Third delay in care of critically ill patients: a qualitative investigation of public hospitals in Kenya

OBJECTIVES

Third delay refers to delays in delivering requisite care to patients after they arrive at a health facility. In low-resource care settings, effective triage and flow of care are difficult to guarantee. In this study, we aimed to identify delays in the delivery of care to critically ill patients and possible ways to address these delays.

DESIGN

This was an exploratory qualitative study using in-depth interviews and patient journeys. The qualitative data were transcribed and aggregated into themes in NVivo V.12 Plus using inductive and deductive approaches.

SETTING

This study was conducted in four secondary-level public Kenyan hospitals across four counties between March and December 2021. The selected hospitals were part of the Clinical Information Network.

PARTICIPANTS

Purposive sampling method was used to identify administrative and front-line healthcare providers and patients. We conducted 12 in-depth interviews with 11 healthcare workers and patient journeys of 7 patients. Informed consent was sought from the participants and maintained throughout the study.

RESULTS

We identified a cycle of suboptimal systems for care with adaptive mechanisms that prevent quality care to critically ill patients. We identified suboptimal systems for identification of critical illness, inadequate resources for continuity care and disruption of the flow of care, as the major causes of delays in identification and the initiation of essential care to critically ill patients. Our study also illuminated the contribution of inflexible bureaucratic non-clinical business-related organisational processes to third delay.

CONCLUSION

Eliminating or reducing delays after patients arrive at the hospital is a time-sensitive measure that could improve the care outcomes of critically ill patients. This is achievable through an essential emergency and critical care package within the hospitals. Our findings can help emphasise the need for standardised effective and reliable care priorities to maintain of care of critically ill patients.

Receive, Sustain, and Flow: A simple heuristic for facilitating the identification and treatment of critically ill patients during their hospital journeys

Background

Hospital patients can become critically ill anywhere in a hospital but their survival is affected by problems of identification and adequate, timely, treatment. This is issue of particular concern in lower middle-income countries' (LMICs) hospitals where specialised units are scarce and severely under-resourced. "Cross-sectional" approaches to improving narrow, specific aspects of care will not attend to issues that affect patients' care across the length of their experience. A simpler approach to understanding key issues across the "hospital journey" could help to deliver life-saving treatments to those patients who need it, wherever they are in the facility.

Methods

We carried out 31 narrative interviews with frontline health workers in five Kenyan and five Tanzanian hospitals from November 2020 to December 2021 during the COVID-19 pandemic and analysed using a thematic analysis approach. We also followed 12 patient hospital journeys, through the course of treatment of very sick patients admitted to the hospitals we studied.

Results

Our research explores gaps in hospital systems that result in lapses in effective, continuous care across the hospital journeys of patients in Tanzania and Kenya. We organise these factors according to the Systems Engineering Initiative for Patient Safety (SEIPS) approach to patient safety, which we extend to explore how these issues affect patients across the course of care. We discern three repeating, recursive phases we term Receive, Sustain, and Flow. We use this heuristic to show how gaps and weaknesses in service provision affect critically ill patients' hospital journeys.

Conclusion

Receive, Sustain, and Flow offers a heuristic for hospital management to identify and ameliorate limitations in human and technical resources for the care of the critically ill.

Hospital care for critical illness in low-resource settings: lessons learned during the COVID-19 pandemic

Care for the critically ill patients is often considered synonymous with a hospital having an intensive care unit. However, a focus on Essential Emergency and Critical Care (EECC) may obviate the need for much intensive care. Severe COVID-19 presented a specific critical care challenge while also being an exemplar of critical illness in general. Our multidisciplinary team conducted research in Kenya and Tanzania on hospitals' ability to provide EECC as the COVID-19 pandemic unfolded. Important basic inputs were often lacking, especially sufficient numbers of skilled health workers. However, we learnt that higher scores on resource readiness scales were often misleading, as resources were often insufficient or not functional in all the clinical areas they are needed. By following patient journeys, through interviews and group discussions, we revealed gaps in timeliness, continuity and delivery of care. Generic challenges in transitions between departments were identified in the receipt of critically ill patients, the ability to sustain monitoring and treatment and preparation for any subsequent transition. While the global response to COVID-19 focused initially on providing technologies and training, first ventilators and later oxygen, organisational and procedural challenges seemed largely ignored. Yet, they may even be exacerbated by new technologies. Efforts to improve care for the critically ill patients, which is a complex process, must include a whole system and whole facility view spanning all areas of patients' care and their transitions and not be focused on a single location providing 'critical care'. We propose a five-part strategy to support the system changes needed.

Wearable devices for remote monitoring of hospitalized patients with COVID-19 in Vietnam

Patients with severe COVID-19 disease require monitoring with pulse oximetry as a minimal requirement. In many low- and middle- income countries, this has been challenging due to lack of staff and equipment. Wearable pulse oximeters potentially offer an attractive means to address this need, due to their low cost, battery operability and capacity for remote monitoring. Between July and October 2021, Ho Chi Minh City experienced its first major wave of SARS-CoV-2 infection, leading to an unprecedented demand for monitoring in hospitalized patients. We assess the feasibility of a continuous remote monitoring system for patients with COVID-19 under these circumstances as we implemented 2 different systems using wearable pulse oximeter devices in a stepwise manner across 4 departments.

COVID-19 and unintended steps towards further equity in global health research

There was, and possibly still is, potential for COVID-19 to disrupt power inequities and contribute to positive transformation in global health research that increases equity. While there is consensus about the need to decolonise by transforming global health, and a roadmap outlining how we could approach it, there are few examples of steps that could be taken to transform the mechanics of global health research. This paper contributes lessons learnt from experiences and reflections of our diverse multinational team of researchers involved in a multicountry research project. We demonstrate the positive impact on our research project of making further steps towards improving equity within our research practices. Some of the approaches adopted include redistributing power to researchers from the countries of interest at various stages in their career, by involving the whole team in decisions about the research; meaningfully involving the whole team in research data analysis; and providing opportunities for all researchers from the countries of interest to voice their perspectives as first authors in publications. Although this approach is consistent with how research guidance suggests research should be run, in reality it does not often happen in this way. The authors of this paper hope that by sharing our experience, we can contribute towards discussions about the processes required to continue developing a global health sector that is equitable and inclusive.

Conceptualising engagement with HIV care for people on treatment: the Indicators of HIV Care and AntiRetroviral Engagement (InCARE) Framework

BACKGROUND

As the crisis-based approach to HIV care evolves to chronic disease management, supporting ongoing engagement with HIV care is increasingly important to achieve long-term treatment success. However, 'engagement' is a complex concept and ambiguous definitions limit its evaluation. To guide engagement evaluation and development of interventions to improve HIV outcomes, we sought to identify critical, measurable dimensions of engagement with HIV care for people on treatment from a health service-delivery perspective.

