Evaluation of demands, usage and unmet needs for emergency care in Yaoundé, Cameroon: a cross-sectional study

OBJECTIVES

To assess the burden of emergent illnesses and emergency care system usage by Yaoundé residents and to evaluate unmet needs for emergency care and associated barriers.

DESIGN

A cross-sectional study using a community-based survey.

SETTING

Yaoundé, Cameroon.

PARTICIPANTS

All residents living in Yaoundé were selected as the target population to investigate the needs and usage of emergency care in Yaoundé. 14 households in every health area (47 in total) were selected using 2-stage sampling.

PRIMARY OUTCOME MEASURES

Unmet needs for emergency care.

RESULTS

Among the 3201 participants from 619 households who completed the survey, 1113 (34.8%) with median age of 22 experienced 1 or more emergency conditions in the previous year. Respondents who experienced emergency conditions used emergency units (7.0%), outpatient clinics (46.5%) or hospitalisation (13.0%), and in overall, 68.8% of them reported unmet needs for emergency care. The primary reasons for not seeking healthcare were economic issues (37.2%) and use of complementary medicine (22.2%). Young age (adjusted OR (95% CI) 1.80 (1.23 to 2.62)), rental housing (1.50 (1.11 to 2.03)) and moderate household income (0.60 (0.36 to 0.99)) were associated with unmet needs for emergency care.

CONCLUSIONS

Residents of Yaoundé had a high demand for emergency care, and high unmet needs were observed due to low emergency care usage. Development of a cost-effective, universal emergency care system is urgently needed in Cameroon.

Community health needs assessment and action planning in seven Dominican bateyes

Haitians and persons of Haitian descent living in the Dominican Republic are often relegated to living in deeply impoverished communities called bateyes. Despite obvious needs and some NGO presence in the bateyes, little assessment has been done to identify specific needs as understood and experienced by community members themselves. This article describes a community health needs assessment and action planning process developed and implemented by university researchers, NGO staff, and community members to identify needed areas for community-based health intervention in seven Dominican bateyes. Surveys and focus groups were used to collect data about the needs and assets of the bateyes and their residents around the following broad topics: demographics, health, education, financial/economy, legal issues, and transportation/infrastructure. These data were then used to guide an action-planning process that identified clean water, access to food and nutritional diversity, and economic development as primary and immediate needs in the communities. The process, its outcomes, and lessons learned are discussed.

Interagency collaboration: Strengthening substance abuse resources in child welfare

Supporting child welfare (CW) workers' ability to accurately assess substance abuse needs and link families to appropriate services is critical given the high prevalence of parental substance use disorders (SUD) among CW-involved cases. Several barriers hinder this process, including CW workers' lack of expertise for identifying SUD needs and scarcity of treatment resources. Drawing from theories and emergent literature on interagency collaboration, this study examined the role of collaboration in increasing the availability of resources for identifying and treating SUDs in CW agencies. Using data from the second cohort of families from the National Survey of Child and Adolescent Well-Being, study findings highlight a lack of SUD resources available to CW workers. On the other hand, the availability of SUD resources was increased when CW agencies had a memorandum of understanding, co-location of staff, and more intense collaboration with drug and alcohol service (DAS) providers. These results provide evidence to support efforts to improve collaboration between CW and DAS providers and showcase specific collaboration strategies to implement in order to improve service delivery.

Resource allocation and organisational features in Swedish primary diabetes care: Changes from 2006 to 2013

AIMS

To compare the resource allocation and organisational features in Swedish primary diabetes care for patients with type 2 diabetes mellitus (T2DM) between 2006 and 2013.

METHODS

Using a repeated cross-sectional study design, questionnaires covering personnel resources and organisational features for patients with T2DM in 2006 and 2013 were sent to all Swedish primary health care centres (PHCCs) during the following year. In total, 684 (74.3%) PHCCs responded in 2006 and 880 (76.4%) in 2013.

RESULTS

Compared with 2006, the median list size had decreased in 2013 (p<0.001), whereas the median number of listed patients with T2DM had increased (p<0.001). Time devoted to patients with T2DM and diabetes-specific education levels for registered nurses (RNs) had increased, and more PHCCs had in-house psychologists (all p<0.001). The use of follow-up systems and medical check-ups had increased (all p<0.05). Individual counselling was more often based on patients' needs, while arrangement of group-based education remained low. Patient participation in setting treatment targets mainly remained low.

