A CAJM survey of out-patience's  failure rate to return for further treatment at  the major Zimbabwe(Rhodesia) hospital, Harare Central.It was an early impression when commencing work in a medical unit at 'Harare Hospital that a large proportion of patients failed to  return to the out-patient clinic on discharge from hospital despite the chronic or serious nature of their disease. An attempt was therefore made to assess the magnitude of the problem, it seeming both of interest and importance to the practicing physician at Harare Hospital to know more, exactly the likelihood of a patient returning for follow-up care, especially where circumstances may force an early discharge due to pressure on beds. These estimations seemed relevant when considering the African patient who usually has no regular private practitioner and relies more heavily on the hospital or clinic. It must also be considered in relation to the costs of modern in-patient care and treatment which may be considered wasted if patients are not followed up. In these oases re-admission may involve further intensive therapy and expenditure which could have been prevented. These thoughts initiated a five months’ survey of return attendances which will be compared to similar problems in other areas

Maar, S. A.

Central African Journal of Medicine

English

IDS OpenDocs

The Central African Journal of Medicine
Editor-.
MICHAEL GELFAND, C.B.E., M.D., F.R.C.P.
Assistant Editor-. 
JOSEPH RITCHKEN, M.D.
Volum e Nineteen 
JANUARY - DECEMBER 
1973
I
Salisbury
igceu ffil
R hodesia
. REFERENCES
Belding, D. S. (1965) Textbook of Parasitology. Apple- 
ton-Century-Crofts. N.Y. 3rd Edition, p. 461.
Capron, A . and R ose, R. (1962) Bull, de la Soc. 
Exotique, 55, 765.
Elsdon-Dew , R . (1964) S. Afr. med. J ., 38, 974. 
Goldsmid, J. M . (1968) . Trans. R. Soc. trop. Med. Hyg., 
62, 619.
Graham, C. F . (1941) Am. J. Trop. Med., 21, 159. 
Mazzotti, L. (1944) Rev. Inst. Salub. y. enferm. trop. 
S, 283.
Mossqp, R. T. (1973). C. Afr. J. Med. 19, 2, 31. 
Pawlowski, Z. and Sch ultz , M. G. (1971) Adv. in 
Parasitology, 10, 267.
Schultz, M. G., H alterman, L. G., R ich, A. B. and 
Martin, G. A. (1969) J. Am. Vet. Med. Ass., 155, 
1708.
Schultz, M . G ., H ermos, J. A. and Steele, J. H.
(1970). U.S. Public Health Reports. 85, 2.
Stoll, N. R. (1947) J. Parasitology, 33, 1.
Thornton, H . and G oldsmid, J. M . (1969) C. Afr. 
J. Med. 15, 47.
Verster, A. (1967) Z. f  Parasitenkunde, 29, 313.
'Vol. 19. No. 7. J uly, 1973.
A Follow-up Survey of 
Out-patients in a Medical Clinic 
for Africans at Harare Hospital 
in  Rhodesia
BY
SIRJE A. MAAR,
M .B ., B.S. (L O N D .) , B .SC., M .R .C .P. ( U .K .)
Physician, Umtali General Hospital
I ntroduction
It was an early impression when commencing 
work in a medical unit at 'Harare Hospital that 
a large proportion of patients failed to ■ return 
to the out-patient clinic on discharge from hos-. 
pital despite the chronic or serious nature of their 
disease. An attempt was therefore made to assess 
the magnitude of the problem, it seeming both of 
interest and importance to the practising physician 
at Harare Hospital to . know more , exactly the 
likelihood of a patient returning for follow-up 
care, especially where circumstances may force 
an early discharge due to pressure on beds. These 
estimations seemed relevant when considering the 
African patient who usually has no regular private 
practitioner and relies more heavily on the hospi­
tal or clinic. It must also be considered in relation 
to the costs of modern in-patient care and treat­
ment which may be considered wasted if patients 
are not followed up. In these oases re-admission 
may involve further intensive therapy and expen­
diture which could have been prevented. These 
thoughts initiated a five months’ survey of return 
attendances whioh will be compared to similar 
problems in other areas. r
T h e  Central African 
J ournal of M edicine
Patients and Methods
A prospective survey was carried out of patients 
discharged from hospital during, the five month 
period from 30th January, 1969 to 26th June, 1969 
who were given appointments to attend one of 
two specific clinics weekly one to four weeks after 
discharge. Only the attendance at the first out­
patient appointment was considered.
The patients were drawn from the medical 
unit of one of four medical consultants practising 
at Harare Hospital. On discharge they were in­
formed of their appointments by the nursing 
staff and were given an appointment card with 
details of the diagnosis and treatment.
Those who attended on the wrong day and 
those who were known to have died or to have 
been readmitted in the interim formed a miscel­
laneous group of 16 patients who will not be 
discussed further.
New diabetic patients were considered separate­
ly because of their attendance at a special diabetic 
clinic held twice monthly.
' Eighteen months after the completion of the 
survey the notes of these patients were re­
examined and a record made of readmission or 
death as reported in the notes. One set of notes 
could not be traced.;;
Results
Table I indicates the rate of turnover of 
patients in the unit in question. The total number 
of patients discharged home from the medical 
unit during the period under consideration was 
