Measuring pediatric quality of care in rural clinics-a multi-country assessment-Cambodia, Guatemala, Zambia and Kenya

A comparative study of home healthcare quality in urban and rural home health agencies throughout the USA (2010-22)

Urban-rural disparities in medical care, including in home healthcare, persist globally. With aging populations and medical advancements, demand for home health services rises, warranting investigation into home healthcare disparities. Our study aimed to (i) investigate the impact of rurality on home healthcare quality, and (ii) assess the temporal disparities and the changes in disparities in home healthcare quality between urban and rural home health agencies (HHAs), incorporating an analysis of geospatial distribution to visualize the underlying patterns. This study analyzed data from HHAs listed on the Centers for Medicare and Medicaid Services website, covering the period from 2010 to 2022. Data were classified into urban and rural categories for each HHA. We employed panel data analysis to examine the impact of rurality on home healthcare quality, specifically focusing on hospital admission and emergency room (ER) visit rates. Disparities between urban and rural HHAs were assessed using the Wilcoxon test, with results visualized through line and dot plots and heat maps to illustrate trends and differences comprehensively. Rurality is demonstrated as the most significant variable in hospital admission and ER visit rates in the panel data analysis. Urban HHAs consistently exhibit significantly lower hospital admission rates and ER visit rates compared to rural HHAs from 2010 to 2022. Longitudinally, the gap in hospital admission rates between urban and rural HHAs is shrinking, while there is an increasing gap in ER visit rates. In 2022, HHAs in Mountain areas, which are characterized by a higher proportion of rural regions, exhibited higher hospital admission and ER visit rates than other areas. This study underscores the persistent urban-rural disparities in home healthcare quality. The analysis emphasizes the ongoing need for targeted interventions to address disparities in home healthcare delivery and ensure equitable access to quality care across urban and rural regions. Our findings have the potential to inform policy and practice, promoting equity and efficiency in the long-term care system, for better health outcomes throughout the USA.

Effectiveness of an electronic clinical decision support system in improving the management of childhood illness in primary care in rural Nigeria: an observational study

OBJECTIVES

To evaluate the impact of ALgorithm for the MANAgement of CHildhood illness ('ALMANACH'), a digital clinical decision support system (CDSS) based on the Integrated Management of Childhood Illness, on health and quality of care outcomes for sick children attending primary healthcare (PHC) facilities.

DESIGN

Observational study, comparing outcomes of children attending facilities implementing ALMANACH with control facilities not yet implementing ALMANACH.

SETTING

PHC facilities in Adamawa State, North-Eastern Nigeria.

PARTICIPANTS

Children 2-59 months presenting with an acute illness. Children attending for routine care or nutrition visits (eg, immunisation, growth monitoring), physical trauma or mental health problems were excluded.

INTERVENTIONS

The ALMANACH intervention package (CDSS implementation with training, mentorship and data feedback) was rolled out across Adamawa's PHC facilities by the Adamawa State Primary Health Care Development Agency, in partnership with the International Committee of the Red Cross and the Swiss Tropical and Public Health Institute. Tablets were donated, but no additional support or incentives were provided. Intervention and control facilities received supportive supervision based on the national supervision protocol.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was caregiver-reported recovery at day 7, collected over the phone. Secondary outcomes were antibiotic and antimalarial prescription, referral, and communication of diagnosis and follow-up advice, assessed at day 0 exit interview.

RESULTS

We recruited 1929 children, of which 1021 (53%) attended ALMANACH facilities, between March and September 2020. Caregiver-reported recovery was significantly higher among children attending ALMANACH facilities (adjusted OR=2·63, 95% CI 1·60 to 4·32). We observed higher parenteral and lower oral antimicrobial prescription rates (adjusted OR=2·42 (1·00 to 5·85) and adjusted OR=0·40 (0·22 to 0·73), respectively) in ALMANACH facilities as well as markedly higher rates for referral, communication of diagnosis, and follow-up advice.

