A novel method of obtaining accurate home addresses from out-patients was

introduced as a routine procedure in 6 chest clinics of Madras City, following highly

satisfactory results under study conditions. In this method, the patient is given

a card (the address card), and asked to get his exact address entered on it by any

knowledgeable person of his choice such as a landlord or neighbour. An assessment

of the system was undertaken after it had been in operation for about 8 months.

A complete and legible address was available for 82 % of 3956 patients, the range in

the 6 clinics being 74 % to 91 %. The main causes for failure were : not giving address

card to patient (7 %), patient not reattending the clinic (6 %), and patient reattending

but not returning the address card (3%). Corrective measures have now been

introduced, and a re-assessment will be undertaken in due course

Fox, Wallace

Krishnaswami, K V

Radhakrishna, S

Satagopan, M C

Somasundaram, P R

Tripathy, S P

NIRT Institutional Repository

Tubercle 65 (1984) 41-45© Longman Group Ltd.A NOVEL SYSTEM TO OBTAIN ADDRESSES OF OUT-PATIENTS–ASSESSMENT IN ROUTINE CLINIC PRACTICE IN MADRAS,S. INDIA*M. C. Satagopan and S. RadhakrishnaICMR Institute for Research in Medical Statistics (Madras Chapter), Sathyamurthi road, Madras-600 031, IndiaK. V. Krishnaswami †Institute of Tuberculosis and Chest Diseases, Spur Tank road, Madras-600 031, IndiaP. R. Somasundaram and S. P. TripathyICMR Tuberculosis Research Centre, Spur Tank road, Madras-600 031, IndiaWallace FoxMedical Research Council, Brompton Hospital, Fulham road, London, SW3 6HPSummaryA novel method of obtaining accurate home addresses from out-patients wasintroduced as a routine procedure in 6 chest clinics of Madras City, following highlysatisfactory results under study conditions. In this method, the patient is givena card (the address card), and asked to get his exact address entered on it by anyknowledgeable person of his choice such as a landlord or neighbour. An assessmentof the system was undertaken after it had been in operation for about 8 months.A complete and legible address was available for 82 % of 3956 patients, the range inthe 6 clinics being 74 % to 91 %. The main causes for failure were : not giving addresscard to patient (7 %), patient not reattending the clinic (6 %), and patient reattendingbut not returning the address card (3%). Corrective measures have now beenintroduced, and a re-assessment will be undertaken in due course.RésuméUne méthode nouvelle en vue de I’obtention de I’adresse precise du domicile desmalades externes a été introduite en tant que processus de routine dans 6 consulta-tions pour maladie du thorax dans la ville de Madras, après que des résultats trèssatisfaisants aient été obtenus dans des conditions d’étude. Selon cette méthode,on donne au malade une carte (la carte d’adresse) et on lui demande de faire inscrireson adresse exacte sur cette carte par n’importe quelle personne instruite de son choix,comme son propriétaire ou un voisin. Une évaluation du système a été entrepriseaprès qu’il ait été en operation pendant environ 8 mois. Une adresse complete etlisible existait pour 82 % des 3956 malades, l’éventail entre les 6 consultations allantde 74 % à 91 %. Les causes principales d’échec étaient le fait de n’avoir pas donné decarte d’adresse au malade (7 %), le fait que le malade n’était pas revenu à la consulta-*This paper is also published in the Indian Journal of Tuberculosis (1983), 30, 93.† Present address: 4, 17th Avenue, Harrington Road, Madras-600 031, India.42 Satagopan and otherstion (6 %) et le fait que le malade, bien que revenu à la consultation, n’avait pasrapporté sa carte d’adresse (3 %). Des mesures de correction ont été introduites et unereevaluation sera entreprise en temps voulu.ResumenEn 6 dispensarios de enfermedades respiratorias de la ciudad de Madras se introdujoun nuevo método, coma procedimiento de rutina, para obtener la dirección precisa deldomicilio de los pacientes externos, después de haberse obtenido resultados satis-factorios en condictiones experimentales. Según este método se da una tarjeta alpaciente (la tarjeta de dirección) y se le pide hacer inscribir en ella su dirección exactapor cualquier persona instruida, a su elección, como por ejemplo el propietario de suhabitación o un vecino. Se efectuó una evaluación del sistema alrededor de 8 mesesdespués que había sido puesto en ejecución. Para el 82 % de los 3956 enfermos seobtuvo una dirección completa y legible con una variación entre 74 % y 91 % entre los6 dispensarios. Las principales causas de fracaso fueron : el hecho de no haber dada latarjeta de dirección al enfermo (7 %), el hecho que el enfermo no volvió a consultar(6 %) y el hecho que el enfermo aun habiendo vuelto a consultar no trajo su tarjeta dedirección (3 %). Se introdujeron medidas de corrección y se volverá a hacer unaevaluación dentro de un tiempo razonable.IntroductionIn the tuberculosis programme in India, as in many other developing countries, the proceduremost commonly employed to retrieve patients who fail to attend the out-patient clinic on thedue date is to post a reminder letter [1]; very occasionally, a home visit is paid by a