481 and of these 263 (55 per cent.) were new 
patients who were asked to return to out-patients 
for follow-up. Thus roughly half of all dis­
charges fulfilled the criteria for this survey.
Table I
T urnover of Patients in  the U nit  for the 
F ive Month  Period from February,
1969 to June , 1969.
Total Discharges Total New
Home Appointments % Appointments
481 263 55 %
Table II
Attendances related to Patients’ Sex
Sex Attendances Non-Attendances % Attendance
Male 75 71 51%
Female 40 47 46%
Total 115 . 118 49%
Male to Female ratio =  146 to 87 =  1,7 to 1.'
151
J uly, 1973. OUT-PATIENT FOLLOW-UP IN HARARE T h e  Central African 
Journal of Medicine
The results set out in Tables II-VII confirm the 
impression of a remarkably poor reattendance 
rate after discharge from hospital. In fact the 
attendance rate was 49 per cent., as out of 233 
patients, 115 attended and 118 failed to attend.
Table II shows attendances related to patients’ 
sex and although a male to female preponderance 
of 1,7 to 1 is demonstrated, the attendance rates 
for males and females were of the same order, 
being 51 per cent, and 46 per cent, respectively 
(Chi square test not significant).
Table III
Attendances related to Clinic  Days
Day Sex of Patient
Attend­
ances
Non-
Attend­
ances
ofo Attend­
ance
Monday Male 33 42 44%
Female 16 22 42%
49 64 43%
Thursday Male 42 29 59%
Female 24 25 49%
66 54 55%
TOTAL 115 118 49%
Table III shows attendances related to clinic 
days and again the attendance is of the order 
of 50 per cent. Apparent differences such as a 
lower male attendance for Monday clinics (44 
per cent.) than for Thursday clinics (59 per cent.) 
are not statistically significant (Chi square test).
Table IV
Attendances related to time period between 
D ischarge and next Out-Patient
APPOINTM ENT
Period in 
weeks Attendances
Non-
Attendances
%
Attendance
1 18 13 58%
2 36 38 49%
3 13 16 45%
4 42 49 46%
Unspecified 6 2
Total 115 118 49%
Table IV relates attendances to the time period 
■between discharges and the next out-patient ap­
pointment and Table V relates attendances to the 
month of the out-patient appointment. Neither 
factor has a significant effect on attendance.
Thus the attendance rate of 49 per cent, is 
unaffected by factors such as sex differences, 
preference for a particular clinic day, the time 
lapsing before out-patient attendance or the month 
of the appointment.
Table V
Attendances related to the month  of the 
Out-Patient appointment
Month Attendances
Non-
Attendances
%
Attendance
February 8 14 36%
March 15 21 42%
April 26 24 52%
May 34 31 52%
June 26 19 58%
July 6 9 40%
TOTAL 115 .118 -49%
Table VI relates out-patient attendance to the 
discharge diagnosis. The diagnoses are classified 
under systems affected and in order of prevalence. 
Twenty-five double diagnoses were made and the 
group of 14 diabetics haVe been added, making 
a total of 272 diagnoses i in 247 patients. This 
represents an analysis o f  the major conditions 
treated, diseases of the respiratory system •repre­
senting the highest prevalence (27 per cent.), 
followed by those of the cardio-vascular system 
(18,7 per cent.) and the central nervous system 
(8 per cent.). The respiratory group consisted 
mainly o'f patients with asthma, pneumonia or 
lung abscess, whereas in the cardio-vascular group, 
Secretary of Health for his permission to publish, 
congestive cardiac failure patients with either 
rheumatic heart disease or hypertensive heart 
disease predominate. The central nervous system 
group has a preponderance of epileptics and of 
males (4,5 to 1 compared to the average male 
to female ratio of 1,7 to 1), but the apparently 
higher attendance rate (64 per cent, compared to 
■the average of 49 per cent.) is. not statistically 
significant.
Of the small series of new diabetics discharged 
in this five month period, 13 out of 14 reattended 
on the expected date showing a considerably 
higher attendance rate than other groups. Reasons 
for this will be discussed.
Table VII relates attendance to readmission or 
death 18 months later. It is shown that only 12 
per cent, of the patients in this study had been 
readmitted and that three per cent, had died in 
this time. Attendance or .non-attendance at the 
first out-patient appointment appears to have little 
bearing on the likelihood of re-admission or death
152
July, 1973. OUT-PATIENT FOLLOW -UP IN  HARARE t «  cental a™ca»
J ournal of Medicine
Table VI
Out-Patient attendance related to D ischarge D iagnosis
System
Involved
No. of 
Patients
%
Patients Attendances
Non-
Attendances
%
Attendance
Respiratory 74 27% 30 44 41%
Cardiovascular 51 18,7% 27 24 53%
C.N.S. 22 8% 14 8 64%
Hepatic 20 7,4% 12 8 60%
Haematological Reticuloses 19 7% 11 8 58%
Alimentary 17 6,2% 11 6 65%
Renal 16 5,9% 9 7 56%
Diabetes 14 5,2% 13 1 93%
Rheumatic 13 4,8% 6 7 46%
Pyrexias 12 4,4% 6 6 50%
Miscellaneous 14 5,2% 3 11 22%
TOTAL 272 99,8% 142 130 52%
N.B. 25 double diagnoses were made and 14 diabetics included making a total of 272 diagnoses in 247 patients.
Table VU
Attendances.related to Re -admission or Death w ith in  18 Months
Not Admitted
Number % Attendances N on-Attendances % Attendance
197 85% 94 103 48%
Re-Admitted 28 12% 16 > 12 57%
Deaths 7 3% 4 3 57%
TOTAL 232 100% 114 118 49%
18 months later. Thus, of the 28 patients re­
