Background: Interventions are needed to reduce poor perinatal health. We trained community health workers (CHWs) as home visitors to address maternal/infant risks.
Methods: In a cluster randomised controlled trial in Cape Town townships, neighbourhoods were randomised within matched pairs to 1) the control, healthcare at clinics (n = 12 neighbourhoods; n = 594 women), or 2) a home visiting intervention by CBW trained in cognitive-behavioural strategies to address health risks (by the Philani Maternal, Child Health and Nutrition Programme), in addition to clinic care (n = 12 neighbourhoods; n = 644 women). Participants were assessed during pregnancy (2% refusal) and 92% were reassessed at two weeks post-birth, 88% at six months and 84% at 18 months later. We analysed 32 measures of maternal/infant well-being over the 18 month follow-up period using longitudinal random effects regressions. A binomial test for correlated outcomes evaluated overall effectiveness over time. The 18 month post-birth assessment outcomes also were examined alone and as a function of the number of home visits received.
Results: Benefits were found on 7 of 32 measures of outcomes, resulting in significant overall benefits for the intervention compared to the control when using the binomial test (p = 0.008); nevertheless, no effects were observed when only the 18 month outcomes were analyzed. Benefits on individual outcomes were related to the number of home visits received. Among women living with HIV, intervention mothers were more likely to implement the PMTCT regimens, use condoms during all sexual episodes (OR = 1.25; p = 0.014), have infants with healthy weight-for-age measurements (OR = 1.42; p = 0.045), height-for-age measurements (OR = 1.13, p<0.001), breastfeed exclusively for six months (OR = 3.59; p<0.001), and breastfeed longer (OR = 3.08; p<0.001). Number of visits was positively associated with infant birth weight ≥2500 grams (OR = 1.07; p = 0.012), healthy head-circumference-for-age measurements at 6 months (OR = 1.09, p = 0.017), and improved cognitive development at 18 months (OR = 1.02, p = 0.048).
Conclusions: Home visits to neighbourhood mothers by CHWs may be a feasible strategy for enhancing maternal/child outcomes. However, visits likely must extend over several years for persistent benefits.
Context: Diabetes care is complex, requiring motivated patients, providers, and systems that enable guideline-based preventative care processes, intensive risk-factor control, and positive lifestyle choices. However, care delivery in low- and middle-income countries (LMIC) is hindered by a compendium of systemic and personal factors. While electronic medical records (EMR) and computerized clinical decision-support systems (CDSS) have held great promise as interventions that will overcome system-level challenges to improving evidence-based health care delivery, evaluation of these quality improvement interventions for diabetes care in LMICs is lacking.
Objective and Data Sources: We reviewed the published medical literature (systematic search of MEDLINE database supplemented by manual searches) to assess the quantifiable and qualitative impacts of combined EMR–CDSS tools on physician performance and patient outcomes and their applicability in LMICs.
Study Selection and Data Extraction: Inclusion criteria prespecified the population (type 1 or 2 diabetes patients), intervention (clinical EMR–CDSS tools with enhanced functionalities), and outcomes (any process, self-care, or patient-level data) of interest. Case, review, or methods reports and studies focused on nondiabetes, nonclinical, or in-patient uses of EMR–CDSS were excluded. Quantitative and qualitative data were extracted from studies by separate single reviewers, respectively, and relevant data were synthesized.
Results: Thirty-three studies met inclusion criteria, originating exclusively from high-income country settings. Among predominantly experimental study designs, process improvements were consistently observed along with small, variable improvements in risk-factor control, compared with baseline and/or control groups (where applicable). Intervention benefits varied by baseline patient characteristics, features of the EMR–CDSS interventions, motivation and access to technology among patients and providers, and whether EMR–CDSS tools were combined with other quality improvement strategies (e.g., workflow changes, case managers, algorithms, incentives). Patients shared experiences of feeling empowered and benefiting from increased provider attention and feedback but also frustration with technical difficulties of EMR–CDSS tools. Providers reported more efficient and standardized processes plus continuity of care but also role tensions and “mechanization” of care.
Conclusions: This narrative review supports EMR–CDSS tools as innovative conduits for structuring and standardizing care processes but also highlights setting and selection limitations of the evidence reviewed. In the context of limited resources, individual economic hardships, and lack of structured systems or trained human capital, this review reinforces the need for well-designed investigations evaluating the role and feasibility of technological interventions (customized to each LMIC's locality) in clinical decision making for diabetes care.
