General outpatient department in tertiary care institute: A model to be adopted by medical colleges.

CONTEXT: Teaching medical institutes and tertiary care hospitals in various cities are overcrowded and overburdened. The general outpatient department (GOPD) plays a vital role as screening OPD to triage patients who require secondary or tertiary care and refer them to appropriate OPD. Primary health care is initiated at the GOPD itself and the mechanism of referral is established. AIM: To study GOPD model and its services in the institute. To assess perception of patients towards it. SETTINGS AND
DESIGN: It was an observational study conducted in a medical college of Mumbai, Maharashtra for 1 month on persons attending the GOPD.
MATERIALS AND METHODS: Data and monthly reports were used for baseline comparisons and exit interviews of patients were taken using questionnaire. STATISTICAL ANALYSIS USED: Quantitative analysis was done using the proportions and means for the number of patients served daily by the GOPD and medicine OPD.
RESULTS: Around 44% of services were therapeutic in nature and it had contributed to a significant reduction in patient load into another specialist department. Nearly 30% cases needed referrals during the study period. Statistically, the significant value was obtained for patient satisfaction for consultation services from GOPD.
CONCLUSIONS: A statistically significant value for patient satisfaction for consultation services from GOPD indicates that patients were in favor of such type of services. Copyright:

Introduction

Teaching medical institutes and tertiary care hospitals in various cities are overcrowded and overburdened all the time. It was found that the reason for overburdened tertiary care centers at various places is due to the unavailability of services at the local level. The other reason which was cited by the patients in various patient satisfaction studies done at medical colleges and hospitals, for taking services from the specialist institute, was failure of primary and secondary health care even for minor ailments.

To tackle the overcrowding and long-waiting time for services from the medicine OPD, segregation of patients was required. This segregation was added with the responsibilities to give curative, preventive, and promotive services. In this regard, the general outpatient department (GOPD) was started in the year 2010 in K.E.M Hospital, Mumbai.[1] It is now daily serving 60% of patient load coming to the institute. The GOPD is run daily by the resident doctors, lecturers, and professors of department of Community Medicine Seth G. S. Medical College.

The GOPD or preventive medicine clinics play a vital role as screening OPD to triage patients who require secondary or tertiary care, refer them to appropriate OPD and manage the ones that do not need such referral.

The National Medical Council has included community medicine under the clinical subject's category and has recommended provision of clinical services by the resident medical practitioners and trainee doctors.

This study was undertaken to study the GOPD model and its role in providing services in the institution. To assess patient satisfaction for GOPD services.

Subjects and Methods

This observational study was carried out in a teaching institute of Mumbai for a period of 1 month from April 2017 to May 2017 (Ethical approval under the protocol nber EC/OA-78/2017 obtained in May 2017 and completion report submitted on 08/10/2018). The study population comprised of persons attending the GOPD during the study period. Unpublished data from the year before starting up the GOPD with due permission from the institute was used to know the status of outpatient services from the institute. Enumeration of the roles and services of GOPD was done with the help of the mission and vision statement of the department of community medicine. These were pre-decided by the experts in the field and department. Patient flow analysis was carried out to know the present status of the GOPD services. A patient satisfaction survey was carried out for 84 systematically and randomly selected patients attending the GOPD using modified questionnaire of NABH (National Accredited Board of Hospitals). The sampling interval was approximated to four.

Results

Nearly 50% (2104 out of 6616 individuals) of all the patients were coming to GOPD for follow-up as compared to the new patients. Almost 43% of patients are between the ages group of 30 to 50 years (2841 patients out of 6616), followed by 50 to 70 years (1998 patients out of 6616). Around 44% of services are therapeutic in nature given through OPD followed by diagnostic services (30%).

The majority of patients came for musculoskeletal complaints (16.14%) followed by fever (15.25%) and headache (12.09%). Nearly 20% of patients came for complaints that involved sexology, learning disability, or gynecological opinion.

It was observed that 15.75% of patients were referred to as medicine, surgical specialty. GOPD being a filter clinic screens the patients for referral and treats remaining who were having minor ailments.

Almost 82% were satisfied with the overall services given through the GOPD and there was a statically significant association between patient satisfaction and consultation services through GOPD. (Chi-square = 10.29, P value = 0.001)

Table 1 shows the distribution of patients as per the types of services received from the GOPD in 1 month. Diagnostic services include all the OPD based investigations for e.g., complete blood count (CBC). Therapeutic services include treatment for the ailments which do not need any specialist consultation e.g., acute febrile illness. Municipal medical examinations (MME) were done for the employees of municipal corporations. Others constituted services like family screening of patients of tuberculosis etc.