admitted, 16 had attended out-patients at the 
required time and so had four patients of the 
total of seven patients who died.
D iscussion
The attendance rate of 49 per cent, reported in 
this series is -lower than any reported in the 
literature. Generally out-patient attendance has 
varied from 65 per cent, to 100 per -cent. Factors 
which have ibeen shown to affect attendance in­
clude distance from the hospital (Chamberlain, et 
al. 1966, and Fendall 1965), transport and -access 
to the telephone (Alper-t, 1964), individual atten­
tion and a remediable condition (Richard­
son et al., 1964). Ill-health of well-being 
on a clinic day may itself affect out-patient 
attendance (Redhead and Reid 1963). Attendances 
oan also be increased by individual efforts and 
enthusiasm, e.g. Turner, (1962), who achieved 
a 90 per -cent, attendance rate for patients with 
tuberculosis in the Nyeri District of Kenya by 
meticulous follow-up methods. Similarly in 
Rhodesia, the follow-up rate for patients with 
tuberculosis at the end of 18 months was - 85 
per cent. (Westwater, personal communication).'
Factors which may have -reduced attendance 
here include distance from the hospital, financial 
difficulties involved in travel, failure of communi­
cation due to -language barriers, attendance at 
another medical centre and a -more fatalistic atti­
tude to disease among the African population. 
The higher attendance of diabetics in this series 
may reflect the particular interest of the physician 
running the diabetic clinic, leading to a better 
explanation and understanding of the disease. It 
has also been suggested that diabetic Africans 
•tend to be Of a higher social grade (Gelfand and 
Forbes, 1963).
Examination of Table VI listing the prevalence 
of disease -in this group of patients as a whole 
is of interest, in that the spectrum of disease 
correlates well with the diseases encountered in 
the out-patient department in the Groote Schuur 
Hospital (Nel, 1964) and differs from the West 
Indies (Montgomery, 1969), where there is a 
higher incidence of diabetes, coronary artery 
disease and rheumatic disorders and England 
(Priest, 1962) where 23,8 per cent, of out­
patient referrals have no organic disease. The 
list of diseases also gives some indication of how
153
Vol. 19. No. 7. J uly, 1973.
many patients (estimated as 153 of the total 233) 
would require continued medical surveillance. 
The strain of suoh increasing loads, estimated at 
360 per year for this clinic alone would pose 
impossible burdens on the facilities and staff 
available.
How important is careful follow-up for the 
average patient discharged from hospital? Other 
series have stressed the risks in terms of mortality 
and morbidity of ex-hospital patients (Ferguson, 
1961), but the prophylactic effect of out-patient 
care for ex-hospital patients has not been well 
established. In this series the records failed to 
demonstrate an advantage in terms of re-admission 
or death within 18 months, but the figures are 
incomplete as factual analysis of the fate of all 
patients was outside the scope of this survey.
In conclusion it has been shown that 49 per 
cent of ex-hospital patients failed to follow the 
advice of their medical attendants in terms of 
after care. These are the numerical facts of the 
problem. The questions which remain unanswered 
are how far each medical attendant should strive 
to provide effective after care for the chronic 
sick in the community, whether such care can be 
shown to be effective in maintaining the health 
of such patients in the community and to what 
extent the onus of seeking such medical care 
should rest with the patient rather than his 
attendant.
Summary
In a prospective study of 233 medical 
patients discharged from a medical unit of Harare 
Hospital, only 115 (49 per cent.) attended for their 
follow-up appointments. Reasons for this are 
discussed in relation to social factors, discharge 
diagnosis and re-admission 18 months 'later.
Acknowledgments
I wish to thank Dr. I. I. Forbes, Dr. S. 
Cornthwaite, Dr. W. Castle and Mr. D. R. 
Barley for their help with this paper and the 
Secretary of Health for his permission to pub- 
' fish.
R eferences
Alpert, J. 1. (1964), Pediatrics, 34, 127.
Chamberlain, J., Acheson , R. M., Butterfield, W. J.
H. and Blaney, R. (1966), Medical Care, 4, 81. 
F endall, N . R. E. (i1965), J. Tropical Medicine and
Hygiene, 68, 12.
F erguson, T. (1961), Brit. Med. J. 1, 1242 and 2, 5234. 
Gelfand, M. and F orbes, J. I., (1963), S. Afr. Med. J.
37, 1208.
M ontgomery, R. D. (1969), W. Ind. Med. J. 8, 119. 
N el, B. M., (1964 ) 5. At. Med. J., 38, 827.
Priest, W. M . (1962), Lancet, 2, 1043.
Redhead, I. H. and R eid, J. J. A. (1963), lamcet, 1, 
‘ 159.' '
R ichardson, W. P., H iggins, A. C. and Ames, R. G.
(1964) Amer. J. Pub. Health, 54, 1177.
Turner, P. P. (1962), Tubercle, 43, 76.
Westwater, M. L., (:1971) (Personal Communication)
L
c
n
a
f
c
t
1
I
c
r
1
1
1
c
1
5
i
(
3
i
i
i
1
-154
This work is licensed under a 
Creative Commons
Attribution -  Noncommercial - NoDerivs 3.0 License.
To view a copy of the license please see: 
http://creativecommons.org/licenses/by-nc-nd/3.0/
This is a download from the BLDS Digital Library on OpenDocs
h ttp ://o p e n d o c s .id s .a c .u k /o p e n d o c s /
Institute of 
Development Studies