METHODS

We used a pragmatic, iterative approach to develop a framework, combining insights from researcher experience, a narrative literature review, framework mapping, expert stakeholder input and a formal scoping review of engagement measures. These inputs helped to refine the inclusion and definition of important elements of engagement behaviour that could be evaluated by the health system.

RESULTS

The final framework presents engagement with HIV care as a dynamic behaviour that people practice rather than an individual characteristic or permanent state, so that people can be variably engaged at different points in their treatment journey. Engagement with HIV care for those on treatment is represented by three measurable dimensions: 'retention' (interaction with health services), 'adherence' (pill-taking behaviour), and 'active self-management' (ownership and self-management of care). Engagement is the product of wider contextual, health system and personal factors, and engagement in all dimensions facilitates successful treatment outcomes, such as virologic suppression and good health. While retention and adherence together may lead to treatment success at a particular point, this framework hypothesises that active self-management sustains treatment success over time. Thus, evaluation of all three core dimensions is crucial to realise the individual, societal and public health benefits of antiretroviral treatment programmes.

CONCLUSIONS

This framework distils a complex concept into three core, measurable dimensions critical for the maintenance of engagement. It characterises elements that the system might assess to evaluate engagement more comprehensively at individual and programmatic levels, and suggests that active self-management is an important consideration to support lifelong optimal engagement. This framework could be helpful in practice to guide the development of more nuanced interventions that improve long-term treatment success and help maintain momentum in controlling a changing epidemic.

Protocol for the Pathways Study: a realist evaluation of staff social ties and communication in the delivery of neonatal care in Kenya

INTRODUCTION

The informal social ties that health workers form with their colleagues influence knowledge, skills and individual and group behaviours and norms in the workplace. However, improved understanding of these 'software' aspects of the workforce (eg, relationships, norms, power) have been neglected in health systems research. In Kenya, neonatal mortality has lagged despite reductions in other age groups under 5 years. A rich understanding of workforce social ties is likely to be valuable to inform behavioural change initiatives seeking to improve quality of neonatal healthcare.This study aims to better understand the relational components among health workers in Kenyan neonatal care areas, and how such understanding might inform the design and implementation of quality improvement interventions targeting health workers' behaviours.

METHODS AND ANALYSIS

We will collect data in two phases. In phase 1, we will conduct non-participant observation of hospital staff during patient care and hospital meetings, a social network questionnaire with staff, in-depth interviews, key informant interviews and focus group discussions at two large public hospitals in Kenya. Data will be collected purposively and analysed using realist evaluation, interim analyses including thematic analysis of qualitative data and quantitative analysis of social network metrics. In phase 2, a stakeholder workshop will be held to discuss and refine phase one findings.Study findings will help refine an evolving programme theory with recommendations used to develop theory-informed interventions targeted at enhancing quality improvement efforts in Kenyan hospitals.

ETHICS AND DISSEMINATION

The study has been approved by Kenya Medical Research Institute (KEMRI/SERU/CGMR-C/241/4374) and Oxford Tropical Research Ethics Committee (OxTREC 519-22). Research findings will be shared with the sites, and disseminated in seminars, conferences and published in open-access scientific journals.

Same label, different patients: Health-workers' understanding of the label 'critical illness'

Background

During the course of patients' sickness, some become critically ill, and identifying them is the first important step to be able to manage the illness. During the course of care provision, health workers sometimes use the term 'critical illness' as a label when referring to their patient's condition, and the label is then used as a basis for communication and care provision. Their understanding of this label will therefore have a profound impact on the identification and management of patients. This study aimed to determine how Kenyan and Tanzanian health workers understand the label 'critical illness'.

Methods

A total of 10 hospitals-five in Kenya and five in Tanzania-were visited. In-depth interviews were conducted with 30 nurses and physicians from different departments in the hospitals who had experience in providing care for sick patients. We conducted a thematic analysis of the translated and transcribed interviews, synthesized findings and developed an overarching set of themes which captured healthcare workers' understandings of the label 'critical illness'.

Results

Overall, there does not appear to be a unified understanding of the label 'critical illness' among health workers. Health workers understand the label to refer to patients in four thematic ways: (1) those in a life-threatening state; (2) those with certain diagnoses; (3) those receiving care in certain locations; and (4) those in need of a certain level of care.

Conclusion

There is a lack of a unified understanding about the label 'critical illness' among health workers in Tanzania and Kenya. This potentially hampers communication and the selection of patients for urgent life-saving care. A recently proposed definition, "a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility", could be useful for improving communication and care.

The CINAMR (Clinical Information Network-Antimicrobial Resistance) Project: A pilot microbial surveillance using hospitals linked to regional laboratories in Kenya: Study Protocol

Background: Antimicrobial resistance (AMR) is a global threat and is thought to be acute in low-and middle-income country (LMIC) settings, including in Kenya, but there is limited unbiased surveillance that can provide reliable estimates of its burden. Current efforts to build capacity for microbiology testing in Kenya are unlikely to result in systematic routine microbiological testing in the near term. Therefore, there is little prospect for microbiological support to inform clinical diagnoses nor for indicating the burden of AMR and for guiding empirical choice of antibiotics. Objective: We aim to build on an existing collaboration, the Clinical Information Network (CIN), to pilot microbiological surveillance using a 'hub-and-spoke' model where selected hospitals are linked to high quality microbiology research laboratories. Methods: Children admitted to paediatric wards of 12 participating hospitals will have a sample taken for blood culture at admission before antibiotics are started. Indication for blood culture will be a clinician's prescription of antibiotics. Samples will then be transported daily to the research laboratories for culture and antibiotic susceptibility testing and results relayed back to clinicians for patient management. The surveillance will take place for 6 months in each hospital. Separately, we shall conduct semi-structured interviews with frontline health workers to explore the feasibility and utility of this approach. We will also seek to understand how the availability of microbiology results might inform antibiotic stewardship, and as an interim step to the development of better national or regional laboratories linked to routine surveillance. Conclusions: If feasible, this approach is less costly and periodic 'hub-and-spoke' surveillance can be used to track AMR trends and to broadly guide empirical antibiotic guidance meaning it is likely to be more sustainable than establishing functional microbiological facilities in each hospital in a LMIC setting.

Wearable devices for remote monitoring of hospitalized patients with COVID-19 in Vietnam

Patients with severe COVID-19 disease require monitoring with pulse oximetry as a minimal requirement. In many low- and middle- income countries, this has been challenging due to lack of staff and equipment. Wearable pulse oximeters potentially offer an attractive means to address this need, due to their low cost, battery operability and capacity for remote monitoring.  Between July and October 2021, Ho Chi Minh City experienced its first major wave of SARS-CoV-2 infection, leading to an unprecedented demand for monitoring in hospitalized patients. We assess the feasibility of a continuous remote monitoring system for patients with COVID-19 under these circumstances as we implemented 2 different systems using wearable pulse oximeter devices in a stepwise manner across 4 departments.

