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Brault MA, Linnander EL, Ginindza TM, Mabuza K, Christie S, Canavan ME, Jones A, Desai MM. Assessing changes in adolescent girls' and young women's sexual and reproductive health service utilisation following a COVID-19 lockdown in eSwatini. Glob Health Action 2023; 16:2243760. [PMID: 37565704 PMCID: PMC10424588 DOI: 10.1080/16549716.2023.2243760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/28/2023] [Indexed: 08/12/2023] Open
Abstract
The effects of COVID-19-associated restrictions on youth sexual and reproductive health (SRH) care during the pandemic remain unclear, particularly in sub-Saharan Africa. This study uses interrupted time series analyses to assess changes in SRH care utilisation (including visits for HIV testing and treatment, family planning, and antenatal care) adolescent girls' and young women's (AGYW; aged 15-24 years old) in eSwatini following COVID-19 lockdown beginning in March 2020. SRH utilisation data from 32 clinics in the Manzini region that remained open throughout the 2020 COVID-19 period were extracted from eSwatini's electronic health record system. We tabulated and graphed monthly visits (both overall and by visit type) by AGYW during the two-year period between January 2019 and December 2020. Despite the March to September 2020 lockdown, we did not detect significant changes in monthly visit trends from 2019 to 2020. Our findings suggest little change to AGYW's SRH utilisation in eSwatini during the 2020 COVID-19 lockdown period.
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Affiliation(s)
- Marie A. Brault
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston School of Public Health, San Antonio, TX, USA
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Erika L. Linnander
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, CT, USA
- Department of Health Policy & Management, Yale School of Public Health, New Haven, CT, USA
| | - Thokozani M. Ginindza
- Health Management Information Systems (HMIS), eSwatini Ministry of Health, Mbabane, eSwatini
| | | | - Sarah Christie
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- School of Public Health, University of the Western Cape, Bellville, Republic of South Africa
| | - Maureen E. Canavan
- Yale School of Medicine, Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT, USA
| | - Anastasia Jones
- Department of Epidemiology, Human Genetics & Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, San Antonio, TX, USA
| | - Mayur M. Desai
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, CT, USA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
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Linnander EL, Ayedun A, Boatright D, Ackerman-Barger K, Morgenthaler TI, Ray N, Roy B, Simpson S, Curry LA. Mitigating structural racism to reduce inequities in sepsis outcomes: a mixed methods, longitudinal intervention study. BMC Health Serv Res 2022; 22:975. [PMID: 35907839 PMCID: PMC9338573 DOI: 10.1186/s12913-022-08331-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/14/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Sepsis affects 1.7 million patients in the US annually, is one of the leading causes of mortality, and is a major driver of US healthcare costs. African American/Black and LatinX populations experience higher rates of sepsis complications, deviations from standard care, and readmissions compared with Non-Hispanic White populations. Despite clear evidence of structural racism in sepsis care and outcomes, there are no prospective interventions to mitigate structural racism in sepsis care, nor are we aware of studies that report reductions in racial inequities in sepsis care as an outcome. Therefore, we will deliver and evaluate a coalition-based intervention to equip health systems and their surrounding communities to mitigate structural racism, driving measurable reductions in inequities in sepsis outcomes. This paper presents the theoretical foundation for the study, summarizes key elements of the intervention, and describes the methodology to evaluate the intervention. METHODS Our aims are to: (1) deliver a coalition-based leadership intervention in eight U.S. health systems and their surrounding communities; (2) evaluate the impact of the intervention on organizational culture using a longitudinal, convergent mixed methods approach, and (3) evaluate the impact of the intervention on reduction of racial inequities in three clinical outcomes: a) early identification (time to antibiotic), b) clinical management (in-hospital sepsis mortality) and c) standards-based follow up (same-hospital, all-cause sepsis readmissions) using interrupted time series analysis. DISCUSSION This study is aligned with calls to action by the NIH and the Sepsis Alliance to address inequities in sepsis care and outcomes. It is the first to intervene to mitigate effects of structural racism by developing the domains of organizational culture that are required for anti-racist action, with implications for inequities in complex health outcomes beyond sepsis.
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Affiliation(s)
- Erika L Linnander
- Department of Health Policy and Management, Yale School of Public Health, New Haven, USA.
- Yale Global Health Leadership Initiative, Yale School of Public Health, New Haven, USA.
