Statistical analysis of waiting time of patients by queuing techniques: case study of large hospital in Pakistan

[EN] The purpose of this empirical research was to analyze the comfortable waiting time (CWT) of patients at the outpatient department (OPD) of Gastrology of ABC hospital of Karachi. It is based on the analysis of CWT of patients who were being served at the OPD of Gastrology of ABC hospital of Karachi. The data was collected by the help of questionnaire. Altogether 250 questionnaires were distributed among the patients, 210 of them were collected back and 10 of them were incompletely filled. Data was analysed in the statistical package for social sciences (SPSS) version 22. Data analysis included frequency distribution of various demographics;stratification tables were made for the comparison of CWT across various demographics. Results indicated that more females (old aged) had greater CWT in the comparison of males. It is found that the mean CWT of patients decreased with decreasing age, increasing OPD visiting time and increasing income. It is also found that he mean CWT for the patients from Afghanistan was greater than the patients from other regions i.e. Baluchistan, interior Sindh and Karachi. The authors highlighted that when patients arrive at the hospital and wait for their service, in this scenario, waiting cost is associated with their waiting time; since it is the matter of cost, thus it should be known to the hospital that if patients are made to wait longer, it can lead to the customer dissatisfaction. In this regard, analysis of comfortable waiting time of patients was extremely needed. Since, Karachi is the biggest city of Pakistan and targeted hospital is one the biggest private hospitals of Karachi and in the analysis of this paper. Only 200 patients were approached for data collection which is the main limitation of the paper. In future, the researchers should also focus on the same OPD for more responses and at the same time, other departments can also be targeted for conclude better and precise results. The authors have tried to focus on the CWT of patients so that the waiting capacity of patients could be highlighted. At the same time, detailed analysis was conducted across demographics so that their influence on CWT could be analysed. Authors of this research paper thank the management committee of ABC private hospital of Karachi for allowing us to collect the data and we are also thankful to the patients who cooperated in filling the questionnaires.Kalwar, MA.; Memon, MS.; Khan, MA.; Tanwari, A. (2021). Statistical analysis of waiting time of patients by queuing techniques: case study of large hospital in Pakistan. 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Calidad de atención y tiempo de espera en consultorio obstétrico de un centro de salud público de Lima, 2020

El presente estudio tiene como objetivo general determinar si existe relación entre la calidad de atención y el tiempo de espera en usuarios de consultorio externo del servicio de obstetricia de un Centro de Salud Público de Lima 2020, estudio de tipo básica, descriptivo, correlacional, no experimental; la población objetivo estuvo conformada por 80 usuarios atendidos durante el mes de junio, la técnica utilizada fue la encuesta observándose que el 78.8% manifiesta que la calidad de atención del servicio de obstetricia es media y el 3.8% es alta; así también el 78.8% manifiesta que el tiempo de espera es regular, mientras que el 10.0% refiere que es ideal. Donde se concluye que la variable calidad de atención y tiempo de espera, bajo el análisis inferencial mediante la prueba Tau b de Kendall tienen un valor de significancia p=0.108 concluyendo que no existe relación entre la calidad de atención y el tiempo de espera en usuarios de consultorio externo del servicio de obstetricia. No se mostró relación entre las dimensiones fiabilidad, seguridad, empatía y aspectos tangibles, a excepción de la dimensión capacidad de respuesta que si guarda relación positiva de intensidad débil con el tiempo de espera

Efectividad de un nuevo modelo de derivación telefónica programada entre atención primaria y atención hospitalaria

La evolución de los modelos sanitarios, cada vez más sofisticados y costosos, en la búsqueda por la excelencia en el servicio prestado a los ciudadanos, exigen una mayor implicación de los médicos de atención primaria (MAP) en la atención sanitaria a los pacientes, familias y comunidades. Para ello es necesario capacitar la atención primaria (AP) y un nivel alto de coordinación entre ésta y la atención hospitalaria (AH) para que la mayor parte de los problemas de los pacientes se puedan solucionar desde AP, dejando a la AH solo aquellos problemas en los que sea estrictamente necesario pasar por el hospital. Para mejorar la capacidad de resolución de la AP y evitar las temidas listas de espera para AH, se han intentado muchas cosas a nivel mundial, pero aquellas que mejoran la comunicación entre AH, AP y pacientes, son las que tienen una mayor evidencia a su favor. Una de estas intervenciones, cuyo desarrollo se ha acelerado de manera vertiginosa con la epidemia de COVID-19 es la telemedicina, que incluyen plataformas de consultas asincrónicas (e-Consultas) y consultas telefónicas a