Advancing Dermatology Education and Care in Rwanda: The Impact of a New Academic Partnership

It is the realization of a long-dreamed aspiration to create a university that would advance global health delivery by training a new generation of global health leaders who are equipped to not just build, but sustain effective and equitable health systems.

Determining Critical Topics for Undergraduate Surgical Education in Rwanda: Results of a Modified Delphi Process and a Consensus Conference

Background Developing a contextually appropriate curriculum is critical to train physicians who can address surgical challenges in sub-Saharan Africa. An innovative modified Delphi process was used to identify contextually optimized curricular content to meet sub-Saharan Africa and Rwanda's surgical needs. Methods Participants were surgeons from East, Central, Southern, and West Africa and general practitioners with surgical experience. Delphi participants excluded or prioritized surgical topic areas generated from extensive grey and formal literature review. Surgical educators first screened and condensed identified topics. Round 1 screened and prioritized identified topics, with a 75% consensus cut-off based on the content validity index and a prioritization score. Topics that reached consensus were screened again in round 2 and re-prioritized, following controlled feedback. Frequencies for aggregate prioritization scores, experts in agreement, item-level content validity index, universal agreement and scale-level content validity index based on the average method (S-CVI/Ave) using proportion relevance, and intra-class correlation (ICC) (based on a mean-rating, consistency, two-way mixed-effects model) were performed. We also used arithmetic mean values and modal frequency. Cronbach's Alpha was also calculated to ascertain reliability. Results were validated through a multi-institution consensus conference attended by Rwanda-based surgical specialists, general practitioners, medical students, surgical educators, and surgical association representatives using an inclusive, participatory, collaborative, agreement-seeking, and cooperative, a priori consensus decision-making model. Results Two-hundred and sixty-seven broad surgical content areas were identified through the initial round and presented to experts. In round 2, a total of 247 (92%) content areas reached 75% consensus among 31 experts. Topics that did not achieve consensus consisted broadly of small intestinal malignancies, rare hepatobiliary pathologies, and transplantation. In the final round, 99.6% of content areas reached 75% consensus among 31 experts. The highest prioritization was on wound healing, fluid and electrolyte management, and appendicitis, followed by metabolic response, infection, preoperative preparation, antibiotics, small bowel obstruction and perforation, breast infection, acute urinary retention, testicular torsion, hemorrhoids, and surgical ethics. Overall, the consistency and average agreement between panel experts was strong. ICC was 0.856 (95% CI: 0.83-0.87). Cronbach's Alpha for round 2 was very strong (0.985, 95% CI: 0.976-0.991) and higher than round 1, demonstrating strong reliability. All 246 topics from round 4 were verbally accepted by 40 participants in open forum discussions during the consensus conference. Conclusions A modified Delphi process and consensus were able to identify essential topics to be included within a highly contextualized, locally driven surgical clerkship curriculum delivered in rural Rwanda. Other contexts can use similar processes to develop relevant curricula.

The impact of pediatric early warning score and rapid response algorithm training and implementation on interprofessional collaboration in a resource-limited setting

Introduction

Improved teamwork and communication have been associated with improved quality of care. Early Warning Scores (EWS) and rapid response algorithms are a way of identifying deteriorating patients and providing a common framework for communication and response between physicians and nurses. The impact of EWS implementation on interprofessional collaboration (IPC) has been minimally studied, especially in resource-limited settings.

Methods

The study took place in the Pediatric Department of the main academic referral hospital in Rwanda between April 2019 and January 2020. Pediatric nurses and residents were trained on the use of the Pediatric Warning Score for Resource-Limited Settings (PEWS-RL) and a rapid response algorithm. Training included vital sign collection, PEWS-RL calculation, IPC and rapid response algorithm implementation. Prior to training, participants completed surveys on IPC with Likert scale responses (from “strongly disagree” to “strongly agree”). Follow-up surveys were then administered nine months later and also included an open-response question on the impact of the PEWS-RL implementation on IPC.

Results

Sixty-five (96%) nurses were trained and completed the pre-survey and thirty-seven (54%) of the trained nurses completed the post-survey. Twenty-two (59%) pediatric residents were trained in the workshop and completed the pre-survey and twenty-four physicians (4 pediatricians (40%) and 20 pediatric residents (53%)) completed the post-implementation survey. There was a statistically significant increase in the percent of nurses indicating strong agreement across all domains of communication and collaboration from the pre- to the post-survey. Although the percent of physicians indicating strong agreement increased in the post-survey for all items, only the “share information” item was statistically significant.

Conclusion

Training and implementation of a PEWS-RL and a rapid response algorithm at a tertiary hospital in Rwanda resulted in significant improvement of nurse and physician ratings of IPC nine months later.

