Family Medicine Specialist Clinics in Hospital Authority: A cross-sectional study

Ching-luen Ng 吳清聯, Yuk-kwan Yiu 姚玉筠

HK Pract 2007;29:261-270

Summary

Objective: To analyze the case load, the disease profile and the outcomes of patients seen in the 4 Family Medicine Specialist Clinics (FMSCs) in Kowloon West Cluster of Hospital Authority within first year of service.

Design: A cross-sectional study.

Subjects: All patients who attended the 4 FMSCs between November 2005 and October 2006.

Main outcome measures: Number of consultations, waiting time for first appointment, final diagnosis, discharge destinations.

Results: 1083 patients were seen in the 4 FMSCs in the study period. The usual waiting time for first appointment of FMSCs was 2 weeks, compared with more than 7 months in the Internal Medicine Specialist Out-Patient Clinics (SOPC). For patients being referred to FMSCs, majority of them were diagnosed to have uncomplicated conditions. 79% of the patients being discharged from the services did not need to be referred to SOPC.

Conclusion: FMSCs can manage large varieties of uncomplicated conditions in internal medicine, with shorter waiting time compared with SOPC. If FMSCs service can expand to manage a larger number of patients in future, it may become an effective medical service to reduce the number of referrals of uncomplicated cases to SOPC.

Keywords: Family Medicine Specialist Clinics, cross-sectional study.

摘要

目的： 在醫院管理局轄下四所首年開辦的家庭醫學診所(FMSC)分析其病人的病例比重，病例概況和治療結果。

設計： 橫剖面研究。

研究對象： 2005年11月至2006年10月期間，在該四所FMSC求診的全部病人。

主要測量內容： 診病次數，首次診症的排期等候時間，最後診斷，病人去向。

結果： 在進行研究期間共有1083人在該四所FMSC看病。平均首次排期為兩週， 相對於內科專科門診的7個月為短。大部份在FMSC診斷的都是非複雜病例。79%的病人都無需轉介其他專科門診。

結論： FMSCs能為多種非複雜內科病例作出診治，而其排期時間相對專科門診為短。假如能在未來將FMSC服務擴充，將使轉介到專科門診的非複雜病例減少。

主要詞彙： 家庭醫學專科門診，橫剖面研究。

Background

The long waiting time for Specialist Out-Patient Clinics (SOPC) of Hospital Authority (HA) is a well known problem in the public health care system in Hong Kong. In May 2006, the median waiting time for first appointment of non-urgent cases in SOPC in many specialties was more than 30 weeks: Surgery SOPC (34 weeks), Orthopaedic & Traumatology SOPC (35 weeks) and Internal Medicine SOPC (31 week).¹ Experiences in other countries have shown that Family Physicians can provide specialist clinical services that are traditionally provided by secondary care specialists. For example, in UK about 1250 General Practitioners (GPs) are providing clinical services in other specialties such as dermatology, cardiology, neurology, rheumatology, ENT.... etc.² These GPs are known as GPs with special interests (GPwSIs).³ Over half of these GPwSIs sessions are being undertaken outside the own practices of these GPs, mostly in local hospitals.⁴ Thus hospital specialists can then offer faster access to patients with more complex problems, while more straightforward cases are diverted to clinics run by GPwSIs.

The HA in Hong Kong also had the concept of extending the role of Family Physicians to provide a wider range of specialist services. In late November 2005, the HA launched 18 Family Medicine Specialist Clinics (FMSCs). The objectives of FMSCs are:

1. To act as gate-keeper of inappropriate referrals to SOPC.
2. To act as safety net of the SOPC triage system (to avoid delay in diagnosis and management).
3. To provide/ enhance community-based care.
4. To facilitate public-private cooperation of health care system.

This article first describes the special features and the referral system of the FMSCs. Then it will discuss the results of a cross-sectional study on the number of patients seen, the disease profiles of patients and the outcomes of patients seen in 4 FMSCs in the Kowloon West Cluster (KWC) of the HA in the first year of services of these FMSCs.

Family Medicine Specialist Clinics

There are totally 4 FMSCs in the KWC of the HA:- Ha Kwai Chung (HKC) FMSC, Yan Chai Hospital (YCH) FMSC, Cheung Sha Wan (CSW) FMSC and East Kowloon (EK) FMSC. Each FMSC is attached to a parent hospital (Table 1). There are several special features of FMSCs:-

Access to special investigations

One of the main roles of FMSCs of KWC is to reduce the number of patients referred to the Internal Medicine SOPC of their parent hospitals. In order to carry out this role, each FMSC has a special arrangement with her parent hospital to have direct access to certain special investigations such as upper GI endoscopy (OGD), ultrasound scan (USG), CT scan, treadmill, lung function test, ambulatory BP monitoring and 24 hour holter (Table 1).

