Diseño de la Interfaz del Usuario de la Aplicación Móvil

In the Islington study, a third of all structured diabetic reviews in the prompted group occurred in hospital outpatients. These

consultations, it is contended, do not detract from the

effectiveness of the prompted care package as a whole. Rather, they reveal that effective community care needs to allow for easy referral to and from hospital clinics. A two thirds/one third apportionment of total doctor patient contact for structured diabetic review between community and hospital in a 2^/2 year period is a significant achievement in the case of seasoned hospital attenders who have been discharged from ’their hospital* clinic

(Beardshaw 1992).

Some 40% of prompted patients who were reviewed in hospital diabetic clinics were seen as a result of referrals outwith the participating GPs. As already discussed, these patients were referred by other hospital outpatient departments and following in-patient episodes; five patients changed their minds about accepting prompted care after the start of the study; for a few patients, the route by which they found their way back to the hospital clinic could not be identified - some patients may have referred themselves.

In the case of the prompted patients who were referred from within

the prompting system, the referral letter stated that the p a t i e n t ’s normal care involved community prompting. A label in the outpatient

notes advised the clinic doctor that the patient should be assessed in terms of the particular reason for referral and, in the absence of any complicating factors, should be discharged back to prompted care (see Figure 7). In this way, it was hoped to minimise the number of prompted patients who might become 'trapped' in hospital outpatients as a result of referral. However, on reviewing the hospital notes of prompted patients seen in hospital diabetic clinics, it was frequently difficult, in many instances, to discern w h y a patient had been given another hospital clinic appointment rather than being discharged back to prompted care in the community. This was also true in the case of patients who found their w a y back to the hospital clinic without referral from within the prompting system. In this situation, there was no label in the hospital outpatient notes to advise the reviewing doctor to discharge the patient back to prompted care. Although the hospital notes of all prompted patients had been stamped w ith a notice to this effect, if the notice was not immediately apparent to the reviewing doctor, and the patient did not strongly identify w i t h prompted care, there was little to indicate to the clinic doctor that this patient usually received prompted care. The low visibility of the prompted community care scheme in the hospital clinic was partly a function of the small size of the study; the reappearance of 52 prompted patients in hospital clinics over 2^/2 years amounted to only IZ of the total number of patients seen in these clinics (see Table 6). A n adequate awareness amongst the staff of hospital clinics about existing arrangements for community care is essential if patients are not to be 'sucked back' into hospital clinic care following referral.

The different routes by which a high proportion of the prompted group returned for review in the hospital diabetic clinic probably reflects the influence of several factors upon the partition of care between primary and secondary care. Nationally, all-reason hospital referral rates by GPs are extremely variable w i t h little consensus about which factors most influence referral (Acheson 1981, Acheson 1986, Wilkin & Smith 1987, Morris & Roland 1988, Moore & Roland 1989, Bradlow et al 1992, Roland & Coulter 1992). Although some studies have concentrated on influences acting upon the threshold of

patient referral from GP to hospital, little is known about the factors wh i c h influence the number of subsequent hospital consultations after referral, hospital follow-up intervals, or the rate of discharge back to GP care. One study has shown that the adoption of simple clear guidelines in hospital outpatient clinics can have a decisive effect upon these process measures in a hospital general medical clinic (Hall et al 1988).

In the case of diabetes, approximately 13% of all diabetes-related consultations w i t h GPs nationally result in hospital referral (National Morbidity Statistics 1979), but little is known either about the determinants or appropriateness of these referrals. Referral studies not specifically concerning diabetes have tended to focus upon thresholds influencing patient ’f l o w s ’ across the primary secondary interface rather than upon factors which might have an influence upon the ’v o l u m e ’ of patients who can be contained within primary or secondary care. The author has not been able to find studies w hich chart the pattern of primary and secondary care received by a cohort of diabetic patients over a period of time. A retrospective study of the diabetic notes in 7 non mini-clinic practices in Southampton (Burrows et al 1987) found a falling trend for GPs to refer newly diagnosed NIDDM patients to hospital clinics over three periods: before 1975, 1975-79 and post 1979. The authors comment that this finding is in keeping w i t h GPs assuming increased responsibility for the care of patients w i t h chronic conditions generally. This conclusion is also supported by National Morbidity Studies which have shown a trebling in the patient consulting rate

for diabetes over the period 1955-1981 (National Morbidity

Statistics 1986) However, such studies provide only ’s n apshot’ pictures of the pattern of diabetic care. W hat is needed is a record linkage study (Acheson 1968) of the care of diabetic patients in a locality. This could yield the information needed to properly inform attempts to reconstruct rationally the relationship between primary and secondary care in the case of this complex chronic disease.