| | - Adeola Ayedun
- Yale Global Health Leadership Initiative, Yale School of Public Health, New Haven, USA
| | - Dowin Boatright
- Department of Emergency Medicine, Yale School of Medicine, New Haven, USA
| | - Kupiri Ackerman-Barger
- Betty Irene Moore School of Nursing, University of California Davis Health, Sacramento, USA
| | | | | | - Brita Roy
- Department of Medicine, Yale School of Medicine, New Haven, USA
| | - Steven Simpson
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, University of Kansas, Kansas City, USA
| | - Leslie A Curry
- Department of Health Policy and Management, Yale School of Public Health, New Haven, USA
- Yale Global Health Leadership Initiative, Yale School of Public Health, New Haven, USA
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Christie S, Chahine T, Curry LA, Cherlin E, Linnander EL. The Evolution of Trust Within a Global Health Partnership With the Private Sector: An Inductive Framework. Int J Health Policy Manag 2022; 11:1140-1147. [PMID: 33904694 PMCID: PMC9808177 DOI: 10.34172/ijhpm.2021.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 02/12/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Public-private partnerships (PPPs) in global health are increasingly common to support sustainable development and strengthen health systems in low- and middle-income countries. Since the release of the Sustainable Development Goals (SDGs) in 2015 culminating in a discrete goal "to revitalize the global partnership for sustainable development," public health scholars have sought to understand what makes PPPs successful in different contexts. While trust has long been identified as a key component of successful strategic alliances in the private sector, less is known about how trust emerges between public- and private- sector partners, particularly in global health. Therefore, we investigated how trust between partners evolved in the context of Project Last Mile (PLM), a global health partnership that translates the business acumen of The Coca-Cola Company to strengthen public health systems across Africa. METHODS This study draws upon secondary analysis of qualitative data generated as part of the longitudinal, mixed-methods evaluation of PLM across country settings. Seventy-seven interviews with a purposeful sample of key stakeholders were conducted in Mozambique, South Africa and eSwatini between August 2016 and July 2018. Trained qualitative interviewers followed a standard discussion guide, and audio-recorded interviews with participants' consent. In this secondary analysis, we analyzed qualitative data to understand how trust between partners was cultivated across settings. RESULTS We drew upon stakeholder experiences to inform an inductive framework for how trust develops over time. Our analysis revealed five domains that were foundational to building trust: (1) reputational context, (2) team composition, (3) tangible outputs, (4) shared values, and (5) effective communication. CONCLUSION The framework may be useful for private and public sector entities seeking to establish and sustain trust within their global health partnerships.
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Affiliation(s)
- Sarah Christie
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, CT, USA
| | | | - Leslie A. Curry
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, CT, USA
| | - Emily Cherlin
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, CT, USA
| | - Erika L. Linnander
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, CT, USA
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Ineza L, Bechtold K, Mwisongo A, Kwedi Nolna S, Linnander EL. Building leadership and management competencies of national immunization teams in 16 Gavi-eligible countries through the EPI leadership and management programme. Vaccine 2022; 40:3581-3587. [DOI: 10.1016/j.vaccine.2022.04.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/22/2022] [Accepted: 04/23/2022] [Indexed: 11/30/2022]
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Brault MA, Christie S, Manchia A, Mabuza K, Dlamini M, Linnander EL. Girl Champ in eSwatini: A Strategic Marketing Campaign to Promote Demand for Sexual and Reproductive Health Services Among Young Women. AIDS Behav 2022; 26:853-863. [PMID: 34463895 PMCID: PMC8840893 DOI: 10.1007/s10461-021-03446-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2021] [Indexed: 11/25/2022]
Abstract
Efforts to engage adolescent girls and young women (AGYW) in HIV services have struggled, in part, due to limited awareness of services and stigma. Strategic marketing is a promising approach, but the impact on youth behavior change is unclear. We report findings from a mixed methods evaluation of the Girl Champ campaign, designed to generate demand for sexual and reproductive services among AGYW, and piloted in three clinics in the Manzini region of eSwatini. We analyzed and integrated data from longitudinal, clinic-level databases on health service utilization among AGYW before and after the pilot, qualitative interviews with stakeholders responsible for the implementation of the pilot, and participant feedback surveys from attendees of Girl Champ events. Girl Champ was well received by most stakeholders based on event attendance and participant feedback, and associated with longitudinal improvements in demand for HIV services. Findings can inform future HIV demand creation interventions for youth.
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Affiliation(s)
- Marie A Brault
- Department of Social and Behavioral Sciences, Yale School of Public Health, 60 College Street, New Haven, CT, 06510-3201, USA.
| | - Sarah Christie
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, 06510, USA
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, CT, 06510, USA
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | | | | | - Muhle Dlamini
- Ministry of Health, Government of the Kingdom of eSwatini, Mbabane, Eswatini
| | - Erika L Linnander
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, 06510, USA
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, CT, 06510, USA
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Brault MA, Christie S, Aquino S, Rendin A, Manchia A, Curry LA, Linnander EL. Project Last Mile and the development of the Girl Champ brand in eSwatini: engaging the private sector to promote uptake of health services among adolescent girls and young women. SAHARA J 2021; 18:52-63. [PMID: 33685358 PMCID: PMC7946024 DOI: 10.1080/17290376.2021.1894224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In eSwatini and across sub-Saharan Africa, adolescent girls and young women (AGYW) are at significantly higher risk of HIV infection and poorer sexual and reproductive health (SRH) than their male counterparts. AGYW demonstrate low demand for SRH services, further contributing to poor outcomes. Strategic marketing approaches, including those used by multinational corporations, have potential to support demand creation for SRH services among AGYW, but there is limited empirical evidence on the direct application of private-sector strategic marketing approaches in this context. Therefore, we examined how Project Last Mile worked with eSwatini's Ministry of Heath to translate strategic marketing approaches from the Coca-Cola system to attract AGYW to SRH services. We present qualitative market research using the ZMET® methodology with 12 young Swazi women (ages 15-24), which informed development of a highly branded communication strategy consistent with other successful gain-framing approaches. Qualitative in-depth interviews with 19 stakeholders revealed receptivity to the market research findings, and highlighted local ownership over the strategic marketing process and brand. These results can inform similar efforts to translate strategic marketing to support demand generation in pursuit of public health goals to reduce HIV risk and improve SRH.