Training background and qualifications of doctors

Doctors of FMSCs are all ex-trainees in Family Medicine. They should either possess the FHKAM (Family Medicine) qualification, or at least possess the intermediate qualifications in Family Medicine, e.g. Fellow of Royal Australian College of General Practitioners (FRACGP) and Fellow of Hong Kong College of Family Physicians (FHKCFP).

Patients suitable to be referred to FMSCs

1) Patients who need special investigations (e.g. OGD, treadmill) that are not available in primary care setting.
2) Patients with uncertain diagnosis, and need more comprehensive assessment than the usual consultation in General Out-Patient Department (GOPD).
3) Patients with conditions in Internal Medicine that have not responded to treatment in primary care setting. (e.g. patient with dyspepsia that have not responded to drug treatment in GOPD).

Patients not suitable to be referred to FMSCs

1) Patients who have unstable clinical conditions, e.g. those with unstable angina.
2) Patients who have conditions that need to be managed by specialists of other specialties, e.g. those with end-stage renal failure.
3) Patients who need special investigations not available in FMSCs, e.g. those who need colonoscopy.

Limited number of consultations

The target is to discharge uncomplicated cases within 3 visits. But this is not an absolute rule: the number of visits can be extended to more than 3, depending on the clinical conditions. For instance, a patient presented with chronic headache and dizziness was diagnosed to have depression in FMSCs. Before this patient was discharged back to the referral source, he would need 4 to 5 consultations to initiate treatment of his depression in FMSC, and be observed whether the treatment on his depression was effective or not.

Referral system of FMSCs in KWC

1) Referral system of HKC/YCH/EK FMSCs - All referrals to Internal Medicine SOPC of the parent hospitals are screened initially by triage nurses (and/or triage doctors) of the Internal Medicine SOPC. These referrals will be classified into 3 categories of urgency:
(1) "Urgent cases" (waiting time usually within 2 weeks);
(2) "semi-urgent cases" (waiting time usually within 2 months); and
(3) "non-urgent cases" (waiting time usually more than 6 months). The triage nurses /doctors would select non-urgent cases that are suitable to be managed by FMSCs, and send the referral letters of these cases to the screening doctors of the associated FMSCs for second screening. The FMSCs doctors would make the decision of accepting or rejecting these cases. If the patient is accepted by a FMSC, and the patient agrees to attend the FMSC, this patient would be given a FMSC appointment (instead of an Internal Medicine SOPC appointment of the parent hospital).

2) Referral system of CSW FMSC - Doctors in various GOPDs in Shamshuipo, Cheung Sha Wan and Shek Kip Mei districts can refer suitable patients (e.g. patients with unresolved dyspepsia and need OGD) directly to CSW FMSC.

To promote community based care

Most of the patients could be discharged from FMSCs within 3 consultations. These patients will be discharged back to the various community based health services, such as private family doctors or GOPD.

Discharge to appropriate health care services

Some patients of FMSCs would still need to be referred to SOPC subsequently because:

1) Some patients actually suffer from conditions which need to be managed by hospital specialists (e.g. patients with clinical diagnosis of rheumatoid arthritis who need management by Rheumatologists).

2) Further investigations and treatments are not available in FMSCs (e.g. patients with deterioration of ischaemic heart disease and need cardiac catheterization).

These categories of patients, who are being referred to SOPC, would be given an earlier appointment by certain subspecialty clinics of Internal Medicine SOPC (e.g. Cardiac SOPC of certain parent hospital) if their medical conditions warrant earlier investigations and management by the physicians.

Method

A cross-sectional study on: 1) the number of patients seen in the 4 FMSCs within the 1-year period from November 2005 to October 2006; 2) the sources of referral; 3) the top 10 commonest reasons of referral; and 4) outcomes of the patients as at Jan 2007. Data extraction from the electronic database and the electronic patient records of the 4 FMSCs in KWC was done during the period 1^st Jan 2007 to 10^th Jan 2007. Data analysis was performed with the aid of the computer software Excel of Microsoft Office XP.