PURPOSE OF REVIEW: Globally, HIV infection remains a significant issue for key populations such as men who have sex with men (MSM) and female sex workers. A review of recent articles was conducted for west African countries to assess the burden of disease among female sex workers and MSM, access to services and identify barriers to implementation of services for key populations.
RECENT FINDINGS: In west Africa, key populations engage in high-risk practices for the acquisition of HIV and other sexually transmitted infections. Available HIV prevalence data fluctuate across and within countries for both MSM and female sex workers and may be five to ten times as high as that of the general population. HIV prevalence varied from 15.9% in The Gambia to 68% in Benin among female sex workers, whereas it ranged from 9.8% in The Gambia to 34.9% in Nigeria for MSM. Yet, important data gaps exist, including key populations size estimations in several countries as well as HIV prevalence, incidence and other biomarkers of HIV risk. Because of sociocultural, legal, political and economic challenges, exacerbated by a poor health system infrastructure, the HIV response is not strategically directed toward programs for key populations in countries with concentrated epidemics. Noteworthy is the low coverage of prevention care and treatment interventions offered to key populations.
SUMMARY: Sufficient planning and political will with legal and structural frameworks that reconcile public health and human rights are needed to prioritize HIV prevention, care and treatment programming for key populations programs in west Africa.
Purpose: Outcomes are excellent following surgical management of displaced supracondylar humerus fractures. Short delays until surgical fixation have been shown to be equivalent to immediate fixation with regards to complications. We hypothesized that insurance coverage may impact access to care and the patient’s ability to return to the operating room for outpatient surgery. Methods: A retrospective review of supracondylar humerus fractures treated at a large urban pediatric hospital from 2008 to 2012 was performed. Fractures were classified by the modified Gartland classification and baseline demographics were collected. Time from discharge to office visits and subsequent surgical fixation was calculated for all type II fractures discharged from the emergency department. Insurance status and primary carrier were collected for all patients. Results: 2584 supracondylar humerus fractures were reviewed, of which 584 were type II fractures. Of the 577 type II fractures with complete records, 383 patients (61 %) were admitted for surgery and the remaining 194 were discharged with plans for outpatient follow-up. There was no difference in insurance status between patients admitted for immediate surgery. Of the 194 patients who were discharged with type 2 fractures after gentle reduction, 59 patients (30.4 %) ultimately underwent surgical fixation. Of these, 42 patients were privately insured (58.3 % of patients with private insurance), 16 had governmental insurance (15.1 %), and 1 was uninsured (6.3 %). Patients with private insurance were 2.46 times more likely to have surgery than patients with public or no insurance (p = 0.005). Of the 135 patients who did not eventually have surgery, 92 (68.1 %) were seen in the clinic. Patients with private insurance were 2.78 times more likely to be seen back in the clinic when compared to publicly insured or uninsured patients (p = 0.0152). Conclusions: Despite an equivalent number of privately insured and publicly insured patients undergoing immediate surgery for type II fractures, those with public or no insurance who were discharged were 2.46 times less likely to obtain outpatient surgery when compared to privately insured patients. Patient insurance status and the ability to follow up in a timely manner should be assessed at the time of initial evaluation in the emergency department. Level of evidence Level 3
Aim: To assess the level of adherence to diabetes care processes, and associated clinic and patient factors at general practices in Delhi, India.
Methods: We interviewed physicians (n = 23) and patients with diabetes (n = 406), and reviewed patient charts at general practices (government = 5; private = 18). We examined diabetes care processes, specifically measurement of weight, blood pressure (BP), glycated hemoglobin (HbA1c), lipids, electrocardiogram, dilated eye, and a foot examination in the last one year. We analyzed clinic and patient factors associated with a number of care processes achieved using multilevel Poisson regression model.
Results: The average number of clinic visits per patient was 8.8/year (standard deviation = 5.7), and physicians had access to patient's previous records in only 19.7% of patients. Dilated eye exam, foot exam, and electrocardiogram were completed in 7.4%, 15.1%, and 29.1% of patients, respectively. An estimated 51.7%, 88.4%, and 28.1% had ≥1 measurement of HbA1c, BP, and lipids, respectively. Private clinics, physician access to patient's previous records, use of nonphysicians, patient education, and the presence of diabetes complication were positively associated with a number of care processes in the multivariable model.
