(Submitted November 12, 1968; revision accepted for publication January 23, 1969.)
Presented in part at the Ambulatory Pediatric Association Annual Meeting, Atlantic City, New Jersey, April 1968.
ADDRESS: (D.F.) Department of Pediatrics, University of California-San Francisco Medical Center, San Francisco, California 94122.
PEDIATRICS, Vol. 43, No. 6, June 1969
927
EFFECTIVE
PATIENT
CARE
IN THE
PEDIATRIC
AMBULATORY
SETTING:
A STUDY
OF
THE
ACUTE
CARE
CLINIC
D. Fink, M.D., M. J. Malloy, M.D., M. Cohen, M.S.W., M. A. Greycloud, RN.,
and F. Martin, R.N.
Frcnn the Department of Pediatrze.s, Universitf,I of California-San Francisco Medical Center, San Francisco
ABSTRACT. Our study used family compliance and understanding as indices of effectiveness. In a
control population of 142 cases, effectiveness
aver-aged 52% of the desired level but only 8%
achieved desired levels of effectiveness in all mea-sured categories. Scores were highest in
appoint-meat keeping, lowest in understanding of the
child’s condition, and intermediate for medication taking and procedure J)erfOrfllance. The services
of family health management specialists were
added to the regular clinic services and resulted in significant improvement in all measured categories. These specialists were trained public health nurses
and directed their efforts to an understanding of
total family health situation and the capacity and
resources of the family for completing
recom-mended care. They undertook full responsibility
for medical follow-up in a significant number of
cases. Through them the average percentage of
ef-fectiveness was raised to an average of 82%. of the
(lesired level, although only 31% of the cases were
judged to he at an adequate level in all of the tate-gories.
Questions still unanswered are which aspects of the services of the family health mnanagemcnt spe-cialist were responsible for the improvement in ef-fectiveness, whether non-professionals can achieve the same improvements, and whether such services can he applied to other clinic and private pr1ctice
settings. Pediatrics, 43:927, 1969, AMBULATORY
HEALTH CARE, PEDIATRIC CARE, NURSING,
PEDIAT-RIC ASSISTANTS.
N
EW METHODS of improving tilequan-tity, quality, and effectiveness of
health services to children and their
fami-lies in an ambulatory setting have 1)een
in-vestigated by us with the following basic
assumptions: (1) most families have
prob-lems in carrying out recommendations for
medical care so that a significant loss of
medical effectiveness often results, (2)
medical effectiveness can be improved
before this failure of management has
oc-curred by routine investigation of
individ-ual family Ileeds and planning for
individu-alized care, and (3) management should be
assumed by a single individual designated
as “management specialist”-since our focus
is on the family as well as the patient, we
use the term “family health management
specialist” (FHMS).
A pilot study in the acute care clinic with
cases of respiratory illness had indicated
that a physician and nurse functioned with
equal effectiveness in the role of FHMS
and that both working together were no
more effective than either alone.1 Because
we were interested in applicability and
efficiency as well as effectiveness, only
nurses were used in the role of FHMS in
this more extensive study which included
patients with all diagnoses in the acute care
clinic.
Our objectives were: to define and
mea-sure existing effectiveness of care, to
de-velop a method of identifying individual
family needs and the management services
that could meet those needs, and to
deter-mine whether the addition of such
manage-ment services produced a measurable
in-crease in effectiveness of care.
METHODS
Selection of Patients
The population who uses the Pediatric
Cali-TABLE I
FORMAT OF MEDICAL CARE
(‘ontrol Patient-s (Usual Nursing Service) Physician visit Procedures Physician follow-up Study Pahents (with FHMS)
FilMS family preliminary
interview Physician visit FHMS.physician conference FilMS-physician family conference FHMS-family conference Procedures FHMS follow-up
fornia-San Francisco Medical Center in San
Francisco is heterogeneous with respect to
factors of income, ethnicity, education, geo-graphic location in the city, and so forth. All
patients who came to the clinic for the first
visit concerning an illness were included in
the study (from September 1967 to January
1968) and were assigned randomly to study
and control groups-a total of 274 cases
(142 control and 132 study).