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Affiliation(s)
- Marie A. Brault
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Sarah Christie
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, CT, USA
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | | | | | | | - Leslie A. Curry
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, CT, USA
| | - Erika L. Linnander
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, CT, USA
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Brewster AL, Lee YSH, Linnander EL, Curry LA. Creativity in problem solving to improve complex health outcomes: Insights from hospitals seeking to improve cardiovascular care. Learn Health Syst 2021; 6:e10283. [PMID: 35434357 PMCID: PMC9006532 DOI: 10.1002/lrh2.10283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/29/2021] [Accepted: 06/22/2021] [Indexed: 12/04/2022] Open
Abstract
Introduction Improving performance often requires health care teams to employ creativity in problem solving, a key attribute of learning health systems. Despite increasing interest in the role of creativity in health care, empirical evidence documenting how this concept manifests in real‐world contexts remains limited. Methods We conducted a qualitative study to understand how creativity was fostered during problem solving in 10 hospitals that took part in a 2‐year collaborative to improve cardiovascular care outcomes. We analyzed interviews with 197 hospital team members involved in the collaborative, focusing on work processes or outcomes that participants self‐identified as creative or promoting creativity. We sought to identify recurrent patterns across instances of creativity in problem solving. Results Participants reported examples of creativity at both stages typically identified in problem solving research and practice: uncovering non‐obvious problems and finding novel solutions. Creativity generally involved the assembly of an “ecological view” of the care process, which reflected a more complete understanding of relationships between individual care providers, organizational sub‐units, and their environment. Teams used three prominent behaviors to construct the ecological view: (a) collecting new and diverse information, (b) accepting (rather than dismissing) disruptive information, and (c) employing empathy to understand and share feelings of others. Conclusions We anticipate that findings will be useful to researchers and practitioners who wish to understand how creativity can be fostered in problem solving to improve clinical outcomes and foster learning health systems.
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Affiliation(s)
- Amanda L. Brewster
- Health Policy and Management, School of Public Health University of California Berkeley California USA
| | - Yuna S. H. Lee
- Health Policy and Management Columbia Mailman School of Public Health New York New York USA
| | - Erika L. Linnander
- Global Health Leadership Initiative Yale School of Public Health New Haven Connecticut USA
| | - Leslie A. Curry
- Health Policy and Management Yale School of Public Health New Haven Connecticut USA
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Liu L, Christie S, Munsamy M, Roberts P, Pillay M, Shenoi SV, Desai MM, Linnander EL. Correction to: Expansion of a national differentiated service delivery model to support people living with HIV and other chronic conditions in South Africa: a descriptive analysis. BMC Health Serv Res 2021; 21:549. [PMID: 34088315 PMCID: PMC8178930 DOI: 10.1186/s12913-021-06561-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Lingrui Liu
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, USA.,Department of Health Policy and Management, Yale School of Ptublic Health, New Haven, USA
| | - Sarah Christie
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, USA
| | | | | | | | - Sheela V Shenoi
- Department of Medicine, Yale School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, USA
| | - Mayur M Desai
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, USA.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, USA
| | - Erika L Linnander
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, USA. .,Department of Health Policy and Management, Yale School of Ptublic Health, New Haven, USA.
