Paediatric utilisation of a teaching hospital and a community health centre. Predictors of level of care used by children from Khayelitsha, Cape Town

Abstract

Rationale: Inappropriate utilisation of hospital services for primary curative care aggravates inefficiencies and inadequacies in health care delivery. Identification of reasons for such malutilisation may assist the development of appropriate strategies for development of rationally organised primary and secondary care services that will provide improved quality of care.

Subjects: Children under 6 years of age living in Khayelitsha.

Objectives: To ascertain: (i) the proportion of visits made to Red Cross Children's Hospital (RXH) that could be more appropriately handled at primary care level; (ii) reasons for attendance at RXH, compared with attendance at a large community health centre (Site B day hospital) in Khayelitsha; (iii) predictors of inappropriate attendance at the teaching hospital for primary care problems.

Methods: A case-referent study design was used to compare children attending RXH with children attending Site B day hospital. All care-givers attending the respective outpatient departments on 2 randomly selected days were included in the study sample. Data were collected by semi-structured interview and record review, on reasons for attendance, demographic and social variables relating to the child and care-giver, as well as clinical data on the final diagnosis contained in the patients' folders. Criteria for determining appropriateness of attendance by level of care were developed a priori via a modification of published measures.

Main outcome measures: Reasons for attendance at the facility, appropriateness of the visit by level of care and predictors of inappropriate attendance at the teaching hospital.

Results: Sixty-nine per cent of RXH visits were identified as inappropriate for a tertiary institution. The main reasons given by care-givers for attending Site B were convenience and the prohibitive cost of travel to RXH. Mothers interviewed at RXH reported problems with failure of treatment at primary care clinics, and being turned away at Site B because of overcrowding as the main reasons for attending RXH. Attendance at RXH was predicted by: (i) children who were infants; (ii) no other domestic child care responsibilities for the care-giver; and (iii) no previous attendance documented in the hospital folder.

Conclusion: Appropriate service utilisation by level of care needs to be improved. Users' choice of service appears to be a rational decision based on the accessibility of local primary care services and perceptions of the quality of these services. More appropriate use of primary care facilities therefore requires better access and perceived quality.