Study Format
The families in the control group
re-ceived the usual medical and nursing
ser-vices (Table I). The physician, usually
an intern, obtained the customary history,
performed the physical examination,
dis-cussed his findings and recommendations
with the family, and arranged for any
nec-essary follow-up. He also completed a
spe-cial form which described the diagnoses,
the regimen prescribed, recommendations
to the family, and his estimate of the
fami-ly’s understanding.
The families assigned to the study group
met with the FHMS for an interview which
focused on the family (i.e., its chief
con-cerns in health and related areas, its
struc-ture and general functioning and its
experi-ence and capacity for health care) for
approximately 20 minutes before the
physi-cian’s examination. Two nurses experienced
in public health nursing participated
equally in this study.
After the physical examination, the
phy-sician and FHMS jointly formulated a plan
of management. This discussion averaged
about 5 minutes and could include all
as-pects of management, e.g., choice of
medi-cation, frequency and type of follow-up
vis-its, special instructions, and utilization of
additional resources to assist with care. The
decisions were based on the capacity of
that particular family to deal with the
pre-senting illness and other identified family
problems.
The FHMS and the physician together
then explained the findings, made
recoin-mendations to the family, and discussed the
implementation of the management plan.
Further alterations were made by the
FHMS following a nurse-family conference
which usually lasted 3 to 15 minutes. In
cases where further physician services were
not compulsory, the FHMS then assumed
primary responsibility for follow-up care.
She continued to assess the need for
fol-low-up activities, made changes in the
med-ical regimen as required by the family
situ-ation, and drew on physician services when
she judged it necessary. The services of the
FHMS included general health education,
counseling, coordination of care of other
family members, and traditional clinic
nurs-ing services. The average time spent by the
FHMS with each family was 56 minutes.
Evaluation
A “final interview” was conducted with
the families of the control and study
pa-tients approximately 3 weeks after the
ini-tial visit by a person on the project team
who was not involved in that family’s care.
Two experienced and skilled individuals, a
physician and a social worker, interviewed
a similar number of control and study
groups. Evaluation of the interview data
and other case records was performed by
another individual who was not a member
of the project. Six major items were
se-lected to measure effectiveness: compliance
in medications, procedure performance,
ap-pointment keeping, total compliance,
un-derstanding, and total effectiveness.
To evaluate compliance in medications,
as-ARTICLES 929
signed an arbitrary value of 2, and the total
prescribed regimen was expressed as an
ad-ditive score. For example, if penicillin and
triprolidine hydrochloride (Actifed) were
prescribed, the possible score would be 4.
The giving of each medication was then
evaluated as an individual item and rated
as adequate performance
(
value of 2)
,in-adequate
(
value of 1)
, or not performed(value of 0). If the penicillin was given
ade-quately and the triprolidine was not given
at all, the performance score would be 2 out
of 4, or 50%. Adequacy of performance was
defined in practical terms rather than
per-fection. For instance, minor variation in
ad-ministration of antibiotics that did not alter
the effectiveness of the drug were included
in the adequate category. Similar scoring
was used for procedure performance and
appointment keeping. Total compliance
was used to express the ratio of the sum of
all performance scores to the sum of all
prescribed scores. Level of understanding
was evaluated in the sub-categories of signs,
and symptoms, course, and implications
were evaluated by a similar rating system.
The ratio of observed understanding to
ex-pected understanding was expressed as a
percentage. Expected understanding was
defined for each condition as the specific
and practical understanding of the child’s
illness and treatment necessary for effective
care. Total effectiveness was expressed as
the average performance of the four
cate-gories (medications, procedures,
appoint-ments, understanding).
RESULTS
Tile level of existing effectiveness in the
control group was low in all categories
nleasured and improved significantly in the
study group (p < .001). No significant
differences were noted between the two
different FHMS or the two different
inter-viewers.
Medications
Figure 1 shows the average effectiveness
scores for study and control groups and the
percentage of families which gave all
pre-scribed medications adequately, i.e., 18% of
the control group and 69% of the study
group.
Procedures
Average effectiveness in performance of
procedures (temperature taking, use of a
vaporizer, skin care, dietary
recommenda-tions, and so forth) for the control group
was 47% and 88% for the study
group-24% of the control group performed all
procedures adequately compared to 69% of
the study group (Fig. 2).
Appointments
Both the control and study groups had
the highest effectiveness scores in the area
of appointment keeping (Fig. 3).
