First-visit patients without a referral to the Department of Internal Medicine at a medium-sized acute care hospital in Japan: an observational study

Abstract

Purpose: We sought to profile first-time patients without a referral who sought medical care at the Department of Internal Medicine at a medium-sized acute care hospital in Japan. We anticipated that the analysis would highlight the demand for medical care needs from acute care hospitals and help confirm one of the problems associated with primary care in Japan.

Patients and methods: The study population comprised 765 patients who sought outpatient consultation without a referral at "the Department of General Internal Medicine" at the Ikeda City Hospital on Fridays over 4 years. Data on the following variables were collected: age, sex, examination date, reason for encounter (RFE), diagnosis, as well as history of consultation with or without antibiotic treatment at another medical institution for the same RFE. We used the International Classicication of Primary Care, Revised Second edition (ICPC-2-R) codes for RFEs and diagnoses.

Results: The main RFE fields were digestive (ICPC-2-R Chapter D), general and unspecified (A), and respiratory (R). The main diagnosis fields were digestive (D), respiratory (R), general and unspecified (A), and musculoskeletal (L). In total, 27.6% of patients had sought consultation at another medical institution for the same RFE. Of these, 64.7% of patients for whom the RFE was cough (ICPC-2-R code, R05), and 72.0% for whom the RFE was fever (A03) were prescribed antibiotics. In total, 62.4% of patients underwent emergency investigations and waited for the results; 4.3% were hospitalized on the same day; and 60.5% were medicated at the initial examination. In 11.5%, the main underlying problem appeared to be psychosomatic.

Conclusion: We used the ICPC-2-R to analyze the state of first-visit patients without a referral visiting the Department of Internal Medicine at a medium-sized acute care hospital in Japan. Common RFEs were abdominal pain, cough, and fever. A tendency toward overprescription of antibiotics was observed among primary care physicians.

Keywords: International Classification of Primary Care; antibiotic overuse; general internal medicine; general practice; medium-sized hospital; reason for encounter.

Figure 1

Frequency of RFEs classified by the ICPC-2-R for 765 first-visit patients who presented to the Department of Internal Medicine at the Ikeda City Hospital without a referral on Fridays between April 2012 and March 2016. Notes: A = general and unspecified; B = blood, blood-forming organs, and immune mechanisms; D = digestive; F = eye; H = ear; K = circulatory; L = musculoskeletal; N = neurological; P = psychological; R = respiratory; S = skin; T = endocrine, metabolic, and nutritional; U = urological; W = pregnancy, child-bearing, and family planning; X = female genital; Y = male genital; Z = social problems. Abbreviations: ICPC-2-R, International Classification of Primary Care, Revised Second edition; RFE, reason for encounter.

Figure 2

Frequency of diagnoses classified by the International Classification of Primary Care, Revised Second edition (ICPC-2-R) for 765 first-visit patients who presented to the Department of Internal Medicine at the Ikeda City Hospital without a referral on Fridays between April 2012 and March 2016. Notes: A = general and unspecified; B = blood, blood-forming organs, and immune mechanisms; D = digestive; F = eye; H = ear; K = circulatory; L = musculoskeletal; N = neurological; P = psychological; R = respiratory; S = skin; T = endocrine, metabolic, and nutritional; U = urological; W = pregnancy, child-bearing, and family planning; X = female genital; Y = male genital; Z = social problems.

Figure 3

First-visit patients (n=765) who presented to the Department of Internal Medicine at the Ikeda City Hospital without a referral on Fridays between April 2012 and March 2016, who visited another medical institution, and who were or were not prescribed antibiotics. Notes: Results are categorized by reason for encounter fields classified by the International Classification of Primary Care, Revised Second edition (ICPC-2-R) and whether or not patients who visited another medical institution before presenting to our hospital were prescribed antibiotics by that institution. RFEs on the far right edge exhibit an A03 and R05 overlap with the number of cases of A and R on the left. Legend (n=the number of patients who did not visit another medical institution, the number of patients who visited another medical institution and did not receive an antibiotics prescription, and the number of patients who were prescribed antibiotics at another medical institution, respectively.): A = general and unspecified (n=113, 21, 21); B = blood, blood-forming organs, and immune mechanisms (n=14, 2, 0); D = digestive (n=152, 55, 3); F = eye (n=3, 0, 0); H = ear (n=0, 0, 0); K = circulatory (n=35, 6, 1); L = musculoskeletal (n=44, 19, 0); N = neurological (n=53, 16, 0); P = psychological (n=4, 0, 0); R = respiratory (n=95, 24, 27); S = skin (n=8, 1, 0); T = endocrine, metabolic, and nutritional (n=18, 9, 0); U = urological (n=16, 4, 1); W = pregnancy, child-bearing, and family planning (n=0, 0, 0); X = female genital (n=0, 0, 0); Y = male genital (n=0, 0, 0); Z = social problems (n=0, 0, 0); A03 = fever (n=60, 7, 18); R05 = cough (n=54, 12, 22). Abbreviation: RFE, reason for encounter.

Figure 4

Antibiotics prescribed at another medical institution to 765 first-visit patients who presented to the Department of Internal Medicine at the Ikeda City Hospital without a referral on Fridays between April 2012 and March 2016 (n=53).