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Comparison of Clinical Interventions between Student Pharmacists on Advanced Pharmacy Practice Experiences in Indianapolis, Indiana versus Eldoret, Kenya. PHARMACY 2023; 11:92. [PMID: 37368418 DOI: 10.3390/pharmacy11030092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/07/2023] [Accepted: 05/13/2023] [Indexed: 06/28/2023] Open
Abstract
Student pharmacists can have a positive impact on patient care. The objective of this research was to compare clinical interventions made by Purdue University College of Pharmacy (PUCOP) student pharmacists completing internal medicine Advanced Pharmacy Practice Experiences (APPE) in Kenya and the US. A retrospective analysis of interventions made by PUCOP student pharmacists participating in either the 8-week global health APPE at Moi Teaching and Referral Hospital (MTRH-Kenya) or the 4-week adult medicine APPE at the Sydney & Lois Eskenazi Hospital (SLEH-US) was completed. Twenty-nine students (94%) documented interventions from the MTRH-Kenya cohort and 23 (82%) from the SLEH-US cohort. The median number of patients cared for per day was similar between the MTRH-Kenya (6.98 patients per day, interquartile range [IQR] = 5.75 to 8.15) and SLEH-US students (6.47 patients per day, IQR = 5.58 to 7.83). MTRH-Kenya students made a median number of 25.44 interventions per day (IQR = 20.80 to 28.95), while SLEH-US students made 14.77 (IQR = 9.80 to 17.72). The most common interventions were medication reconciliation/t-sheet rewrite and patient chart reviews for MTRH-Kenya and the SLEH-US, respectively. This research highlights how student pharmacists, supported in a well-designed, location-appropriate learning environment, can positively impact patient care.
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Telehospice for Cancer Patients Discharged from a Tertiary Care Hospital in Western Kenya. J Pain Symptom Manage 2023; 65:378-387. [PMID: 36773732 PMCID: PMC10106447 DOI: 10.1016/j.jpainsymman.2023.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/11/2023] [Accepted: 01/27/2023] [Indexed: 02/11/2023]
Abstract
CONTEXT Worldwide, most patients lack access to hospice services. OBJECTIVES Assess the feasibility of telephone monitoring (Telehospice) in providing symptom management for patients discharged from a tertiary care hospital in Western Kenya. METHODS Inclusion criteria included adults with cancer no longer eligible for chemo-radiation and receiving opioid therapy. Thirty patients were enrolled in a weekly monitoring program assessing physical symptoms and patient and caregiver distress. The participants also had access to a 24-hour hotline. Symptom assessment included 18 questions with 8 from the African Palliative Outcome Scale. Participants were followed for eight weeks or until death or admission to an inpatient hospital or hospice. RESULTS The primary objective was participation in weekly calls, and we obtained 100% participation. A secondary objective was the use of "comfort kits" which contained 30 doses of six medications. Most patients utilized one or more of the provided medications, with high usage of bisacodyl, paracetamol, and omeprazole. While 12% of weekly calls and 24% of hotline calls led to medication changes, participants continued to express worry and there was only a modest decrease in pain scores despite having morphine available throughout the follow-up period. Family confidence in providing care and access to information remained high. At the end of the eight-weeks of observation, eight participants were alive, 10 died at home, and 12 were admitted to an in-patient facility. CONCLUSION Patient and family participation in Telehospice is feasible and may provide an interim solution to managing end-of-life patients who lack access to home hospice.
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Intravenous ketamine for severe alcohol use disorder at Moi Teaching & Referral Hospital, Kenya: a case report. Subst Abuse Treat Prev Policy 2023; 18:11. [PMID: 36803380 PMCID: PMC9936629 DOI: 10.1186/s13011-023-00519-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/28/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Alcohol use disorder is prevalent globally and in Kenya, and is associated with significant health and socio-economic consequences. Despite this, available pharmacological treatment options are limited. Recent evidence indicates that intravenous (IV) ketamine can be beneficial for the treatment of alcohol use disorder, but is yet to be approved for this indication. Further, little has been done to describe the use of IV ketamine for alcohol use disorder in Africa. The goal of this paper, is to: 1) describe the steps we took to obtain approval and prepare for off-label use of IV ketamine for patients with alcohol use disorder at the second largest hospital in Kenya, and 2) describe the presentation and outcomes of the first patient who received IV ketamine for severe alcohol use disorder at the hospital. CASE PRESENTATION In preparing for the off-label use of ketamine for alcohol use disorder, we brought together a multi-disciplinary team of clinicians including psychiatrists, pharmacists, ethicists, anesthetists, and members of the drug and therapeutics committee, to spearhead the process. The team developed a protocol for administering IV ketamine for alcohol use disorder that took into account ethical and safety issues. The national drug regulatory authority, the Pharmacy and Poison's Board, reviewed and approved the protocol. Our first patient was a 39-year-old African male with severe alcohol use disorder and comorbid tobacco use disorder and bipolar disorder. The patient had attended in-patient treatment for alcohol use disorder six times and each time had relapsed between one to four months after discharge. On two occasions, the patient had relapsed while on optimal doses of oral and implant naltrexone. The patient received IV ketamine infusion at a dose of 0.71 mg/kg. The patient relapsed within one week of receiving IV ketamine while on naltrexone, mood stabilizers, and nicotine replacement therapy. DISCUSSION & CONCLUSIONS This case report describes for the first time the use of IV ketamine for alcohol use disorder in Africa. Findings will be useful in informing future research and in guiding other clinicians interested in administering IV ketamine for patients with alcohol use disorder.