Focused Cardiac Ultrasound Findings in Children Presenting With Shock to a Tertiary Care Hospital in Rwanda

OBJECTIVES

Shock remains a leading proximate cause of death in children. Children in sub-Saharan African (SSA) countries present with shock from a wide range of pathologies. Routine physiologic parameters may not reflect underlying physiology. No previous work has systematically described ultrasound findings in children with shock in an SSA country. We set out to perform focused cardiac ultrasound (FOCUS) on children with shock in Rwanda and describe the findings in this pilot study.

METHODS

In a prospective descriptive study, we trained pediatric residents to perform FOCUS on children presenting with shock to an urban tertiary care pediatric emergency department in Kigali, Rwanda. Images were transmitted via cellphone network and reviewed by experts. Primary outcome was expert's description of the FOCUS findings. Secondary outcomes included mortality at 48-hour, change in assessment and treatment after FOCUS, and agreement of FOCUS findings between residents and experts.

RESULTS

Between January 2020 and April 2020, 25 subjects were enrolled by 8 residents. Eleven of 25 (44%) were newly diagnosed with acquired or congenital heart disease. The 48-hour mortality rate was higher in this group compared with those without heart disease (8 of 11 vs 1 of 14). The resident reported changing assessment and treatment based on FOCUS findings in 60% of patients (15 of 25). There was good to excellent agreements between residents and FOCUS experts on left ventricle function, pericardial effusion, and intravascular volume.

CONCLUSIONS

In children presenting with signs and symptoms of shock in SSA, one could perform a screening FOCUS to distinguish between hypovolemic and cardiogenic shock.

Impact of structured basic life-support course on nurses' cardiopulmonary resuscitation knowledge and skills: Experience of a paediatric department in low-resource country

INTRODUCTION

The study aimed to assess the impact of a modified paediatric basic life support (BLS) training on paediatric nurses' knowledge and skills in the main tertiary level public hospital in Rwanda.

METHODS

A prospective, before-and-after educational intervention study was performed. Nurses working in the paediatric department at Centre Hospitalier Universitaire de Kigali (CHUK) were enrolled after consenting to the study. A modified BLS training was administered using didactic lectures, videos, case discussions, and simulations. Knowledge and skills were assessed before, immediately and six months after the training, using the American Heart Association (AHA) multiple-choice questions test and simulation scenarios. Ethical approval from the hospital's investigational review board was obtained before the start of the study.

RESULTS

Fifty-seven nurses working in paediatric department were included in the study, most with advanced nursing degrees. At baseline, only 3.5% scored above 80% on the knowledge test and none were able to perform high-quality one-rescuer CPR. Knowledge and high-quality one-rescuer CPR skills improved significantly immediately after the training, with 63.2% scoring above 80% and 63.2% capable of performing high-quality one-rescuer CPR (p < 0.01). Six months later, only 45.6% scored above 80% and 15.8% were capable of performing high-quality one-rescuer CPR (p < 0.01). Some skills, such as delivering breaths using bag-mask device, showed better retention.

CONCLUSION

In the paediatric department of the main public tertiary care hospital in Rwanda, nurses' baseline knowledge and skills in providing BLS was poor but can increase with focused BLS training. Due to the decline in knowledge and skills over six months, the use of debriefing and focused trainings following resuscitation events and improved implementation of yearly departmental refresher courses are recommended.

Pediatric self-medication use in Rwanda - a cross sectional study

BACKGROUND

Self-medication, a worldwide practice, has both benefits and risks. Many countries have regulated non-prescription medications available for use in self-medication. However, in countries such as Rwanda, where prescriptions are not required to purchase medications, prescription, non-prescription and traditional medications have been used for self-medication.

OBJECTIVES

To determine the reported self-medication use in Rwanda and to determine attitudes and reasons associated with parental decisions to self-medicate their children.

METHODS

A cross-sectional multi-center questionnaire based quantitative study of 154 parents/caregivers of children under ten years undertaken in private and public health facilities.

RESULTS

The use of self-medication was reported to be 77.9%. Among these parents/caregivers, 50.8% used modern self-medication only, 15.8% used traditional self-medication only and 33.3% used both types of self-medication. Paracetamol was the most commonly used drug in modern self-medication; the traditional drugs used were Rwandan local herbs. Parents/caregivers who used modern medicines had slightly more confidence in self-medication than self-medication users of traditional medicines (p=0.005). Parents/caregivers who used modern self-medication reported barriers to consultation as a reason to self-medicate more frequently than those who used traditional drugs. Having more than one child below 10 years of-age was the only socio-demographic factor associated with having used self-medication (AOR=4.74, CI: 1.94-11.58, p=0.001). Being above 30 years (AOR= 5.78, CI: 1.25-26.68, p=0.025) and living in Kigali (AOR=8.2, CI: 1.58-43.12, p=.0.012) were factors associated with preference of modern self- medication compared to traditional self-medication.