healthvisitor. Obviously, an accurate home address is a s ne qua non for the success of these attempts.Unfortunately, under the pressure of a long queue of patients, addresses are often elicited byregistry clerks in a hurried or casual manner, and have been reported to have a disappointinglylow level (about 65 %) of accuracy [2, 3]. Motivation of the clerk by a senior consultantphysician had little effect [4]. Further, the use of experienced health visitors to elicit addressesresulted in only limited improvement [4]. We therefore evolved a new method (the address cardmethod), which consists of giving the patient a card with a printed message in Tamil, the locallanguage, and asking him to get his exact address entered on it by a responsible person of hischoice, such as a neighbour, the landlord, a friend or the local postman. This method wastested under study conditions in 4 chest clinics in Madras City [4] and in 4 large towns inTamil Nadu State [3], and was found to be highly satisfactory (Table I), the overall accept-ability being 97 % and the accuracy being 84 %. Following these findings, the address cardwas introduced as a routine procedure in 6 chest clinics in Madras City, and this paper describesan assessment of the system after it had been in operation for about 8 months.MethodsAt a special meeting of the health visitors, nurses and medical officers in charge of the 6 chestclinics, the Director (K. V. K.) briefed them about the findings of the research studies with theaddress card [2, 3, 4], and outlined the procedures to be employed for introducing the cardinto routine practice in the clinics, A cyclostyled set of instructions for health visitors wasalso given. (see Appendix).The address card was to be given to every patient admitted to treatment for tuberculosis.No special inputs or supervision were provided-that is, the system was left to function as aroutine clinic procedure. Subsequently, at monthly meetings with his medical officers, theAddresses of outpatients 43Table I. Acceptability and accuracy of the address card under study conditionsCentre Acceptability* Accuracy** (%) (%)Madras–Clinic 1 97 (150)† 84–Clinic 2 98 (123) 81–Clinic 3 97 (101) 96–Clinic 4 89 (111) 81Madurai 98 (275) 82Coimbatore 97 (287) 83Salem 96 (308) 82Tiruchirapalli 99 (394) 88Total 97 (1749) 84(136)(110)(95)(78)(132)(156)(102)(122)(931)*That is, among patients who reattended, the percentage who returned a completedaddress card.**That is, percentage of letters posted to the ‘address card’ address that werereceived by the patients.† Numbers in brackets are the denominators on which the percentages are based.Director made routine enquiries about the working of the address card system. None of theclinic staff knew that a formal assessment would be undertaken at a later date.When the system had been in operation for about 8 months, 2 statisticians from the Institutefor Research in Medical Statistics visited each clinic and collected appropriate data to provide ageneral assessment of the operational aspects of the system, and in particular to determine theproportion of patients for whom a completed address card was available. No attempt wasmade in this study to investigate the accuracy of the address recorded on the address card.ResultsDuring the 8-month period, 4276 patients were admitted to treatment in the 6 clinics. Thetreatment card (the patient’s record card), to which the address card was supposed to bepinned, could not be traced for 320 (7.5 %) patients despite a careful search (some of thesepatients could have been transferred to other clinics of their choice). The address card systemcould therefore be assessed in the remaining 3956 patients only (Table II).Table II. Findings of interim assessment at 8 monthsTotal for 6 clinics Findings in individual clinics (%)No. %A B C D E FAddress card not given to the patientAddress card given, but patient did not reattendPatient attended, but address card not returnedAddress card returned, but(a) not traced in the clinic(b) entry incomplete(c) entry illegibleAddress card with complete address availableTotal patients in analysis269 6.8 12.2 5.4 2.1 7.0 11.4 5.0254 6.4 6.1 10.2 6.7 3.3 2.7 3.3128 3.2 5.2 3.4 2.6 3.1 2.7 0.061 1.5 2.2 1.7 0.8 1.3 2.4 0.77 0.2 0.3 0.3 0.1 0.0 0.0 0.06 0.2 0.1 0.4 0.1 0.0 0.0 0.03231 81.7 74.0 78.6 87.5 85.4 80.8 91.13956 100.0 872 1002 951 459 369 30344 Satagopan and othersThe clinic staff failed to give the patient an address card in 6.8 % of instances, the range being2.1 % to 12.2 % in the 6 clinics. The patient received the address card but did not reattend theclinic subsequently in 6.4 % of cases (range 2.7 % to 10.2 %), and reattended but did notreturn the card in 3.2 % (range 0.0 % to 5.2 %). The address card was returned but mislaid orlost in the clinic in 1.5 % of instances (range 0.7 % to 2.4 %), while the entries were incompletein 0.2 % and illegible in 0.2 %. The net result was that an address card with a complete addresswas available for 81.7 % of the patients, the proportions in the individual clinics ranging from74.0 % to 91.1 %.Among 3433 patients who were given an address card and who reattended, 3305 (96.3 %)returned the address card. However, a complete and legible address was available for