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Risk of Bleeding Associated With Outpatient Use of Rivaroxaban in VTE Management at a National Referral Hospital in Western Kenya. Clin Appl Thromb Hemost 2023; 29:10760296231184216. [PMID: 37448336 DOI: 10.1177/10760296231184216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023] Open
Abstract
There is limited data on the bleeding safety profile of direct oral anticoagulants, such as rivaroxaban, in low- and middle-income country settings like Kenya. In this prospective observational study, patients newly started on rivaroxaban or switching to rivaroxaban from warfarin for the management of venous thromboembolism (VTE) within the national referral hospital in western Kenya were assessed to determine the frequency of bleeding during treatment. Bleeding events were assessed at the 1- and 3-month visits, as well as at the end of follow-up. The International Society of Thrombosis and Hemostasis (ISTH) and the Bleeding Academic Research Consortium (BARC) criteria were used to categorize the bleeding events, and descriptive statistics were used to summarize categorical variables. Univariate and multivariate logistic regression model was used to calculate unadjusted and adjusted associations between patient characteristics and bleeding. The frequency of any type of bleeding was 14.4% (95% CI: 9.3%-20.8%) for an incidence rate of 30.9 bleeding events (95% CI: 20.1-45.6) per 100 patient-years of follow-up. The frequency of major bleeding was 1.9% while that of clinically relevant non-major bleeding was 13.8%. In the multivariate logistic regression model, being a beneficiary of the national insurance plan was associated with a lower risk of bleeding, while being unemployed was associated with a higher bleeding risk. The use of rivaroxaban in the management of VTE was associated with a higher frequency of bleeding. These findings warrant confirmation in larger and more targeted investigations in a similar population.
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Implementation of a Global Health Equity Fellowship Established in Partnership Between an Academic Institution and Governmental Agency. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Solving the problem of access to cardiovascular medicines: revolving fund pharmacy models in rural western Kenya. BMJ Glob Health 2021; 5:bmjgh-2020-003116. [PMID: 33214173 PMCID: PMC7678234 DOI: 10.1136/bmjgh-2020-003116] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/17/2020] [Accepted: 09/20/2020] [Indexed: 12/13/2022] Open
Abstract
Availability of medicines for treatment of cardiovascular disease (CVD) is low in low-income and middle-income countries (LMIC). Supply chain models to improve the availability of quality CVD medicines in LMIC communities are urgently required. Our team established contextualised revolving fund pharmacies (RFPs) in rural western Kenya, whereby an initial stock of essential medicines was obtained through donations or purchase and then sold at a small mark-up price sufficient to replenish drug stock and ensure sustainability. In response to different contexts and levels of the public health system in Kenya (eg, primary versus tertiary), we developed and implemented three contextualised models of RFPs over the past decade, creating a network of 72 RFPs across western Kenya, that supplied 22 categories of CVD medicines and increased availability of essential CVD medications from <30% to 90% or higher. In one representative year, we were able to successfully supply 5 793 981 units of CVD and diabetes medicines to patients in western Kenya. The estimated programme running cost was US$6.5–25 per patient, serving as a useful benchmark for public governments to invest in medication supply chain systems in LMICs going forward. One important lesson that we have learnt from implementing three different RFP models over the past 10 years has been that each model has its own advantages and disadvantages, and we must continue to stay nimble and modify as needed to determine the optimal supply chain model while ensuring consistent access to essential CVD medications for patients living in these settings.
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Maintaining care delivery for non-communicable diseases in the face of the COVID-19 pandemic in western Kenya. Pan Afr Med J 2021; 39:143. [PMID: 34527159 PMCID: PMC8418157 DOI: 10.11604/pamj.2021.39.143.29708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/19/2021] [Indexed: 11/24/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has disrupted health systems worldwide, gravely threatening continuity of care for non-communicable diseases (NCDs), particularly in low-resource settings. We describe our efforts to maintain the continuity of care for patients with NCDs in rural western Kenya during the COVID-19 pandemic, using a five-component approach: 1) Protect: protect staff and patients; 2) Preserve: ensure medication availability and clinical services; 3) Promote: conduct health education and screenings for NCDs and COVID-19; 4) Process: collect process indicators and implement iterative quality improvement; and 5) Plan: plan for the future and ensure financial risk protection in the face of a potentially overwhelming health and economic catastrophe. As the pandemic continues to evolve, we must continue to pursue new avenues for improvement and expansion. We anticipate continuing to learn from the evolving local context and our global partners as we proceed with our efforts.