CONCLUSIONS

Even though the diabetes-specific educational level among RNs increased, the arrangement of group-based education and patient participation in setting treatment targets remained low. These results are of concern and should be prioritised as key features in the care of patients with T2DM.

Giving the community a voice: Lessons learned from a comprehensive survey in an urban neighborhood

Weinland Park, an urban neighborhood adjacent to The Ohio State University, has been targeted for revitalization following several decades of disinvestment. The goal of these efforts is to develop holistic solutions that break the cycle of poverty. Such an undertaking requires collecting baseline data to understand community needs, inform programming, and guide revitalization efforts. This paper describes the development and implementation of the Weinland Park Evaluation Project (WPEP) - a collaborative and comprehensive neighborhood survey and needs assessment. Using the RE-AIM framework as a conceptual model, the paper describes how the WPEP was designed to meet short-, medium-, and long-term community needs. In addition, it offers lessons learned as a guide for researchers designing neighborhood surveys and conducting community assessments. An Appendix A includes indicators measured via the survey tool.

Broadening the Reach of Cardiac Rehabilitation to Rural and Remote Australia

BACKGROUND

Cardiac rehabilitation (CR) has an evidence base but traditional models may not readily apply to people living in rural and remote regions.

AIM

: To outline published comprehensive and non-hospital based CR models used for people discharged from hospital after a cardiac event that have potential relevance to those living in rural and remote areas in Australia.

METHODS

The PubMed database was searched using Medical subject headings (MeSH) terms and the key word 'cardiac rehabilitation' limited to clinical trials. Articles were retrieved if they included at least two components of CR and were not based in an outpatient setting.

RESULTS

No CR models specifically developed for rural and remote areas were identified. However, 14 studies were found that outlined 11 non-conventional comprehensive CR models. All provided CR in a home-based setting. Health professionals provided support via telephone contact or home visits, and via resources such as the Heart Manual. Reported outcomes from these CR programs varied: ranging from an increase in knowledge of risk factors, to improvements in physical activity, decreased risk factor profile, improved psychological and social functioning and reductions in health service costs and mortality.

CONCLUSION

Home-based, CR models have the most substantive evidence base and, therefore the greatest potential to be developed and made accessible to eligible people living in rural and remote areas.

Organizing Eldercare for Geographic Communities

The dramatically increasing prevalence of elderly persons disabled by conditions associated with aging could motivate reexamination of service delivery and financing for this population, seeking quality, reliability, and efficiency. Research and innovation have established many components of effective reforms, such as patient-directed care planning, encouragement of volunteer networks and family caregiving, mobilizing services to the home, adhering to patient goals and priorities, limiting poly-pharmacy, reducing the risk of falls, and providing adequate support services for people with disabilities. However, none have become widespread and rarely, if ever, are all of the evidence-based improvements available to a particular disabled elder. This essay argues that reform for disabled elders should be anchored in geographic communities, with a new organizational entity having responsibility for measuring performance and implementing improvements. This entity would use data and public input to set priorities, test improvement strategies, and take steps to assure adequate workforce and service supply. In this MediCaring Community, sustaining finances could come from local taxes or capturing the savings in Medicare that arise with optimal comprehensive services. Generating a new structure to monitor and manage eldercare services for a geographic community would be readily accomplished in some communities and would be worth testing.

Getting past the dual logic: findings from a pilot asset mapping exercise in Sheffield, UK