CONCLUSION

Implementation of digital CDSS with training, mentorship and feedback in primary care can improve quality of care and recovery of sick children in resource-constrained settings, likely mediated by better guideline adherence. These findings support the use of CDSS for health systems strengthening to progress towards universal health coverage.

Isolation of Escherichia coli and Its Associated Risk Factor from Diarrheic Children in Wolaita Sodo Town, Southern Ethiopia

INTRODUCTION

Escherichia coli are among the major causes of mortality and morbidity in under-five children in developing nations including Ethiopia.

METHODS

A non-analytical observational study design followed by a purposive sampling technique was conducted from October 2017 to June 2018, to isolate Escherichia coli and determine its associated risk factors from diarrheic children that were admitted to Christian hospital, Wolaita Sodo town. E. coli was confirmed using standard culture and biochemical analyses of the bacterium. In addition, a semi-structured questionnaire was provided to evaluate the potential risk factors that contribute to diarrhea in children.

RESULTS

The overall isolation rate of E. coli in diarrheic children was 61.8% (68/110) (95% CI: 52.1-70.9%). Factors such as age, contact with either animals or manure, negligence to handwashing before a meal with soap, and exclusive breastfeeding at six months (p<0.05) has significant contribution to the prevalence of the E. coli in diarrheic children. The odds of being infected were highest in children whose caretakers had a habit of the negligence of handwashing before the meal (AOR = 6; 95% CI 30.8-49.8%; p = 0.01).

CONCLUSION

Improving the hygienic practices amongst parents of children reduces its Escherichia coli occurrence. Furthermore, awareness of the importance of exclusive breastfeeding to parents of children should be maximized.

Can social accountability mechanisms using community scorecards improve quality of pediatric care in rural Cambodia?

Objective

To determine the effect of social accountability strategies on pediatric quality of care.

Design and Setting

A non-randomized quasi experimental study was conducted in four districts in Cambodia and all operational public health facilities were included.

Participants

Five patients under 5 years and their caretakers were randomly selected in each facility.

Interventions

To determine the effect of maternal and child health interventions integrating citizen voice and action using community scorecards on quality of pediatric care.

Outcome Measures

Patient observations were conducted to determine quality of screening and counseling, followed by exit interviews with caretakers.

Results

Results indicated significant differences between intervention and comparison facilities; screening by Integrated Management of Childhood Illness (IMCI) trained providers (100% vs 67%, P &lt; 0.019), screening for danger signs; ability to drink/breastfeed (100% vs 86.7%, P &lt; 0.041), lethargy (86.7% vs 40%, P &lt; 0.004) and convulsions (83.3 vs 46.7%, P &lt; 0.023). Screening was significantly higher for patients in the intervention facilities for edema (56.7% vs 6.7%, P &lt; 0.000), immunization card (90% vs 40%, P &lt; 0.002), child weight (100 vs 86.7, P &lt; 0.041) and checking growth chart (96.7% vs 66.7%, P &lt; 0.035). The IMCI index, constructed from key performance indicators, was significantly higher for patients in the intervention facilities than comparison facilities (screening index 8.8 vs 7.0, P &lt; 0.018, counseling index 2.7 vs 1.5, P &lt; 0.001). Predictors of screening quality were child age, screening by IMCI trained provider, wealthier quintiles and intervention facilities.

Conclusion

The institution of social accountability mechanisms to engage communities and facility providers showed some improvements in quality of care for common pediatric conditions, but socioeconomic disparities were evident.

Towards improved health service quality in Tanzania: contribution of a supportive supervision approach to increased quality of primary healthcare

Background

Universal Health Coverage only leads to the desired health outcomes if quality of health services is ensured. In Tanzania, quality has been a major concern for many years, including the problem of ineffective and inadequate routine supportive supervision of healthcare providers by council health management teams. To address this, we developed and assessed an approach to improve quality of primary healthcare through enhanced routine supportive supervision.

Methods

Mixed methods were used, combining trends of quantitative quality of care measurements with qualitative data mainly collected through in-depth interviews. The former allowed for identification of drivers of quality improvements and the latter investigated the perceived contribution of the new supportive supervision approach to these improvements.