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Supply-chain strategies for essential medicines in rural western Kenya during COVID-19. Bull World Health Organ 2021; 99:388-392. [PMID: 33958827 PMCID: PMC8061666 DOI: 10.2471/blt.20.271593] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 12/08/2020] [Accepted: 12/14/2020] [Indexed: 12/12/2022] Open
Abstract
Problem The coronavirus disease 2019 (COVID-19) pandemic has disrupted health systems worldwide and threatened the supply of essential medicines. Especially affected are vulnerable patients in low- and middle-income countries who can only afford access to public health systems. Approach Soon after physical distancing and curfew orders began on 15 March 2020 in Kenya, we rapidly implemented three supply-chain strategies to ensure a continuous supply of essential medicines while minimizing patients’ COVID-19 exposure risks. We redistributed central stocks of medicines to peripheral health facilities to ensure local availability for several months. We equipped smaller, remote health facilities with medicine tackle boxes. We also made deliveries of medicines to patients with difficulty reaching facilities. Local setting Τo implement these strategies we leveraged our 30-year partnership with local health authorities in rural western Kenya and the existing revolving fund pharmacy scheme serving 85 peripheral health centres. Relevant changes In April 2020, stocks of essential chronic and non-chronic disease medicines redistributed to peripheral health facilities increased to 835 140 units, as compared with 316 330 units in April 2019. We provided medicine tackle boxes to an additional 46 health facilities. Our team successfully delivered medications to 264 out of 311 patients (84.9%) with noncommunicable diseases whom we were able to reach. Lessons learnt Our revolving fund pharmacy model has ensured that patients’ access to essential medicines has not been interrupted during the pandemic. Success was built on a community approach to extend pharmaceutical services, adapting our current supply-chain infrastructure and working quickly in partnership with local health authorities.
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Global service learning: A unique educational pathway for community engagement and student scholarship development. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Evaluating the impact of a 15‐year academic partnership to promote sustainable engagement, education, and scholarship in global health. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1249] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Framework and case study for establishing impactful global health programs through academia - biopharmaceutical industry partnerships. Res Social Adm Pharm 2020; 16:1519-1525. [PMID: 32792324 DOI: 10.1016/j.sapharm.2020.07.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/06/2020] [Accepted: 07/17/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The field of global health has grown with multiple different public and private stakeholders engaging in the effort to improve health outcomes for underserved populations around the world. There is, however, only limited published guidance on how to promote successful partnerships between academia and the biopharmaceutical industry. OBJECTIVE This analysis will provide a framework for developing successful partnerships around five central principles. This framework will then be applied to two representative pharmacy collaboration case studies focused on training and donations. FRAMEWORK DESCRIPTION AND CASE STUDY FINDINGS Within the Academic Model Providing Access to Healthcare (AMPATH), successful collaborations between the biopharmaceutical industry philanthropic entities and academic partners have consistently prioritized 1) contextualization, 2) collaboration, 3) local priorities, 4) institutional commitment, and 5) integration. In the first case study, the application of this framework to clinical pharmacy training activities sponsored by Celgene and implemented by the Purdue Kenya Partnership has helped the program transition from an entirely donor dependent training program to a revenue generating, locally administered program which is now recognized and accredited by the Kenyan government. In the second case study, medication donations from Eli Lilly and Company have been converted from a traditional donation program in one Kenyan health facility to a replicable and sustainable supply chain model which has been expanded to more than 70 public sector facilities across western Kenya. CONCLUSION Adherence to the five core principles of the proposed framework can help guide partnerships between academic institutions and the biopharmaceutical industry to advance healthcare services for underserved populations around the world. As large-scale government-based development agencies continue to primarily focus on specific disease states, biopharmaceutical industry-based collaborations can help initiate activities in underfunded therapeutic areas such as non-communicable diseases.
