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English M, Irimu G, Akech S, Aluvaala J, Ogero M, Isaaka L, Malla L, Tuti T, Gathara D, Oliwa J, Agweyu A. Employing learning health system principles to advance research on severe neonatal and paediatric illness in Kenya. BMJ Glob Health 2021; 6:e005300. [PMID: 33758014 PMCID: PMC7993294 DOI: 10.1136/bmjgh-2021-005300] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/03/2021] [Accepted: 03/07/2021] [Indexed: 11/03/2022] Open
Abstract
We have worked to develop a Clinical Information Network (CIN) in Kenya as an early form of learning health systems (LHS) focused on paediatric and neonatal care that now spans 22 hospitals. CIN's aim was to examine important outcomes of hospitalisation at scale, identify and ultimately solve practical problems of service delivery, drive improvements in quality and test interventions. By including multiple routine settings in research, we aimed to promote generalisability of findings and demonstrate potential efficiencies derived from LHS. We illustrate the nature and range of research CIN has supported over the past 7 years as a form of LHS. Clinically, this has largely focused on common, serious paediatric illnesses such as pneumonia, malaria and diarrhoea with dehydration with recent extensions to neonatal illnesses. CIN also enables examination of the quality of care, for example that provided to children with severe malnutrition and the challenges encountered in routine settings in adopting simple technologies (pulse oximetry) and more advanced diagnostics (eg, Xpert MTB/RIF). Although regular feedback to hospitals has been associated with some improvements in quality data continue to highlight system challenges that undermine provision of basic, quality care (eg, poor access to blood glucose testing and routine microbiology). These challenges include those associated with increased mortality risk (eg, delays in blood transfusion). Using the same data the CIN platform has enabled conduct of randomised trials and supports malaria vaccine and most recently COVID-19 surveillance. Employing LHS principles has meant engaging front-line workers, clinical managers and national stakeholders throughout. Our experience suggests LHS can be developed in low and middle-income countries that efficiently enable contextually appropriate research and contribute to strengthening of health services and research systems.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Oxford Centre for Global Health Research, Nuffield Department of Clinical Medicine, Oxford, UK
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Morris Ogero
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Lynda Isaaka
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Lucas Malla
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Timothy Tuti
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Jacquie Oliwa
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Ambrose Agweyu
- Epidemiology and Demography, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
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Cao C, Zhen Z, Kuang S, Xu T. Reduning injection combined with western medicine for pneumonia: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e22757. [PMID: 33120780 PMCID: PMC7581155 DOI: 10.1097/md.0000000000022757] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 09/16/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Pneumonia is a common respiratory disease. In severe cases, it can induce cardiovascular disease and even life-threatening. In particular, pneumonia caused by the new coronavirus (SARS-CoV-2) that broke out at the end of 2019 has seriously affected the health of people in all countries. In recent years, it has been treated with the combination of traditional Chinese medicine (TCM) (such as Reduning injection) and Western medicine, and its mortality has decreased significantly. But their efficacy has not been scientifically and systematically assessed. Accordingly, it is essential to provide a systematized review program to estimate the efficacy and safety of Reduning injection combined with Western medicine to treat pneumonia. METHODS The following databases are retrieved from start to September 2020: Pubmed, Cochrane Library, EMBASE, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Wanfang database, the Chongqing VIP Chinese Science and Technology Periodical Database (VIP) databases, Chinese Biomedical Literature Database (CBM), and other databases, which are absorbed into clinical RCTs of pneumonia using western medicine alone or plus Reduning injections. The selection of studies, data extraction, and assessment of risk of bias will be performed independently by 2 reviewers. At the same time, Review Manager V.5.3.5 (Rev Man V.5.3.5) was used for bias risk assessment and data synthesis. RESULTS The efficacy and safety of Reduning injection combined with western medicine in the treatment of pneumonia were evaluated in terms of overall effective rate, the patient's antipyretic time, antitussive time, rales disappearing time, X-ray recovery time, and the incidence of adverse reactions. CONCLUSIONS This study provides reliable evidence-based support for the clinical application of Reduning injection combined with western medicine for pneumonia. ETHICS AND DISSEMINATION Ethical approval is not required in this secondary research evidence, and we will publish the results of this study in a journal or relevant conferences. REGISTRATION NUMBER DOI 10.17605/OSF.IO/VS75Y.