Measuring patient engagement with HIV care in sub-Saharan Africa: a scoping study

INTRODUCTION

Engagement with HIV care is a multi-dimensional, dynamic process, critical to maintaining successful treatment outcomes. However, measures of engagement are not standardized nor comprehensive. This undermines our understanding of the scope of challenges with engagement and whether interventions have an impact, complicating patient and programme-level decision-making. This study identified and characterized measures of engagement to support more consistent and comprehensive evaluation.

METHODS

We conducted a scoping study to systematically categorize measures the health system could use to evaluate engagement with HIV care for those on antiretroviral treatment. Key terms were used to search literature databases (Embase, PsychINFO, Ovid Global-Health, PubMed, Scopus, CINAHL, Cochrane and the World Health Organization Index Medicus), Google Scholar and stakeholder-identified manuscripts, ultimately including English evidence published from sub-Saharan Africa from 2014 to 2021. Measures were extracted, organized, then reviewed with key stakeholders.

RESULTS AND DISCUSSION

We screened 14,885 titles/abstracts, included 118 full-texts and identified 110 measures of engagement, categorized into three engagement dimensions ("retention," "adherence" and "active self-management"), a combination category ("multi-dimensional engagement") and "treatment outcomes" category (e.g. viral load as an end-result reflecting that engagement occurred). Retention reflected status in care, continuity of attendance and visit timing. Adherence was assessed by a variety of measures categorized into primary (prescription not filled) and secondary measures (medication not taken as directed). Active self-management reflected involvement in care and self-management. Three overarching use cases were identified: research to make recommendations, routine monitoring for quality improvement and strategic decision-making and assessment of individual patients.

CONCLUSIONS

Heterogeneity in conceptualizing engagement with HIV care is reflected by the broad range of measures identified and the lack of consensus on "gold-standard" indicators. This review organized metrics into five categories based on the dimensions of engagement; further work could identify a standardized, minimum set of measures useful for comprehensive evaluation of engagement for different use cases. In the interim, measurement of engagement could be advanced through the assessment of multiple categories for a more thorough evaluation, conducting sensitivity analyses with commonly used measures for more comparable outputs and using longitudinal measures to evaluate engagement patterns. This could improve research, programme evaluation and nuanced assessment of individual patient engagement in HIV care.

Measuring patient engagement with HIV care in sub-Saharan Africa: a scoping study

INTRODUCTION

Engagement with HIV care is a multi-dimensional, dynamic process, critical to maintaining successful treatment outcomes. However, measures of engagement are not standardized nor comprehensive. This undermines our understanding of the scope of challenges with engagement and whether interventions have an impact, complicating patient and programme-level decision-making. This study identified and characterized measures of engagement to support more consistent and comprehensive evaluation.

METHODS

We conducted a scoping study to systematically categorize measures the health system could use to evaluate engagement with HIV care for those on antiretroviral treatment. Key terms were used to search literature databases (Embase, PsychINFO, Ovid Global-Health, PubMed, Scopus, CINAHL, Cochrane and the World Health Organization Index Medicus), Google Scholar and stakeholder-identified manuscripts, ultimately including English evidence published from sub-Saharan Africa from 2014 to 2021. Measures were extracted, organized, then reviewed with key stakeholders.

RESULTS AND DISCUSSION

We screened 14,885 titles/abstracts, included 118 full-texts and identified 110 measures of engagement, categorized into three engagement dimensions ("retention," "adherence" and "active self-management"), a combination category ("multi-dimensional engagement") and "treatment outcomes" category (e.g. viral load as an end-result reflecting that engagement occurred). Retention reflected status in care, continuity of attendance and visit timing. Adherence was assessed by a variety of measures categorized into primary (prescription not filled) and secondary measures (medication not taken as directed). Active self-management reflected involvement in care and self-management. Three overarching use cases were identified: research to make recommendations, routine monitoring for quality improvement and strategic decision-making and assessment of individual patients.

CONCLUSIONS

Heterogeneity in conceptualizing engagement with HIV care is reflected by the broad range of measures identified and the lack of consensus on "gold-standard" indicators. This review organized metrics into five categories based on the dimensions of engagement; further work could identify a standardized, minimum set of measures useful for comprehensive evaluation of engagement for different use cases. In the interim, measurement of engagement could be advanced through the assessment of multiple categories for a more thorough evaluation, conducting sensitivity analyses with commonly used measures for more comparable outputs and using longitudinal measures to evaluate engagement patterns. This could improve research, programme evaluation and nuanced assessment of individual patient engagement in HIV care.

Improving facility-based care: eliciting tacit knowledge to advance intervention design

Attention has turned to improving the quality and safety of healthcare within health facilities to reduce avoidable mortality and morbidity. Interventions should be tested in health system environments that can support their adoption if successful. To be successful, interventions often require changes in multiple behaviours making their consequences unpredictable. Here, we focus on this challenge of change at the mesolevel or microlevel. Drawing on multiple insights from theory and our own empirical work, we highlight the importance of engaging managers, senior and frontline staff and potentially patients to explore foundational questions examining three core resource areas. These span the physical or material resources available, workforce capacity and capability and team and organisational relationships. Deficits in all these resource areas may need to be addressed to achieve success. We also argue that as inertia is built into the complex social and human systems characterising healthcare facilities that thought on how to mobilise five motive forces is needed to help achieve change. These span goal alignment and ownership, leadership for change, empowering key actors, promoting responsive planning and procurement and learning for transformation. Our aim is to bridge the theory-practice gap and offer an entry point for practical discussions to elicit the critical tacit and contextual knowledge needed to design interventions. We hope that this may improve the chances that interventions are successful and so contribute to better facility-based care and outcomes while contributing to the development of learning health systems.

The social networks of hospital staff: A realist synthesis

OBJECTIVES

The social ties people have with one another are known to influence behaviour, and how information is accessed and interpreted. It is unclear, however, how the social networks that exist in multi-professional health care workplaces might be used to improve quality in hospitals. This paper develops explanatory theory using realist synthesis to illuminate the details and significance of the social ties between health care workers. Specifically we ask: How, why, for whom, to what extent and in what context, do the social ties of staff within a hospital influence quality of service delivery, including quality improvement?

METHODS

From a total of 75 included documents identified through an extensive systematic literature search, data were extracted and analysed to identify emergent explanatory statements.

