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Thakkar A, Valente T, Andesia J, Njuguna B, Miheso J, Mercer T, Mwangi E, Pastakia SD, Pillsbury MM, Pathak S, Kamano J, Naanyu V, Vedanthan R, Bloomfield GS, Akwanalo C. P6371Network characteristics of a hypertension referral system in western kenya. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Introduction
The Strengthening Referral Networks for Management of Hypertension Across the Health System (STRENGTHS) trial is creating and testing interventions to improve the effectiveness of referral networks for patients with hypertension in Western Kenya.
Purpose
Network analysis of facility-based healthcare providers was used to understand the existing network of referrals. The ultimate goal was to identify both structural gaps and opportunities for implementation of the planned intervention.
Methods
A network survey was administered to providers who deliver care to patients with hypertension asking individuals to nominate a) individuals to whom, and b) facilities to which they refer patients, both up and down the health system. We analyzed survey data using centrality measures of in-degree and out-degree (number of links each provider received and sent, respectively), as well as fitting a core-periphery (CP) model. A higher CP indicates a strong referral network, while a lower CP indicates a relatively weaker network.
Results
Data were collected from 130 providers across 39 sites within 7 geographically separate network clusters. Each cluster consists of a mix of primary, secondary, and/or tertiary facilities. Compared to a perfect CP referral network model (Correlation Score [CP] = 1.00) and a random referral network model (CP = 0.200), the provider referral networks within each cluster showed a weak tendency for CP structure. There was a large range in CP from 0.334 to 0.639. In contrast, cluster-level facility networks showed a strong tendency for CP structure, with a CP range of 0.857 to 0.949.
Core Periphery Correlation Scores [CP] Network Cluster 1 Cluster 2 Cluster 3 Cluster 4 Cluster 5 Cluster 6 Cluster 7 Provider Referrals 0.433 0.424 0.334 0.639 0.535 0.448 0.407 Facility Referrals 0.949 0.894 0.871 0.949 0.949 0.904 0.857 Each cluster represents a geographically separate referral network. A random referral network would reveal a CP score of 0.200; while a perfect referral network would give a CP of 1.00.
Referral Network Models
Conclusions
The current health system across Western Kenya does not demonstrate a strong network of referrals between providers for patients with hypertension. While facility-to-facility referrals are more in-line with a perfect referral model, there are gaps in communication between the specific providers. These results highlight the need for STRENGTHS to design and test interventions that strengthen provider referral patterns in order to improve blood pressure control and reduce cardiovascular risk.
Acknowledgement/Funding
National Institutes of Health: National Heart Lung and Blood Institute, Doris Duke Charitable Foundation:International Clinical Research Fellowship
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Affiliation(s)
- A Thakkar
- Duke University School of Medicine, Durham, United States of America
| | - T Valente
- University of Southern California, Los Angeles, United States of America
| | - J Andesia
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - B Njuguna
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - J Miheso
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - T Mercer
- University of Texas at Austin, Austin, United States of America
| | - E Mwangi
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - S D Pastakia
- Purdue University, College of Pharmacy, West Lafayette, United States of America
| | - M M Pillsbury
- University of California San Francisco, School of Medicine, San Francisco, United States of America
| | - S Pathak
- Mount Sinai School of Medicine, New York, United States of America
| | - J Kamano
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | | | - R Vedanthan
- New York University Langone Medical Center, New York, United States of America
| | - G S Bloomfield
- Duke University School of Medicine, Durham, United States of America
| | - C Akwanalo
- Moi Teaching and Referral Hospital, Eldoret, Kenya
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Maina MW, Pastakia SD, Manji I, Kirui N, Kirwa C, Karwa R. Describing the profile of patients on concurrent rifampin and warfarin therapy in western Kenya: a case series. Drugs R D 2014; 13:191-7. [PMID: 23982688 PMCID: PMC3784049 DOI: 10.1007/s40268-013-0023-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background Rifampicin’s ability to induce hepatic enzymes is responsible for causing a clinically significant drug interaction with warfarin. Little data exists to guide clinicians on managing this interaction, especially in Sub-Saharan Africa where many patients are exposed to this combination due to a higher burden of tuberculosis. Objective The objective of the case series is to provide insight to practicing clinicians of the unique dynamics of this drug interaction in resource-constrained settings. The case series will provide details on commonly encountered scenarios and the dosage adjustments required to maintain a therapeutic INR. Methods A retrospective chart review was conducted of patients attending the Moi Teaching and Referral Hospital anticoagulation clinic in Eldoret, Kenya. Patients were included if they had a history of concurrent rifampicin and warfarin therapy and a minimum follow up of 2 months. Descriptive statistics were used to explain the demographic characteristics, time to therapeutic INR and average weekly warfarin dose. The inference on proportions test was conducted to compare the time in the therapeutic range (TTR) for patients on concurrent rifampicin to the rest of the patients not receiving rifampicin in the clinic. Results Of the 350 patient charts evaluated, 10 met the inclusion criteria. The median percentage increase of the weekly warfarin dose from baseline was 15.7 %. For the patients in this analysis, the median TTR was 47 %. Discussion Patients on concurrent therapy should be rigorously monitored with regular INR checks and warfarin dosage adjustments. Empiric dosage adjustments of warfarin should be avoided but patient characteristics can aid in understanding the alterations seen in INR.