A Follow-Up Survey Of Out-Patients In A Medical Clinic For Africans At Harare Hospital In Rhodesia

It was an early impression when commencing work in a medical unit at 'Harare Hospital that a large proportion of patients failed to  return to the out-patient clinic on discharge from hospital despite the chronic or serious nature of their disease. An attempt was therefore made to assess the magnitude of the problem, it seeming both of interest and importance to the practicing physician at Harare Hospital to know more, exactly the likelihood of a patient returning for follow-up care, especially where circumstances may force an early discharge due to pressure on beds. These estimations seemed relevant when considering the African patient who usually has no regular private practitioner and relies more heavily on the hospital or clinic. It must also be considered in relation to the costs of modern in-patient care and treatment which may be considered wasted if patients are not followed up. In these oases re-admission may involve further intensive therapy and expenditure which could have been prevented. These thoughts initiated a five monthsâ€™ survey of return attendances which will be compared to similar problems in other areas

Maar,  S. A.

National Research Database of Zimbabwe

https://opendocs.ids.ac.uk/opendocs/bitstream/20.500.12413/5292/1/Maar%2c%20Sirje%20%20CAJM%20%20vol.%2019%2c%20no.7.pdf

A Follow-Up Survey Of Out-Patients In A Medical Clinic For Africans At Harare Hospital In Rhodesia

Abstract

Similar works

Full text

Available Versions

IDS OpenDocs

National Research Database of Zimbabwe