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Liu L, Christie S, Munsamy M, Roberts P, Pillay M, Shenoi SV, Desai MM, Linnander EL. Title: Expansion of a national differentiated service delivery model to support people living with HIV and other chronic conditions in South Africa: a descriptive analysis. BMC Health Serv Res 2021; 21:463. [PMID: 34001123 PMCID: PMC8127180 DOI: 10.1186/s12913-021-06450-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/21/2021] [Indexed: 11/16/2022] Open
Abstract
Background South Africa is home to 7.7 million people living with HIV and supports the largest antiretroviral therapy (ART) program worldwide. Despite global investment in HIV service delivery and the parallel challenge of non-communicable diseases (NCDs), there are few examples of integrated programs addressing both HIV and NCDs through differentiated service delivery. In 2014, the National Department of Health (NDoH) of South Africa launched the Central Chronic Medicines Dispensing and Distribution (CCMDD) program to provide patients who have chronic diseases, including HIV, with alternative access to medications via community-based pick-up points. This study describes the expansion of CCMDD toward national scale. Methods Yale monitors CCMDD expansion as part of its mixed methods evaluation of Project Last Mile, a national technical support partner for CCMDD since 2016. From March 2016 through October 2019, cumulative weekly data on CCMDD uptake [patients enrolled, facilities registered, pick-up points contracted], type of medication provided [ART only; NCD only; and ART-NCD] and collection sites preferred by patients [external pick-up points; adherence/outreach clubs; or facility-based fast lanes], were extracted for descriptive, longitudinal analysis. Results As of October 2019, 3,436 health facilities were registered with CCMDD across 46 health districts (88 % of South Africa’s districts), and 2,037 external pick-up points had been contracted by the NDoH. A total of 2,069,039 patients were actively serviced through CCMDD, a significant increase since 2018 (p < 0.001), including 76 % collecting ART [64 % ART only, 12 % ART plus NCD/comorbidities] and 479,120 [24 %] collecting medications for chronic diseases only. Further, 734,005 (35 %) of patients were collecting from contracted, external pick-up points, a 73 % increase in patient volume from 2018. Discussion This longitudinal description of CCMDD provides an example of growth of a national differentiated service delivery model that integrates management of HIV and noncommunicable diseases. This study demonstrates the success of the program in engaging patients irrespective of their chronic condition, which bodes well for the potential of the program to address the rising burden of both HIV and NCDs in South Africa. Conclusions The CCMDD program expansion signals the potential for a differentiated service delivery strategy in resource-limited settings that can be agnostic of the patients chronic disease condition.
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Affiliation(s)
- Lingrui Liu
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, USA.,Department of Health Policy and Management, Yale School of Public Health, New Haven, USA
| | - Sarah Christie
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, USA
| | | | | | | | - Sheela V Shenoi
- Department of Medicine, Yale School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, USA
| | - Mayur M Desai
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, USA.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, USA
| | - Erika L Linnander
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, USA. .,Department of Health Policy and Management, Yale School of Public Health, New Haven, USA.
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Abstract
OBJECTIVE Leadership is associated with organisational performance in healthcare, including quality, safety and clinical outcomes for patients. Leadership development programmes have proliferated in recent years. Nevertheless, very few have examined participant experiences in depth in order to understand which programmatic aspects they regard as most valuable relative to leadership in increasingly complex systems, or whether and how learnings may sustain over time. Accordingly, we explored experiences of participants in an interdisciplinary leadership development programme using qualitative methods over an extended look-back period. SETTING Health and social care sectors in the UK. PARTICIPANTS Key informants from three cohorts of individuals working in leadership roles in health and social care in the UK: 2013/2014, 2015/2016 and 2017/2018. We contacted 32 participants, and 26 completed interviews (81% response rate). PRIMARY AND SECONDARY OUTCOMES We explored (1) whether and how specific skills and competencies developed during the programme were applied and/or sustained over time, and (2) whether and how the impact of the programme changed as alumni progressed through their career. RESULTS Three major recurrent themes emerged from participants' experiences: (1) specific features of the programme meaningfully impact professional development at multiple levels; (2) the coupling of a professional network and practical tools allowed participants to address system-wide problems in new ways and (3) participants describe a level of learning that sustained and amplified over time with increased complexity in their work. CONCLUSION This work highlights specific design characteristics of leadership development programmes that may help promote relevance and impact. Programme learnings can be translated into practice in substantive ways, with potential for the benefits of successful leadership development efforts to amplify, not fade, over time.
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Affiliation(s)
- Leslie A Curry
- Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, Connecticut, USA
| | - Adeola A Ayedun
- Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, Connecticut, USA
| | - Emily J Cherlin
- Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, Connecticut, USA
| | - Nikole H Allen
- Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
- Yale Institute for Global Health, Yale School of Public Health, New Haven, Connecticut, USA
| | - Erika L Linnander
- Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
- Global Health Leadership Initiative, Yale School of Public Health, New Haven, Connecticut, USA
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Curry LA, Brault MA, Linnander EL, McNatt Z, Brewster AL, Cherlin E, Flieger SP, Ting HH, Bradley EH. Influencing organisational culture to improve hospital performance in care of patients with acute myocardial infarction: a mixed-methods intervention study. BMJ Qual Saf 2018; 27:207-217. [PMID: 29101292 PMCID: PMC5867431 DOI: 10.1136/bmjqs-2017-006989] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/28/2017] [Accepted: 10/03/2017] [Indexed: 12/04/2022]
Abstract
BACKGROUND Hospital organisational culture affects patient outcomes including mortality rates for patients with acute myocardial infarction; however, little is known about whether and how culture can be positively influenced. METHODS This is a 2-year, mixed-methods interventional study in 10 US hospitals to foster improvements in five domains of organisational culture: (1) learning environment, (2) senior management support, (3) psychological safety, (4) commitment to the organisation and (5) time for improvement. Outcomes were change in culture, uptake of five strategies associated with lower risk-standardised mortality rates (RSMR) and RSMR. Measures included a validated survey at baseline and at 12 and 24 months (n=223; average response rate 88%); in-depth interviews (n=393 interviews with 197 staff); and RSMR data from the Centers for Medicare and Medicaid Services. RESULTS We observed significant changes (p<0.05) in culture between baseline and 24 months in the full sample, particularly in learning environment (p<0.001) and senior management support (p<0.001). Qualitative data indicated substantial shifts in these domains as well as psychological safety. Six of the 10 hospitals achieved substantial improvements in culture, and four made less progress. The use of evidence-based strategies also increased significantly (per hospital average of 2.4 strategies at baseline to 3.9 strategies at 24 months; p<0.05). The six hospitals that demonstrated substantial shifts in culture also experienced significantly greater reductions in RSMR than the four hospitals that did not shift culture (reduced RSMR by 1.07 percentage points vs 0.23 percentage points; p=0.03) between 2011-2014 and 2012-2015. CONCLUSIONS Investing in strategies to foster an organisational culture that supports high performance may help hospitals in their efforts to improve clinical outcomes.