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Integration of contraceptive services into anticoagulation management services improves access to long-acting reversible contraception. Contraception 2018; 98:486-491. [PMID: 30076833 PMCID: PMC6941485 DOI: 10.1016/j.contraception.2018.07.139] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 07/22/2018] [Accepted: 07/29/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Integration of services is a promising way to improve access to contraception in sub-Saharan Africa, but few studies have evaluated this strategy to increase access to contraception among women requiring anticoagulation. Our objective was to evaluate a model of care integrating contraceptive counseling and provision within an anticoagulation management clinic in Eldoret, Kenya, to determine the impact on long-acting reversible contraception (LARC) use. STUDY DESIGN We performed a prospective observational study of reproductive-age women referred for integrated services from the anticoagulation management clinic at Moi Teaching and Referral Hospital from March 2015 to March 2016. All participants received disease-specific contraceptive counseling and provision, free reversible methods (excluding hormonal intrauterine devices [IUDs]) and follow-up care. We compared LARC use 3 months postintervention to preintervention using the proportions test. Logistic regression analysis was used to determine factors related to use of contraceptive implants and copper IUDs. RESULTS Of 190 participants, 171 (90%) completed 3-month follow-up. There was a significant increase in contraceptive implant use from 10% to 19%, p=.02, and injectable contraceptive use from 14% to 24%, p=.013. There was a concomitant decrease in the use of no method/abstinence from 57% to 39% (33% decrease, p<.001). Younger age, having at least one child and discussing family planning with a partner were predictive of LARC use. CONCLUSION Integrating contraceptive services into an anticoagulation management clinic increases the use of highly effective contraception for women with cardiovascular disease. Implementation of similar models of care should be evaluated within other sites for chronic disease management. IMPLICATIONS A model of care integrating contraceptive counseling and provision into anticoagulation management services is an effective strategy to improve LARC and overall highly effective contraceptive use among women with cardiovascular disease requiring anticoagulation. This model of care may be utilized to prevent maternal morbidity and mortality among this high-risk population.
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Integration of contraceptive services into cardiovascular disease management improves access to long-acting reversible contraception. Contraception 2018. [DOI: 10.1016/j.contraception.2018.07.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Building reliable supply chains for noncommunicable disease commodities: lessons learned from HIV and evidence needs. AIDS 2018; 32 Suppl 1:S55-S61. [PMID: 29952791 DOI: 10.1097/qad.0000000000001878] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Successful noncommunicable disease (NCD) management requires a reliable supply chain. The objectives of this article are to examine lessons learned from HIV supply chain initiatives, describe opportunities to advance supply chain systems for NCD health commodities based on HIV supply chain successes and identify areas where additional research is still needed for reliable NCD supply chains in LMICs. DESIGN We describe practical experiences gained from developing HIV supply chain systems and how those lessons can be used to inform NCD supply chain systems. METHODS Supply chain challenges with HIV commodities in low and middle-income countries (LMICs) are identified and categorized using literature review and expert experiences. Solutions are described on the basis of lessons learned from global HIV initiatives. Opportunities to further advance NCD supply chain systems are recommended. RESULTS Supply chain challenges can be organized into two groups: 1) resource mobilization and 2) resource utilization. Global HIV initiatives have responded to resource mobilization challenges by increasing availability of funding, filling human resource gaps, improving essential storage and creating better transport mechanisms and information technology infrastructure. These initiatives have assisted in better resource utilization by strengthening procurement processes, standardizing and simplifying supply chain systems, reducing integrity and security vulnerabilities and harnessing the power of better data. Advances achieved through HIV initiatives are readily transferrable to NCD supply chains with minimal additional investment. Research opportunities exist to identify the most efficient and cost-effective ways to develop more reliable supply chains for NCDs.
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Clinical characteristics and 12-month outcomes of patients with valvular and non-valvular atrial fibrillation in Kenya. PLoS One 2017; 12:e0185204. [PMID: 28934312 PMCID: PMC5608343 DOI: 10.1371/journal.pone.0185204] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 08/30/2017] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a major contributor to the global cardiovascular disease burden. The clinical profile and outcomes of AF patients with valvular heart diseases in sub-Saharan Africa (SSA) have not been adequately described. We assessed clinical features and 12-month outcomes of patients with valvular AF (vAF) in comparison to AF patients without valvular heart disease (nvAF) in western Kenya. METHODS We performed a cohort study with retrospective data gathering to characterize risk factors and prospective data collection to characterize their hospitalization, stroke and mortality rates. RESULTS The AF patients included 77 with vAF and 69 with nvAF. The mean (SD) age of vAF and nvAF patients were 37.9(14.5) and 69.4(12.3) years, respectively. There were significant differences (p<0.001) between vAF and nvAF patients with respect to female sex (78% vs. 55%), rates of hypertension (29% vs. 73%) and heart failure (10% vs. 49%). vAF patients were more likely to be taking anticoagulation therapy compared to those with nvAF (97% vs. 76%; p<0.01). After 12-months of follow-up, the overall mortality, hospitalization and stroke rates for vAF patients were high, at 10%, 34% and 5% respectively, and were similar to the rates in the nvAF patients (15%, 36%, and 5%, respectively). CONCLUSION Despite younger age and few comorbid conditions, patients with vAF in this developing country setting are at high risk for nonfatal and fatal outcomes, and are in need of interventions to improve short and long-term outcomes.