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Affiliation(s)
| | - Zelong Zhen
- Chongqing Rongchang District People's Hospital
| | | | - Tao Xu
- Chongqing Fifth People's Hospital, Chongqing, Chongqing Municipality, China
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Ogero M, Akech S, Malla L, Agweyu A, Irimu G, English M. Examining which clinicians provide admission hospital care in a high mortality setting and their adherence to guidelines: an observational study in 13 hospitals. Arch Dis Child 2020; 105:648-654. [PMID: 32169853 PMCID: PMC7361020 DOI: 10.1136/archdischild-2019-317256] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 12/23/2019] [Accepted: 01/03/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND We explored who actually provides most admission care in hospitals offering supervised experiential training to graduating clinicians in a high mortality setting where practices deviate from guideline recommendations. METHODS We used a large observational data set from 13 Kenyan county hospitals from November 2015 through November 2018 where patients were linked to admitting clinicians. We explored guideline adherence after creating a cumulative correctness of Paediatric Admission Quality of Care (cPAQC) score on a 5-point scale (0-4) in which points represent correct, sequential progress in providing care perfectly adherent to guidelines comprising admission assessment, diagnosis and treatment. At the point where guideline adherence declined the most we dichotomised the cPAQC score and used multilevel logistic regression models to explore whether clinician and patient-level factors influence adherence. RESULTS There were 1489 clinicians who could be linked to 53 003 patients over a period of 3 years. Patients were rarely admitted by fully qualified clinicians and predominantly by preregistration medical officer interns (MOI, 46%) and diploma level clinical officer interns (COI, 41%) with a median of 28 MOI (range 11-68) and 52 COI (range 5-160) offering care per study hospital. The cPAQC scores suggest that perfect guideline adherence is found in ≤12% of children with malaria, pneumonia or diarrhoea with dehydration. MOIs were more adherent to guidelines than COI (adjusted OR 1.19 (95% CI 1.07 to 1.34)) but multimorbidity was significantly associated with lower guideline adherence. CONCLUSION Over 85% of admissions to hospitals in high mortality settings that offer experiential training in Kenya are conducted by preregistration clinicians. Clinical assessment is good but classifying severity of illness in accordance with guideline recommendations is a challenge. Adherence by MOI with 6 years' training is better than COI with 3 years' training, performance does not seem to improve during their 3 months of paediatric rotations.
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Affiliation(s)
- Morris Ogero
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- School of Mathematics, University of Nairobi College of Biological and Physical Sciences, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Lucas Malla
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ambrose Agweyu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Pediatrics, University of Nairobi, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Malla L, Perera-Salazar R, Akech S, Ogero M, Julius T, Irimu G, English M. Examining the effectiveness of zinc treatment in children admitted with diarrhoea in Kenya's public hospitals: an observational comparative effectiveness study. J Glob Health 2019; 9:020416. [PMID: 31555441 PMCID: PMC6748787 DOI: 10.7189/jogh.09.020416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Kenyan paediatric treatment protocols recommend the use of zinc supplement for all children with diarrhoea. However, there is limited evidence of benefit for young children aged 1-5 months and those who are well-nourished. We examine effectiveness of zinc supplementation for children admitted with diarrhoea to Kenya’s public hospitals with different nutritional and age categories. This is to determine whether the current policy where zinc is prescribed for all children with diarrhoea is appropriate. Methods We explore the effect of zinc treatment on time to discharge for children aged 1-5 and 6-59 months and amongst those classified as either severely – moderately under-nourished or well-nourished. To overcome the challenges associated with non-random allocation of treatments and missing data in these observational data, we use propensity score methods and multiple imputation to minimize bias. Results The analysis included 1645 (1-5 months) and 11 546 (6-59 months) children respectively. The estimated sub-distribution hazard ratios for being discharged in the zinc group vs the non-zinc group were 1.25 (95% confidence interval (CI) = 1.07, 1.46) and 1.17 (95% CI = 1.10, 1.24) in these respective age categories. Zinc treatment was associated with shorter time to discharge in both well and under-nourished children. Conclusion Zinc treatment, in general, was associated with shorter time to discharge. In the absence of significant adverse effects, these data support the continued use of zinc for admissions with diarrhoea including those aged 1-5 months and in those who are well-nourished.