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Affiliation(s)
- Leslie A Curry
- Yale School of Public Health and Yale Global Health Leadership Institute, New Haven, Connecticut, USA
| | - Marie A Brault
- Yale School of Public Health and Yale Global Health Leadership Institute, New Haven, Connecticut, USA
| | - Erika L Linnander
- Yale School of Public Health and Yale Global Health Leadership Institute, New Haven, Connecticut, USA
| | - Zahirah McNatt
- Columbia University Mailman School of Public Health, New York, USA
| | - Amanda L Brewster
- Yale School of Public Health and Yale Global Health Leadership Institute, New Haven, Connecticut, USA
| | - Emily Cherlin
- Yale School of Public Health and Yale Global Health Leadership Institute, New Haven, Connecticut, USA
| | | | - Henry H Ting
- Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Bradley EH, Brewster AL, McNatt Z, Linnander EL, Cherlin E, Fosburgh H, Ting HH, Curry LA. How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study. BMJ Qual Saf 2017; 27:218-225. [PMID: 29101290 PMCID: PMC5867433 DOI: 10.1136/bmjqs-2017-006574] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/11/2017] [Accepted: 05/06/2017] [Indexed: 01/05/2023]
Abstract
Background Quality collaboratives are widely endorsed as a potentially effective method for translating and spreading best practices for acute myocardial infarction (AMI) care. Nevertheless, hospital success in improving performance through participation in collaboratives varies markedly. We sought to understand what distinguished hospitals that succeeded in shifting culture and reducing 30-day risk-standardised mortality rate (RSMR) after AMI through their participation in the Leadership Saves Lives (LSL) collaborative. Procedures We conducted a longitudinal, mixed methods intervention study of 10 hospitals over a 2-year period; data included surveys of 223 individuals (response rates 83%–94% depending on wave) and 393 in-depth interviews with clinical and management staff most engaged with the LSL intervention in the 10 hospitals. We measured change in culture and RSMR, and key aspects of working related to team membership, turnover, level of participation and approaches to conflict management. Main findings The six hospitals that experienced substantial culture change and greater reductions in RSMR demonstrated distinctions in: (1) effective inclusion of staff from different disciplines and levels in the organisational hierarchy in the team guiding improvement efforts (referred to as the ‘guiding coalition’ in each hospital); (2) authentic participation in the work of the guiding coalition; and (3) distinct patterns of managing conflict. Guiding coalition size and turnover were not associated with success (p values>0.05). In the six hospitals that experienced substantial positive culture change, staff indicated that the LSL learnings were already being applied to other improvement efforts. Principal conclusions Hospitals that were most successful in a national quality collaborative to shift hospital culture and reduce RSMR showed distinct patterns in membership diversity, authentic participation and capacity for conflict management.
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Affiliation(s)
| | - Amanda L Brewster
- Yale School of Public Health, Global Health Leadership Institute, New Haven, Connecticut, USA
| | - Zahirah McNatt
- Columbia University Mailman School of Public Health, New York, New York, USA
| | - Erika L Linnander
- Yale School of Public Health, Global Health Leadership Institute, New Haven, Connecticut, USA
| | - Emily Cherlin
- Yale School of Public Health, Global Health Leadership Institute, New Haven, Connecticut, USA
| | - Heather Fosburgh
- Yale School of Public Health, Global Health Leadership Institute, New Haven, Connecticut, USA
| | - Henry H Ting
- Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Leslie A Curry
- Yale School of Public Health, Global Health Leadership Institute, New Haven, Connecticut, USA
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Linnander EL, Mantopoulos JM, Allen N, Nembhard IM, Bradley EH. Professionalizing Healthcare Management: A Descriptive Case Study. Int J Health Policy Manag 2017; 6:555-560. [PMID: 28949471 PMCID: PMC5627783 DOI: 10.15171/ijhpm.2017.40] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/18/2017] [Indexed: 11/29/2022] Open
Abstract
Despite international recognition of the importance of healthcare management in the development of high-performing systems, the path by which countries may develop and sustain a professional healthcare management workforce has not been articulated. Accordingly, we sought to identify a set of common themes in the establishment of a professional workforce of healthcare managers in low- and middle-income country (LMIC) settings using a descriptive case study approach. We draw on a historical analysis of the development of this profession in the United States and Ethiopia to identify five common themes in the professionalization of healthcare management: (1) a country context in which healthcare management is demanded; (2) a national framework that elevates a professional management role; (3) standards for healthcare management, and a monitoring function to promote adherence to standards; (4) a graduatelevel educational path to ensure a pipeline of well-prepared healthcare managers; and (5) professional associations to sustain and advance the field. These five components can to inform the creation of a long-term national strategy for the development of a professional cadre of heathcare managers in LMIC settings.