Effective-ness in appointment keeping included
follow-up clinic visits, arrangements for
tele-phone calls, referrals to other health
facili-ties, laboratory tests, and home visits.
Total Compliance
In total compliance (the ratio of the SUfll
of all performance scores to the sum of all
prescribed scores), 59% of the study cases
carried out all items in the prescribed
regi-men adequately compared with 18% of the
control cases (Fig. 4).
Understanding
In the area of understanding, the lowest
percentage of effectiveness and adequate
scores were evident in both groups,
although there was a significant difference
between the control and study groups (Fig.
5). Even in the study group, less than half
of the families had adequate
understand-ing.
Total Effectiveness
The average scores for the study group
was 82% compared to 52% for the control
group (Fig. 6). However, the magnitude of
the problem seems best illustrated in the
scores for “adequate in total effectiveness,”
i.e., the percentage of cases where all
mea-sured objectives of care were adequately
achieved-only 31% of the study group
achieved 100% effectiveness scores
N83
N83
5(
4(
3(
N85
group group
%
Effectiveness%
Adequate
conk
group group
Fic. 1. Effectiveness scores for study and control groups and percentage giving medications adequately.
DISCUSSION
It seems appropriate here to question the
validity of svhether these methods measure
the effectiveness of pediatric care. It is also
important to emphasize that “effectiveness”
as used in this study is not intended to
nec-essarily impugn the parent or the
profes-sional staff, but it serves as an indicator of
the entire care system. Using Haggerty’s
classification,2 there is no doubt that
mea-surement of “output factors,” i.e., the
ac-tual health status of individuals receiving
care under a program, is most important in
any assessment of the usefulness of
estab-lished or new methods of care. Such studies
are difficult in terms of methodology and
require a relatively stable and static
popula-tion in both control and experimental
groups. The “intervening factors” carry the
assumption (not always entirely justified)
that the prescribed regimen and increased
understanding is beneficial to the patient.
In spite of this, it is only through such
in-tervening factors that the health care
sys-tern can influence individuals rather than
populations, and seems sufficient
justifica-tion for a study of the “physiology” of such
factors.
The low level of effectiveness in tile
con-trol groups reveals a major defect in our
ability to translate medical
recommenda-tions into medical care. The results are
even more disturbuiig in view of the fact
that, since much of the information on
med-ication and procedures necessarily came
from interview data, it probably reflects a
higher level of performance than actually
existed. However, the results on the more
objective measure of appointment keeping
and understanding are also poor.
The results are similar to other studies
which have revealed a significant defect
in compliance ill medications,
appoint-ments,4’5 and understanding.’ When the
ser-vice of the FHMS was added to the system,
a significant improvement in medical
effec-tiveness occurred in all measured areas.
70
-60
-50-
____
40-30- #{149}:#{149}:#{149}:#{149}:#{149}:#{149}
20-
#{149}:#{149}::#{149}::#{149}
10- #{149}‘#{149}#{149}
N76
%
Effectiveness
%
Adequate
N78
90
80
70
60
50
1-78
N76
3
10
ly
group group group group
Fic. 3. Effectiveness in appointment keeping.
100
-90
-80
-N67
ARTICLES 931
control study group group
N67
control study group group
40
FIc. 2. Effectiveness in performance of procedures.
N117
Nll7
10
N127
study
group group group
50
40
-30
-20
-10
-N140
N131
N140
1iii!
__________
control study group group
% Adequate
Fic. 5. Understanding.
control
group
%
Effectiveness
%
Adequate
100
90
80
-70
-60
-Fic. 4. Total compliance.
N131
control study
-group group
N132
N132
N142
group group group group
% Effectiveness
% Adequate
AHTICLES 933
Fic. 6. Total effectiveness.
of the elements added b the FilMS were
responsible for tile increased effectiveness
One possii)ilitv iS tile qualitative addition in
the type of services rell(lered. The FHMS
provided teaching and demonstration,
fol-low-up of presenting symptoms,
investiga-tion of new svniptoms, and referrals to
ap-propriate community agencies. Preliminary
analysis does not reveal a significant
correla-tion of effectiveness with the type of service
rell(lered. Our piot stud’ indicated that a
1)hvSician directed to these tasks was as
(1-fective as a nurse, and that i)Otil together
were no more effective than either alolle.