CONCLUSION

Self-medication is common in Rwanda. Parents/caregivers are involved in this practice regardless of their socio-demographic background.

Validation of a wearable biosensor device for vital sign monitoring in septic emergency department patients in Rwanda

Objective

Critical care capabilities needed for the management of septic patients, such as continuous vital sign monitoring, are largely unavailable in most emergency departments (EDs) in low- and middle-income country (LMIC) settings. This study aimed to assess the feasibility and accuracy of using a wireless wearable biosensor device for continuous vital sign monitoring in ED patients with suspected sepsis in an LMIC setting.

Methods

This was a prospective observational study of pediatric (≥2 mon) and adult patients with suspected sepsis at the Kigali University Teaching Hospital ED. Heart rate, respiratory rate and temperature measurements were continuously recorded using a wearable biosensor device for the duration of the patients’ ED course and compared to intermittent manually collected vital signs.

Results

A total of 42 patients had sufficient data for analysis. Mean duration of monitoring was 32.8 h per patient. Biosensor measurements were strongly correlated with manual measurements for heart rate (r = 0.87, p < 0.001) and respiratory rate (r = 0.75, p < 0.001), although were less strong for temperature (r = 0.61, p < 0.001). Mean (SD) differences between biosensor and manual measurements were 1.2 (11.4) beats/min, 2.5 (5.5) breaths/min and 1.4 (1.0)°C. Technical or practical feasibility issues occurred in 12 patients (28.6%) although were minor and included biosensor detachment, connectivity problems, removal for a radiologic study or exam, and patient/parent desire to remove the device.

Conclusions

Wearable biosensor devices can be feasibly implemented and provide accurate continuous heart rate and respiratory rate monitoring in acutely ill pediatric and adult ED patients with sepsis in an LMIC setting.

Measuring change in knowledge acquisition of Rwandan residents: using the American Board of Pediatrics International In-Training Examination (I-ITE) as an independent tool to monitor individual and departmental improvements during the Human Resources for Health program: an observational study

BACKGROUND

Rwanda is the only African country to use the pediatric International In-Training Examination (I-ITE). The objectives of this study were to use the scores from the I-ITE to outline the baseline level of knowledge of Rwandan residents entering the pediatric residency and the trends in knowledge acquisition from 2012 to 2018, during the Human Resources for Health (HRH) Program, an education partnership between the Rwanda Ministry of Health and a consortium of US universities.

METHODS

A retrospective descriptive analysis of the I-ITE exam scores, taken by all Rwandan pediatric residents for five of the six academic years of the study period. Individual resident scores were weighted using the non-Rwandan I-ITE sites to minimise confounding from annual variations in exam difficulty. Statistical analysis included descriptives with ANOVA to compare variation in annual mean scores.

RESULTS

Eighty-four residents took 213 I-ITE exam sittings over the five exam cycles. The mean weighted I-ITE score of all residents increased from 34% in 2013 to 49% (p < 0.001) in 2018. The 32-point gap between the mean US-ITE and Rwandan I-ITE score in 2012-2013 was reduced to a 16-point gap in 2017-2018. First year resident (PG1) scores, which likely reflect the knowledge level of undergraduate medical students entering the residency program, increased from 34.8 to 44.3% (p = 0.002) between 2013 and 2018.

CONCLUSIONS

The I-ITE is an independent, robust tool, measuring both learners and the institutional factors supporting residents. This is the first study to demonstrate that the I-ITE can be used to monitor resident knowledge acquisition in resource-limited settings, where assessment of resident knowledge can be a major challenge facing the academic medicine community. The significant increase in I-ITE scores between 2012 and 18 reflects the substantial curricular reorganisation accomplished through collaboration between Rwandan and US embedded faculty and supports the theory that programs such as HRH are highly effective at improving the quality of residency programs and undergraduate medical education.

Provisional Validation of a Pediatric Early Warning Score for Resource-Limited Settings

BACKGROUND AND OBJECTIVES

The use of Pediatric Early Warning Scores is becoming widespread to identify and rapidly respond to patients with deteriorating conditions. The ability of Pediatric Early Warning Scores to identify children at high risk of deterioration or death has not, however, been established in resource-limited settings.

METHODS

We developed the Pediatric Early Warning Score for Resource-Limited Settings (PEWS-RL) on the basis of expert opinion and existing scores. The PEWS-RL was derived from 6 equally weighted variables, producing a cumulative score of 0 to 6. We then conducted a case-control study of admissions to the pediatrics department of the main public referral hospital in Kigali, Rwanda between November 2016 and March 2017. We defined case patients as children fulfilling the criteria for clinical deterioration, who were then matched with controls of the same age and hospital ward.