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Affiliation(s)
- Erika L Linnander
- Yale School of Public Health, Yale University, New Haven, CT, USA.,Yale Global Health Leadership Institute, Yale University, New Haven, CT, USA
| | - Jeannie M Mantopoulos
- Yale School of Public Health, Yale University, New Haven, CT, USA.,Yale Global Health Leadership Institute, Yale University, New Haven, CT, USA
| | - Nikole Allen
- Yale School of Public Health, Yale University, New Haven, CT, USA.,Yale Global Health Leadership Institute, Yale University, New Haven, CT, USA
| | - Ingrid M Nembhard
- Yale School of Public Health, Yale University, New Haven, CT, USA.,Yale Global Health Leadership Institute, Yale University, New Haven, CT, USA
| | - Elizabeth H Bradley
- Yale School of Public Health, Yale University, New Haven, CT, USA.,Yale Global Health Leadership Institute, Yale University, New Haven, CT, USA
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14
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Curry LA, Linnander EL, Brewster AL, Ting H, Krumholz HM, Bradley EH. Organizational culture change in U.S. hospitals: a mixed methods longitudinal intervention study. Implement Sci 2015; 10:29. [PMID: 25889753 PMCID: PMC4356105 DOI: 10.1186/s13012-015-0218-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 02/13/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improving outcomes for patients with acute myocardial infarction (AMI) is a priority for hospital leadership, clinicians, and policymakers. Evidence suggests links between hospital organizational culture and hospital performance; however, few studies have attempted to shift organizational culture in order to improve performance, fewer have focused on patient outcomes, and none have addressed mortality for patients with AMI. We sought to address this gap through a novel longitudinal intervention study, Leadership Saves Lives (LSL). METHODS This manuscript describes the methodology of LSL, a 2-year intervention study using a concurrent mixed methods design, guided by open systems theory and the Assess, Innovate, Develop, Engage, Devolve (AIDED) model of diffusion, implemented in 10 U.S. hospitals and their peer hospital networks. The intervention has three primary components: 1) annual convenings of the ten intervention hospitals; 2) semiannual workshops with guiding coalitions at each hospital; and 3) continuous remote support across all intervention hospitals through a web-based platform. Primary outcomes include 1) shifts in key dimensions of hospital organizational culture associated with lower mortality rates for patients with AMI; 2) use of targeted evidence-based practices associated with lower mortality rates for patients with AMI; and 3) in-hospital AMI mortality. Quantitative data include annual surveys of guiding coalition members in the intervention hospitals and peer network hospitals. Qualitative data include in-person, in-depth interviews with all guiding coalition members and selective observations of key interactions in care for patients with AMI, collected at three time points. Data integration will identify patterns and major themes in change processes across all intervention hospitals over time. CONCLUSIONS LSL is novel in its use of a longitudinal mixed methods approach in a diverse sample of hospitals, its focus on objective outcome measures of mortality, and its examination of changes not only in the intervention hospitals but also in their peer hospital networks over time. This paper adds to the methodological literature for the study of complex interventions to promote hospital organizational culture change.
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Affiliation(s)
- Leslie A Curry
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA. .,Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA.
| | - Erika L Linnander
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA.
| | - Amanda L Brewster
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA.
| | - Henry Ting
- New York Presbyterian Hospital, New York, NY, USA.
| | - Harlan M Krumholz
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA. .,Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA. .,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA. .,Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA.
| | - Elizabeth H Bradley
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA. .,Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA.