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Ensuring Patient-Centered Access to Cardiovascular Disease Medicines in Low-Income and Middle-Income Countries Through Health-System Strengthening. Cardiol Clin 2017; 35:125-134. [DOI: 10.1016/j.ccl.2016.08.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Venous Thromboembolism Requiring Extended Anticoagulation Among HIV-Infected Patients in a Rural, Resource-Constrained Setting in Western Kenya. Ann Pharmacother 2017; 51:380-387. [PMID: 28056524 DOI: 10.1177/1060028016686106] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND HIV-infected patients are at an increased risk of developing venous thromboembolism (VTE), and minimal data are available to describe the need for extended treatment. OBJECTIVE To evaluate the frequency of and determine predictive risk factors for extended anticoagulation of VTE in HIV-infected patients in rural, western Kenya. METHODS A retrospective chart review was conducted at the Anticoagulation Monitoring Service affiliated with Moi Teaching and Referral Hospital and the Academic Model Providing Access to Healthcare. Data were collected on patients who were HIV-infected and receiving anticoagulation for lower-limb deep vein thrombosis. The need for extended anticoagulation, defined as receiving ≥7 months of warfarin therapy, was established based on patient symptoms or Doppler ultrasound-confirmed diagnosis. Evaluation of the secondary outcomes utilized a univariate analysis to identify risk factors associated with extended anticoagulation. RESULTS A total of 71 patients were included in the analysis; 27 patients (38%) required extended anticoagulation. The univariate analysis showed a statistically significant association between the need for extended anticoagulation and achieving a therapeutic international normalized ratio within 21 days in both the unadjusted and adjusted analysis. Patients with a history of opportunistic infections required an extended duration of anticoagulation in the adjusted analysis: odds ratio = 3.42; 95% CI = 1.04-11.32; P = 0.04. CONCLUSIONS This study shows that there may be a need for increased duration of anticoagulation in HIV-infected patients, with a need to address the issue of long-term management. Guideline recommendations are needed to address the complexity of treatment issues in this population.
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Engaging the Entire Care Cascade in Western Kenya: A Model to Achieve the Cardiovascular Disease Secondary Prevention Roadmap Goals. Glob Heart 2016; 10:313-7. [PMID: 26704963 DOI: 10.1016/j.gheart.2015.09.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of death in the world, with a substantial health and economic burden confronted by low- and middle-income countries. In low-income countries such as Kenya, there exists a double burden of communicable and noncommunicable diseases, and the CVD profile includes many nonatherosclerotic entities. Socio-politico-economic realities present challenges to CVD prevention in Kenya, including poverty, low national spending on health, significant out-of-pocket health expenditures, and limited outpatient health insurance. In addition, the health infrastructure is characterized by insufficient human resources for health, medication stock-outs, and lack of facilities and equipment. Within this socio-politico-economic reality, contextually appropriate programs for CVD prevention need to be developed. We describe our experience from western Kenya, where we have engaged the entire care cascade across all levels of the health system, in order to improve access to high-quality, comprehensive, coordinated, and sustainable care for CVD and CVD risk factors. We report on several initiatives: 1) population-wide screening for hypertension and diabetes; 2) engagement of community resources and governance structures; 3) geographic decentralization of care services; 4) task redistribution to more efficiently use of available human resources for health; 5) ensuring a consistent supply of essential medicines; 6) improving physical infrastructure of rural health facilities; 7) developing an integrated health record; and 8) mobile health (mHealth) initiatives to provide clinical decision support and record-keeping functions. Although several challenges remain, there currently exists a critical window of opportunity to establish systems of care and prevention that can alter the trajectory of CVD in low-resource settings.
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Building Sustainable Capacity for Cardiovascular Care at a Public Hospital in Western Kenya. J Am Coll Cardiol 2016; 66:2550-60. [PMID: 26653630 DOI: 10.1016/j.jacc.2015.09.086] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 09/06/2015] [Accepted: 09/28/2015] [Indexed: 10/22/2022]
Abstract
Cardiovascular disease deaths are increasing in low- and middle-income countries and are exacerbated by health care systems that are ill-equipped to manage chronic diseases. Global health partnerships, which have stemmed the tide of infectious diseases in low- and middle-income countries, can be similarly applied to address cardiovascular diseases. In this review, we present the experiences of an academic partnership between North American and Kenyan medical centers to improve cardiovascular health in a national public referral hospital. We highlight our stepwise approach to developing sustainable cardiovascular services using the health system strengthening World Health Organization Framework for Action. The building blocks of this framework (leadership and governance, health workforce, health service delivery, health financing, access to essential medicines, and health information system) guided our comprehensive and sustainable approach to delivering subspecialty care in a resource-limited setting. Our experiences may guide the development of similar collaborations in other settings.