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Affiliation(s)
- Lucas Malla
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rafael Perera-Salazar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Samuel Akech
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Morris Ogero
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Thomas Julius
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Grace Irimu
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
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Macpherson L, Ogero M, Akech S, Aluvaala J, Gathara D, Irimu G, English M, Agweyu A. Risk factors for death among children aged 5-14 years hospitalised with pneumonia: a retrospective cohort study in Kenya. BMJ Glob Health 2019; 4:e001715. [PMID: 31544003 PMCID: PMC6730574 DOI: 10.1136/bmjgh-2019-001715] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/30/2019] [Accepted: 07/30/2019] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION There were almost 1 million deaths in children aged between 5 and 14 years in 2017, and pneumonia accounted for 11%. However, there are no validated guidelines for pneumonia management in older children and data to support their development are limited. We sought to understand risk factors for mortality among children aged 5-14 years hospitalised with pneumonia in district-level health facilities in Kenya. METHODS We did a retrospective cohort study using data collected from an established clinical information network of 13 hospitals. We reviewed records for children aged 5-14 years admitted with pneumonia between 1 March 2014 and 28 February 2018. Individual clinical signs were examined for association with inpatient mortality using logistic regression. We used existing WHO criteria (intended for under 5s) to define levels of severity and examined their performance in identifying those at increased risk of death. RESULTS 1832 children were diagnosed with pneumonia and 145 (7.9%) died. Severe pallor was strongly associated with mortality (adjusted OR (aOR) 8.06, 95% CI 4.72 to 13.75) as were reduced consciousness, mild/moderate pallor, central cyanosis and older age (>9 years) (aOR >2). Comorbidities HIV and severe acute malnutrition were also associated with death (aOR 2.31, 95% CI 1.39 to 3.84 and aOR 1.89, 95% CI 1.12 to 3.21, respectively). The presence of clinical characteristics used by WHO to define severe pneumonia was associated with death in univariate analysis (OR 2.69). However, this combination of clinical characteristics was poor in discriminating those at risk of death (sensitivity: 0.56, specificity: 0.68, and area under the curve: 0.62). CONCLUSION Children >5 years have high inpatient pneumonia mortality. These findings also suggest that the WHO criteria for classification of severity for children under 5 years do not appear to be a valid tool for risk assessment in this older age group, indicating the urgent need for evidence-based clinical guidelines for this neglected population.
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Affiliation(s)
- Liana Macpherson
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Morris Ogero
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- University of Nairobi College of Health Sciences, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK
| | - Ambrose Agweyu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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Gachau S, Owuor N, Njagi EN, Ayieko P, English M. Analysis of Hierarchical Routine Data With Covariate Missingness: Effects of Audit & Feedback on Clinicians' Prescribed Pediatric Pneumonia Care in Kenyan Hospitals. Front Public Health 2019; 7:198. [PMID: 31380338 PMCID: PMC6646705 DOI: 10.3389/fpubh.2019.00198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 07/02/2019] [Indexed: 12/22/2022] Open
Abstract
Background: Routine clinical data are widely used in many countries to monitor quality of care. A limitation of routine data is missing information which occurs due to lack of documentation of care processes by health care providers, poor record keeping, or limited health care technology at facility level. Our objective was to address missing covariates while properly accounting for hierarchical structure in routine pediatric pneumonia care. Methods: We analyzed routine data collected during a cluster randomized trial to investigating the effect of audit and feedback (A&F) over time on inpatient pneumonia care among children admitted in 12 Kenyan hospitals between March and November 2016. Six hospitals in the intervention arm received enhance A&F on classification and treatment of pneumonia cases in addition to a standard A&F report on general inpatient pediatric care. The remaining six in control arm received standard A&F alone. We derived and analyzed a composite outcome known as Pediatric Admission Quality of Care (PAQC) score. In our analysis, we adjusted for patients, clinician and hospital level factors. Missing data occurred in patient and clinician level variables. We did multiple imputation of missing covariates within the joint model imputation framework. We fitted proportion odds random effects model and generalized estimating equation (GEE) models to the data before and after multilevel multiple imputation. Results: Overall, 2,299 children aged 2 to 59 months were admitted with childhood pneumonia in 12 hospitals during the trial period. 2,127 (92%) of the children (level 1) were admitted by 378 clinicians across the 12 hospitals. Enhanced A&F led to improved inpatient pediatric pneumonia care over time compared to standard A&F. Female clinicians and hospitals with low admission workload were associated with higher uptake of the new pneumonia guidelines during the trial period. In both random effects and marginal model, parameter estimates were biased and inefficient under complete case analysis. Conclusions: Enhanced A&F improved the uptake of WHO recommended pediatric pneumonia guidelines over time compared to standard audit and feedback. When imputing missing data, it is important to account for the hierarchical structure to ensure compatibility with analysis models of interest to alleviate bias.
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Affiliation(s)
- Susan Gachau
- Health Services Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya.,School of Mathematics, University of Nairobi, Nairobi, Kenya
| | - Nelson Owuor
- School of Mathematics, University of Nairobi, Nairobi, Kenya
| | - Edmund Njeru Njagi
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Philip Ayieko
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mike English
- Health Services Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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