Asset-based approaches seek to identify and mobilise the personal, social and organisational resources available to communities. Asset mapping is a recognised method of gathering an inventory of neighbourhood assets and is underpinned by a fundamentally different logic to traditional needs assessments. The aim of this paper is to explore how asset mapping might be used as a tool for health improvement. It reports on a qualitative evaluation of a pilot asset mapping project carried out in two economically disadvantaged neighbourhoods in Sheffield, UK. The project involved community health champions working with two community organisations to identify assets linked to the health and wellbeing of their neighbourhoods. The evaluation was undertaken in 2012 after mapping activities had been completed. A qualitative design, using theory of change methodology, was used to explore assumptions between activities, mechanisms and outcomes. Semi structured interviews were undertaken with a purposive sample of 11 stakeholders including champions, community staff and strategic partners. Thematic analysis was used and themes were identified on the process of asset mapping, the role of champions and the early outcomes for neighbourhoods and services. Findings showed that asset mapping was developmental and understandings grew as participatory activities were planned and implemented. The role of the champions was limited by numbers involved, nonetheless meaningful engagement occurred with residents which led to personal and social resources being identified. Most early outcomes were focused on the lead community organisations. There was less evidence of results feeding into wider planning processes because of the requirements for more quantifiable information. The paper discusses the importance of relational aspects of asset mapping both within communities and between communities and services. The conclusions are that it is insufficient to switch from the logic of needs to assets without building asset mapping as part of a broader planning process.

Merchants of Health: Shaping the Experience of Illness Among Older People

Despite nearly universal health-care coverage for older Americans, the quality of care for the sickest and frailest remains sub-optimal. Understanding why requires analysis of the medical ecosystem. This paper considers the role of four of the principal actors in this system: physicians, hospitals, drug companies, and Medicare. Physicians spend more time in the office addressing diabetes and hypertension than they do evaluating falls and impaired cognition because of their training and their interests. Hospital administrators affect the hospital experience by investing in procedural specialties at the expense of low-tech, high-touch care. Pharmaceutical companies affect the medications older patients take by direct-to-consumer advertising and marketing to physicians. Medicare affects the patient's experience by prospective payment for hospitals, resulting in the burgeoning of post-acute care to accommodate early hospital discharges. Determining how to improve the quality of care for older people requires identifying a lever that affects the entire system. Medicare is uniquely positioned to serve this role. Reforming Medicare by introducing cost-effectiveness criteria for reimbursement of expensive devices, by instituting requirements that medical resident training programs include exposure to multidisciplinary team care, and by introducing a new benefit package for the frail elderly could improve American geriatric care.

Using CBPR to Extend Prostate Cancer Education, Counseling, and Screening Opportunities to Urban-Dwelling African-Americans

Community-based participatory research (CBPR) is becoming one of the dominant approaches for bringing evidence- and consensus-based cancer prevention and control practices to medically underserved communities. There are many examples of how CBPR has been useful for generating culturally specific solutions for different health issues that affect African-Americans. However, few examples exist in the literature on how the CBPR approach can be applied to address prostate cancer. This paper describes a collaborative process for linking inner-city, African-American men to free prostate cancer education, physician counseling, and screening opportunities (prostate-specific antigen (PSA) testing and digital rectal examination (DRE)). The site of this community-based participatory project was the city of Buffalo, located in Erie County, New York. The collaborative, community-academic process that is described includes the following: (1) planning and conducting a community needs assessment to contextualize local prostate cancer issues, (2) organizing town and gown event planning, and (3) manipulating aspects of the built environment to build an infrastructure within the community to address disparities in screening opportunities. This paper concludes with a description of lessons learned that can help others develop and implement similar activities in other communities.

A holistic model for evaluating the impact of individual technology-enhanced learning resources

BACKGROUND

The use of technology within education has now crossed the Rubicon; student expectations, the increasing availability of both hardware and software and the push to fully blended learning environments mean that educational institutions cannot afford to turn their backs on technology-enhanced learning (TEL). The ability to meaningfully evaluate the impact of TEL resources nevertheless remains problematic.

AIMS

This paper aims to establish a robust means of evaluating individual resources and meaningfully measure their impact upon learning within the context of the program in which they are used.

METHODS

Based upon the experience of developing and evaluating a range of mobile and desktop based TEL resources, this paper outlines a new four-stage evaluation process, taking into account learner satisfaction, learner gain, and the impact of a resource on both the individual and the institution in which it has been adapted.

RESULTS

A new multi-level model of TEL resource evaluation is proposed, which includes a preliminary evaluation of need, learner satisfaction and gain, learner impact and institutional impact. Each of these levels are discussed in detail, and in relation to existing TEL evaluation frameworks.

CONCLUSIONS

This paper details a holistic, meaningful evaluation model for individual TEL resources within the specific context in which they are used. It is proposed that this model is adopted to ensure that TEL resources are evaluated in a more meaningful and robust manner than is currently undertaken.