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Meeting the Needs of Underserved Patients in Western Kenya by Creating the Next Generation of Global Health Pharmacists. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2016; 80:22. [PMID: 27073275 PMCID: PMC4827573 DOI: 10.5688/ajpe80222] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 11/16/2015] [Indexed: 05/11/2023]
Abstract
Objective. To describe a novel training model used to create a sustainable public health-focused pharmacy residency based in Kenya and to describe the outcomes of this training program on underserved populations. Design. The postgraduate year 2 residency was designed to expose trainees to the unique public health facets of inpatient, outpatient, and community-based care delivery in low and middle-income countries. Public health areas of focus included supply chain management, reproductive health, pediatrics, HIV, chronic disease management, and teaching. Assessment. The outcomes of the residency were assessed based on the number of new clinical programs developed by residents, articles and abstracts written by residents, and resident participation in grant writing. To date, six residents from the United States and eight Kenyan residents have completed the residency. Eleven sustainable patient care services have been implemented as a result of the residency program. Conclusion. This pharmacy residency training model developed accomplished pharmacists in public health pharmacy, with each residency class expanding funding and clinical programming, contributing to curriculum development, and creating jobs.
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The Revolving Fund Pharmacy Model: backing up the Ministry of Health supply chain in western Kenya. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2016; 24:358-66. [PMID: 26913925 DOI: 10.1111/ijpp.12254] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 01/07/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES A pressing challenge in low and middle-income countries (LMIC) is inadequate access to essential medicines, especially for chronic diseases. The Revolving Fund Pharmacy (RFP) model is an initiative to provide high-quality medications consistently to patients, using revenues generated from the sale of medications to sustainably resupply medications. This article describes the utilization of RFPs developed by the Academic Model Providing Access to Healthcare (AMPATH) with the aim of stimulating the implementation of similar models elsewhere to ensure sustainable access to quality and affordable medications in similar LMIC settings. METHODS The service evaluation of three pilot RFPs started between April 2011 and January 2012 in select government facilities is described. The evaluation assessed cross-sectional availability of essential medicines before and after implementation of the RFPs, number of patient encounters and the impact of community awareness activities. FINDINGS Availability of essential medicines in the three pilot RFPs increased from 40%, 36% and <10% to 90%, 94% and 91% respectively. After the first year of operation, the pilot RFPs had a total of 33 714 patient encounters. As of February 2014, almost 3 years after starting up the first RFP, the RFPs had a total of 115 991 patient encounters. In the Eldoret RFP, community awareness activities led to a 51% increase in sales. CONCLUSIONS With proper oversight and stakeholder involvement, this model is a potential solution to improve availability of essential medicines in LMICs. These pilots exemplify the feasibility of implementing and scaling up this model in other locations.
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Genetic mutations in African patients with atrial fibrillation: Rationale and design of the Study of Genetics of Atrial Fibrillation in an African Population (SIGNAL). Am Heart J 2015; 170:455-64.e5. [PMID: 26385028 DOI: 10.1016/j.ahj.2015.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 06/10/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND There is an urgent need to understand genetic associations with atrial fibrillation in ethnically diverse populations. There are no such data from sub-Saharan Africa, despite the fact that atrial fibrillation is one of the fastest growing diseases. Moreover, patients with valvular heart disease are underrepresented in studies of the genetics of atrial fibrillation. METHODS We designed a case-control study of patients with and without a history of atrial fibrillation in Kenya. Cases with atrial fibrillation included those with and without valvular heart disease. Patients underwent clinical phenotyping and will have laboratory analysis and genetic testing of >240 candidate genes associated with cardiovascular diseases. A 12-month follow-up assessment will determine the groups' morbidity and mortality. The primary analyses will describe genetic and phenotypic associations with atrial fibrillation. RESULTS We recruited 298 participants: 72 (24%) with nonvalvular atrial fibrillation, 78 (26%) with valvular atrial fibrillation, and 148 (50%) controls without atrial fibrillation. The mean age of cases and controls were 53 and 48 years, respectively. Most (69%) participants were female. Controls more often had hypertension (45%) than did those with valvular atrial fibrillation (27%). Diabetes and current tobacco smoking were uncommon. A history of stroke was present in 25% of cases and in 5% of controls. CONCLUSION This is the first study determining genetic associations in valvular and nonvalvular atrial fibrillation in sub-Saharan Africa with a control population. The results advance knowledge about atrial fibrillation and will enhance international efforts to decrease atrial fibrillation-related morbidity.