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Affiliation(s)
- M. W. Maina
- Moi Teaching and Referral Hospital-Anticoagulation Clinic, P.O Box 3-30100, Eldoret, Kenya
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN USA
| | - S. D. Pastakia
- Moi Teaching and Referral Hospital-Anticoagulation Clinic, P.O Box 3-30100, Eldoret, Kenya
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN USA
- Department of Pharmacology, Moi University School of Medicine, Eldoret, Kenya
- Indiana University School of Medicine, Indianapolis, USA
| | - I. Manji
- Moi Teaching and Referral Hospital-Anticoagulation Clinic, P.O Box 3-30100, Eldoret, Kenya
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - N. Kirui
- Moi Teaching and Referral Hospital-Anticoagulation Clinic, P.O Box 3-30100, Eldoret, Kenya
| | - C. Kirwa
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Rakhi Karwa
- Moi Teaching and Referral Hospital-Anticoagulation Clinic, P.O Box 3-30100, Eldoret, Kenya
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN USA
- Department of Pharmacology, Moi University School of Medicine, Eldoret, Kenya
- Indiana University School of Medicine, Indianapolis, USA
- Wishard Health Services, W7555 Myers Building, 1001 W. 10th Street, Indianapolis, IN 46202-2879 USA
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Cheng S, Kamano J, Kirui NK, Manuthu E, Buckwalter V, Ouma K, Pastakia SD. Prevalence of food insecurity in patients with diabetes in western Kenya. Diabet Med 2013; 30:e215-22. [PMID: 23506405 DOI: 10.1111/dme.12174] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 12/20/2012] [Accepted: 03/13/2013] [Indexed: 11/28/2022]
Abstract
AIMS To determine the characteristics of patients with diabetes who reported food insecurity at three diabetes clinics in western Kenya. METHODS This study includes routinely collected demographic data at the first presentation of patients with diabetes at clinics in western Kenya from 1 January 2006 to 24 September 2011. A validated questionnaire was used to assess food insecurity with descriptive and comparative statistics being used to analyse the food-secure and food-insecure populations. RESULTS The number of patients presenting to these clinics who were food-secure and those who were food-insecure was 1179 (68.0%) and 554 (32.0%), respectively. Comparative analysis shows a statistically significant difference in weight, BMI, the presence of a caretaker, and use of insulin between the two groups. These variables were lower in the food-insecure group. The overall assessment of the clinic population revealed an abnormally high mean HbA1c concentration of 81 mmol/mol (9.6%). CONCLUSIONS Despite the widely recognized contribution of caloric over-nutrition to the development of diabetes, this study highlights the high prevalence of food insecurity amongst patients with diabetes in rural, resource-constrained settings. Other factors, such as the lower prevalence of obesity, poor glucose control, challenges in the use of insulin because of the risk of hypoglycaemia, and varying subtypes of diabetes in this population, point to the need for additional research in understanding the aetiology, pathophysiology and optimum management of this condition, as well as understanding the effects of enhancing food security.