Public Health Emergencies

During a public health emergency such as an influenza pandemic or a bioterrorism attack, nurses may be at risk for exposure to lethal infectious diseases when caring for victims. The aim of this study was to identify interventions nurses believe will support their ability to cope during public health emergencies. A qualitative research design was used with 33 nurses from designated bioterrorism-receiving hospitals. Nurses recommended adequate protective equipment, education, drills, accessible information and available content experts, and available administrators. Other recommendations included increased security to protect nurses, emotional and physical support, communication with nurses' families, and commitment from institutions to care for ill or injured nurses. Preparations for emergencies should include assessments of nurses' and other stakeholders' concerns. These nurses proposed specific measures to improve safety, reduce anxiety, increase trust in hospitals, and provide physical and emotional support.

Information Needs of Myocardial Infarction Patients

The main objectives of this study were to assess the perceptions of patients immediately after their first myocardial infarction of their needs in a cardiac education programme and to compare these with their perceptions 6 weeks after the event and also with their nurse educators. The data were collected by a questionnaire, the cardiac patients' learning needs inventory which was administered to both patients and nurses. It comprised 37 ‘needs’ items grouped into seven categories, each item to be scored into one of five levels of importance. There were 27 patients interviewed on the first occasion, of whom 18 responded to a postal questionnaire on the second occasion. A census of three groups of nurses was taken in the study, namely all nurses employed in one coronary care unit and in a cardiac ward at a large Dublin Hospital and all nurses employed as cardiac rehabilitation nurses/officers in Ireland at the time of commencement of the study. Sixty-eight nurses responded, a response rate of 80%. A key finding was that the responses were highly skewed, with two-thirds in the top grade (‘very important’) and less than 1% in the two lowest grades (‘not important’ and ‘somewhat important’). The overall response score distribution of the patients differed somewhat from that of the nurses, but this difference was accounted for by mainly three items, all in the ‘physical activity’ category, namely ‘when to resume driving’, ‘when to resume sexual activity’, and ‘when to resume work’, which the nurses scored high and the patients low. Both patients and nurses gave the highest mean scores to four items, namely ‘what to do when in chest pain’, ‘what are the symptoms of a heart attack’, ‘when to call a doctor’, and ‘what to do to reduce the chance of another heart attack’. The first three of these are in the ‘symptom management’ category. These findings support previous studies on the topic. The findings also support the need for individualised nurse/patient negotiated cardiac teaching programmes that can be tailored to suit each patient's needs.

Adapting the I-PASS Handoff Program for Emergency Department Inter-Shift Handoffs

INTRODUCTION

Academic emergency department (ED) handoffs are high-risk transfer of care events. Emergency medicine residents are inadequately trained to handle these vital transitions. We aimed to explore what modifications the I-PASS (illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver) handoff system requires to be effectively modified for use in ED inter-shift handoffs.

METHODS

This mixed-method needs assessment conducted at an academic ED explored the suitability of the I-PASS system for ED handoffs. We conducted a literature review, focus groups, and then a survey. We sought to identify the distinctive elements of ED handoffs and discern how these could be incorporated into the I-PASS system.

RESULTS

Focus group participants agreed the patient summary should be adapted to include anticipated disposition of patient. Participants generally endorsed the order and content of the other elements of the I-PASS tool. The survey yielded several wording changes to reflect contextual differences. Themes from all qualitative sources converged to suggest changes for brevity and clarity. Most participants agreed that the I-PASS tool would be well suited to the ED setting.

CONCLUSION

With modifications for context, brevity, and clarity, the I-PASS system may be well suited for application to the ED setting. This study provides qualitative data in support of using the I-PASS tool and concrete suggestions for how to modify the I-PASS tool for the ED. Implementation and outcome research is needed to investigate if the I-PASS tool is feasible and improves patient outcomes in the ED environment.

Applying geo-spatial analysis in community needs assessment: Implications for planning and prioritizing based on data

BACKGROUND

Colonias are sub standardized and unincorporated areas located along the US-Mexico border, with severely lacking infrastructure. Residents have poor health and limited availability, accessibility and/or utilization of healthcare services in the region.

