as information about use of health service facilities, use of oral contraceptives, breast self-examination, smoking, alcoholism, and prior Pap testing. The results showed that 666 (69%) of the women said they had received a Pap test in the past; 588 (61%) said they had one within three years of the interview; and 399 (41%) said they had one during the past year. Statistically significant relationships were found between Pap testing sometime in the past (and also Pap testing within the preceding three years) and age, education, marital status, use of oral contraceptives, breast self-examination, and consulting with a physician during the year preceding the interview. Adjustment for all the other statistically significant variables through multivariate analysis influenced but did not undo the statistical significance of each of these relationships. Overall, the results of this study point to levels of Pap test coverage exceeding those found by other São Paulo studies. One reason could have been this study's inclusion of Pap tests obtained at medical clinics that were not specifically accredited to give the test; another, which does not exclude the first, could have been a real increase in coverage resulting from increasing dissemination of messages in the 1980s stressing the importance of Pap testing. It is also noteworthy that 40% of the women interviewed said they had not had the test within the preceding three years. Characteristics associated with those not having had the test were youth (being 15-24 years old), being single, having low socioeconomic status, not having consulted a physician for a year, not having used oral contraceptives, and not having performed breast self-examination for a year. Knowing these characteristics could help implement measures to increase Pap test coverage of specific subgroups.

The cost-effectiveness of mammography screening: evidence from a microsimulation model for New Zealand

Mammography screening currently represents the only means by which the mortality rate from breast cancer can be modified substantially. A national mammography screening programme is being considered for New Zealand, and pilot programmes were established in two regions (Otago/Southland and Waikato) in 1991 to determine the potential costs and benefits of mammography for New Zealand women. The aim of this paper is to explore the cost-effectiveness of mammography screening in New Zealand relative to no screening, and to examine the marginal change in costs and benefits of altering programme characteristics such as the age of women invited and screening frequency. Cost-effectiveness is measured by the net cost (the costs of screening minus the treatment savings averted by the early detection of cancers) per year of life gained, from the perspective of the public health care sector. A microsimulation computer model, MICROLIFE, was developed to facilitate the estimation of mortality reduction and cost-effectiveness. The results show that, while mammography screening does not 'save money' overall, the cost per year of life saved for a range of policies compares favourably with other New Zealand health services, and is comparable to the results from economic evaluations of mammography screening overseas. Of those regimes considered, screening women 50-64 years of age at 3-yearly intervals appears to be most cost-effective.

Evaluation of the woman's drop-in service in Benarty, Fife

BACKGROUND

A survey of the health needs of women aged between 16 and 64 years of age in the Benarty area was carried out by the Department of Public Health in Fife. In response to the findings of this survey and in particular to the expressed wish for a drop-in service to be made available and for access to self-help groups and counselling sessions, a multi-agency project was established in the Benarty area of Fife. Two drop-in centres were set up, in a local community centre and in a primary care clinic, and were staffed by health visitors, social workers and staff from the community education department. The centres were each open twice a week for 2-3 hours on each occasion and crèche facilities were made available. The aims of the service were to provide counselling on a one-to-one basis, to establish self-help groups based on the expressed needs of women and to refer people on to the most appropriate services, if necessary. The service was established on a pilot basis and an essential component of the project was an evaluation of the service.

METHODS

To evaluate the service a community survey was carried out involving a random sample of 370 women taken from the community health index, and a register was kept to record details of attendances.

RESULTS

Two hundred and sixty-five women were successfully interviewed, a response rate of 72 per cent. The major finding of concern was that 63 per cent of women had not heard of the drop-in service, suggesting that the advertising of the centres had been ineffective. Analysis of the clinic register showed that a total of only 77 women had attended the two drop-in centres over a 12-month period.