RESULTS

The synthesis found that within the hospital workforce, an individual's place in the social whole can be understood across four identified domains: (1) social group, (2) hierarchy, (3) bridging distance and (4) discourse. Thirty-five context-mechanism-outcome configurations were developed across these domains.

CONCLUSIONS

The relative position of individual health care workers within the overall social network in hospitals is associated with influence and agency. As such, power to bring about change is inequitably and socially situated, and subject to specific contexts. The findings of this realist synthesis offer a lens through which to understand social ties in hospitals. The findings can help identify possible strategies for intervention to improve communication and distribution of power, for individual, team and wider multi-professional behavioural change in hospitals.

Digital Health Policy and Programs for Hospital Care in Vietnam: Scoping Review

Background

There are a host of emergent technologies with the potential to improve hospital care in low- and middle-income countries such as Vietnam. Wearable monitors and artificial intelligence–based decision support systems could be integrated with hospital-based digital health systems such as electronic health records (EHRs) to provide higher level care at a relatively low cost. However, the appropriate and sustainable application of these innovations in low- and middle-income countries requires an understanding of the local government’s requirements and regulations such as technology specifications, cybersecurity, data-sharing protocols, and interoperability.

Objective

This scoping review aims to explore the current state of digital health research and the policies that govern the adoption of digital health systems in Vietnamese hospitals.

Methods

We conducted a scoping review using a modification of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. PubMed and Web of Science were searched for academic publications, and Thư Viện Pháp Luật, a proprietary database of Vietnamese government documents, and the Vietnam Electronic Health Administration website were searched for government documents. Google Scholar and Google Search were used for snowballing searches. The sources were assessed against predefined eligibility criteria through title, abstract, and full-text screening. Relevant information from the included sources was charted and summarized. The review process was primarily undertaken by one researcher and reviewed by another researcher during each step.

Results

In total, 11 academic publications and 20 government documents were included in this review. Among the academic studies, 5 reported engineering solutions for information systems in hospitals, 2 assessed readiness for EHR implementation, 1 tested physicians’ performance before and after using clinical decision support software, 1 reported a national laboratory information management system, and 2 reviewed the health system’s capability to implement eHealth and artificial intelligence. Of the 20 government documents, 19 were promulgated from 2013 to 2020. These regulations and guidance cover a wide range of digital health domains, including hospital information management systems, general and interoperability standards, cybersecurity in health organizations, conditions for the provision of health information technology (HIT), electronic health insurance claims, laboratory information systems, HIT maturity, digital health strategies, electronic medical records, EHRs, and eHealth architectural frameworks.

Conclusions

Research about hospital-based digital health systems in Vietnam is very limited, particularly implementation studies. Government regulations and guidance for HIT in health care organizations have been released with increasing frequency since 2013, targeting a variety of information systems such as electronic medical records, EHRs, and laboratory information systems. In general, these policies were focused on the basic specifications and standards that digital health systems need to meet. More research is needed in the future to guide the implementation of digital health care systems in the Vietnam hospital setting.

First do no harm: practitioners' ability to 'diagnose' system weaknesses and improve safety is a critical initial step in improving care quality

Healthcare systems across the world and especially those in low-resource settings (LRS) are under pressure and one of the first priorities must be to prevent any harm done while trying to deliver care. Health care workers, especially department leaders, need the diagnostic abilities to identify local safety concerns and design actions that benefit their patients. We draw on concepts from the safety sciences that are less well-known than mainstream quality improvement techniques in LRS. We use these to illustrate how to analyse the complex interactions between resources and tools, the organisation of tasks and the norms that may govern behaviours, together with the strengths and vulnerabilities of systems. All interact to influence care and outcomes. To employ these techniques leaders will need to focus on the best attainable standards of care, build trust and shift away from the blame culture that undermines improvement. Health worker education should include development of the technical and relational skills needed to perform these system diagnostic roles. Some safety challenges need leadership from professional associations to provide important resources, peer support and mentorship to sustain safety work.

Spatial ecology of endangered roseate terns and foraging habitat suitability around a colony in the western North Atlantic

Predicting habitat suitability and understanding habitat utilization are important to inform and orient conservation and management decisions for the recovery of endangered species. In North America, the roseate tern Sterna dougallii is listed as endangered in both the northeastern USA and Canada, where little is known about the foraging spatial ecology of the species. We equipped breeding roseate terns with miniature GPS tracking devices during incubation at North Brother Island, the main Canadian colony. Our aim was to characterize the spatial foraging ecology of the species, identify marine zones of importance, and develop a habitat suitability model around the colony. Our results provide novel, high resolution information on individual foraging trips, notably showing that individuals restricted their range around the colony (15.4 km) while performing multiple foraging trips: up to 11 daytime trips and a maximum total of 152.9 km travelled per day. Roseate terns concentrated their foraging effort around the colony and further south along the coast to the Cockerwit Passage. Using distance from colony, sea surface temperature, distance from land, bathymetry, and subtidal substrate type as covariates in a habitat suitability model, a high proportion of the deviance was explained (72.4%); the model also predicted high occurrence of foraging near the colony, in Cockerwit Passage, and at additional sites to which the birds were not tracked. Along with the description of important marine areas for roseate terns nesting on North Brother Island, this habitat suitability model provides a relevant and essential context for understanding roseate tern habitat use in a broad sense, but with a focus on habitat requirements during incubation.

Information asymmetry in the Kenyan medical laboratory sector

BACKGROUND

Important information about medical laboratory providers is not readily available to all patients, clinicians nor regulators in Kenya. This study was conducted as part of a wider project aiming to improve access to high quality diagnostics by addressing information asymmetries in the Kenyan market for laboratory services.

OBJECTIVES

The purpose of this study was to: 1) Gather pricing information for 49 common laboratory tests from medical laboratories in Nairobi, Kenya, noting where these prices were publicly available or withheld. 2) Assess patients' knowledge of testing information including: turnaround time, price, and test availability.

METHOD

This was a cross-sectional study where a mystery caller approach was used to survey 49 tests for turnaround time, price, and availability across 13 laboratories selected purposively. The mystery shopper survey was complemented by 251 patient exit interviews at two Kenyan hospitals to understand whether patients seeking laboratory tests in Nairobi had access to such information. All 251 patients were selected by convenience sampling.

RESULTS

We noted that 85% of the private laboratories did not disclose test prices and turnaround times to their patients. There was a wide range of prices on several key tests, with private in-facility laboratories charging an average test price of 468% of the average test price in public laboratories across all the 49 tests. We also found that many patients lacked key information regarding the tests they needed: 65% did not know the purpose of the test while 41% did not know the test price at all.

CONCLUSION

Under the current system, patients have limited access to information regarding the key criteria required to make a rational decision. This has a significant impact on the quality, price, and turnaround time (TAT) offered by the medical laboratories that operate in this dysfunctional market.

Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol

In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes.  Our programme theory is an expression of our assumptions about what actions will be both useful and feasible.  It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.

Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol

In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes.  Our programme theory is an expression of our assumptions about what actions will be both useful and feasible.  It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.

Socio-economic status and mortality in people with type 1 diabetes in Scotland 2006-2015: a retrospective cohort study

AIMS

To describe the association between socio-economic status and mortality in a nation-wide cohort of people with type 1 diabetes in Scotland and to compare patterns over time and with the general population.

METHODS

A retrospective cohort study was performed using data for people with type 1 diabetes from a population-based register linked to mortality records. Socio-economic status was derived from quintiles of an area-based measure: the Scottish Index of Multiple Deprivation. Sex-specific directly age-standardized mortality rates for each Scottish Index of Multiple Deprivation quintile and rate ratios comparing the most vs least deprived quintile were calculated for two time periods: 2006-2010 and 2011-2015. Data for the population without type 1 diabetes between 2011 and 2015 were available for comparison.

RESULTS

Data for 3802 deaths among 33 547 people with type 1 diabetes were available. The age-standardized mortality rate per 1000 person-years decreased over time (from 2006-2010 to 2011-2015) for men and women with type 1 diabetes: 24.8 to 20.2 and 22.5 to 17.6, respectively. Mortality in populations with and without type 1 diabetes was generally higher for men than women and was inversely associated with socio-economic status. Rate ratios for the most vs least deprived groups increased over time among people with type 1 diabetes (men: 2.49 to 2.81; women: 1.92 to 2.86) and were higher than among populations without type 1 diabetes in 2011-2015 (men: 2.06; women: 1.66).

CONCLUSIONS

Socio-economic deprivation was associated with a steeper mortality gradient in people with type 1 diabetes than in the population without type 1 diabetes in Scotland. Age-standardized mortality has decreased over time but socio-economic inequalities may be increasing.

Are health care assistants part of the long-term solution to the nursing workforce deficit in Kenya?

This commentary article addresses a critical issue facing Kenya and other Low- and Middle-Income Countries (LMIC): how to remedy deficits in hospitals' nursing workforce. Would employing health care assistants (HCAs) provide a partial solution? This article first gives a brief introduction to the Kenyan context and then explores the development of workforce roles to support nurses in Europe to highlight the diversity of these roles. Our introduction pinpoints that pressures to maintain or restrict costs have led to a wide variety of formal and informal task shifting from nurses to some form of HCA in the EU with differences noted in issues of appropriate skill mix, training, accountability, and regulation of HCA. Next, we draw from a suite of recent studies in hospitals in Kenya which illustrate nursing practices in a highly pressurized context. The studies took place in neo-natal wards in Kenyan hospitals between 2015 and 2018 and in a system with no legal or regulatory basis for task shifting to HCAs. We proffer data on why and how nurses informally delegate tasks to others in the public sector and the decision-making processes of nurses and frame this evidence in the specific contextual conditions. In the conclusion, the paper aims to deepen the debates on developing human resources for health. We argue that despite the urgent pressures to address glaring workforce deficits in Kenya and other LMIC, caution needs to be exercised in implementing changes to nursing practices through the introduction of HCAs. The evidence from EU suggests that the rapid growth in the employment of HCA has created crucial issues which need addressing. These include clearly defining the scope of practice and developing the appropriate skill mix between nurses and HCAs to match the specific health system context. Moreover, we suggest efforts to develop and implement such roles should be carefully designed and rigorously evaluated to inform continuing policy development.

Infection prevention and control during the COVID-19 pandemic: challenges and opportunities for Kenyan public hospitals

Background: Infection prevention and control, and water sanitation and hygiene have an essential role in ensuring the quality of care and patient outcomes in hospitals. Using a modification of the World Health Organization's water sanitation and hygiene facility improvement tool, we undertook assessments in 14 public hospitals in Kenya in 2018. The hospitals received written feedback on areas where they could make improvements. Following the first confirmed cases of COVID-19 in Kenya, we were drawn to ask whether the results of our pre-pandemic survey had led to action, and whether or not the threat of COVID-19 had focused more attention on infection prevention and control and water sanitation and hygiene. Methods: Using a semi-structured interview guide, we carried out phone interviews with key hospital leaders in 11 of the 14 hospitals. The data were transcribed and coded into thematic areas. We draw on these interviews to describe the status and awareness of infection prevention and control. Results: The infection prevention and control committee members are training health workers on infection prevention and control procedures and proper use of personal protective equipment and in addition, providing technical support to hospital managers. While some hospitals have also accessed additional funds to improve infection prevention and control, they tended to be small amounts of money.  Long-standing challenges with supplies of infection prevention and control materials and low staff morale persist.  Crucially, the reduced supply of personal protective equipment has led to fear and anxiety among health care personnel. Conclusions: As funds are mobilised to support care for COVID-19, we ask that funds prioritise infection prevention and control measures. This would have a profoundly positive effect on within hospital virus transmission, patient and staff safety but also lasting benefits beyond the COVID-19 pandemic.

Evaluating hospital performance in antibiotic stewardship to guide action at national and local levels in a lower-middle income setting

BACKGROUND

Inappropriate use of antibiotics can lead to the development of resistant pathogens. Ensuring proper use of these important drugs in all healthcare facilities is essential. Unfortunately, however, very little is known about how antibiotics are used in LMIC clinical settings, nor to what degree antibiotic stewardship programmes are in place and effective.

OBJECTIVE

We aimed to record all Antibiotic Stewardship policies and structures in place in 16 Kenyan hospitals. We also wanted to examine the context of antibiotic-related practices in these hospitals.

METHODS

We generated a set of questions intended to assess the knowledge and application of antibiotic stewardship policies and practices in Kenya. Using a set of 17 indicators grouped into four categories, we surveyed 16 public hospitals across the country. Additionally, we conducted 31semi-structured interviews with frontline healthcare workers and hospital managers to explore the context of, and reasons for, the results.

RESULTS

Only one hospital had a resourced ABS policy in place. In all other hospitals, our survey teams commonly identified structures, resources and processes that in some way demonstrated partial or full control of antibiotic usage. This was verified by the qualitative interviews that identified common underlying issues. Most positively, we find evidence discipline-specific clinical guidelines have been well accepted and have conditioned and restricted antibiotic use.

CONCLUSION

Only one hospital had an official ABS programme, but many facilities had existing structures and resources that could be used to improve antibiotic use. Thus, ABS Strategies should be built upon existing practices with national ABS policies taking maximum advantage of existing structures to manage the supply and prescription of antimicrobials. We conclude that ABS interventions that build on established responsibilities, methods and practices would be more efficient than interventions that presume a need to establish new ABS apparatus.