Results

The results showed that the new approach managed to address quality issues that could be solved either solely by the healthcare provider, or in collaboration with the council. The new approach was able to improve and maintain crucial primary healthcare quality standards across different health facility level and owner categories in various contexts.

Conclusion

Together with other findings reported in companion papers, we could show that the new supportive supervision approach not only served to assess quality of primary healthcare, but also to improve and maintain crucial primary healthcare quality standards. The new approach therefore presents a powerful tool to support, guide and drive quality improvement measures within council. It can thus be considered a suitable option to make routine supportive supervision more effective and adequate.

Diagnosis and treatment of acute respiratory illness in children under five in primary care in low-, middle-, and high-income countries: A descriptive FRESH AIR study

BACKGROUND

Respiratory disease and, specifically, pneumonia, is the major cause of mortality and morbidity in young children. Diagnosis of both pneumonia and asthma in primary care rests principally on clinical signs, history taking, and bronchodilator responsiveness. This study aimed to describe clinical practices in diverse global primary care settings concerning differential diagnosis of respiratory disease in young children, especially between pneumonia and asthma.

METHODS

Health professionals in Greece, Kyrgyzstan, Vietnam, and Uganda were observed during consultations with children aged 2-59 months, presenting with cough and/or difficult breathing. Data were analyzed descriptively and included consultation duration, practices, diagnoses and availability/use of medications and equipment. The study is part of the European Horizon 2020 FRESH AIR project.

RESULTS

In total, 771 consultations by 127 health professionals at 74 facilities in the four countries were observed. Consultations were shorter in Vietnam and Uganda (3 to 4 minutes) compared to Greece and Kyrgyzstan (15 to 20 minutes). History taking was most comprehensive in Greece. Clinical examination was more comprehensive in Vietnam and Kyrgyzstan and less in Uganda. Viral upper respiratory tract infections were the most common diagnoses (41.7% to 67%). Pneumonia was diagnosed frequently in Uganda (16.3% of children), and rarely in other countries (0.8% to 2.9%). Asthma diagnosis was rare (0% to 2.8%). Antibiotics were prescribed frequently in all countries (32% to 69%). Short acting β-agonist trials were seldom available and used during consultations in Kyrgyzstan (0%) and Uganda (1.8%), and often in Greece (38.9%) and Vietnam (12.6%).

CONCLUSIONS

Duration and comprehensiveness of clinical consultations observed in this study seemed insufficient to guide respiratory diagnosis in young children. Appropriate treatment options may further not be available in certain studied settings. Actions aiming at educating and raising professional awareness, along with developing easy-to-use tools to support diagnosis and a general strengthening of health systems are important goals.

Development of a prognostic risk score to aid antibiotic decision-making for children aged 2-59 months with World Health Organization fast breathing pneumonia in Malawi: An Innovative Treatments in Pneumonia (ITIP) secondary analysis

Background

Due to increasing antimicrobial resistance in low-resource settings, strategies to rationalize antibiotic treatment of children unlikely to have a bacterial infection are needed. This study’s objective was to utilize a database of placebo treated Malawian children with World Health Organization (WHO) fast breathing pneumonia to develop a prognostic risk score that could aid antibiotic decision making.

Methods

We conducted a secondary analysis of children randomized to the placebo group of the Innovative Treatments in Pneumonia (ITIP) fast breathing randomized, controlled, noninferiority trial. Participants were low-risk HIV-uninfected children 2–59 months old with WHO fast breathing pneumonia in Lilongwe, Malawi. Study endpoints were treatment failure, defined as either disease progression at any time on or before Day 4 of treatment or disease persistence on Day 4, or relapse, considered as the recurrence of pneumonia or severe disease among previously cured children between Days 5 and 14. We utilized multivariable linear regression and stepwise model selection to develop a model to predict the probability of treatment failure or relapse.