RESULTS

During the study period, 627 children were admitted, from whom we selected 79 case patients and 79 controls. For a PEWS-RL of ≥3, sensitivity was 96.2%, and specificity was 87.3% for identifying patients at risk for clinical deterioration. A total PEWS-RL of ≥3 was associated with a substantially increased risk of clinical deterioration (odds ratio 129.3; 95% confidence interval 38.8-431.6; P <.005).

CONCLUSIONS

This study reveals that the PEWS-RL, a simple score based on vital signs, mental status, and presence of respiratory distress, was feasible to implement in a resource-limited setting and was able to identify children at risk for clinical deterioration.

Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda

BACKGROUND

The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda.

METHODS

The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors.

RESULTS

In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions.

CONCLUSION

The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals.

Global Health: Preparation for Working in Resource-Limited Settings

Trainees and clinicians from high-income countries are increasingly engaging in global health (GH) efforts, particularly in resource-limited settings. Concomitantly, there is a growing demand for these individuals to be better prepared for the common challenges and controversies inherent in GH work. This is a state-of-the-art review article in which we outline what is known about the current scope of trainee and clinician involvement in GH experiences, highlight specific considerations and issues pertinent to GH engagement, and summarize preparation recommendations that have emerged from the literature. The article is focused primarily on short-term GH experiences, although much of the content is also pertinent to long-term work. Suggestions are made for the health care community to develop and implement widely endorsed preparation standards for trainees, clinicians, and organizations engaging in GH experiences and partnerships.

The in-vitro response of 4 antisteroid receptor agents on the hormone-responsive prostate-cancer cell-line lncap

Previous reports indicate that flutamide withdrawal is associated with PSA declines and tumor shrinkage in selected patients with 'hormone-refractory' prostate cancer. Though the mechanisms underlying this effect are not clear, investigators have hypothesized that these effects are mediated by mutant androgen receptors recognizing hydroxy-flutamide as an androgenic agonist. Such receptors have been well described in the human prostate cancer cell line LNCaP. Despite the finding that the androgen receptor of LNCaP aberrantly recognizes a variety of steroids, including estrogen and progesterone, as androgenic agonists, there are no studies which examine the effect of estrogen antagonists and progesterone antagonist on baseline and androgen-stimulated LNCaP growth. In this report, LNCaP cells were cultured in phenol red-free media using charcoal-stripped sera. As previously reported, flutamide enhanced LNCaP growth and bicalutamide inhibited androgen-stimulated LNCaP proliferation. Neither tamoxifen nor RU486 influenced LNCaP growth (either in the presence or absence of exogenous androgens). From these data we conclude that antagonists of estrogen and progesterone action have no anti-proliferative effect on LNCaP cells and that the mutant androgen receptor expressed in these cells is quite restrictive in the recognition of compounds with antagonistic activity. The clinical implications of these findings are discussed.

Burden of disease caused by Haemophilus influenzae type b in children younger than 5 years: global estimates

BACKGROUND

Haemophilus influenzae type b (Hib) is a leading cause of childhood bacterial meningitis, pneumonia, and other serious infections. Hib disease can be almost completely eliminated through routine vaccination. We assessed the global burden of disease to help national policy makers and international donors set priorities.

METHODS

We did a comprehensive literature search of studies of Hib disease incidence, case-fatality ratios, age distribution, syndrome distribution, and effect of Hib vaccine. We used vaccine trial data to estimate the proportion of pneumonia cases and pneumonia deaths caused by Hib. We applied these proportions to WHO country-specific estimates of pneumonia cases and deaths to estimate Hib pneumonia burden. We used data from surveillance studies to develop estimates of incidence and mortality of Hib meningitis and serious non-pneumonia, non-meningitis disease. If available, high-quality data were used for national estimates of Hib meningitis and non-pneumonia, non-meningitis disease burden. Otherwise, estimates were based on data from other countries matched as closely as possible for geographic region and child mortality. Estimates were adjusted for HIV prevalence and access to care. Disease burden was estimated for the year 2000 in children younger than 5 years.

FINDINGS

We calculated that Hib caused about 8.13 million serious illnesses worldwide in 2000 (uncertainty range 7.33-13.2 million). We estimated that Hib caused 371,000 deaths (247,000-527,000) in children aged 1-59 months, of which 8100 (5600-10,000) were in HIV-positive and 363,000 (242,000-517,000) in HIV-negative children.

INTERPRETATION

Global burden of Hib disease is substantial and almost entirely vaccine preventable. Expanded use of Hib vaccine could reduce childhood pneumonia and meningitis, and decrease child mortality.