METHODS

Using 2006-2007 community needs assessment (CNA) surveys collected by the Center for Housing and Urban Development of Texas A&M University, 410 randomly selected surveys from Hidalgo County, Texas were analyzed. Descriptive and spatial analyses were performed and Odds ratio (OR) was calculated.

RESULTS

Out of 410 surveys, 333 were geo-coded to identify areas most in need of dental and vision care. Two hospitals existed within 5 miles radius of the mean centers for the two areas. Distance to health care facility was not statistically predictive of the need of dental care OR=0.96 (95% CI=0.855-1.078, p value=0.492) and vision care OR=1.083 (95% CI=0.968-1.212, p value=0.164).

CONCLUSION

Integrating spatial analysis and CNA enhances planning to improve service accessibility and utilization in underserved areas.

Providing hospice care in rural areas: Challenges and strategies

Hospices in rural settings face challenges in the provision of hospice care as a result of their location and the size of their service area population. To ascertain the challenges that hospices face in serving rural communities, researchers conducted in-depth case studies of four different models of hospice care in rural areas. The authors describe strategies used by the case study hospices and recommend policies that could increase access to hospice care for rural Medicare beneficiaries and other rural residents. National initiatives to improve end-of-life care need to consider the special challenges faced by rural hospices.

A Patient-Centered Approach to Postgraduate Trainee Health and Wellness: An Applied Review and Health Care Delivery Model

Attention to the health and wellness of postgraduate medical trainees has increased considerably in recent years, yet the scholarly literature consistently indicates that, in many instances, the medical and mental health care needs of this population remain unmet or only partially met. As a result, trainee health care often falls short of the current standards of the medical profession. Combined with the prevalence of burnout and other mental health conditions among trainees, inadequate health care for this patient population may result in significant negative consequences for trainees' health, safety, and performance.Here, the authors review the scholarly literature explicating the health care needs of postgraduate trainees. They explore the patient-centered medical home model as a potentially effective solution to address the unmet and partially met health care needs of trainees. The authors describe several practical interventions to improve access to care. These include care coordination and referral support, confidential care without perceived conflicts of interest in the training environment, co-location of medical and mental health care, and accommodations for schedule constraints. Finally, the authors explore the role of the medical home in developing and supporting broader institutional efforts to promote wellness.

The Efficiency of Increasing the Capacity of Physiotherapy Screening Clinics or Traditional Medical Services to Address Unmet Demand in Orthopaedic Outpatients: A Practical Application of Discrete Event Simulation with Dynamic Queuing

BACKGROUND

Hospital outpatient orthopaedic services traditionally rely on medical specialists to assess all new patients to determine appropriate care. This has resulted in significant delays in service provision. In response, Orthopaedic Physiotherapy Screening Clinics and Multidisciplinary Services (OPSC) have been introduced to assess and co-ordinate care for semi- and non-urgent patients.

OBJECTIVES

To compare the efficiency of delivering increased semi- and non-urgent orthopaedic outpatient services through: (1) additional OPSC services; (2) additional traditional orthopaedic medical services with added surgical resources (TOMS + Surg); or (3) additional TOMS without added surgical resources (TOMS - Surg).

METHODS

A cost-utility analysis using discrete event simulation (DES) with dynamic queuing (DQ) was used to predict the cost effectiveness, throughput, queuing times, and resource utilisation, associated with introducing additional OPSC or TOMS ± Surg versus usual care.

RESULTS

The introduction of additional OPSC or TOMS (±surgery) would be considered cost effective in Australia. However, OPSC was the most cost-effective option. Increasing the capacity of current OPSC services is an efficient way to improve patient throughput and waiting times without exceeding current surgical resources. An OPSC capacity increase of ~100 patients per month appears cost effective (A$8546 per quality-adjusted life-year) and results in a high level of OPSC utilisation (98 %).

CONCLUSION

Increasing OPSC capacity to manage semi- and non-urgent patients would be cost effective, improve throughput, and reduce waiting times without exceeding current surgical resources. Unlike Markov cohort modelling, microsimulation, or DES without DQ, employing DES-DQ in situations where capacity constraints predominate provides valuable additional information beyond cost effectiveness to guide resource allocation decisions.