Qualitative interview study exploring frontline managers' contributions to hand hygiene standards and audit: Local knowledge can inform practice

BACKGROUND

Frontline managers promote hand hygiene standards and adherence to hand hygiene protocols. Little is known about this aspect of their role.

METHODS

Qualitative interview study with frontline managers on 2 acute admission wards in a large National Health Service Trust in the United Kingdom.

RESULTS

Managers reported that hand hygiene standards and audit were modeled on World Health Organization guidelines. Hand hygiene outside the immediate patient zone was not documented but managers could identify when additional indications for hand hygiene presented. They considered that audit was worthwhile to remind staff that hand hygiene is important but did not regard audit findings as a valid indicator of practice. Managers identified differences in the working patterns of nurses and doctors that affect the number and types of hand hygiene opportunities and barriers to hand hygiene. Ward managers were accepted as the custodians of hand-hygiene standards.

CONCLUSIONS

Frontline managers identified many of the issues currently emerging as important in contemporary infection prevention practice and research and could apply them locally. Their views should be represented when hand hygiene guidelines are reviewed and updated.

Lessons from a Health Policy and Systems Research programme exploring the quality and coverage of newborn care in Kenya

There are global calls for research to support health system strengthening in low-income and middle-income countries (LMICs). To examine the nature and magnitude of gaps in access and quality of inpatient neonatal care provided to a largely poor urban population, we combined multiple epidemiological and health services methodologies. Conducting this work and generating findings was made possible through extensive formal and informal stakeholder engagement linked to flexibility in the research approach while keeping overall goals in mind. We learnt that 45% of sick newborns requiring hospital care in Nairobi probably do not access a suitable facility and that public hospitals provide 70% of care accessed with private sector care either poor quality or very expensive. Direct observations of care and ethnographic work show that critical nursing workforce shortages prevent delivery of high-quality care in high volume, low-cost facilities and likely threaten patient safety and nurses' well-being. In these challenging settings, routines and norms have evolved as collective coping strategies so health professionals maintain some sense of achievement in the face of impossible demands. Thus, the health system sustains a functional veneer that belies the stresses undermining quality, compassionate care. No one intervention will dramatically reduce neonatal mortality in this urban setting. In the short term, a substantial increase in the number of health workers, especially nurses, is required. This must be combined with longer term investment to address coverage gaps through redesign of services around functional tiers with improved information systems that support effective governance of public, private and not-for-profit sectors.

Collective strategies to cope with work related stress among nurses in resource constrained settings: An ethnography of neonatal nursing in Kenya

Kenyan neonatal nurses are asked to do the impossible: to bridge the gap between international standards of nursing and the circumstances they face each day. They work long hours with little supervision in ill-designed wards, staffed by far too few nurses given the pressing need. Despite these conditions, a single neonatal nurse can be tasked with looking after forty sick babies for whom very close care is a necessity. Our 18-month ethnography explores this uniquely stressful environment in order to understand how nurses operate under such pressures and what techniques they use to organise work and cope. Beginning in January 2015, we conducted 250 h of non-participant observation and 32 semi-structured interviews in three newborn units in Nairobi to describe how nurses categorise babies, balance work across shifts, use routinised care, and demonstrate pragmatism and flexibility in their dealings with each other in order to reduce stress. In so doing, we present an empirically based model of the ways in which nurses cope in a lower-middle income setting and develop early work in nursing studies that highlighted collective strategies for reducing anxiety. This allows us to address the gap left by prevalent theories of nursing stress that have focused on the personal characteristics of individual nurses. Finally, we extend outwards from our ethnographic findings to consider how a deeper understanding of these collective strategies to reduce stress might inform policy, and why, even when the forces that create stress are alleviated, the underlying model of nursing work may prevail.

Extending the use of the World Health Organisations' water sanitation and hygiene assessment tool for surveys in hospitals - from WASH-FIT to WASH-FAST

BACKGROUND

Poor water sanitation and hygiene (WASH) in health care facilities increases hospital-associated infections, and the resulting greater use of second-line antibiotics drives antimicrobial resistance. Recognising the existing gaps, the World Health Organisations' Water and Sanitation for Health Facility Improvement Tool (WASH-FIT) was designed for self-assessment. The tool was designed for small primary care facilities mainly providing outpatient and limited inpatient care and was not designed to compare hospital performance. Together with technical experts, we worked to adapt the tool for use in larger facilities with multiple inpatient units (wards), allowing for comparison between facilities and prompt action at different levels of the health system.

METHODS

We adapted the existing facility improvement tool (WASH-FIT) to create a simple numeric scoring approach. This is to illustrate the variation across hospitals and to facilitate monitoring of progress over time and to group indicators that can be used to identify this variation. Working with stakeholders, we identified those responsible for action to improve WASH at different levels of the health system and used piloting, analysis of interview data to establish the feasibility and potential value of the WASH Facility Survey Tool (WASH-FAST) to demonstrate such variability.

RESULTS

We present an aggregate percentage score based on 65 indicators at the facility level to summarise hospitals' overall WASH status and how this varies. Thirty-four of the 65 indicators spanning four WASH domains can be assessed at ward level enabling within hospital variations to be highlighted. Three levels of responsibility for WASH service monitoring and improvement were identified with stakeholders: the county/regional level, senior hospital management and hospital infection prevention and control committees.

CONCLUSION

We propose WASH-FAST can be used as a survey tool to assess, measure and monitor the progress of WASH in hospitals in resource-limited settings, providing useful data for decision making and tracking improvements over time.

Establishing the cascade of care for patients with tuberculous meningitis

Meningitis is a relatively rare form of tuberculosis, but it carries a high mortality rate, reaching 50% in some settings, with higher rates among patients with HIV co-infection and those with drug-resistant disease. Most studies of tuberculosis meningitis (TBM) tend to focus on better diagnosis, drug treatment and supportive care for patients in hospital. However, there is significant variability in mortality between settings, which may be due to specific variation in the availability and quality of health care services, both prior to, during, and after hospitalization. Such variations have not been studied thoroughly, and we therefore present a theoretical framework that may help to identify where efforts should be focused in providing optimal services for TBM patients. As a first step, we propose an adjusted cascade of care for TBM and patient pathway studies that might help identify factors that account for losses and delays across the cascade. Many of the possible gaps in the TBM cascade are related to health systems factors; we have selected nine domains and provide relevant examples of systems factors for TBM for each of these domains that could be the basis for a health needs assessment to address such gaps. Finally, we suggest some immediate action that could be taken to help make improvements in services. Our theoretical framework will hopefully lead to more health system research and improved care for patients suffering from this most dangerous form of tuberculosis.

