Specialist outreach clinics in primary care and rural hospital settings.

 

Abstract

Background

Specialist medical practitioners have conducted clinics in primary care and rural hospital settings for a variety of reasons in many different countries. Such clinics have been regarded as an important policy option for increasing the accessibility and effectiveness of specialist services and their integration with primary care services.

Objectives

To undertake a descriptive overview of studies of specialist outreach clinics and to assess the effectiveness of specialist outreach clinics on access, quality, health outcomes, patient satisfaction, use of services, and costs.

Search methods

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) specialised register (March 2002), the Cochrane Controlled Trials Register (CCTR) (Cochrane Library Issue 1, 2002), MEDLINE (including HealthStar) (1966 to May 2002), EMBASE (1988 to March 2002), CINAHL (1982 to March 2002), the Primary-Secondary Care Database previously maintained by the Centre for Primary Care Research in the Department of General Practice at the University of Manchester, a collection of studies from the UK collated in "Specialist Outreach Clinics in General Practice" (Roland 1998), and the reference lists of all retrieved articles.

Selection criteria

Randomised trials, controlled before and after studies and interrupted time series analyses of visiting specialist outreach clinics in primary care or rural hospital settings, either providing simple consultations or as part of complex multifaceted interventions. The participants were patients, specialists, and primary care providers. The outcomes included objective measures of access, quality, health outcomes, satisfaction, service use, and cost.

Data collection and analysis

Four reviewers working in pairs independently extracted data and assessed study quality.

Main results

73 outreach interventions were identified covering many specialties, countries and settings. Nine studies met the inclusion criteria. Most comparative studies came from urban non-disadvantaged populations in developed countries. Simple 'shifted outpatients' styles of specialist outreach were shown to improve access, but there was no evidence of impact on health outcomes. Specialist outreach as part of more complex multifaceted interventions involving collaboration with primary care, education or other services wasassociated with improved health outcomes, more efficient and guideline-consistent care, and less use of inpatient services. The additional costs of outreach may be balanced by improved health outcomes.

Authors' conclusions

This review supports the hypothesis that specialist outreach can improve access, outcomes and service use, especially when delivered as part of a multifaceted intervention. The benefits of simple outreach models in urban non-disadvantaged settings seem small. There is a need for good comparative studies of outreach in rural and disadvantaged settings where outreach may confer most benefit to access and health outcomes.

 

Plain language summary

Specialist outreach clinics in primary care and rural hospital settings may improve access to care, quality of care, health outcomes, patient satisfaction and use of hospital services. They may also be more costly.

This review examines the benefits and costs of outreach in a range of specialties and in a variety of settings. Simple 'shifted outpatients' styles of specialist outreach were shown to improve access, but there was no evidence of their impact on health outcomes. Outreach as part of more complex multifaceted interventions involving primary care collaborations, education and other services was associated with improved health outcomes, more efficient and guideline-consistent care, and less use of inpatient services. There is a need for better quality evidence evaluating specialist outreach in all settings, but especially in rural and disadvantaged populations.

 

摘要

背景

專科醫師擴大服務到初級照護及鄉下的醫院機構

許多不同的國家因為各種理由，實施專科醫師醫療實務者擴大服務到初級照護及鄉下的醫院機構。這種醫院被視為是一種重要的政策選擇，用來增加專科醫師服務與初級照護服務整合的可近性與效果。

目標

對於專科醫師擴大服務到診所的研究進行整體描述性的回顧，並評估專科醫師擴大服務到醫院對於可近，品質，健康結果，病患滿意度，服務利用，及成本的效果。

搜尋策略

我們檢索the Cochrane Effective Practice and Organisation of Care (EPOC)專業的登記資料庫(2002年3月)，the Cochrane Controlled Trials Register (CCTR) (考科藍圖書館2002年，第1期)，MEDLINE (包括HealthStar) (1966至2002年5月)，EMBASE (1988至2002年3月)，CINAHL (1982至2002年3月)，以前由曼徹斯特大學一般醫療部之初級照護研究中心維護的PrimarySecondary Care Database，整理於“Specialist Outreach Clinics in General Practice”的英國研究(Roland 1998)，以及所有檢索文章的參考文獻。

選擇標準

就診於專科醫師擴大服務到初級照護或鄉下的醫院機構，其提供簡單的諮詢或作為綜合多面向介入措施的一部分的隨機試驗，前後對照研究及間斷時間序列分析。研究對象為病患，專科醫師，及初級照護提供者。研究結果包括客觀測量的可近，品質，健康結果，滿意度，服務利用，及成本。

資料收集與分析

四名回顧作者兩兩成對分別摘錄資料並評估研究品質。

主要結論

確定了73種擴大服務的介入措施，包含許多專科醫師，國家與機構。9篇研究符合納入標準。大部分可比較的研究來自已開發國家中都市的非弱勢族群。單純”門診轉介”的專科醫師擴大服務方式顯示可以改善可近，但沒有影響健康結果的證據。作為綜合多面向介入措施的一部分的專科醫師擴大服務，包含整合初級照護，教育或其他服務，顯示與促進健康結果，較有效率及一致的照護指引，及較少使用住院服務有關。因為擴大服務而增加的成本也許會被改善的健康結果所平衡。

作者結論

這篇回顧支持專科醫師擴大服務可以改善可近，結果及服務利用的假設，尤其是當所提供的服務作為多面向介入措施的一部分時。單純的擴大服務模式對於都市中非弱勢機構的利益似乎不大。需要有良好可比較的研究關於擴大服務在鄉下與弱勢機構的評估，在這種機構中擴大服務也許會提供最有利的可近性與健康結果。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

專科醫師擴大服務到初級照護及鄉下的醫院機構也許可以促進照護的可近，照護品質，健康結果，病患滿意度及醫院服務的利用。它們的成本也許較高。這篇回顧評估某一範圍的專科醫師擴大服務及實施於各種機構的利益與成本。單純”門診轉介”的專科醫師擴大服務方式顯示可以促進可近，但沒有影響健康結果的證據。作為綜合多面向介入措施的一部分的擴大服務，包含初級照護整合，教育及其他服務，顯示與改善健康結果，較有效率及一致的照護指引，及較少的住院服務利用有關。需要評估專科醫師擴大服務到所有機構之品質較佳的證據，尤其是對於鄉下與弱勢族群。