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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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An innovative pay-for-performance (P4P) strategy for improving malaria management in rural Kenya: protocol for a cluster randomized controlled trial. Implement Sci 2013; 8:48. [PMID: 23656836 PMCID: PMC3664216 DOI: 10.1186/1748-5908-8-48] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 04/11/2013] [Indexed: 11/25/2022] Open
Abstract
Background In high-resource settings, ‘pay-for-performance’ (P4P) programs have generated interest as a potential mechanism to improve health service delivery and accountability. However, there has been little or no experimental evidence to guide the development or assess the effectiveness of P4P incentive programs in developing countries. In the developing world, P4P programs are likely to rely, at least initially, on external funding from donors. Under these circumstances, the sustainability of such programs is in doubt and needs assessment. Methods/design We describe a cluster-randomized controlled trial underway in 18 health centers in western Kenya that is testing an innovative incentive strategy to improve management of an epidemiologically and economically important problem—diagnosis and treatment of malaria. The incentive scheme in this trial promotes adherence to Ministry of Health guidelines for laboratory confirmation of malaria before treatment, a priority area for the Ministry of Health. There are three important innovations that are unique to this study among those from other resource-constrained settings: the behavior being incentivized is quality of care rather than volume of service delivery; the incentives are applied at the facility-level rather than the individual level, thus benefiting facility infrastructure and performance overall; and the incentives are designed to be budget-neutral if effective. Discussion Linking appropriate case management for malaria to financial incentives has the potential to improve patient care and reduce wastage of expensive antimalarials. In our study facilities, on average only 25% of reported malaria cases were confirmed by laboratory diagnosis prior to the intervention, and the total treatment courses of antimalarials dispensed did not correspond to the number of cases reported. This study will demonstrate whether facility rather than individual incentives are compelling enough to improve case management, and whether these incentives lead to offsetting cost-savings as a result of reduced drug consumption. Trial registration ClinicalTrials.gov Registration Number NCT01809873
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The Unique Dynamics of Venous Thromboembolism in the Presence of HIV in a Rural, Resource-Constrained Setting in Western Kenya. Chest 2012. [DOI: 10.1378/chest.1387462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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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] [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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Clinical pharmacy consultations provided by American and Kenyan pharmacy students during an acute care advanced pharmacy practice experience. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2011; 75:42. [PMID: 21655396 PMCID: PMC3109796 DOI: 10.5688/ajpe75342] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Accepted: 12/06/2010] [Indexed: 05/13/2023]
Abstract
OBJECTIVE To compare the clinical consultations provided by American and Kenyan pharmacy students in an acute care setting in a developing country. METHODS The documented pharmacy consultation recommendations made by American and Kenyan pharmacy students during patient care rounds on an advanced pharmacy practice experience at a referral hospital in Kenya were reviewed and classified according to type of intervention and therapeutic area. RESULTS The Kenyan students documented more interventions than American students (16.7 vs. 12.0 interventions/day) and provided significantly more consultations regarding human immunodeficiency virus (HIV) and antibiotics. The top area of consultations provided by American students was cardiovascular diseases. CONCLUSIONS American and Kenyan pharmacy students successfully providing clinical pharmacy consultations in a resource-constrained, acute-care practice setting suggests an important role for pharmacy students in the reconciliation of prescriber orders with medication administration records and in providing drug information.
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Needs assessment analysis for vitamin K antagonist anticoagulation in the resource-constrained setting of Eldoret, Kenya. J Am Pharm Assoc (2003) 2011; 50:723-5. [PMID: 21071317 DOI: 10.1331/japha.2010.09226] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To assess the frequency of indications for vitamin K antagonist (VKA) therapy in the inpatient and outpatient setting in Eldoret, Kenya, and to describe the strategies used for managing these conditions. METHODS All inpatient admissions during a 1.5-month period were prospectively assessed for any indications for VKA therapy by clinical pharmacy staff. For the outpatient assessment, the files of all patients receiving care in the outpatient adult cardiology clinic within the previous 6 months were identified and evaluated for indications for VKA therapy. For patients identified with an indication for VKA therapy, additional information was collected, including the VKA indication, pharmacologic management, and any other risk-modifying conditions. RESULTS In the primary analysis, 20 of the 554 patients admitted to the public adult wards (3.61% [95% CI 2.14-5.08]) were candidates for VKA therapy. Of the 168 outpatient cardiology clinic charts reviewed, 72 patients (42.8% [37.96-47.76]) had indications for VKA therapy. In the secondary analysis, 70% of the inpatient population and 93% of the outpatient population received suboptimal VKA therapy. Of these patients in need of VKA therapy, 53.3% were on aspirin therapy only and 33.7% were not receiving any pharmacologic therapy. CONCLUSION As developing countries begin to address the growing burden of chronic diseases, a commensurate focus on providing infrastructure for comprehensive cardiovascular care, including an organized VKA monitoring service, needs to occur.
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Marketing the GP/specialist referral system: an opportunity for the future. IMPLANT DENT 2001; 9:27-9. [PMID: 11307231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Despite the predictions of some gloom casters, there is a strong economic future for dentistry. One of the ways to ensure this strength is to develop an enhanced integrated approach to the general practitioner/specialist referral system. This requires a planned marketing technique that draws the two practices--GP and specialist--into an alliance of greater understanding.