FUNDING

GAVI Alliance and the Vaccine Fund.

Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates

BACKGROUND

Streptococcus pneumoniae is a leading cause of bacterial pneumonia, meningitis, and sepsis in children worldwide. However, many countries lack national estimates of disease burden. Effective interventions are available, including pneumococcal conjugate vaccine and case management. To support local and global policy decisions on pneumococcal disease prevention and treatment, we estimated country-specific incidence of serious cases and deaths in children younger than 5 years.

METHODS

We measured the burden of pneumococcal pneumonia by applying the proportion of pneumonia cases caused by S pneumoniae derived from efficacy estimates from vaccine trials to WHO country-specific estimates of all-cause pneumonia cases and deaths. We also estimated burden of meningitis and non-pneumonia, non-meningitis invasive disease using disease incidence and case-fatality data from a systematic literature review. When high-quality data were available from a country, these were used for national estimates. Otherwise, estimates were based on data from neighbouring countries with similar child mortality. Estimates were adjusted for HIV prevalence and access to care and, when applicable, use of vaccine against Haemophilus influenzae type b.

FINDINGS

In 2000, about 14.5 million episodes of serious pneumococcal disease (uncertainty range 11.1-18.0 million) were estimated to occur. Pneumococcal disease caused about 826,000 deaths (582,000-926,000) in children aged 1-59 months, of which 91,000 (63,000-102,000) were in HIV-positive and 735,000 (519,000-825,000) in HIV-negative children. Of the deaths in HIV-negative children, over 61% (449,000 [316,000-501,000]) occurred in ten African and Asian countries.

INTERPRETATION

S pneumoniae causes around 11% (8-12%) of all deaths in children aged 1-59 months (excluding pneumococcal deaths in HIV-positive children). Achievement of the UN Millennium Development Goal 4 for child mortality reduction can be accelerated by prevention and treatment of pneumococcal disease, especially in regions of the world with the greatest burden.

FUNDING

GAVI Alliance and the Vaccine Fund.

William Stewart Halsted: letters to a young female admirer

OBJECTIVE

To present the first new information in the past 25 years concerning the life of Dr. William Stewart Halsted. This paper reports on recently discovered personal correspondence of Dr. Halsted, beginning at age 66, to a young lady, Elizabeth Blanchard Randall, 40 years his junior.

SUMMARY BACKGROUND DATA

Dr. William Stewart Halsted is generally considered the most important and influential surgeon that this country has produced. During his Hopkins days in Baltimore (1886-1922) he was rather reclusive, and little is known of his personal life. He was married but had no children. Several biographies written by Halsted's contemporaries constitute the bulk of what is known about Halsted's personal life.

METHODS

All extant letters from Dr. Halsted to Miss Randall were reviewed. Archival materials were consulted to understand the context for this friendship. The correspondence between Halsted and Randall took place during a 3-year period, although their acquaintance was probably long-standing.

RESULTS

The letters reveal Dr. Halsted and Miss Randall's great and warm affection for each other, despite their 40-year age difference. The letters have a playful nature absent in Halsted's other correspondence. This relationship has not been previously noted.

CONCLUSIONS

Late in Halsted's life, he developed a warm and affectionate relationship with a young lady 40 years his junior, as revealed in Halsted's correspondence. Halsted's warm, personal, and playful letters are in stark contrast to his biographers' portrayals of him as a more serious and reclusive person.

Financial performance and participation in Medicaid and Medi-Cal managed care

This article assesses the participation and the financial performance of licensed health maintenance organization (HMOs) in the Medicaid market. The study found that participation by Medicaid Dominant plans has more than doubled from 11 percent in 1992 to 23 percent in 1998 while Medicaid membership in Commercial Dominant plans declined from 71 percent in 1994 to 51 percent in 1998. Both participating and non-participating plans incurred operating losses in 1998. Medi-Cal participating plans had higher operating margins than Medicaid participating plans throughout the United States. Interviews with key informants express concern about competence in program management, rate adequacy, decline in Medicaid enrollment, and turbulence forces of managed care market on Medicaid programs.

Setting the target for a better cervical screening test: characteristics of a cost-effective test for cervical neoplasia screening

OBJECTIVE

To determine the potential effects on costs and outcomes of changes in sensitivity and specificity with new screening methods for cervical cancer.

METHODS

Using a Markov model of the natural history of cervical cancer, we estimated the effects of sensitivity, specificity, and screening frequency on cost-effectiveness. Our estimates of conventional Papanicolaou test sensitivity of 51% and specificity of 97% were obtained from a meta-analysis. We estimated the effect of reducing false-negative rates from 40-90% and increasing false-positive rates by up to 20%, independently and jointly. We varied the marginal cost of improving sensitivity from $0 to $15.