Results

Number of patients seen

Between Nov 2005 and Oct 2006, 1083 patients were seen in these 4 FMSCs. The distribution of these patients was shown in Figure 1. There were two HKC FMSC sessions per week (on Monday and Wednesday, 3 hours per session), and approximately 10 new cases were seen in HKC FMSC per week. There was only 1 clinic session per week (3 hours per session) in each of YCH FMSC, CSW FMSC and EK FMSC. Figures showed that utilization rates of CSW FMSC and EK FMSC were lower than those of the other two FMSCs.

Sources of referral

The sources of referral of these patients were as follow:

It is thus obvious that majority of referral came from GOPD, since special investigations are not available in GOPD.

Shortening of waiting time for selected patients

The usual waiting time of new cases of Internal Medicine SOPC in the KWC is more than 7 months. When patients with uncomplicated conditions were diverted to FMSCs, the waiting time of these patients was greatly shortened (Figure 2).

Top 10 commonest reasons for referrals

There were totally 1194 "reasons for referral" among these 1083 patients (some patients had more than 1 "reason for referral", e.g. patient had both DM and HT). The top 10 commonest reasons for referral were shown below: (Percentage of the total 1194 reasons of referral)

Outcome of patients

Analysis of outcome of patients referred to our FMSCs with epigastric discomfort/ dyspepsia, DM, chest discomfort, palpitation and abnormal liver function tests was made:

Epigastric discomfort/ dyspepsia

By Jan 2007, 124 patients with epigastric discomfort/ dyspepsia had been discharged from FMSCs. The final diagnoses or outcomes of these patients were summarized in Table 2. 74 (60.0%) of these patients underwent OGD: most of them were found to have uncomplicated conditions such as gastritis. 2 patients (out of 74) were found to have carcinoma of stomach: the first patient received operation within 2 weeks of diagnosis; the second patient was found to have inoperable carcinoma of stomach, and he received chemotherapy in another hospital. Other investigations ordered were ¹³C Urea Breath test (in private sector) and USG. 4 were referred to the SOPC because they needed further investigations that were not available in FMSCs. 39 patients (31.5%) were discharged without the need of special investigations or referral to SOPC.

Diabetes mellitus

130 patients attended the FMSCs because of DM. They were either: (1) referred from SOPC, AED or private doctors because of newly diagnosed DM; or (2) referred from GOPD because of unsatisfactory control of DM. By Jan 2007, the outcomes of these patients were as follow:

(*1 patient died because of stroke, the other patient died because of acute myocardial infarction).

Chest discomfort

By Jan 2007, 76 patients referred to FMSCs because of chest discomfort had been "case closed". The outcomes of these patients were shown in Table 3. Most of them (n = 61) were discharged with clinical diagnosis of non-cardiac chest pain made by the FMSCs doctors. 3 patients were diagnosed to have ischaemic heart disease (IHD) by CT coronary angiogram: One of them was referred back to GOPD after commencement of drug treatment in FMSC; two of them were subsequently referred to the Internal Medicine SOPCs because of worsening of their IHD.

Palpitation

Totally, 63 patients were referred to our FMSCs because of palpitation.

Abnormal liver function tests

61 patients were referred to our FMSCs because of abnormal liver function tests (LFTs). By Jan 2007, 20 patients were still under the care of our FMSCs (waiting for repeat blood tests or USG), and 41 patients had been discharged. The breakdown of outcomes of these 41 patients was as follow:

22 out of 33 patients (67%) were found to have fatty liver by USG. Before discharging these patients who had fatty liver, the doctors in FMSCs would advised them the importance of regular monitoring of their condition. The detection of chronic active hepatitis B and hepatitis C in 2 out of 35 patients with persistent abnormal LFTs seems to support the need of FMSCs to shorten waiting time for patients.

By Jan 2007, out of the total 1083 patients seen, 784 of them had been "case closed" in FMSCs. The average number of visits of these discharged cases was 2.52 (95% confidence interval: 2.44-2.60). A total of 201 special investigations (i.e. investigations not available in GOPD, as in Table 1) were done on these 784 patients (25 of these special investigations were done in private sector). Therefore 1 special investigation was done per 3.9 patients being discharged. The outcomes of these patients were as follows:

Thus only about 21 % of patients discharged from FMSCs were referred to SOPC, and 79% of these patients did not need to be referred to SOPC.