Results

Treatment failure or relapse occurred in 11.5% (61/526) of children included in this analysis. The final model incorporated the following predictors: heart rate terms, mid-upper arm circumference, malaria status, water source, family income, and whether or not a sibling or other child in the household received childcare outside the home. The model’s area under the receiver operating characteristic score was 0.712 (95% confidence interval 0.66, 0.78) and it explained 6.1% of the variability in predicting treatment failure or relapse (R², 0.061). For the model to categorize all children with treatment failure or relapse correctly, 77% of children without treatment failure or relapse would require antibiotics.

Conclusion

The model had inadequate discrimination to be appropriate for clinical application. Different strategies will likely be required for models to perform accurately among similar pediatric populations.

Towards improved health service quality in Tanzania: appropriateness of an electronic tool to assess quality of primary healthcare

BACKGROUND

Progress in health service quality is vital to reach the target of Universal Health Coverage. However, in order to improve quality, it must be measured, and the assessment results must be actionable. We analyzed an electronic tool, which was developed to assess and monitor the quality of primary healthcare in Tanzania in the context of routine supportive supervision. The electronic assessment tool focused on areas in which improvements are most effective in order to suit its purpose of routinely steering improvement measures at local level.

METHODS

Due to the lack of standards regarding how to best measure quality of care, we used a range of different quantitative and qualitative methods to investigate the appropriateness of the quality assessment tool. The quantitative methods included descriptive statistics, linear regression models, and factor analysis; the qualitative methods in-depth interviews and observations.

RESULTS

Quantitative and qualitative results were overlapping and consistent. Robustness checks confirmed the tool's ability to assign scores to health facilities and revealed the usefulness of grouping indicators into different quality dimensions. Focusing the quality assessment on processes and structural adequacy of healthcare was an appropriate approach for the assessment's intended purpose, and a unique key feature of the electronic assessment tool. The findings underpinned the accuracy of the assessment tool to measure and monitor quality of primary healthcare for the purpose of routinely steering improvement measures at local level. This was true for different level and owner categories of primary healthcare facilities in Tanzania.

CONCLUSION

The electronic assessment tool demonstrated a feasible option for routine quality measures of primary healthcare in Tanzania. The findings, combined with the more operational results of companion papers, created a solid foundation for an approach that could lastingly improve services for patients attending primary healthcare. However, the results also revealed that the use of the electronic assessment tool outside its intended purpose, for example for performance-based payment schemes, accreditation and other systematic evaluations of healthcare quality, should be considered carefully because of the risk of bias, adverse effects and corruption.

Comparison of objective measures and patients' perceptions of quality of services in government health facilities in the Democratic Republic of Congo

Objective

Examine the relationship between patients’ perceptions of quality and the objective level of quality at government health facilities, and determine whether the pre-existing attitudes and beliefs of patients regarding health services interfere with their ability to accurately assess quality of care.

Design

Cross-sectional, visit-level analysis.

Setting

Three regions (Nord-Ubangi, Kasai/Kasai-Central and Maniema/Tshopo) of the Democratic Republic of Congo.

Participants

Data related to the inpatient and outpatient visits to government health facilities made by all household members who were included in the survey was used for the analysis. Data were collected from patients and the facilities they visited.

Main Outcome Measures

Patients’ perceptions of the level of quality related to availability of drugs and equipment; patient-centeredness and safety serve compared with objective measures of quality.

Results

Objective measures and patient perceptions of the drug supply were positively associated (β = 0.16, 95% CI = 0.03, 0.28) and of safety were negatively associated (β = −0.12, 95% CI = −0.23, −0.01). Several environmental factors including facility type, region and rural/peri-urban setting were found to be significantly associated with respondents’ perceptions of quality across multiple outcomes.

Conclusions

Overall, patients are not particularly accurate in their assessments of quality because their perceptions are impacted by their expectations and prior experience. Future research should examine whether improving patients’ knowledge of what they should expect from health services, and the transparency of the facility’s quality data can be a strategy for improving the accuracy of patients’ assessments of the quality of the health services, particularly in low-resourced settings.