RESULTS

When specificity was held constant, increasing sensitivity of the Papanicolaou test increased life expectancy and costs. When sensitivity was held constant, decreasing specificity of the Papanicolaou test increased costs, an effect that was more dramatic at more frequent intervals. Decreased specificity had a substantial effect on cost-effectiveness estimates of improved Papanicolaou test sensitivity. Most of those effects are related to the cost of evaluation and treatment of low-grade lesions.

CONCLUSION

Policies or technologies that increased sensitivity of cervical cytologic screening increased overall costs, even if the cost of the technology was identical to that of conventional Papanicolaou smears. These effects appear to be caused by relatively high prevalence of low-grade lesions and are magnified at frequent screening intervals. Efficient cervical cancer screening requires methods with greater ability to detect lesions that are most likely to become cancerous.

Factors affecting progress of Australian and international students in a problem-based learning medical course

CONTEXT

Research on the factors affecting progress in medical schools has typically focused on mainstream (non-Indigenous Australian, non-international) students in traditional, didactic programmes. These results may not be applicable to students, particularly those from culturally diverse backgrounds, undertaking problem-based learning courses.

OBJECTIVE

This study used qualitative methodology to explore and compare factors affecting progress for mainstream Australian students (non-Indigenous Australian, non-international) and international students (full fee-paying students who had relocated countries to study) in a problem-based learning medical course. Intervention strategies were devised on the basis of the participants' experiences.

METHODS

Six focus group discussions were conducted (three with mainstream Australian and three with international participants). Transcripts of these discussions were coded and analysed independently by two researchers and discussed until consensus was attained.

RESULTS

Participants identified both positive and negative experiences related to the course structure, which were consistent with previous findings. The participants' experiences demonstrated a relationship between sense of 'belongingness' to the medical school community, participation in learning opportunities and progress through the course.

CONCLUSIONS

The results suggest that interventions aimed at reducing barriers to progress need to promote students' confidence, motivation and subsequent participation in course learning opportunities. These results have application to other problem-based learning courses particularly those which face the challenge of providing an optimal learning environment for students from diverse backgrounds.

Insurers' views of the partnership for long-term care

The Partnership for Long-Term Care was established in 1986 to demonstrate the feasibility of implementing public-private collaborations to offer affordable long-term care insurance products to a broad range of individuals. A fall 1996 survey of long-term care insurers indicates that those who participate are major players in the market and that most plan to continue their participation. Insurers were motivated to participate because the Partnership provided an opportunity to contribute to "good" public policy, market a product with a state seal of approval, and potentially increase their market share. While the survey did reveal dissatisfaction with some aspects of the Partnership, it also demonstrated that it is possible to develop a working partnership between states and insurers despite the need for compromise.

Factors important in the purchase of partnership long-term care insurance

OBJECTIVE

To understand the factors important in the purchase of long-term care insurance through the Robert Wood Johnson Foundation Partnership for Long-Term Care.

DATA SOURCES

Information on the Partnership programs, telephone surveys, data on Partnership purchasers, and random sample frames.

STUDY DESIGN

Logistic regression analysis is used to examine characteristics associated with the purchase of a Partnership insurance policy. Independent variables are health status, demographic and financial characteristics, knowledge, and attitudes.

DATA COLLECTION

A telephone survey of Partnership purchasers and a random sample of the population in each Partnership state were conducted. Survey questions included health status, opinions about long-term care and long-term care insurance, financial planning, demographic characteristics, and income and assets.

PRINCIPAL FINDINGS

Important in the purchase of a Partnership policy were variables associated with education and knowledge about long-term care. Other important factors include attitudes and health status. Partnership purchase is associated with higher income and asset levels up to a point, with the effect plateauing and decreasing at the highest income and asset levels.

CONCLUSIONS

Improved education and knowledge are important in increasing long-term care insurance purchase. Attitudes about having a caregiver, and about the government's role in paying for long-term care as well as the potential purchaser's willingness to consider nursing home care affect policy purchase. Also associated with Partnership policy purchase are better health and middle income and asset levels.

The partnership for long-term care: who are the partnership policy purchasers?

Policymakers are increasingly looking toward expanding the role of private insurance in the financing of long-term care. One effort to blend public and private insurance is the Partnership for Long-Term Care sponsored by the Robert Wood Johnson Foundation. This article examines the characteristics of individuals who purchased long-term care insurance through the Partnership for Long-Term Care, as well as their motivation for purchase. Partnership purchasers are found to be a healthier, higher educated, and wealthier group than a comparison group of 55- to 75-year-olds. Partnership purchasers are also more active financial planners, have more self-reliant attitudes, and are more knowledgeable about long-term care. Findings also suggest that the Partnership for Long-Term Care attracts a substantial number of beneficiaries who would not have purchased long-term care insurance in the absence of the Partnership program.