tiempo real (Curbside Consultation). La telemedicina ha abierto nuevas posibilidades a la atención de la salud, al obtener muy buenos resultados en tiempos de espera para primera consulta especializada, disminución de citas presenciales en consulta especializada y satisfacción de pacientes y profesionales; sin embargo, no se han encontrado estudios que aporten datos referentes a días de espera hasta resolución del problema que dio origen a la derivación y existen dudas ético-legales al respecto. Además, las e-Consultas precisan importantes inversiones e implicación institucionales, liderazgo y tiempo de trabajo para los médicos; y con consultas telefónica a tiempo real se detectaron problemas de comunicación, de información incompleta o fragmentada, dificultad para elegir al compañero al que consultar, interrupciones impredecibles con gasto de tiempo no programado y algunos problemas más. Por este motivo desarrollamos un sistema alternativo de derivación telefónica programada (DETELPROG) en el que el MAP solicita una cita programada en AH, integrada dentro del horario de consulta de ambos médicos, para tener una consulta telefónica con el MAH, estando el paciente en la consulta del MAP. El objetivo es mejorar días de espera con respecto la consulta tradicional y evitar consultas presenciales innecesarias, eliminando las barreras de los otros tipos de telemedicina. Objetivos Objetivos generales Comprobar la efectividad de un nuevo modelo de DErivación TELefónica PROGramada (DETELPROG) más ágil que el presencial, que evite desplazamientos innecesarios de los pacientes al hospital y que mejore la continuidad asistencial en el AGSNH evitando las barreras surgidas en las e-consultas y en las consultas telefónicas no programadas. Objetivos específicos 1. Determinar si la DETELPROG reduce los días de espera en la respuesta del MAH al MAP con respecto a la derivación presencial tradicional. 2. Analizar si con la DETELPROG disminuyen los días de espera para resolución del problema por el que el paciente es derivado desde AP a AH con respecto a la derivación presencial tradicional. 3. Calcular la proporción de consultas presenciales evitadas en AH. 4. Conocer las barreras y beneficios percibidos por los MAP y los médicos especialistas en medicina interna (internistas) que participaron en el estudio DETELPROG que ayuden a determinar puntos de mejora en una futura implantación del modelo en el AGSNH u en otras áreas sanitarias similares. Metodología Para conseguir los objetivos del estudio DETELPROG se ha utilizado una metodología mixta cuantitativa para los 3 primeros objetivos específicos y cualitativa para el cuarto. Para nuestros tres primeros objetivos realizamos un ensayo clínico aleatorizado sin enmascaramiento con dos periodos de captación de pacientes. Con el primer periodo conseguimos en tamaño muestral suficiente para conseguir nuestro primer objetivo. Para los 2 siguientes objetivos, que precisaban un tamaño muestral mayor, abrimos un segundo periodo de captación para ampliar dicho tamaño muestral y seguimos la evolución de sus procesos durante un año. Tras el seguimiento de los procesos de los pacientes captados en los dos periodos pudimos conseguir nuestros objetivos 2 y 3. La metodología cualitativa fue necesaria para la consecución de nuestro cuarto objetivo. Realizamos 2 grupos focales, uno para internistas y otro para MAP, buscando las ventajas de las técnicas de recogida de información grupales con respecto a las individuales; y preferimos realizar entrevistas semiestructuradas para 4 médicos que los consideramos informadores clave y nos interesaba tener una visión más profunda de sus impresiones. También usamos las entrevistas para 2 médicos que no pudieron acudir a los grupos focales. Resultados 1. La DETELPROG reduce los días de espera en la respuesta del MAH al MAP con respecto a la derivación presencial tradicional en 27 (IC 95%: 20-33) días. 2. La DETELPROG disminuyen los días de espera para resolución del problema por el que el paciente es derivado desde AP a AH con respecto a la derivación presencial tradicional en 47 (IC 95%: 17-74) días 3. La DETELPROG evita en el 91,7 % de las ocasiones que el paciente tenga que desplazarse de manera presencial a las consultas de AH. 4. En cuanto a los beneficios de la DETELPROG, ha supuesto una experiencia muy positiva tanto para los MAP como para los internistas, le ha dado al MAP un papel más protagonista como coordinador de los problemas de salud de sus pacientes, mejorando la relación MAP-paciente y empoderándolo para mejorar su capacidad de resolución, ha dotado al MAP de capacidad para obtener pruebas complementarias y tratamientos para sus pacientes a las que no tenía acceso de manera independiente y ha permitido a los MAP sentirse más arropados por sus compañeros hospitalarios al tener una comunicación más rápida y directa, que ha mejorado la información transmitida entre ambos profesionales y el paciente sin provocar una sobrecarga de trabajo para ninguno de los profesionales y mejorando la relación AP-AH. Con respecto a las barreras expresadas por los internistas de fiabilidad de la información aportada por los MAP y de las implicaciones legales de sus consejos y la petición de pruebas complementarias y con respecto a los problemas de tardanza