Decreasing triage time: effects of implementing a step-wise ESI algorithm in an EHR

Objectives

To determine if adapting a widely-used triage scale into a computerized algorithm in an electronic health record (EHR) shortens emergency department (ED) triage time.

Design

Before-and-after quasi-experimental study.

Setting

Urban, tertiary care hospital ED.

Participants

Consecutive adult patient visits between July 2011 and June 2013.

Intervention

A step-wise algorithm, based on the Emergency Severity Index (ESI-5) was programmed into the triage module of a commercial EHR.

Main Outcome Measures

Duration of triage (triage interval) for all patients and change in percentage of high acuity patients (ESI 1 and 2) completing triage within 15 min, 12 months before-and-after implementation of the algorithm. Multivariable analysis adjusted for confounders; interrupted time series demonstrated effects over time. Secondary outcomes examined quality metrics and patient flow.

Results

About 32 546 patient visits before and 33 032 after the intervention were included. Post-intervention patients were slightly older, census was higher and admission rate slightly increased. Median triage interval was 5.92 min (interquartile ranges, IQR 4.2-8.73) before and 2.8 min (IQR 1.88-4.23) after the intervention (P < 0.001). Adjusted mean triage interval decreased 3.4 min (95% CI: -3.6, -3.2). The proportion of high acuity patients completing triage within 15 min increased from 63.9% (95% CI 62.5, 65.2%) to 75.0% (95% CI 73.8, 76.1). Monthly time series demonstrated immediate and sustained improvement following the intervention. Return visits within 72 h and door-to-balloon time were unchanged. Total length of stay was similar.

Conclusion

The computerized triage scale improved speed of triage, allowing more high acuity patients to be seen within recommended timeframes, without notable impact on quality.

Validity of World Health Organisation prescribing indicators in Namibia’s primary healthcare: findings and implications

Objective

World Health Organization/International Network of Rational use of Drugs (WHO/INRUD) indicators are widely used to assess medicine use. However, there is limited evidence on their validity in Namibia’s primary health care (PHC) to assess the quality of prescribing. Consequently, our aim was to address this.

Design, setting, participants and interventions

An analytical cross-sectional survey design was used to examine and validate WHO/INRUD indicators in out-patient units of two PHC facilities and one hospital in Namibia from 1 February 2015 to 31 July 2015. The validity of the indicators was determined using two-by-two tables against compliance to the Namibian standard treatment guidelines (NSTG). The receiver operator characteristics for the WHO/INRUD indicators were plotted to determine their accuracy as predictors of compliance to agreed standards. A multivariate logistic model was constructed to independently determine the prediction of each indicator.

Main outcomes and results

Out of 1243 prescriptions; compliance to NSTG prescribing in ambulatory care was sub-optimal (target was >80%). Three of the four WHO/INRUD indicators did not meet Namibian or WHO targets: antibiotic prescribing, average number of medicines per prescription and generic prescribing. The majority of the indicators had low sensitivity and/or specificity. All WHO/INRUD indicators had poor accuracy in predicting rational prescribing. The antibiotic prescribing indicator was the only covariate that was a significant independent risk factor for compliance to NSTGs.

Conclusion

WHO/INRUD indicators showed poor accuracy in assessing prescribing practices in ambulatory care in Namibia. There is need for appropriate models and/or criteria to optimize medicine use in ambulatory care in the future.

Content of Care in 15,000 Sick Child Consultations in Nine Lower-Income Countries

OBJECTIVE

Describe content of clinical care for sick children in low-resource settings.

DATA SOURCES

Nationally representative health facility surveys in Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda from 2007 to 2015.

STUDY DESIGN

Clinical visits by sick children under 5 years were observed and caregivers interviewed. We describe duration and content of the care in the visit and estimate associations between increased content and caregiver knowledge and satisfaction.

PRINCIPAL FINDINGS

The median duration of 15,444 observations was 8 minutes; providers performed 8.4 of a maximum 24 clinical actions per visit. Content of care was minimally greater for severely ill children. Each additional clinical action was associated with 2 percent higher caregiver knowledge.