Establishing the cascade of care for patients with tuberculous meningitis

Meningitis is a relatively rare form of tuberculosis, but it carries a high mortality rate, reaching 50% in some settings, with higher rates among patients with HIV co-infection and those with drug-resistant disease. Most studies of tuberculosis meningitis (TBM) tend to focus on better diagnosis, drug treatment and supportive care for patients in hospital. However, there is significant variability in mortality between settings, which may be due to specific variation in the availability and quality of health care services, both prior to, during, and after hospitalization. Such variations have not been studied thoroughly, and we therefore present a theoretical framework that may help to identify where efforts should be focused in providing optimal services for TBM patients. As a first step, we propose an adjusted cascade of care for TBM and patient pathway studies that might help identify factors that account for losses and delays across the cascade. Many of the possible gaps in the TBM cascade are related to health systems factors; we have selected nine domains and provide relevant examples of systems factors for TBM for each of these domains that could be the basis for a health needs assessment to address such gaps. Finally, we suggest some immediate action that could be taken to help make improvements in services. Our theoretical framework will hopefully lead to more health system research and improved care for patients suffering from this most dangerous form of tuberculosis.

Evaluating the foundations that help avert antimicrobial resistance: Performance of essential water sanitation and hygiene functions in hospitals and requirements for action in Kenya

BACKGROUND

Water Sanitation and Hygiene (WASH) in healthcare facilities is critical in the provision of safe and quality care. Poor WASH increases hospital-associated infections and contributes to the rise of antimicrobial resistance (AMR). It is therefore essential for governments and hospital managers to know the state of WASH in these facilities to set priorities and allocate resources.

METHODS

Using a recently developed survey tool and scoring approach, we assessed WASH across four domains in 14 public hospitals in Kenya (65 indicators) with specific assessments of individual wards (34 indicators). Aggregate scores were generated for whole facilities and individual wards and used to illustrate performance variation and link findings to specific levels of health system accountability. To help interpret and contextualise these scores, we used data from key informant interviews with hospital managers and health workers.

RESULTS

Aggregate hospital performance ranged between 47 and 71% with five of the 14 hospitals scoring below 60%. A total of 116 wards were assessed within these facilities. Linked to specific domains, ward scores varied within and across hospitals and ranged between 20% and 80%. At ward level, some critical indicators, which affect AMR like proper waste segregation and hand hygiene compliance activities had pooled aggregate scores of 45 and 35% respectively. From 31 interviews conducted, the main themes that explained this heterogenous performance across facilities and wards included differences in the built environment, resource availability, leadership and the degree to which local managers used innovative approaches to cope with shortages.

CONCLUSION

Significant differences and challenges exist in the state of WASH within and across hospitals. Whereas the senior hospital management can make some improvements, input and support from the national and regional governments are essential to improve WASH as a basic foundation for averting nosocomial infections and the spread of AMR as part of safe, quality hospital care in Kenya.

Exploring the space for task shifting to support nursing on neonatal wards in Kenyan public hospitals

BACKGROUND

Nursing practice is a key driver of quality care and can influence newborn health outcomes where nurses are the primary care givers to this highly dependent group. However, in sub-Saharan Africa, nursing work environments are characterized by heavy workloads, insufficient staffing and regular medical emergencies, which compromise the ability of nurses to provide quality care. Task shifting has been promoted as one strategy for making efficient use of human resources and addressing these issues.

AIMS AND OBJECTIVES

We aimed to understand the nature and practice of neonatal nursing in public hospitals in Nairobi so as to determine what prospect there might be for relieving pressure by shifting nurses' work to others.

METHODS

This paper is based on an 18-month qualitative study of three newborn units of three public hospitals-all located in Nairobi county-using an ethnographic approach. We draw upon a mix of 32 interviews, over 250 h' observations, field notes and informal conversations. Data were collected from senior nursing experts in newborn nursing, neonatal nurse in-charges, neonatal nurses, nursing students and support staff.

RESULTS

To cope with difficult work conditions characterized by resource challenges and competing priorities, nurses have developed a ritualized schedule and a form of 'subconscious triage'. Informal, organic task shifting was already taking place whereby particular nursing tasks were delegated to students, mothers and support staff, often without any structured supervision. Despite this practice, nurses were agnostic about formal institutionalization of task shifting due to concerns around professional boundaries and the practicality of integrating a new cadre into an already stressed health system.

CONCLUSION

Our findings revealed a routine template of neonatal nursing work which nurses used to control unpredictability. We found that this model of nursing encouraged delegation of less technical tasks to subordinates, parents and other staff through the process of 'subconscious triage'. The rich insights we gained from this organic form of task shifting can inform more formal task-shifting projects as they seek to identify tasks most easily delegated, and how best to support and work with busy nurses.

What does the literature tell us about health workers' experiences of task-shifting projects in sub-Saharan Africa? A systematic, qualitative review

AIMS AND OBJECTIVES

To review systematically, qualitative literature covering the implementation of task shifting in sub-Saharan Africa to address the growing interest in interventions of this kind. This review aims to distil the key practical findings to both guide a specific project aiming to improve the quality of neonatal care in Kenya and to contribute to the broader literature.

BACKGROUND

Task-shifting programmes aim to improve access to healthcare by delegating specific tasks from higher to lower skilled health workers. Evidence suggests that task-shifting programmes in sub-Saharan Africa may improve patient outcomes, but they have also been criticised for providing fragmented, unsustainable services. This systematic review of qualitative literature summarises factors affecting implementation of task shifting and how such interventions in sub-Saharan Africa may have affected health workers' feelings about their own positions and their ability to provide care.

DESIGN

Following literature search, a modified Critical Appraisal Skills Program (CASP) framework was used to assess quality. Thereafter, analysis adopted a thematic synthesis approach.

METHODS

A systematic literature search identified qualitative studies examining task -shifting interventions in sub-Saharan Africa. Thematic synthesis was used to identify overarching themes arising from across the studies and infer how task-shifting interventions may impact on the health workers from whom tasks are being shifted.

RESULTS

From the 230 studies screened, 13 met the inclusion criteria. Overarching themes identified showed that task shifting has been associated with jurisdictional debates linked to new cadres working beyond their scope of practice, and tension around compensation and career development for those taking on tasks that were being delegated.

CONCLUSIONS

Based on the qualitative data available, it appears that task shifting may negatively impact the sense of agency and the ability to perform of health workers' from whom tasks are shifted. The potential implications of task shifting on all health workers should be considered prior to implementing task-shifting solutions.

