Virji A
Lister Health Centre, London.
BMJ. 1990 Jul 7;301(6742):22-6. doi: 10.1136/bmj.301.6742.22.
To ascertain which social and psychological characteristics are associated with patients attending surgeries without appointments.
Prospective study of patients attending an urban centre group practice.
Urban health centre group practice with five doctors and 12,000 patients in an area of high (greater than 20%) unemployment and social deprivation.
All attenders at the open access surgery and one in four consecutive attenders by appointment, selected sequentially from the first three appointments, during 10 days in January 1989. Patients participating in the pilot study, reattending during the study period, or attending antenatal clinics were excluded.
Patients' attitude to making appointments and reasons for attending, including perception of urgency, with respect to sociodemographic and psychosocial data obtained from a self completed questionnaire before the consultation. Doctors' diagnosis and perception of urgency obtained from a separate questionnaire.
86% (141/172) Of patients attending without appointments and 96% (139/145) with appointments responded to the questionnaire. The need for consultation was considered to be "very urgent" or "fairly urgent" in significantly more of the open access group than the appointments group (89%, 124/139 v 66%, 91/138; chi 2 = 27.04, df = 3; p less than 0.001), although the doctors did not share the same views. Significantly more patients had self limiting conditions of recent onset in the open access than in the appointments group (75%, 101/135 v 48%, 59/123: p less than 0.001). Overall, open access attendance was significantly linked with social support (39%, 48/124 v 26%, 32/123; p less than 0.05) and with marital separations or intentions to separate (10%, 9/87 v 0/92; 47%, 32/87 v 22%, 20/92 respectively; both p less than 0.001), but the doctors recorded significantly fewer psychological and social problems in these patients (p less than 0.05). Although almost half those in the appointments group considered that making appointments was inconvenient, more of those in the open access group agreed with this view (47%, 60/129 v 61%, 80/131).
There was an important link between social support problems and a negative attitude to making appointments. In our previous experience encouraging patients to make appointments has been unsuccessful; practices serving areas with a high prevalence of social deprivation providing a mixed open access and appointments system may better serve patients' needs.
确定哪些社会和心理特征与未经预约就前来就诊的患者有关。
对城市中心团体诊所的患者进行前瞻性研究。
城市健康中心团体诊所，有五名医生，服务于一个失业率高（超过20%）且社会贫困的地区的12000名患者。
1989年1月的10天内，所有开放预约就诊的患者以及每四名预约就诊患者中的一名（从前三次预约中依次选取）。参与试点研究、在研究期间复诊或前往产前诊所就诊的患者被排除在外。
根据咨询前患者自行填写的问卷所获得的社会人口统计学和心理社会数据，患者对预约的态度以及就诊原因，包括对紧迫性的认知。从另一份问卷中获取医生的诊断和对紧迫性的认知。
86%（141/172）未经预约就诊的患者和96%（139/145）预约就诊的患者回复了问卷。开放预约组中认为咨询需求“非常紧急”或“相当紧急”的患者比例显著高于预约就诊组（89%，124/139对66%，91/138；卡方检验=27.04，自由度=3；p<0.001），尽管医生们并不认同这一观点。开放预约组中近期发病的自限性疾病患者明显多于预约就诊组（75%，101/135对48%，59/123；p<0.001）。总体而言，开放预约就诊与社会支持显著相关（39%，48/124对26%，32/123；p<0.05），也与婚姻分居或分居意向相关（分别为10%，9/87对0/92；47%，32/87对22%，20/92；p均<0.001），但医生记录这些患者的心理和社会问题明显较少（p<0.05）。尽管预约就诊组中近一半的人认为预约不方便，但开放预约组中更多的人认同这一观点（47%，60/129对61%，80/131）。
社会支持问题与对预约的消极态度之间存在重要联系。根据我们之前的经验，鼓励患者预约并不成功；为社会贫困率高的地区提供开放预约和预约就诊相结合的系统可能更能满足患者的需求。
