[Why patients do not comply with reference decision made by general practitioners?]. / Pourquoi les patients n'adhèrent-ils pas à la décision de référence faite par le médecin généraliste?

ABSTRACT

SUBJECT A health system's efficacy depends on the efficacy of its different components (first-level health services and hospitals). It also depends on the system's ability to ensure the continuity of care among the various levels of the system. Health care officials in Settat Province, Morocco, found continuity in this province to be unsatisfactory. Depending on the health centre involved, only 31 to 52% of patients referred from the first to the second level of care reached the hospital. METHODS: The study was conducted in two rural and two urban health centres (HCs) covering a total population of around 94,000. The methodology consisted of two steps. First we analysed retrospectively various determinants (age, gender, distance, time until appointment) that might influence the compliance of patients referred by the four health centres in 1994. Then we observed curative medical consultations conducted in each of these health centres over a three-day period; the 38 patients referred to the hospital over this period were interviewed and the organisation of the hospital used on was analysed. RESULTS: The results revealed low compliance only 43% (782/1807) of the patients referred actually consulted the hospital's departments. The compliance rates varied from one HC to the other and were lower in rural than urban areas taken as a whole (34% (207/607) versus 48% (575/1200), respectively). The interviews revealed that patients did not trust the last-year medical students who staffed the emergency rooms. Another organisational problem in the hospital was identified patients referred to the hospital to consult a specialist were not seen immediately but given appointments at later dates, and these waiting times influenced the final success of the referral process. Thus, if the patients were seen immediately, compliance increased from 48 to 77% in the case of the urban HCs and from 34 to 67% in the case of the rural HCs. CONCLUSION: The most important determinants of compliance were above all associated with the way health services were organized and the quality of communication between health professionals and patients.