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Affiliation(s)
- S Cheng
- Purdue University College of Pharmacy, West Lafayette, IN, USA
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Kirui NK, Pastakia SD, Kamano JH, Cheng S, Manuthu E, Chege P, Gardner A, Mwangi A, Enarson DA, Reid AJ, Carter EJ. Important co-morbidity in patients with diabetes mellitus in three clinics in Western Kenya. Public Health Action 2012; 2:148-51. [PMID: 26392975 PMCID: PMC4463073 DOI: 10.5588/pha.12.0031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 09/17/2012] [Indexed: 11/10/2022] Open
Abstract
SETTING Diabetes clinics in three hospitals in Western Kenya: Moi Teaching and Referral Hospital and two associated district hospitals. OBJECTIVE To determine the proportion of diabetes patients with a history of tuberculosis ( TB), human immunodeficiency virus (HIV ) infection and tobacco smoking. DESIGN A descriptive study using routinely collected data from patient records in the three diabetes clinics. RESULTS Of 1376 patients analyzed, 750 (55%) were female. The mean age of the patients in the clinics was 53.5 years (95%CI 52.2-54.8), with an average duration of diabetes of 8.1 years (95%CI 7.6-8.7). Of all patients, 5.6% reported a history of TB, similar to the frequency about 20 years earlier (1990) in Tanzania. Only 30% of the patients reported knowing their HIV status; 6% were HIV-positive. A history of tobacco smoking was reported by 3.8% of the patients. CONCLUSION The HIV epidemic does not seem to have significantly changed the relationship between TB and diabetes mellitus (DM) in this cohort of diabetes patients. The frequency of HIV and TB in this special population was comparable to that in the general population, and only a small proportion of patients reported a history of tobacco smoking.
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Affiliation(s)
- N K Kirui
- United States Agency for International Development-Academic Model Providing Access to Healthcare (USAID-AMPATH)/Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - S D Pastakia
- United States Agency for International Development-Academic Model Providing Access to Healthcare (USAID-AMPATH)/Moi Teaching and Referral Hospital, Eldoret, Kenya ; Purdue University College of Pharmacy, Indianapolis, Indiana, USA ; Moi University School of Medicine, Eldoret, Kenya
| | - J H Kamano
- United States Agency for International Development-Academic Model Providing Access to Healthcare (USAID-AMPATH)/Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - S Cheng
- Purdue University College of Pharmacy, Indianapolis, Indiana, USA
| | - E Manuthu
- Kitale District Hospital, Kitale, Kenya
| | - P Chege
- Moi University School of Medicine, Eldoret, Kenya ; Webuye District Hospital, Webuye, Kenya
| | - A Gardner
- Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - A Mwangi
- Moi University School of Medicine, Eldoret, Kenya
| | - D A Enarson
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - A J Reid
- Operational Research Unit, Médecins Sans Frontières (MSF), Operational Centre Brussels, MSF-Luxembourg, Luxembourg
| | - E J Carter
- Moi University School of Medicine, Eldoret, Kenya ; Alpert Medical School at Brown University, Providence, Rhode Island, USA
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Manji I, Pastakia SD, DO AN, Ouma MN, Schellhase E, Karwa R, Miller ML, Saina C, Akwanalo C. Performance outcomes of a pharmacist-managed anticoagulation clinic in the rural, resource-constrained setting of Eldoret, Kenya. J Thromb Haemost 2011; 9:2215-20. [PMID: 21914124 DOI: 10.1111/j.1538-7836.2011.04503.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND It is recommended that warfarin therapy should be managed through an anticoagulation monitoring service to minimize the risk of bleeding and subsequent thromboembolic events. There are few studies in Sub-Saharan Africa that describe warfarin management in spite of the high incidence of venous thromboembolism (VTE) and rheumatic heart disease. OBJECTIVE To examine the feasibility of the Moi Teaching and Referral Hospital anticoagulation monitoring service and compare its performance with clinics in resource-rich settings. METHODS A retrospective chart review compared the percentage time in the therapeutic range (TTR) and rates of bleeding and thromboembolic events to published performance targets using the inference on proportions test. Wilcoxon's rank sum analyses were used to establish predictors of TTR. RESULTS For the 178 patients enrolled, the mean TTR was 64.6% whereas the rates of major bleeds and thromboembolic events per year were 1.25% and 5%, respectively. In the primary analysis, no statistically significant differences were found between the results of TTR, major bleeds and thromboembolic events for the clinic and published performance rates. In the secondary analysis, having an artificial heart valve and a duration of follow-up of > 120 days were positively associated with a higher TTR (P < 0.05) whereas venous thromboembolism, history of tuberculosis, HIV and a duration of follow-up of < 120 days were associated with having a lower TTR (P < 0.05). CONCLUSIONS The performance of the MTRH anticoagulation clinic is non-inferior to published metrics on the performance of clinics in resource-rich settings.
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Affiliation(s)
- I Manji
- Moi Teaching and Referral Hospital, Eldoret, Kenya.
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