CONCLUSIONS

Owing to the low attendance rates, the service was disbanded after one year of operation. It is possible that these low rates may be explained, at least in part, by the fact that a large number of local social services had been developed in the Benarty area since the time of the needs assessment survey in 1991. The introduction of these new local services within this area may have met many of the needs of women who otherwise may have made use of the drop-in service. The results of the survey underline that the introduction of a new service needs to be underpinned by an effective communication strategy which is realistically budgeted and maintained over a period of time if there is to be successful penetration of the messages within the community. One successful aspect of the pilot project was the improved working relationships between the statutory health and social services staff who collaborated in the operation of the service.

The underuse of women's health care services in hungary. A preliminary study

In order to collect baseline data for a 2-year Women's Health Program in Hungary, a survey was conducted of 369 women residing in one community setting. The purpose of this descriptive exploratory study was to gather preliminary data that would help identify perceptions of inhibitors to utilization of women's health services. An additional purpose was to identify perceived health needs in the study setting and to make recommendations for changes in the existing services. The survey results indicated that women were satisfied overall with their health care. Equivocal responses suggested, however, that patient-provider interactions and lack of understanding regarding preventive health care may contribute to the underuse of services. The authors suggest that public feedback that includes women's opinions and perceived needs is essential in health program planning and evaluation. In order to accomplish this, standardized Hungary-specific research instruments must be developed.

The prevalence of clinical preventive services utilization by older women

The purpose of this study was to estimate the extent to which women ages 65 and older were in compliance with the 1989 U.S. Preventive Services Task Force (USPSTF) recommendations for clinical preventive services. Data from the 1991 Health Promotion and Disease Prevention Supplement of the National Health Interview Survey of 5,574 women ages 65 and older were analyzed to determine the proportion in three age-groups (65 to 74 years, 75 to 84 years, and 85 years and older) who reported receiving recommended screening, counseling, and immunization services. Sixty percent of women ages 65 and over had had a routine check-up within the last year, and 78% had had one within the past 2 years. However, fewer than 1% reported receiving all recommended screening services (history, physical examination, and laboratory/diagnostic testing) or all recommended counseling services, and only 5.3% of women were current with recommended immunizations. As age increased, the number of services received tended to decrease in all categories of clinical preventive services except immunizations. The prevalence of receipt of clinical preventive services by older women is unacceptably low. Greater effort must be focused on educating both women and their primary health care providers about the USPSTF recommendations and why they are important in achieving health benefits.

Cost differences among women's primary care physicians

A secondary analysis of data from the 1987 National Medical Expenditure Survey revealed that women with distinct demographic and socio-economic characteristics identify different physician specialty groups as their usual source of care. The use of certain physician groups for primary care resulted in higher rates of use and expenditures, particularly for younger women. Identifying an internist, rather than a family/general practitioner or an obstetrician/gynecologist, as a usual source of care placed one at higher odds of making more visits and incurring higher total outpatient costs.

Factors influencing the type of health problems presented by women in general practice: differences between women's health care and regular health care

OBJECTIVE

Differences between health problems presented by women (aged 20-45) to female "women's health care" doctors and both female and male regular health care doctors were investigated. This article explores the relationship of patients' roles (worker, partner, or parent) and the type of health care, controlling for education, to the presentation of psychological, social, and purely somatic problems in general practice.

METHOD

Data was derived from a "women's health care" practice and twenty-one group practices providing regular care. The doctors registered detailed information about all patient contacts during a three-month period. Logistic regression analysis was used in order to calculate the likelihood of women attending their doctor to present with psychological, social, or somatic health problems.

RESULTS

We found that the effect of education was much stronger than the effect of roles. Women attending women's health care presented more psychological and social problems and less somatic problems than women visiting regular health care doctors. Patients of female and male doctors providing regular care did not differ in this respect between each other.

CONCLUSIONS

This study showed that patient characteristics, like roles and education, are related to the type of health problems presented to general practitioners. The type of health care was also important in explaining differences in the problems presented to them. Future research in primary care should include doctor characteristics to better understand how these characteristics might relate to patient outcomes.