en la recepción de las llamadas por parte de los internistas, creemos que con la organización de encuentros personales periódicos entre los médicos de los dos niveles asistenciales, con la creación de un documento de responsabilidades ante la DETELPROG y con una mejor distribución de las DETELPROG en las agendas de MAP y MAH, se podrían paliar las barreras encontradas. En relación a las causas de rechazo, consideramos que la DETELPROG no es un modelo de derivación para pacientes que no quieren ser derivados vía DETELPROG, que no confíen en su MAP, ni para pacientes en los que el MAP no supiese manejar o encaminar su diagnóstico por falta de conocimiento o de medios aunque, en este último caso, la DETELPROG podría aportar un consejo apropiado mientras llega la cita presencial o un adelanto de dicha cita presencial o de la petición de la una prueba complementaria determinada. Conclusiones Consideramos que la DETELPROG es un modelo de derivación complementario a la derivación presencial, que debería implantarse en nuestra área sanitaria como modelo de derivación inicial para derivaciones desde AP a especialidades hospitalarias médicas, con las excepciones anteriormente comentadas, debido a que disminuye días de espera a los pacientes con respecto a la derivación presencial, y evita la gran mayoría de las barreras de otros métodos de derivación similares como las e-Consultas y las consultas telefónicas en tiempo real. Además, consideramos que la DETELPROG podría implantarse en otras áreas sanitarias, aunque los beneficios pueden cambiar en función de las características de dichas áreas por lo que sería necesario un estudio similar al nuestro antes de su implantación

Postpartum care and postpartum morbidity in Morocco: a mixed methods study

The postpartum period is high-risk for women’s physical and psychological health. This is why the World Health Organisation recommends that women receive four postpartum consultations within six weeks of giving birth, particularly in low-and-middle income countries (LMIC) where maternal mortality and morbidity remain a concern. In Morocco, the use of postpartum care (PPC) has stagnated at a low level (21%) since 2011, while the prevalence of postpartum morbidity (PPM) remains high (28.1%). Very few studies have investigated PPC and its potential relation to PPM in Morocco. In addition, the relationship between the non-utilisation of PPC and PPM has not been systematically researched. This thesis addresses this public health problem in order to understand the factors associated with the low rate of PPC utilisation in Morocco, as well as the relationship between PPC and the occurrence of PPM. The overarching aim of the research is to offer practical recommendations to increase PPC uptake and, ultimately, improve women’s health. The research answered five objectives: 1) to describe PPC uptake in LMIC, 2) to determine the patterns of PPC uptake in Morocco and the factors associated with it, 3) to investigate the relationship between PPC uptake and PPM occurrence in Morocco, 4) to explore women’s experience and perception of PPC and PPM in Morocco, and finally, 5) to examine healthcare professionals’ experience in providing PPC in Morocco. These objectives were addressed using a pragmatic approach based on the use of mixed methods. Three studies were conducted: 1) a systematic review and meta�analysis, 2) a secondary data analysis of a nationally representative database on Moroccan maternal health representing 5593 women of childbearing age, and 3) a qualitative study in two phases: the first one focusing on 17 women’s experiences of PPC and the second one on 19 health professionals’ perceptions and experiences of delivering it. The qualitative data were collected through semi-structured interviews conducted face-to-face in diverse health facilities, at women’s homes in Morocco or via phone calls. Concerning PPC uptake and the factors associated with it, the systematic review and meta-analysis presented an overview of the uptake of PPC in 35 LMIC, which provided 5 the context within which to explore and understand the findings relating to the Moroccan situation. Altogether, the prevalence of PPC utilisation in LMIC within six weeks post-delivery was 55.4%. Twenty-one sociodemographic, environmental, and obstetric factors were reviewed. Among them, urban place of residence, education, exposure to mass media, antenatal care check-ups, wanted pregnancy, primiparity, and delivery in a health facility by caesarean section all facilitated PPC utilisation. Conversely, other factors hindered PPC utilisation namely the lack of knowledge about PPC, poverty, women’s unemployment, women’s low level of autonomy in decision�making, disrespectful maternity care and young age (15-19 years old). From this dataset, a meta-analysis based on 9 population-based studies analysing the Demographic Health Survey concluded that the positive associations of urban place of residence, women’s education level and employment as well as middle and higher socioeconomic level were more strongly associated with PPC uptake within six weeks after delivery (later PPC) than PPC provision within 48 hours post-delivery (early PPC). Based on these findings, several hypotheses on the association between