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15
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Sipsma HL, Curry LA, Kakoma JB, Linnander EL, Bradley EH. Identifying characteristics associated with performing recommended practices in maternal and newborn care among health facilities in Rwanda: a cross-sectional study. Hum Resour Health 2012; 10:13. [PMID: 22776289 PMCID: PMC3444308 DOI: 10.1186/1478-4491-10-13] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Accepted: 07/09/2012] [Indexed: 06/01/2023]
Abstract
BACKGROUND Although rates of maternal and neonatal mortality have decreased in many countries over the last two decades, they remain unacceptably high, particularly in sub-Saharan Africa. Nevertheless, we know little about the quality of facility-based maternal and newborn care in low-income countries and little about the association between quality of care and health worker training, supervision, and incentives in these settings. We therefore sought to examine the quality of facility-based maternal and newborn health care by describing the implementation of recommended practices for maternal and newborn care among health care facilities. We also aimed to determine whether increased training, supervision, and incentives for health workers were associated with implementing these recommended practices. We chose to study these aims in the Republic of Rwanda, where rates of maternal and newborn mortality are high and where substantial attention is currently focused on strengthening health workforce capacity and quality. METHODS We used data from the 2007 Rwanda Service Provision Assessment. Using observations from 455 facilities and interviews from 1357 providers, we generated descriptive statistics to describe the use of recommended practices and frequencies of provider training, supervision, and incentives in the areas of antenatal, delivery, and newborn care. We then constructed multivariable regression models to examine the associations between using recommended practices and health provider training, supervision, and incentives. RESULTS Use of recommended practices varied widely, and very few facilities performed all recommended practices. Furthermore, in most areas of care, less than 25% of providers reported having had any pre-service or in-service training in the last 3 years. Contrary to our hypotheses, we found no evidence that training, supervision, or incentives were consistently associated with using recommended practices. CONCLUSION Our findings highlight the need to improve facility-based maternal and newborn care in Rwanda and suggest that current approaches to workforce training, supervision, and incentives may not be adequate for improving these critical practices.
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Affiliation(s)
- Heather L Sipsma
- Department of Health Policy and Administration, School of Public Health, Yale University, New Haven, CT, USA.
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16
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Wong R, Hathi S, Linnander EL, El Banna A, El Maraghi M, El Din RZ, Ahmed A, Hafez AR, Allam AA, Krumholz HM, Bradley EH. Building hospital management capacity to improve patient flow for cardiac catheterization at a cardiovascular hospital in Egypt. Jt Comm J Qual Patient Saf 2012; 38:147-53. [PMID: 22533126 DOI: 10.1016/s1553-7250(12)38019-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Quality improvement (QI) has been shown to be effective in improving hospital care in high-income countries, but evidence of its use in low- and middle-income countries has been limited to date. The impact of a QI intervention to reduce patient waiting time and overcrowding for cardiac catheterization-the subset of procedures associated with the most severe bottlenecks in patient flow at the National Heart Institute in Cairo-was investigated. METHODS A pre-post intervention study was conducted to examine the impact of a new scheduling system on patient waiting time and overcrowdedness for cardiac catheterization. The sample consisted of 628 consecutive patients in the pre-intervention period (July-August 2009) and 1,607 in the postintervention period (September-November 2010). RESULTS The intervention was associated with significant reductions in waiting time and patient crowdedness. On average, total patient waiting time from arrival to beginning the catheterization procedure decreased from 208 minutes to 180 minutes (13% decrease, p < .001). Time between arrival at registration and admission to inpatient ward unit decreased from 33 minutes to 24 minutes (27% decrease, p < .001). Patient waiting time immediately prior to the catheterization laboratory procedure decreased from 79 minutes to 58 minutes (27% decrease, p < .001). The percentage of patients arriving between 7:00 A.M. and 9:00 A.M. decreased from 88% to 44% (50% decrease, p < .001), reducing patient crowding. CONCLUSION With little financial investment, the patient scheduling system significantly reduced waiting time and crowdedness in a resource-limited setting. The capacity-building effort enabled the hospital to sustain the scheduling system and data collection after the Egyptian revolution and departure of the mentoring team in January 2011.
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Affiliation(s)
- Rex Wong
- Global Health Leadership Institute, Yale University, New Haven, Connecticut, USA
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17
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Cherlin EJ, Allam AA, Linnander EL, Wong R, El-Toukhy E, Sipsma H, Krumholz HM, Curry LA, Bradley EH. Inputs to quality: supervision, management, and community involvement in health facilities in Egypt in 2004. BMC Health Serv Res 2011; 11:282. [PMID: 22014078 PMCID: PMC3216250 DOI: 10.1186/1472-6963-11-282] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2011] [Accepted: 10/20/2011] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND As low- and middle-income countries experience economic development, ensuring quality of health care delivery is a central component of health reform. Nevertheless, health reforms in low- and middle-income countries have focused more on access to services rather than the quality of these services, and reporting on quality has been limited. In the present study, we sought to examine the prevalence and regional variation in key management practices in Egyptian health facilities within three domains: supervision of the facility from the Ministry of Health and Population (MOHP), managerial processes, and patient and community involvement in care. METHODS We conducted a cross-sectional analysis of data from 559 facilities surveyed with the Egyptian Service Provision Assessment (ESPA) survey in 2004, the most recent such survey in Egypt. We registered on the Measure Demographic and Health Survey (DHS) website http://legacy.measuredhs.com/login.cfm to gain access to the survey data. From the ESPA sampled 559 MOHP facilities, we excluded a total of 79 facilities because they did not offer facility-based 24-hour care or have at least one physician working in the facility, resulting in a final sample of 480 facilities. The final sample included 76 general service hospitals, 307 rural health units, and 97 maternal and child health and urban health units (MCH/urban units). We used standard frequency analyses to describe facility characteristics and tested the statistical significance of regional differences using chi-square statistics. RESULTS Nearly all facilities reported having external supervision within the 6 months preceding the interview. In contrast, key facility-level managerial processes, such as having routine and documented management meetings and applying quality assurance approaches, were uncommon. Involvement of communities and patients was also reported in a minority of facilities. Hospitals and health units located in Urban Egypt compared with more rural parts of Egypt were significantly more likely to have management committees that met at least monthly, to keep official records of the meetings, and to have an approach for reviewing quality assurance activities. CONCLUSIONS Although the data precede the recent reform efforts of the MOHP, they provide a baseline against which future progress can be measured. Targeted efforts to improve facility-level management are critical to supporting quality improvement initiatives directed at improving the quality of health care throughout the country.