Patterns of health services utilization and mammography use among women aged 50 to 59 years in the Québec Medicare system

Many studies have identified physicians' recommendation as the single most important predictor of mammography use. Health services utilization is a complex phenomenon, and the contribution of the different dimensions of health services utilization on mammography use is underresearched. This study examines the specific contribution of health services utilization variables in a multivariate model of the recency of mammography use for women aged 50 to 59 years. Subjects were respondents of the 1987 Québec Health Survey. Survey data were then linked on an individual basis to the respondent's records of Medicare physicians' claims for health care services for the 3 years before the survey. This unique data set enabled the inclusion of sociodemographic variables, risk factors, health status, healthy lifestyles, and women's patterns of utilization of general and gynecologic health care services. Multivariate predictors of the recency of mammography are: having an education higher than high school, working outside home, not living in a remote area, suffering from benign breast disease, and not perceiving one's own health as good. The volume of general and gynecologic medical care is associated with the recency of mammography in independent logistic models that include women's predisposing, enabling, and need factors. This study shows that even in a universal third-party payer health care system, physicians are missing opportunities to promote breast cancer screening.

An evaluation of community-based HIV services for women in New York State

The proportion of women in New York State diagnosed with acquired immune deficiency syndrome (AIDS) is increasing dramatically. In 1987, only 12% of cumulative AIDS cases in New York were among women; by 1993, 26% of new cases of AIDS were. This evaluation describes community-based HIV programs that provide services to women in New York State and are funded by the State Department of Health's AIDS Institute. The evaluation assesses the success different programs have had in reaching and engaging women. It also describes the problems organizations face in serving their target populations. Four sets of data were collected and analyzed to assess the care being received by female clients. Programs appear to be reaching women who are human immunodeficiency virus (HIV) positive or at high risk of HIV infection, and once engaged, female clients find the services helpful. However, agencies report difficulties in finding and using the strategies that are most effective with women. Agencies appear to do a better job of addressing their female clients' economic needs than those related to gender, such as reproductive health care, family services, and access to clinical trials.

Care denied: US residents who are unable to obtain needed medical services

OBJECTIVES

This study analyzed data on US residents reporting that they were unable to obtain needed care. Inadequately immunized children and women inadequately screened for breast or cervical cancer were also examined.

METHODS

Data from the 1987 National Medical Expenditure Survey was analyzed.

RESULTS

A total of 6,375,000 (90% confidence interval [CI] = 6,039,000, 6,711,000) people could not get hospitalization, prescription medications, medical equipment/supplies, or emergency, pediatric, mental health, or home care. Although the uninsured were more likely to forego care unavailable, three quarters of those unable to obtain services were insured, and 46% (90% CI = 42.4%, 49.6%) had private coverage. Of those reporting the reason why they failed to obtain care, 65.1% (90% CI = 61.7%, 68.6%) listed high costs or lack of insurance, including 60.7% (90% CI = 57.1%, 64.3%) of the privately insured. More than a third of women had not had a breast examination in the previous 2 years, a fifth had not had a Pap smear within the previous 4 years, and half had never had a mammogram (ages 50-69 only). Of children 2 to 5 years old, 35.1% (90% CI = 31.5%, 35.7%) were inadequately immunized. Medicaid recipients had measures of access to care similar to those of the uninsured.

CONCLUSIONS

Many US residents--most of whom have insurance--are unable to obtain needed care, usually because of high costs.

Gender differences among homeless persons: special services for women

Data from a survey of men and women in urban shelters for the homeless revealed that, while women were more likely than men to request a variety of services, most of the difference was accounted for by the subgroup of women accompanied by children. Homeless men and women without children exhibited few differences in the number of services they requested.