A second possibility is that any
addi-tional servic’ 1)rovided by an illtereSted and
responsive individual could produce the
same benefits. In a retrospective analysis of
cases, the FFIMS felt that 62% could have
been Iielpe.l as effectively 1w a
Iloll-prOfes-sional family health aide, 27i’ could have
i)eefl helped as well by such an aide with
Ilursing consultation, and that only 11%
might require full nursing services. A recent
study investigating the effect of a single
telepllone call by non-professionals and
professional healtil personnel showed an
equal aild P0sitie effect oii appointmeiit
keeping, but no effect in increasing
compli-ance or understanding.7
A third possibility is the factor of tim(’
spent with a fanliiy-80% of the cases had
more than ne contact with the FIlMS, and the average time spent Witil the family was
56 minutes. Since the number of contacts
and amount of time after the initial visit
was decided, irt, by iler estimate of
family needs, one might expect an inverse
correlation. Preliminary analysis of the (lata
does not reveal any sigllificailt correlation
hut requires further investigation.
Perilaps a more significailt qtietion is
why, even with tile addition of the FilMS,
effectiveness levels were still less than
de-sirable (total compliance for tile study
(lS5 was adequate ill OIll’ 59% of the
and total effectiveness was adequate
in only 31). Apparently niany factors
de-termine effectiveness, other than the “input
Our pilot study’ indicated that certain
general social characteristics and variables
in individual family situations influenced
compliance. Income and education were
re-lated to compliance-those with either very
low or very high income and education
were lower in compliance than the middle
brackets. As expected, members of minority
groups, families with one parent, those low
in general social resources, or those who
had transportation difficulties getting to the
clinic were associated with low compliance.
These data indicate that the social
charac-teristics in the family situation may
influ-ence compliance in regular clinic care
nega-tively.
In all cases, however, the study group
had better compliance than the control
group. Therefore, while the services of the
FHMS may not totally eradicate the
nega-tive effects of such factors, they can
signifi-cantly reduce their influence.
Other studies of factors in compliance”
indicate that the family’s feelings of
ur-gency and expectation of risk to the child
are strong factors; congruence of
expecta-tions of the family with the recommended
regimen may also be important.’2
There has been considerable interest in
the development of “assistants” in the
ren-dering of pediatric care.’317 Unfortunately,
the programs that have developed, trained,
and placed individuals in patient care
set-tings have reported results only in terms of patient and professional satisfaction or in
general qualitative terms. This makes it
dif-ficult to evaluate whether effectiveness of
care has been altered. When such
individu-als are placed where there has been no
pre-vious health care at all, it is reasonable to
assume that effectiveness in care would
im-prove. However, the more pressing problem
is to expand the quality and quantity of
health care where structure and staff exist
but have been deficient. Programs designed
to provide “comprehensive care,” when
studied in a controlled manner, have not
produced a significant improvement.’8
A specific question related to FHMS is
whether improvements effected in a clinic
population have significance for a private
practice setting. While there is insufficient
data, compliance in private practice may
also be less than optimal.2O Our
experi-ence with higher income groups in this
study would confirm the idea that the need
for increased effectiveness is not limited to clinic settings.
SPECULATION
Although a “low” level of effectiveness
does not necessarily indict the recipient
family or the health care provider, it is the
implied responsibility of the health care
provider to seek a greater completion of
recommended health care. Perhaps we need
to have a more thorough knowledge of
whether recommended health care is
ap-propriate, as judged by the course of the
patient. Most necessary is a mechanism that
will automatically provide the information
that permits us to judge when
non-compli-ance is appropriate behavior. There is
much to suggest that the non-professional
may be far more successful than the
deter-mined physician or nurse who regard
com-pliance as a personal tribute from a grateful
patient.
CONCLUSION
This study shows that the level of
exist-ing medical effectiveness in the Pediatric
Acute Care Clinic is unsatisfactory, whether
expressed as percentage of effectiveness or
as the number of cases in which adequate
care was achieved.
When clinic services (designed to meet
individual family needs in performance of
medical care) are provided, a significant
and measurable increase in effectiveness
can be demonstrated. However, even with
this intervention, the levels were
considera-bly less than optimal, particularly in tile
area of understanding.