Utilization of services in Arizona's capitated Medicaid program for long-term care beneficiaries

The Arizona Long-Term Care System (ALTCS), Arizona's Medicaid program for long-term care (LTC) beneficiaries, capitates contractors to provide a full range of acute and LTC services to financially-eligible beneficiaries determined to be at risk of institutionalization. This article compares the acute care utilization experience of LTC beneficiaries in ALTCS with those in a fee-for-service (FFS) Medicaid program, linking data from both the Medicare and the Medicaid program files. Patterns of use observed in Arizona seem more consistent with a managed care environment than those observed in the FFS comparison. Rates of acute care utilization observed for both the capitated and the FFS program should be of interest to States considering incorporating LTC beneficiaries into their Medicaid managed care program.

Managed Medicaid cost savings: the Arizona experience

This paper reports on estimated cost savings for acute care beneficiaries in the Arizona Health Care Cost Containment System (AHCCCS) over its first nine years of operation, fiscal years 1983-1991. AHCCCS has similar eligibility and service coverage as a traditional Medicaid program has but capitates health plans to provide medical services to beneficiaries. The results indicate that the program yielded $100 million in savings over estimates of what a traditional Medicaid program would have cost in Arizona. In addition, AHCCCS experienced a smaller rate of increase in program expenditures over time, so that cost savings have increased as the program has matured.

The effectiveness of consumer choice in the Medicare supplemental health insurance market

This article examines the factors that affect Medicare beneficiaries' choices in the supplemental health insurance market. Data include detailed survey information as well as copies of the health insurance policies owned by a sample of approximately 2,500 Medicare beneficiaries in six states during 1982. Logit analysis is employed to analyze the determinants of four dependent variables: whether a person owns (1) one or more private supplemental insurance policies, (2) two or more policies, (3) at least one policy that we define as "effective," and (4) a policy we define to be "less effective." Those who are better off from a socioeconomic standpoint appear to be making more effective choices in the supplemental health insurance market. However, there does not appear to be a relationship between consumer ignorance or vulnerability and the purchase of multiple supplemental insurance policies. Study results imply an important role for public policy in helping to provide the information necessary to ensure that the most vulnerable beneficiaries make insurance choices that are in their best interest.

Access and satisfaction in the Arizona Health Care Cost Containment System

Results of a survey conducted in the summer of 1985 of beneficiaries of the Arizona Health Care Cost Containment System and a matched group of Medicaid beneficiaries concerning their access to and satisfaction with medical care services are described in this article. The Arizona Health Care Cost Containment System is an alternative to Medicaid's acute medical care coverage. The results of the study indicate few differences in access and satisfaction between the two groups of beneficiaries on access to care, reported use of services, or satisfaction with the care received.

Evaluation of Arizona Health Care Cost Containment System, 1984-85

In this article, we describe the evaluation of the Arizona Health Care Cost Containment System (AHCCCS), Arizona's alternative to the acute care portion of Medicaid. We provide an assessment of implementation of the program's innovative features during its second 18 months of operation, from April 1984 through September 1985. Included in the evaluation are assessments of the administration of the program, provider relations, eligibility, enrollment and marketing, information systems, quality assurance and member satisfaction activities, the relationship of the county governments to AHCCCS, the competitive bidding process, and the plans and their financial status.

Consumer knowledge of Medicare and supplemental health insurance benefits

In this article, data from a recent study funded by the Health Care Financing Administration are used to examine the level of knowledge about health care insurance coverage among Medicare beneficiaries. Two related categories of this knowledge are analyzed: knowledge of the Medicare program itself and knowledge of supplemental health insurance policies owned by program beneficiaries. The results indicate that Medicare beneficiaries typically do not have high levels of knowledge either about Medicare or about their supplemental health insurance. Also analyzed are the factors that affect knowledge levels.

Cardiac prognosis in noncardiac geriatric surgery

Predictors of perioperative complications, including cardiac death, ventricular tachycardia or fibrillation, and heart failure or myocardial infarction, were assessed in an initial study of 100 patients aged 65 years or older scheduled for elective abdominal or noncardiac thoracic surgery. Preoperative history, results of physical examination, chest roentgenogram, electrocardiogram, laboratory data, Dripps (American Society of Anesthesiologists) class, and Goldman cardiac risk index were compared with rest and exercise radionuclide ventriculograms. Thirteen patients had perioperative cardiac complications, and 6 died. Multivariate analysis showed that an inability to do 2 minutes of bicycle exercise in the supine position to raise the heart rate above 99 beats/min (sensitivity 85%, specificity 64%) gave predictive information not available from clinical or radionuclide data. On prospective testing involving 55 additional geriatric patients, inability to exercise was the only independent predictor of perioperative complications (p less than 0.05). Data from rest and exercise radionuclide ventriculography added little information for predicting perioperative cardiac risk.

