Introduction: The demand for services in outpatient clinics in university hospitals increased steadily over the last years, in Austria and in other western countries. Although this development is caused inevitably by the efforts to reduce inpatient care, the hospital owners are interested – because of poor cost coverage, to reduce outpatient services. At the same time outpatient services play an important strategic role in recruiting patients for research and for medical training purposes or for covering highly specialised medical fields in order to strengthen the market position of the respective hospital.

Research question: The need for positioning as much as the economic necessity to tighten the health services offered led to the question of: How can the services of outpatient clinics of university hospitals be defined in contrast to health care services offered by specialised physicians and/or outpatient clinics in peripheral hospitals?

Methods:
a) A literature search identified only 34 relevant publications on ‚strategic positioning, spectrum of services, function, documentation and quantification of care/ medical training & teaching/ research, patient access, resource use, appropriateness’ in the setting of outpatient clinics in university hospitals. A systematic literature review complemented by a survey of the management of university hospitals, summarizes the state of the discussion.
b) A methodology to empirically analyse the data on the performed services was developed as a prototype and probed.
c) A matrix for systematically categorising the performed services according to their ‘depth of care’ was developed.

Results of literature review: The discussion on the role of outpatient clinics in university hospitals is dominated by economic arguments. The corner stones of the debate are:
- Debate on structural reforms: In Austria and Germany the role of outpatient clinics is almost always debated as part of structural reforms and the containment of inefficiencies. In the USA structural reorganisation and measures to increase efficiencies are taken to face the strong competition of Managed Care Organisations. In Great Britain outpatient clinics of hospitals play – due to the low density of specialised physicians – a different, but important role. Additionally in the Netherlands and Great Britain the non-medical ‚Health Care Professionals’ are given an important role in the patient care in outpatient-setting.
- Medical training and research: The relevance of outpatient clinics for medical training is emphasised repeatedly, while rather little time is actually devoted to teaching activities. Research activities seem to be of no
importance.
- Patients frequenting outpatient clinic are – tend to have a lower socioeconomic status and are – to a higher extent – responsible for the increasing number of unplanned patient contacts. Only a small part of patient sent to the outpatient clinic by other physicians are clinically indicated. The diagnostic potentials in university hospitals is considered to be the reason for patient assignments, which could be reduced by better training
of the assigning physicians.
- Hospital-operators: outpatient clinics in University hospitals are – if considered isolated - cost drivers, but considered systemically - they can generate profit. Approaches reform the utilisation of outpatient resources
are outcome-related resource allocation according to agreement of objectives, process optimisation and the active implementation of regulatory instruments for patient access.
- Documentation of performance: in the context of the mostly general debate and the lack of empirical materials on actual outpatient clinic activities, the ‘German research on outpatient clinics’ performed (‘Deutsche
Hochschul-Ambulanzenstudie’) pioneer work by comprising and analysing outpatient clinic data for the first time.

Results of development of methodology:
- Development of a prototype for analysing outpatient performance data: the profiles (pattern of services and consecutive trails) of three different groups of patients determining the profile of the delivered services, were
defined: 1.) complex and interdisciplinary cases/ patients vs. noncomplex cases; 2.) emergency-patients vs. non-emergency-patients; 3.) pre- and post inpatient cases and their consequential examinations and therapies, even if those medical services are necessarily complex.
- Development of a matrix for systematically categorising the performed services according to their ‘depth of care’, which was defined by 1.) technical input/ infrastructural need; 2.) complexity/ interdisciplinarity; 3.) specialisation/ low incidence/ rareness/ risk. This definition served for operationalisation for differentiation of medical services that only can be offered in university clinics and such that can be offered in other settings (in group- practices or specialised physicians).

Conclusion: Emergency care as much as the care for pre- and post-inpatients is out of question under the current circumstances. The generation of a profile for outpatient services in university hospitals has to be realigned along the following key elements:
- Clinical factors determining the range of services offered defined by infrastructural need; complexity/ interdisciplinarity; rareness of indication and according need for specialisation.
- Factors determining the needs in medical teaching and research, are led by the need for ‚average’ patients and the need for training in unspecific diseases. Here only the extent/the minimum number of „average“ patients is under question.
- Alternative low threshold institutions for extramural care esp. for those socially disadvantaged that more frequently attend outpatient clinics than specialised physicians.
- Economic rationalities, that show that esp. the care for non-complex patients takes disproportionately more resources - because of additional diagnostic and therapeutic input - than in other settings.