Conclusion: Adherence to diabetes care processes was suboptimal. Encouraging implementation of quality improvement strategies like Chronic Care Model elements at general practices may improve diabetes care.
by
Robert H. Cleveland;
Mark Schluchter;
Beverly P. Wood;
Walter E. Berdon;
M. Ines Boechat;
Kirk Easley;
Moulay Meziane;
Robert B. Mellins;
Karen I. Norton;
Edward Singleton;
Lynn Trautwein
Background. Multicenter studies rely on data derived from different institutions. Forms can be designed to standardize the reporting process allowing reliable comparison of data. Objective. The purpose of the report is to provide a standardized method, developed as a part of a multicenter study of vertically transmitted HIV, for assessing chest radiographic results. Materials and methods. Eight hundred and five infants and children were studied at five centers; 3057 chest radiographs were scored. Data were entered using a forced-choice, graded response for 12 findings. Quality assurance measures and inter-rater agreement statistics are reported. Results. The form used for reporting chest radiographic results is presented. Inter-rater agreement was moderate to high for most findings, with the best correlation reported for the presence of bronchovascular markings and/or reticular densities addressed as a composite question (kappa = 0.71). The presence of nodular densities (kappa = 0.56) and parenchymal consolidation (kappa = 0.57) had moderate agreement. Agreement for lung volume was low. Conclusion. The current tool, developed for use in the pediatric population, is applicable to any study involving the assessment of pediatric chest radiographs for a large population, whether at one or many centers.
BACKGROUND: Among the unique features of the Rare Diseases Clinical Research Network (RDCRN) Program is the requirement for each Consortium to include patient advocacy groups (PAGs) as research partners. This development has transformed the work of the RDCRN and is a model for collaborative research. This article outlines the roles patients and PAGs play in the RDCRN and reports on the PAGs' impact on the Network's success.
METHODS: Principal Investigators from the 17 RDCRN Consortia and 28 representatives from 76 PAGs affiliated with these Consortia were contacted by email to provide feedback via an online RDCRN survey. Impact was measured in the key areas of 1) Research logistics; 2) Outreach and communication; and 3) Funding and in-kind support. Rating choices were: 1-very negative, 2-somewhat negative, 3-no impact, 4-somewhat positive, and 5-very positive.
RESULTS: Twenty-seven of the PAGs (96 %) disseminate information about the RDCRN within the patient community. The Consortium Principal Investigators also reported high levels of PAG involvement. Sixteen (94 %) Consortium Principal Investigators and 25 PAGs (89 %) reported PAGs participation in protocol review, study design, Consortium conference calls, attending Consortium meetings, or helping with patient recruitment.
CONCLUSIONS: PAGs are actively involved in shaping Consortia's research agendas, help ensure the feasibility and success of research protocols by assisting with study design and patient recruitment, and support training programs. This extensive PAG-Investigator partnership in the RDCRN has had a strongly positive impact on the success of the Network.
INTRODUCTION: The emergency medicine clerkship director serves an important role in the education of medical students. The authors sought to update the demographic and academic profile of the emergency medicine clerkship director.METHODS: We developed and implemented a comprehensive questionnaire, and used it to survey all emergency medicine clerkship directors at United States allopathic medical schools accredited by the Liaison Committee on Medical Education. We analyzed and interpreted data using descriptive statistics.RESULTS: One hundred seven of 133 (80.4%) emergency medicine clerkship directors completed the survey. Clerkship Director's mean age was 39.7 years (SD-7.2), they were more commonly male 68.2%, of Caucasian racial backgrounds and at the instructor or assistant professor (71.3%) level. The mean number of years of experience as clerkship director was 5.5 (SD-4.5). The mean amount of protected time for clerkship administration reported by respondents was 7.3 hours weekly (SD-5.1), with the majority (53.8%) reporting 6 or more hours of protected time per week. However, 32.7% of emergency medicine clerkship directors reported not having any protected time for clerkship administration. Most clerkship directors (91.6%) held additional teaching responsibilities beyond their clerkship and many were involved in educational research (49.5%). The majority (79.8%), reported being somewhat or very satisfied with their job as clerkship director.CONCLUSION: Most clerkship directors were junior faculty at the instructor or assistant professor rank and were involved with a variety of educational endeavors beyond the clerkship.