Table 1

Distribution of patients as per the type of services received from the GOPD in 1 month

Types of services	No of patients	Percentage
Diagnostic	1971	30%
Therapeutic	2912	44%
Referral	1352	20%
MME	283	4%
Others	98	2%
Total	6616	100%

Table 2 shows patient satisfaction for the services offered by the GOPD under various domains among patients who were in agreement that they were satisfied with the services (n = 100) (data is not mutually exclusive).

Table 2

Patient satisfaction for the services offered by the GOPD under various domains among patients who were in the agreement that they were satisfied with the services (n=100) ( data is not mutually exclusive)

Domain	Percent of patients satisfied
Waiting	33%
General services	33%
Overcrowding	30%
Signages and disability friendliness	4%

Patient satisfaction considering the waiting time and receipt of general services from GOPD was similar i.e. 33%. Waiting time includes time spent in the institute before consultation from GOPD. General services comprise sitting, water, and toilet and so on.

Table 3 shows an association between patient satisfaction for various components of patient satisfaction form. It was observed that highest level of association was present between patient satisfaction and consultation time. There was statistically significant association between them.

Table 3

Association between patient satisfaction with various factors

		χ2	P
GOPD waiting	Patient satisfaction for overcrowding	5.046	0.025
	Patient satisfaction for waiting	6.074	0.034
Consultation time	Patient satisfaction for services	10.29	0.001
Total time spent	Total patient satisfaction	0.029	0.864

Discussion

GOPD run by community medicine experts is playing a major role in the filter clinic. This OPD not only gives therapeutic services but is also involved in promotive and preventive services. GOPD has also extended its work towards rehabilitative services. It is decreasing the patient load on other specialist departments while maintaining quality care.

According to a report named preventive medicine clinics in hospitals, an opportunity missed in 2013 for competency-based medical education, preventive medicine clinics would serve the population and would decrease the secondary and tertiary care requirement. Clinics not only reduces overcrowding but also had increased efficiency of all the departments.[23]

Average attendance to GOPD has been 300 patients per day and nearly half of them (50%) are old patients who usually come to show up reports of investigations and collect medicines that have been started from specialist clinics. Curative services form nearly 44% of services indicating the management of minor ailments that do not need specialist consultation. A most common symptom for which GOPD consultations made were for musculoskeletal complaints (16.14%) like easy fatigability followed by fever (15.25%), headache (12.09%), and acute respiratory infections (8.91%). Around one-third of patients were referred to medicine surgery and other departments as per the guidelines and protocols.

GOPD was acting as the first point of contact. The screening was done right there, thereby decreasing unnecessary referrals to other specialists. Patient satisfaction was more for consultation from GOPD and the most common reason cited by the patients is the daily running of OPD as compared to specialist OPD which runs on a specific weekday. Another reason cited by patients for high satisfaction was better communication and behavior of staff with them.

A study was done in the year 2013 stated that patient satisfaction was higher for consultation services and better communication of staff with patients than the other specialist OPDs. In Nigeria, there is well established referral system to other departments. This led to development of general clinics run by family physicians.[45] Also, a study done by Solanki et al. in Patan, Gujarat, found that patient satisfaction for overall services from general outpatient clinic was 82%.[6]

A study done in the Maldives, where GOPD is run by the department family medicine had suggested that patient satisfaction improved after segregation of patients which reduces waiting time and improves quality of services.[7]

A similar model like GOPD, known as the preventive clinic was also adopted in Thailand which stated that the quality of medical services improved from preventive clinics.[8]

Private and corporate hospitals started general outpatient clinics with unique identity numbers. They not only provide preventive services but also offer curative services for ailments of nonemergency nature. Other successful models for GOPD which resulted in improved services by proper segregation of patients are seen in B.P.K.I.H.S., Dharan, Nepal.[9]

The concept of GOPD is also taking roots in the private health sector which is evident today in Fortis healthcare and Apollo group of hospitals which not only provides preventive clinics but has a system of unique identity cards to tack all the referrals post the first consultation.[1011]

Recently, the Central Council of Research in Unani Medicine, advices its centers to start the GOPD for preserving public health.[12]

Conclusions and Recommendations

GOPD model involved services from community medicine specialists and acts as a filter clinic which will improve the quality of services in the long run in every medical college and will become essential part of training of postgraduates in community medicine in competency-based education system.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.