only3231 (94.1 %). The proportions in the 6 individual clinics were 90.5%, 93.1 %, 96.0%,95.1 %, 94.0 % and 99.3 %, respectively.DiscussionThe address card method has proved to be highly acceptable even under routine clinic condi-tions. Thus, complete and legible addresses could be obtained from 94 % of 3433 patientswho were given an address card and who reattended, as compared with 97 % of 1749 understudy conditions (Table I). However, considering all patients admitted to treatment in the 6clinics during the 8-month period, an address card with a complete and legible address wasavailable for only 82 %. This is rather disappointing, as the methodology of the address cardis quite simple and one might have expected an outcome in the range of 90-95 % from theexperience under study conditions [3, 4]. The causes for the shortfall are several, but theimportant ones are failure of the health visitors to give the patient an address card (7 %),failure of the patient to reattend the clinic (6 %) and failure of patients who reattended, toreturn the address card (3 %). The first cause is a failure at the clinic level and should belargely overcome by tightening up clinic procedures. The other two depend more upon thepatient, and can be reduced by greater efforts on the part of the clinic staff in explaining to thepatients the importance of reattending the clinic and returning the completed address card.Steps have now been taken to improve the efficiency of the system under routine conditionsand a reassessment will be undertaken in due course. If undertaken too soon, it may yield afalsely high level of success, and so adequate time will be given for the system to settle downinto a routine. At the next assessment it is also planned to test the accuracy of the addressesby posting letters and verifying whether they are, in fact, received by the patients.The findings of the present study emphasise the importance of testing out all new proceduresunder routine conditions. Unfortunately, operational studies of this type are undertakeninfrequently. It is by a process of assessment, evaluation, mid-course correction and reassess-ment that the gap between the results achieved under study conditions and those underroutine conditions can be bridged.AcknowledgementsWe are grateful to Miss R. Jayasri, Mr R. Ramakrishnan and Mr N. Ramalingam for assistancein data collection, and to all the staff members of the 6 chest clinics for their co-operation.References1 National Tuberculosis Institute, Bangalore (1966). District Tuberculosis Programme-Treatment Organizer’s Manual.2 Krishnaswami, K. V., Satagopan, M. C., Somasundaram, P. R., Tripathy, S. P., Radhakrishna, S., & Fox, W. (1979). Aninvestigation of the accuracy of the home address given by patients in an urban community in South India.Tubercle, 60, 1.Addresses of outpatients 453 Radhakrishna, S., Satagopan, M. C., Krishnaswami, K. V., Tripathy, S. P., Vaidyanathan, B., & Fox, W. (1980). A studyof the accuracy, and factors influencing accuracy, of home addresses of patients obtained by registry clerksand address cards in four large towns in South India. Tubercle, 61, 197.4 Radhakrishna, S., Satagopan, M. C., Krishnaswami, K. V., Tripathy, S. P., & Fox, W. (1979). Efficiency of addresscards, experienced health visitors and motivated registry clerks in obtaining the home address of urban patientsin South India. Tubercle, 60, 151.APPENDIX1 GeneralInstructions for Health Visitors1. Make the following entries on the treatment card, preferably using a rubber stamp.Date address card given :Date address card returned :Address on treatment card : Correct/Corrected2. In the treatment register, introduce 2 extra columns headed ‘Date address card given’ and ‘Date address cardreturned’.Il. When a patient is admitted to treatment1. Give the patient an address card, and enter ‘Date card given’ on the treatment card and in the treatment register.2. Ask him to get his exact postal address entered on it by a literate person–e.g. heighbour, landlord, friend, postman.3. Motivate him to return the completed card within a week–e.g. by saying ‘We will often have to write letters toyou about your health. It is important that these letters reach you without delay. So, it is in your interest to ensurethat we have your exact address’.Ill. When the address card is returned(i) Enter ‘Date card returned’ on the treatment card and in the treatment register.(ii) Check whether the address on the card agrees with that on the treatment card. If it does, encircle ‘Correct’in the treatment card. If there is any difference, correct the address on the treatment card and encircle ‘Correct’.(iii) Pin the address card to the treatment card.IV. Once a weekOn a particular day every week (e.g. Saturday), identify from the treatment register patients who have not returned theaddress card within one week, and attach a red slip to their treatment cards.V. When any patient reattendsIf there is a red slip attached to the treatment card, remotivate the patient to bring back the address card (if he haslost it, give him another card).

A novel system to obtain addresses of out-patients-assessent in routine clinic practice in Madras

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