sociodemographic, environmental, and obstetric factors and PPC uptake were tested in the Moroccan context. The sequential data analysis of the Moroccan data (quantitative and qualitative) produced interesting results that corroborated some of the findings related to PPC uptake in other LMIC. The quantitative study showed that in Morocco, between 2013 and 2017, the proportion of women who received early PPC before discharge (EPPC) was 62.6% and 21.3% later within six weeks post-delivery (LPPC). The logistic regression findings indicated that PPC utilisation before discharge was more likely to occur for women who gave birth by caesarean section and those who received postnatal care for their newborn baby. LPPC uptake was also more likely to be associated with these two factors as well as women’s age (30-39), level of education (some education versus none), socio-economic status (rich(er) vs poorer socioeconomic status) and the frequency of antenatal consultations (at least one vs none). Conversely, the multivariate analysis revealed that assisted delivery with only nurses or midwives present (without doctor) was a barrier to LPPC uptake. Other barriers were identified with the univariate analysis namely the absence of PPM, the lack of knowledge and awareness of PPC, financial constraints, and the unavailability of PPC provision. 6 These findings were partly corroborated by the qualitative investigations which highlighted that the mode of delivery (caesarean) and place of delivery (private setting), good relationship between women and health professionals (HPs) and good quality of care were important factors for women when choosing to attend PPC consultations. On the other hand, the reasons explaining the non-utilisation of PPC reported by women were related to the absence of knowledge and awareness of PPC importance, not feeling PPM symptoms, the shortage of financial resources, and the lack of PPC provision in public health centres. Finally, cultural barriers were also reported by HPs as hindering women’s PPC utilisation. With regards to PPM and their development, at the national scale, the quantitative analyses showed that the prevalence of PPM (at least one) reached 28.3%, including pelvic infections (76.2%), breast issues (51%), postpartum haemorrhage (16.7%) and oedema (14.4%). The risk factors for developing PPM included vaginal delivery with instruments and the occurrence of morbidities during pregnancy. Conversely, PPM were less likely to occur among women with secondary and higher education and those who attended antenatal consultations (at least one). The qualitative analysis also highlighted the occurrence of psychological PPM, but these were largely under�reported by women and under-diagnosed by HPs. Other factors contributing to PPM onset included women’s negative delivery experience as reported by the women, and family’s influence and cultural practices as stated by HPs. Finally, in this thesis the relationship between PPC uptake and PPM occurrence in Morocco was also investigated and the results indicate that EPPC provided before discharge was associated with LPPC utilisation and lower PPM onset. The results also show that women seem to use LPPC if they experience PPM. In fact, the provision of PPC was perceived as preventive by HPs, whereas it was seen as a curative recourse by women. The contribution to knowledge of this work is to provide insights into a wider range of factors, compared to existing literature, associated with the low rate of PPC utilisation in Morocco. The research also identified novel inter-personal and ‘softer’ factors that are hindering or contributing to PPC utilisation including family’s influence, cultural beliefs and practices, relationship between HPs and women, alongside differences in 7 quality of care between public and private health structures. These are in addition to demographic and socio-economic factors, which constitute a social gradient and result in health inequalities. The research also brings new insights into the women’s and HPs’ perceptions of PPC – with the former viewing it as a curative measure while the latter consider it to be preventive. In addition, the research contributes new knowledge by furthering our understanding of the way psychological PPM are disclosed and managed. It also sheds light on the relationship between PPC uptake and PPM occurrence, with the association between the two variables relating to the timing of PPC use, that is to say that receiving EPPC before discharge prevents PPM onset whereas receiving LPPC within six weeks post-discharge was associated with PPM symptoms. The research has important practical implications with a need for a holistic approach including the views of women, HPs and policymakers to increase PPC uptake and prevent PPM. This implies a need for behaviour change from all parties, a need to change some healthcare practices and organisation of care, and a need for health promotion interventions to raise the awareness of women and their families about the importance of PPC to prevent or treat PPM. Measures aimed at women, HPs and policymakers could positively contribute towards Morocco’s aim to comply with the WHO recommendations on PPC utilisation and, by extension, to decrease maternal mortality and morbidity