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Implants--now is the time. IMPLANT DENT 1999; 7:254-6. [PMID: 10196801 DOI: 10.1097/00008505-199807040-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pencil and paper: the simple solution to getting the numbers you need to effectively manage your practice. THE ALPHA OMEGAN 1998; 89:22-6. [PMID: 9470543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Once you have mastered the basics by going through the monitoring exercise once or twice, you will find it takes little time and effort to start finding out just where your practice stands. You only solve a problem after you have found out that there is one and you might find that this simple monitoring exercise shows you areas of your practice where a little attention from you will pay big dividends. Monitoring is like a fine wine: it improves with age. As you begin to compile more and more months of data, you will be able to start comparing this month's performance with last month's, or this quarter with last quarter, this year with last year. One of the most useful things monitoring will do for you is to allow you to compare your practice's performance with that of other practices. Averages, norms, and performance survey results are to be found in a range of practice management publications. Using your monitoring information in this comparative way helps you to identify those areas in your practice management that are holding you back from achieving your true potential. This lets you focus your management time and effort on the truly important issues, which, when solved, will help you turn your practice into a less stressful, more enjoyable, and more profitable place to work.
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The business of dentistry. JOURNAL (CANADIAN DENTAL ASSOCIATION) 1997; 63:747-9. [PMID: 9401296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Associateships of a different kind. JOURNAL (CANADIAN DENTAL ASSOCIATION) 1997; 63:591-3. [PMID: 9410546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Opportunity awaits for new and established dentists. JOURNAL (CANADIAN DENTAL ASSOCIATION) 1997; 63:421-3. [PMID: 9203774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Bringing balance into the success equation. JOURNAL (CANADIAN DENTAL ASSOCIATION) 1997; 63:247-50. [PMID: 9125841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Taking stock. JOURNAL (CANADIAN DENTAL ASSOCIATION) 1997; 63:23-4. [PMID: 9009529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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A clean break: exiting dental partnerships. JOURNAL (CANADIAN DENTAL ASSOCIATION) 1996; 62:893-5. [PMID: 8987306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Beyond the bells and whistles: hi-tech/high care dentistry. JOURNAL (CANADIAN DENTAL ASSOCIATION) 1996; 62:658-661. [PMID: 8772000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Beyond the bells and whistles. What high technology really delivers. DENTAL TEAMWORK 1996; 9:12-7. [PMID: 9084237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
There's something seductive about technology. It's exciting, bold, fresh and constantly reinventing itself. This allure is hard to resist, as last year's Windows '95 hype can well attest. In a time-starved society in which automobile drivers become impatient sitting at red lights, it's noteworthy that many spent one night last year lined up in front of retail stores about to release Bill Gates' much ballyhooed software.
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The marketing mind. JOURNAL (CANADIAN DENTAL ASSOCIATION) 1996; 62:483-4. [PMID: 8777744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Heads up on hygiene. JOURNAL (CANADIAN DENTAL ASSOCIATION) 1996; 62:305, 307. [PMID: 9011362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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"2,000 patients"--what do you mean? JOURNAL (CANADIAN DENTAL ASSOCIATION) 1996; 62:221-3. [PMID: 8868164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Fool's gold. JOURNAL (CANADIAN DENTAL ASSOCIATION) 1996; 62:125-126. [PMID: 8820164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Going up or down? JOURNAL (CANADIAN DENTAL ASSOCIATION) 1996; 62:33-5. [PMID: 8673936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Creating value for your staff. JOURNAL (CANADIAN DENTAL ASSOCIATION) 1995; 61:837-9. [PMID: 7497329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Your staff are the agents of success in your practice. It is through their collective, quality efforts that your vision comes to fruition. Treat this investment in human resources with care and nourishment, and you'll be well on your way to establishing a thriving dental practice--one which can claim that not only its patients, but its staff as well, are its biggest fans.
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Creating value for your patients. JOURNAL (CANADIAN DENTAL ASSOCIATION) 1995; 61:761-763. [PMID: 7585264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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Managing emergency patients. JOURNAL (CANADIAN DENTAL ASSOCIATION) 1995; 61:662-663. [PMID: 7553397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Whether it's a new or existing patient who contacts your office about a dental emergency, you and your team have to handle the call with the utmost sensitivity. These patients may be in pain. They need to be treated at a practice that knows how to manage the situation, allowing them to feel relaxed and confident about the impending care. Many new patients find that visiting a dental practice is often an unfamiliar, anxiety-provoking experience. But if you've developed a strong, effective protocol for dealing with dental emergencies, these new patients may ultimately overcome their hesitancy and become enthusiastic patients. It's all about reading and attending to their unique needs.
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Redefining success in dentistry. JOURNAL (CANADIAN DENTAL ASSOCIATION) 1995; 61:570-2. [PMID: 7627883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Strive for excellence, not perfection. JOURNAL (CANADIAN DENTAL ASSOCIATION) 1995; 61:483-4. [PMID: 7614429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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