(*Totally, 137 patients were referred to FMSCs from private sector, and 43 of them were referred back to these private doctors. 31.4% of patients referred to FMSCs from private sector were subsequently discharged back to private sector. **1 patient died because of stroke, the other patient died because of acute myocardial infarction).

Discussion

Achievements of FMSCs

1. To reduce referrals to SOPC. For patients discharged from FMSCs, only 21% of them were finally referred to SOPC. Actually, for the top commonest reasons of referral to FMSCs such as epigastric discomfort/dyspepsia, chest discomfort and abnormal liver function, most of these patients were finally diagnosed to have uncomplicated conditions such as gastritis, non-cardiac chest pain and fatty liver respectively. On the other hand, there were some significant diseases (such as stomach cancer and unstable angina) detected by FMSCs. This showed that FMSCs not only reduced the referral of selected patients with uncomplicated conditions to the SOPC, they also detected significant diseases which needed early intervention by hospital specialists.

2. Promoting community-based patient care. After receiving the appropriate investigations and initial management in FMSCs, patients diagnosed to have uncomplicated conditions can be reassured that their conditions are suitable to be managed in their original GOPCs or by private family doctors, and referral to SOPCs in hospital is not necessary.

3. Better access and substantial shorter waiting time. The waiting time for new cases of most of our FMSCs (except YCH FMSC) is about 2 weeks. This thus created better access and great convenience to patients waiting for specialist medical care.

4. Public-private co-operation. 31.4% of patients referred to FMSCs from the private sector were referred back to these private doctors (instead of discharged to GOPD). Subsequently, our GOPD (a public health care service) did not need to takeover all patients referred from the private sector. Some patients of FMSCs were referred to the private sector for some special investigations (e.g. CT coronary angiogram and ¹³C Urea breath test) because of the longer waiting time of the alternative investigations in FMSCs (e.g. treadmill and OGD). This was a good starting point in encouraging more affluent patients to utilize medical services in the private sector in the future.

Limitation of FMSCs

1. The low utilization rate of CSW FMSC was due to the fact that it only accepted direct referrals from GOPDs (i.e. limited referral sources). The low utilization rate of EK FMSC was due to lack of referrals in the first few months of services. Actually the selection of suitable cases to FMSCs had increased workload of SOPC triage nurses. After encouraging SOPC triage nurses to divert more suitable cases to FMSC, the referral rate of EK FMSC improved since April 2006.

2. With the aim of discharging patients within few visits, the doctors in FMSCs sometimes will have a tendency to over-investigate in order not to miss serious but less likely differential diagnoses. For example, for patients complaining of persistent epigastric pain/ dyspepsia not responding to antacid and H2-blocker, OGD was performed on 60% of these patients to exclude serious conditions such as malignancy.

3. Continuity of care, a major attribute of Family Medicine, is not practised in FMSCs (due to intention of discharging patients within a few visits).

Future directions

Only 1083 patients were seen in the 4 FMSCs in KWC within the first year of its services. Comparing with the 81,000 new cases seen in the Internal Medicine SOPC in HA in 2005,¹ this is actually a small number. Our report showed that clinics run by specialists in Family Medicine in Hong Kong, equipped with the direct access to some special investigations, could manage a large variety of uncomplicated conditions in Internal Medicine. If the FMSCs service can be expanded to manage a larger number and larger varieties of patients (e.g. uncomplicated surgical cases, uncomplicated orthopaedic cases), it may have the potential to become an effective medical service to reduce the number of referrals of uncomplicated cases to SOPC in future.

Conclusion

By providing some special investigations (that are not available in GOPD) and initial management to patients, FMSCs are able to manage a large variety of uncomplicated conditions in Internal Medicine. Besides, FMSCs also provide better access and shorter waiting time for patients who need to wait longer for specialist medical care. Since only 1083 patients were seen in our FMSCs in the first year, there is still room for further expansion of FMSCs services in future.

Acknowledgements

The authors are especially grateful to Dr Alvin Chan Chung Yuk and Dr Luk Wan for their assistance in data collection. The authors would also like to thank Dr Allen Ngai Ho Yin for his valuable suggestions on this study.

Key messages

1. FMSCs are able to manage large varieties of uncomplicated conditions in Internal Medicine.
2. Comparing with the Internal Medicine SOPCs, FMSCs provide a substantial shorter waiting time for patients who need to wait for specialist medical services.
3. If FMSCs service in Hospital Authority can be further expanded, it may become an effective service model to reduce the workload of SOPC in future.