Validation and determination of taselisib, a β-sparing phosphoinositide 3-kinase (PI3K) inhibitor, in human plasma by LC-MS/MS

A liquid chromatographic-tandem mass spectrometry (LC-MS/MS) method for the determination of taselisib (GDC-0032, RO5537381) concentrations in human plasma has been developed and validated to support bioanalysis of clinical samples. Solid phase extraction (SPE) was used to extract plasma samples (50μL) and the resulting samples were analyzed using reversed phase chromatography and mass spectrometry coupled with an atmospheric pressure chemical ionization interface. The mass analysis of taselisib was performed using multiple reaction monitoring transitions in positive ionization mode. The method was validated over the calibration curve range 0.400-400ng/mL using linear regression and 1/x(2) weighting. The within-run relative standard deviation (%RSD) ranged from 1.3 to 5.6%, while the between-run %RSD varied from 2.0 to 4.5% for LLOQ, low, medium, medium high and high QCs. The accuracy ranged from 94.7 to 100.3% of nominal for within-run and 96.0-99.0% of nominal for between-run for the same QCs. Extraction recovery of taselisib was between 83.8% and 92.9%. Stability of taselisib was established in human plasma for 977days at -20°C and -70°C and established in sample extracts for 96h when stored at 2 - 8°C. Stable-labeled internal standard was used to minimize matrix effects. Mean single dose pharmacokinetic parameters determined using this method for a phase I/II clinical trial were: Cmax=35.2ng/mL, AUC0-inf=1570ngh/mL, and T1/2=39.3h.

End-stage renal disease and survival in people with diabetes: a national database linkage study

BACKGROUND

Increasing prevalence of diabetes worldwide is projected to lead to an increase in patients with end-stage renal disease (ESRD) requiring renal replacement therapy (RRT).

AIM

To provide contemporary estimates of the prevalence of ESRD and requirement for RRT among people with diabetes in a nationwide study and to report associated survival.

METHODS

Data were extracted and linked from three national databases: Scottish Renal Registry, Scottish Care Initiative-Diabetes Collaboration and National Records of Scotland death data. Survival analyses were modelled with Cox regression.

RESULTS

Point prevalence of chronic kidney disease (CKD)5 in 2008 was 1.63% of 19 414 people with type 1 diabetes (T1DM) compared with 0.58% of 167 871 people with type 2 diabetes (T2DM) (odds ratio for DM type 0.97, P = 0.77, on adjustment for duration. Although 83% of those with T1DM and CKD5 and 61% of those with T2DM and CKD5 were receiving RRT, there was no difference when adjusted for age, sex and DM duration (odds ratio for DM type 0.83, P = 0.432). Diabetic nephropathy was the primary renal diagnosis in 91% of people with T1DM and 58% of people with T2DM on RRT. Median survival time from initiation of RRT was 3.84 years (95% CI 2.77, 4.62) in T1DM and 2.16 years (95% CI: 1.92, 2.38) in T2DM.

CONCLUSION

Considerable numbers of patients with diabetes continue to progress to CKD5 and RRT. Almost half of all RRT cases in T2DM are considered to be due to conditions other than diabetic nephropathy. Median survival time for people with diabetes from initiation of RRT remains poor. These prevalence data are important for future resource planning.

Delay in starting insulin after failure of other treatments in patients with type 2 diabetes mellitus

BACKGROUND AND AIM

In type 2 diabetes mellitus (T2DM), therapies to maintain blood glucose control usually fail after several years. The aim of this study was to estimate the time to insulin initiation, the glycemic burden that patients are exposed prior to conversion to insulin and their HbA1c level at that time and a year later.

MATERIAL AND METHODS

Five hundred nine patients were included in this retrospective study. We identified patients with T2DM who started insulin therapy from 01/01/2002 to 30/06/2011, from the Scottish Care Information-Diabetes Collaboration (SCI-DC) database of Western General Hospital, Edinburgh, Scotland. We estimated the duration of diabetes prior to conversion to insulin therapy, the months they spent with glycated hemoglobin (HbA1c) above 7%, 8% or 9% until starting insulin, HbA1c and body weight (BW) at the time of conversion, at 6 and at 12 months before and after conversion.

RESULTS

Patients started insulin therapy after a median period of 6.2 (1-30) years after diagnosis of T2DM. Median HbA1c was 10% (range 7.2-17.9) at the time of conversion, 8.8% (5. 8-16.9) at six months before and 8.3% (5.2-15) at 12 months before conversion, and 8.4% (4.7-14.3) at 6 months and 8.2% (5-14.7) at 12 months after conversion. Body weight (BW) was 86.6 kg (39.6-179.8) at the time of conversion and 91 kg (42.7-196) at 12 months after conversion. Patients spent a median period of 49 (0-325) months with HbA1c >7%, 25 (0-163) months with HbA1c >8% and 10 (0-135) months with HbA1c >9%. Insulin treatment resulted in a decrease in HbA1c at 12 months of 1.8% (p<0.05) but in an increase in BW by 2.9 kg (p<0.05).

CONCLUSION

Healthcare professionals delay the initiation of insulin in patients with type 2 diabetes until their HbA1c exceeds 10%. As a result, patients are exposed to a significant glycemic burden. Change in treatment improves their glycemic control for the next 12 months. Hippokratia 2014; 18 (4): 306-309.

A supported liquid extraction-LC-MS/MS method for determination of GDC-0980 (Apitolisib), a dual small-molecule inhibitor of class 1A phosphoinositide 3-kinase and mammalian target of rapamycin, in human plasma

A liquid chromatographic-tandem mass spectrometry (LC-MS/MS) method for the determination of GDC-0980 (Apitolisib) concentrations in human plasma has been developed and validated to support clinical development. Supported liquid extraction (SLE) was used to extract plasma samples (80μL) and the resulting samples were analyzed using reverse-phase chromatography and mass spectrometry coupled with a turbo-ionspray interface. The mass analysis of GDC-0980 was performed using multiple reaction monitoring (MRM) transitions in positive ionization mode. The method was validated over the calibration curve range 0.0500-25.0ng/mL using linear regression and 1/x(2) weighting. Within-run relative standard deviation (%RSD) ranged from 0.4 to 3.9%, while the between-run %RSD varied from 1.1 to 1.5% for QCs. The accuracy ranged from 96.1% to 106.7% of nominal for within-run and 96.7-106.7% of nominal for between-run at all concentrations including the LLOQ quality control at 0.0500ng/mL. Extraction recovery of GDC-0980 was between 72.4% and 75.5%. Stability of GDC-0980 was established in human plasma for 547 days at -20°C and -70°C and established in reconstituted sample extracts for 146h when stored at 2-8°C. Stable-labeled internal standard was used to minimize matrix effects. Mean pharmacokinetic parameters determined using this method for the day 1 control group in a phase I trial were: Cmax=11.1ng/mL, AUC0-inf=108ngh/mL, and T1/2=13.1h.