CONCLUSIONS

Consultations for children in nine lower-income countries are brief and limited. A greater number of clinical actions was associated with caregiver knowledge and satisfaction.

Factors associated with malnutrition among children <5 years old in Burkina Faso: evidence from the Demographic and Health Surveys IV 2010

Objective

To assess the factors associated with malnutrition among children <5 years in Burkina Faso.

Design

This study was based on secondary analysis of cross-sectional population-based data from Burkina-Faso Demographic Health Surveys 2010.

Setting

This study was carried out in Burkina Faso, West Africa.

Participants

The participants were 6337 children <5 years and their mothers.

Main outcome measures

Demographic characteristics, child nutrition and health status, and maternal and household information were collected. Survey-specific SAS procedures for weighting, clustering and stratification in the survey design were used. The distribution of different nutritional status, such as underweight, stunting and wasting and the effects of risk factors on malnutrition was analyzed.

Results

Out of 6337 children <5 years, 51.0% of children were male and 57.8% of children had an average size at birth. There were 15.6, 21.5 and 10.6% of children who recently suffered from diarrhea, fever and acute respiratory infection, respectively. Child sex, age, size at birth, child morbidity, mother's education and body mass index and household wealth index were significantly associated with undernutrition among children <5 years in Burkina Faso.

Conclusions

In addition to the improvement of household wealth index, more health and nutritional education for mothers should be implemented by the government to improve health and nutritional status of children <5 years in Burkina Faso.

Adherence to the integrated management of childhood illness guidelines in Namibia, Kenya, Tanzania and Uganda: evidence from the national service provision assessment surveys

Background

Integrated Management of Childhood Illness (IMCI) is regarded as a standard public health approach to lowering child mortality in developing countries. However, little is known about how health workers adhere to the guidelines at the national level in sub-Saharan African countries.

Methods

Data from the Service Provision Assessment surveys of Namibia (NA) (survey year: 2009), Kenya (KE) (2010), Tanzania (TZ) (2006) and Uganda (UG) (2007) were analysed for adherence to the IMCI guidelines by health workers. Potential influencing factors included the survey country, patient’s age, the different levels of the national health system, the training level of the health care provider (physician, non-physician clinician, nurse-midwife, auxiliary staff), and the status of re-training in IMCI.

Results

In total, 6856 children (NA: 1495; KE: 1890; TZ: 2469; UG: 1002 / male 51.2–53.5%) aged 2–73 months (2–24 months, 65.3%; median NA: 19 months; KE: 18 months; TZ: 16 months; UG: 15 months) were clinically assessed by 2006 health workers during the surveys.

Less than 33% of the workers carried out assessment of all three IMCI danger signs, namely inability to eat/drink, vomiting everything, and febrile convulsions (NA: 11%; KE: 11%; TZ: 14%; UG: 31%) while the rate for assessing all three of the IMCI main symptoms of cough/difficult breathing, diarrhoea, and fever was < 60% (NA: 48%; KE: 34%; TZ: 50%; UG: 57%). Physical examination rates for fever (temperature) (NA: 97%; KE: 87%; TZ: 73%; UG: 90%), pneumonia (respiration rate/auscultation) (NA: 43%; KE: 24%; TZ: 25%; UG: 20%) and diarrhoea (dehydration status) (NA: 29%; KE: 19%; TZ: 20%; UG: 39%) varied widely and were highest when assessing children with the actual diagnosis of pneumonia and diarrhoea.

Adherence rates tended to be higher in children ≤ 24 months, at hospitals, among higher-qualified staff (physician/non-physician clinician) and among those with recent IMCI re-training.

Conclusion

Despite nationwide training in IMCI the adherence rates for assessment and physical examination remained low in all four countries. IMCI training should continue to be provided to all health staff, particularly nurses, midwives, and auxiliary staff, with periodic re-training and an emphasis to equally target children of all age groups.