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Affiliation(s)
- Emily J Cherlin
- Section of Health Policy and Administration, School of Public Health, New Haven, CT, USA
| | - Adel A Allam
- Al Azhar University and National Bank of Egypt, Cairo, Egypt
| | - Erika L Linnander
- Section of Health Policy and Administration, School of Public Health, New Haven, CT, USA
| | - Rex Wong
- Section of Health Policy and Administration, School of Public Health, New Haven, CT, USA
| | | | - Heather Sipsma
- Section of Health Policy and Administration, School of Public Health, New Haven, CT, USA
| | - Harlan M Krumholz
- Section of Health Policy and Administration, School of Public Health, New Haven, CT, USA
- Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale New-Haven Hospital, New Haven, Connecticut, USA
| | - Leslie A Curry
- Section of Health Policy and Administration, School of Public Health, New Haven, CT, USA
- Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Elizabeth H Bradley
- Section of Health Policy and Administration, School of Public Health, New Haven, CT, USA
- Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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18
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Butala NM, Desai MM, Linnander EL, Wong YR, Mikhail DG, Ott LS, Spertus JA, Bradley EH, Aaty AA, Abdelfattah A, Gamal A, Kholeif H, el-Baz M, Allam AH, Krumholz HM. Gender differences in presentation, management, and in-hospital outcomes for patients with AMI in a lower-middle income country: evidence from Egypt. PLoS One 2011; 6:e25904. [PMID: 22022463 PMCID: PMC3192760 DOI: 10.1371/journal.pone.0025904] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Accepted: 09/13/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Many studies in high-income countries have investigated gender differences in the care and outcomes of patients hospitalized with acute myocardial infarction (AMI). However, little evidence exists on gender differences among patients with AMI in lower-middle-income countries, where the proportion deaths stemming from cardiovascular disease is projected to increase dramatically. This study examines gender differences in patients in the lower-middle-income country of Egypt to determine if female patients with AMI have a different presentation, management, or outcome compared with men. METHODS AND FINDINGS Using registry data collected over 18 months from 5 Egyptian hospitals, we considered 1204 patients (253 females, 951 males) with a confirmed diagnosis of AMI. We examined gender differences in initial presentation, clinical management, and in-hospital outcomes using t-tests and χ(2) tests. Additionally, we explored gender differences in in-hospital death using multivariate logistic regression to adjust for age and other differences in initial presentation. We found that women were older than men, had higher BMI, and were more likely to have hypertension, diabetes mellitus, dyslipidemia, heart failure, and atrial fibrillation. Women were less likely to receive aspirin upon admission (p<0.01) or aspirin or statins at discharge (p = 0.001 and p<0.05, respectively), although the magnitude of these differences was small. While unadjusted in-hospital mortality was significantly higher for women (OR: 2.10; 95% CI: 1.54 to 2.87), this difference did not persist in the fully adjusted model (OR: 1.18; 95% CI: 0.55 to 2.55). CONCLUSIONS We found that female patients had a different profile than men at the time of presentation. Clinical management of men and women with AMI was similar, though there are small but significant differences in some areas. These gender differences did not translate into differences in in-hospital outcome, but highlight differences in quality of care and represent important opportunities for improvement.
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Affiliation(s)
- Neel M Butala
- Yale School of Medicine, New Haven, Connecticut, United States of America.
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Safavi K, Linnander EL, Allam AA, Bradley EH, Krumholz HM. Implementation of a registry for acute coronary syndrome in resource-limited settings: barriers and opportunities. Asia Pac J Public Health 2010; 22:90S-95S. [PMID: 20566539 DOI: 10.1177/1010539510373017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cardiovascular disease (CVD) is the leading cause of death in Egypt and worldwide, placing great strain on the world's health systems. High-quality treatment of CVD requires a valid, reliable measurement for ensuring evidence-based care. Clinical outcomes registries have been used to support quality improvement activities in some countries, but there are few examples of their implementation in resource-limited settings. A registry for acute coronary syndrome was piloted in 5 hospitals in Egypt, and observations regarding barriers and enabling factors related to implementation are summarized. Themes that emerged from daily observations include the importance of rapid cycles of change, the need to build a culture of applied research, the importance of modeling a blame-free culture, and key constraints encountered related to human resources and technical infrastructure. This pilot demonstrates that clinical registries may be a cost-effective investment in data infrastructure to support quality improvement in low- and middle-income countries.
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