The treatment-seeking woman at menopause

Recent studies suggest that health care utilisation by women during menopause transition in general is highly idiosyncratic, despite the widespread advocation of prophylactic hormone therapy and increased health vigilance. The Melbourne Women's Midlife Health Study, a community-based cross-sectional study of 2001 urban Australian-born women aged 45-55 years, evaluated women's physical and emotional experiences, past and present health status, attitudes and beliefs about menopause, health behaviours and current menopausal status in a 30-min telephone interview. This paper reports on those factors related to help-seeking and health care utilisation. Findings show that treatment utilisers, in contrast to non-utilisers, reported a wider range of general symptoms, but reports on vasomotor symptoms did not contribute to the regression analysis. Treatment utilisers were further identified as problem-related or prevention-related utilisers. In three-way analyses, the past and present social and physical health of the problem-related treatment user was reportedly worse than either the prevention-related utiliser or non-utiliser. These findings suggest that medical and societal views about the health of middle-aged women during menopausal transition are likely to be based on the experiences of a particular segment of the population only. It is proposed that biased views of menopause as a time of considerable distress and ill-health are being perpetuated and over-generalised. This perspective appears to have little relevance for the majority of middle-aged women.

A study of the services provided by the women's health nurses in a Sydney Area Health Service

OBJECTIVES

To describe the client characteristics and nature of services provided by women's health nurses and to examine whether the goals set for the service are being met.

DESIGN

A retrospective study of women's health nurse (WHN) records from 1987 to 1991.

SETTING AND SUBJECTS

All women attending the women's health nurse in the Southern Sydney Area Health Service, 1987 to 1991. Older women and women of non English-speaking background are specific targets for this service.

OUTCOME MEASURES

Pap test and breast self-examination practices were examined in relation to age and ethnic background. Use of general practitioner services was examined for all women attending the women's health nurse in 1991.

RESULTS

Forty-five per cent of clients were aged over 50, and 29 per cent were from a non English-speaking background. Older women were more likely to return for subsequent visits to the women's health nurse. The practice of breast self-examination increased significantly between visits among all women. Forty-one per cent of women had not had a Pap test for at least three years, 93 per cent of these women were screened at their first visit. Eighty-seven per cent of women on their first visit and 86 per cent of women revisiting the women's health nurse had seen their general practitioner within the previous year.

CONCLUSION

Women's health nurses are meeting the goals set for their service in relation to health promotion and the screening of women. Their services are perceived by their clients as complementary to those provided by their general practitioners.

Preventive care for women. Does the sex of the physician matter?

BACKGROUND

Emphasis on ensuring women's access to preventive health services has increased over the past decade. Relatively little attention has been paid to whether the sex of the physician affects the rates of cancer screening among women. We examined differences between male and female physicians in the frequency of screening mammograms and Pap smears among women patients enrolled in a large Midwestern health plan.

METHODS

We identified claims for mammography and Pap tests submitted by primary care physicians for 97,962 women, 18 to 75 years of age, who were enrolled in the health plan in 1990. The sex of the physician was manually coded, and the physician's age was obtained from the state licensing board. After identifying a principal physician for each woman, we calculated the frequency of mammography and Pap smears for each physician, using the number of women in his or her practice during 1990 as the denominator. Using unconditional logistic regression, we also calculated the odds ratio of having a Pap smear or mammogram for women patients with female physicians as compared with those with male physicians, controlling for the physician's and the patient's age.

RESULTS

Crude rates for Pap smears and mammography were higher for the patients of female than male physicians in most age groups of physicians. The largest differences between female and male physicians were in the rates of Pap smears among the youngest physicians. For the subgroup of women enrolled in the health plan for a year who saw only one physician, after adjustment for the patient's age and the physician's age and specialty, the odds ratio for having a Pap smear was 1.99 (95 percent confidence interval, 1.72 to 2.30) for the patients of female physicians as compared with those of male physicians. For women 40 years old and older, the odds ratio for having a mammogram was 1.41 (95 percent confidence interval, 1.22 to 1.63). For both Pap smears and mammography, the differences between female and male physicians in screening rates were much more pronounced in internal medicine and family practice than in obstetrics and gynecology.

CONCLUSIONS

Women are more likely to undergo screening with Pap smears and mammograms if they see female rather than male physicians, particularly if the physician is an internist or family practitioner.