This study also demonstrates the
impor-tance of including some measure of
effec-tiveness in any evaluation of new
ambula-tory services.
Although other approaches may also lead
ARTICLES 935
Clinic.
should be made to develop more effective
family health management services,
includ-ing use of non-professional personnel,
which could have applicability to all areas
of pediatric ambulatory care.
REFERENCES
1. Fink, D. K., Malloy, M. J., Cohen, M.,
Grey-cloud, M. A., and Martin, F. : The
manage-ment specialist in effective pediatric
ambula-tory care. Amer. J. Pub. Health, 59:527,
1969.
2. Haggerty, B. J.: Evaluation of health services,
two case studies. in Bergman, A. B., ed.:
Assessing the Effectiveness of Child Health Services. Report of the fifty-sixth Ross
Conference on Pediatric Research.
Colum-bus, Ohio: Ross Laboratories, pp. 62-69,
1967.
3. Bergman, A. B., and Werner, R. J.: Failure of
children to receive penicillin by mouth. New
Eng. J. Med., 268: 1334, 1963.
4. Alpert, J. J.: Broken appointments. PEDIATRICS,
34:127, 1964.
5. Badglev, B. F., and Furnal, M. A.:
Appoint-ment breaking in a pediatric clinic. Yale J.
Biol. Med., 34:117, 1961.
6. Korsch, B., Gozzi, E., and Francis, V.: Gaps in
doctor-patient communication. I.
Doctor-pa-tient interaction and patient satisfaction. PE-DIATRICS, 42:855, 1968.
7. Barken, R., and Olivieri, M.: The role of
inter-vention by telephone in effective
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Epidemiology Research Program, California
State Health Department, August 23, 1968.
8. Ciovannoni, J., Fink, D., Cohen, M.,
Grey-cloud, M., Malloy, M., and Martin, F.: The
impingement of social factors on compliance in an acute care clinic. Proceedings of the
Ambulatory Pediatric Association Meeting,
Atlantic City, New Jersey, April 1968. 9. Elling, B., Whiteemore, B., and Green, M.:
Patient participation in a pediatric program. J. Health Hum. Behav., 1:183, 1960. 10. Cordis, L., Markowitz, M., and Lilienfeld,
A. M.: Studies in the epidemiology and preventability of rheumatic fever. IV. A quantitative determination of compliance in
children on oral penicillin prophylaxis.
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11. Ambuel, J., Cebulla, J., Watt, N., and Crowne,
D. P.: Urgency as a factor in clinic
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13. Ford, P. A., Seacat, M. S., and Silver, G. A.:
The relative roles of the public health nurse
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1966.
14. Silver, H. K., Ford, L. C., and Stearly, S. G.:
Pediatric nurse practitioner program.
PEDI-ATISICS, 39:756, 1967.
15. Blum, H. L.: Multipurpose worker, a family
specialist, Amer. J. Pub. Health, 55:367,
1965.
16. Siegel, E., Dihlehey, B., and Fitzgerald, C. J.:
Bole changes within the child health confer-ence. Attitudes and professional prepared-ness of public health nurses and physicians. Amer. J. Pub. Health, 55:832, 1965.
17. Yankauer, A., Connelly, J. P., and Feldman, J.: A survey of allied health worker utilization in pediatric practice, in Massachusetts and in the United States. PEDIATRICS, 42:733,
1968.
18. Elinson, J.: Effectiveness of social action pro-grams in health and welfare. In Bergman, A. B., ed.: Assessing the Effectiveness of Child
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Co-lumbus, Ohio: Ross Laboratories, pp. 77-89,
1967.
19. Charney, E., Bynum, B., Eldredge, D., Frank,
D., MacWhinney, J. B., McNabb, N., Schei-ner, A., Sumpter, E. A., and Iker, H.: How well do patients take oral penicillin, a col-laborative study in private practice.
PEDIAT-RICS, 40:188, 1967.
20. Williams, T. F., Martin, D. A., Hogan, M. D., Watkins, J. D., and Ellis, E. V.: The clinical picture of diabetic control, studied in four settings. Amer. J. Pub. Health, 57:441, 1967.
Acknowledgment
We are indebted to Rona Rudolph, M.D., for her
case evaluations and Jacqueline Schlumpf, RN., for