Evaluation of the Arizona health care cost-containment system

This article evaluates Arizona's alternative to the acute portion of Medicaid, the Arizona Health Care Cost-Containment System (AHCCCS), during its first 18 months of operation from October 1982 through March 1984. It focuses on the program's implementation and describes and evaluates the program's innovative features. The features of the program outlined in the original AHCCCS legislation included: Competitive bidding, prepaid capitation of providers, capitation of the State by the Health Care Financing Administration, assignment of gatekeepers, beneficiary copayment, private administration, inclusion of private and public employees and county financed long-term care. An assessment of implementation during the second 18 months of the program reporting on more recent developments and is now being prepared by SRI International.

Utilization and costs of Medicare services by beneficiaries in their last year of life

This study examines Medicare utilization in the last year of life by over 10,000 beneficiaries who died in the state of Colorado in 1978. Overall, Medicare use averaged over $6,000 in 1978, compared with use by a random sample of survivors of less than $1,000. Eighty-nine percent of the charges during the last year of life were for services received in a hospital. Average charges vary by entitlement status, with the aged using, on the average, $5,955, the disabled $7,771, and end-stage renal disease (ESRD) beneficiaries an average of $44,400 in their last year. These charges are more than six times greater than yearly charges for aged and disabled survivors and more than three times greater than the yearly charges for ESRD survivors. The distributions of data for the groups who died is highly skewed, but not as skewed as that for the survivors. The top 1% of the survivors consumed 21% of the total charges, compared with less than 9% total charges consumed by the top 1% of those who died. When the data are examined by date of service divided into quarterly periods in the last year, more than 60% of the expenditures are in the last quarter just before death, with more hospital days and more intensive hospital ancillary service use during this period.

An analysis of the use of Medicare services by the continuously enrolled aged

This article discusses the utilization patterns of the Medicare aged who were continuously enrolled in the program for over a 4-year period. Data used for this study were compiled from a random sample of Medicare beneficiaries in Colorado who were continuously enrolled from October 1974 through December 1978. Five utilization variables: medical office visits, medical relative value units (RVUs), surgical RVUs, inpatient days, and covered dollars were examined in the article. Results from this study are consistent with previous longitudinal analyses. Consistent high users of services who consume substantial proportions of total expenditures and consistent nonusers having no or few services were found. During an average year of the 4-year period, it was observed that 18 per cent of the beneficiaries accounted for 88 per cent of the cost of services delivered. Because these high users tend to remain high users over time--more than one third of the high users in a given year continue to be high users during the following year--the findings here suggest that cost-containment strategies targeted to these high users may have a strong impact on overall Medicare program costs. Multivariate analysis is also conducted in this article so that the determinants of utilization patterns over time could be examined. Of particular interest is the finding that seasonal and trend variables play an important role in determining utilization over time.

Utilization of Medicare services by beneficiaries having partial Medicare coverage

With the rapid increases in Medicare expenditures, policymakers are constantly reevaluating the use of and the need for services provided. One approach to better understand these issues is to identify major subgroups of the Medicare population for more detailed evaluation. A disaggregation of the data can pinpoint critical high expenditure areas for further study and may suggest potential cost containment strategies. With funding from the Health Care Financing Administration (HCFA), a series of investigations were designed to study utilization of services by particular types of Medicare beneficiaries. These include: Those who are continuously enrolled in the program over time. Those who died. Those who recently joined Medicare. Those who have one part of Medicare without the other part. This article discusses findings concerning beneficiaries who have only partial Medicare coverage (such as those who are enrolled under one part of Medicare without the other part).

Changes in Medicare reimbursement in Colorado: impact on physicians' economic behavior

In 1976 there was a change in Medicare reimbursement policy in the State of Colorado. This study analyzes the impact of that change on physicians' economic behavior. Through 1976, prevailing charges (one of the determinants of the level of physician reimbursement under Medicare) were computed separately within each of 10 regions of Colorado. Since then, they have been computed for the State as a whole, and thus, physicians in like specialties have had equal prevailing charges throughout the State. This change in reimbursement policy led to a relative increase in prevailing charges for physicians in small urban and nonurban areas of the State, and a relative decrease for physicians in the major urban areas. In this paper we analyze the impact of this change on several aspects of physician behavior. We found that physicians whose reimbursement rates declined as a result of the change--primarily those in the Denver/Boulder area--provided more-intensive medical services, had lower assignment rates, and charged lower prices than they would have in the absence of the change.