Health System Approach Research Articles

Achieving CT Regulatory Compliance: A Comprehensive and Continuous Quality Improvement Approach

Computed tomography (CT) represents one of the largest sources of radiation exposure to the public in the United States. Regulatory requirements now mandate dose tracking for all exams and investigation of dose events that exceed set dose thresholds. Radiology practices are tasked with ensuring quality control and optimizing patient CT exam doses while maintaining diagnostic efficacy. Meeting regulatory requirements necessitates the development of an effective quality program in CT. This review provides a template for accreditation compliant quality control and CT dose optimization. The following paper summarizes a large health system approach for establishing a quality program in CT and discusses successes, challenges, and future needs.

Text2Connect: a health system approach to engage tobacco users in quitline cessation services via text messaging.

Mobile technology has created the opportunity for health systems to provide low cost tobacco cessation assistance to patients. The goal of the present study was to examine the feasibility and effectiveness of an intervention (Text2Connect) that uses text messages to offer proactive connection to the New York State Smokers' Quitline. The electronic health record at two urban health systems was queried for patients who were current smokers and who had an outpatient visit between March 2015 and February 2016. Smokers (N = 4000) were sent an informational letter. Those who did not opt out (N = 3719) were randomized to one of 6 message sequences in order to examine the effect of theoretically informed message frames on response rates. Participants were sent a series of text messages at baseline and at 1 month and were asked to reply in order to be contacted by the state quitline (QL). After removing 1403 nonworking numbers, texts were sent to 2316 patients, and 10.0% (205/2060) responded with a QL request. Almost one quarter (23.6%, 486/2060) replied STOP and 66.4% (1369/2060) never responded. QL request rates were significantly higher when response efficacy messages were not used (p < .001). There were no differences by message framing on STOP requests (p > .05). The Text2Connect intervention was well accepted with a minority opting out. A 10% QL response rate is noteworthy given that only 5-7 brief outreach text messages were used. Results indicate that simple self-efficacy-focused messaging is most effective at supporting response rates.

Health inequities in unscheduled healthcare for children with intellectual disabilities in Ireland: a study protocol

Background: Health inequities for children with intellectual disabilities (ID) are prevalent within different health systems, and children with ID have shorter life expectancies than the general population, higher mortality rates before the age of 17 and have a greater risk of potentially preventable hospitalisations. A health systems approach to research in this area provides a useful means through which research can inform policy and practice to ensure people with ID receive equitable healthcare; however, there is a paucity of evidence regarding how to address differences that have been described in the literature to date. The overall aim of this research is to establish the extent of health inequities for children with ID in Ireland compared to children without ID with respect to their utilisation of primary care and rates of hospitalisation, and to gain a better understanding of what influences utilisation of primary care and ED services in this population. Methods and analysis: The design of this research adopts a mixed-methods approach: statistical analysis of health data to determine the extent of health inequities in relation to healthcare utilisation; discrete choice experiments to explore General Practitioners' decision making and parental preferences for optimal care; and concept mapping to develop consensus between stakeholders on how to address current healthcare inequities. Discussion: By applying a systems lens to the issue of health inequities for children with ID, the research hopes to gain a thorough understanding of the varying components that can contribute to the maintenance of such healthcare inequities. A key output from the research will be a set of feasible solutions and interventions that can address health inequities for this population.

Racial Disparities in Pediatric Psychiatric Emergencies: A Health Systems Approach.

Less than half of African American youth with severe mental disorders receive psychiatric care. When they do receive care, African American youth use the Emergency Department at higher rates than whites. We examine whether rapid expansion of primary mental health care at Community Health Centers reduces Emergency Department visits for psychiatric care especially among African American youth. Through four studies, we examine (1) the impact of mental health service capacity on the disparity of psychiatric care among African American youth; (2) how Community Health Center mental health visits vary with repeat psychiatric emergency visits; (3) the county-level drivers of the expansion of Community Health Centers; and (4) how Community Health Center expansion affects overall psychiatric emergency care. Results indicate that increased continuity of mental health care at Community Health Centers corresponds with a reduction in racial disparities in youth psychiatric ED visits. In addition, an increase in Community Health Center capacity varies inversely with repeated psychiatric Emergency Department visits and inversely with psychiatric Emergency Department visits overall. And finally, results show an increase in Community Health Center mental health services among counties with greater poverty, lower physician availability, and higher percentage of uninsured. Our studies indicate that expansion of federally-funded primary mental health services affects the overall system of emergency psychiatric care. However, this expansion does not appear to dramatically reduce racial/ethnic disparities in psychiatric emergency department visits.

The impact of health education on attitudes of parents and religious leaders towards female genital mutilation

BackgroundPrevious studies conducted in Iraqi Kurdistan have reported that parent’s decisions to circumcise their daughters are based on religious or cultural beliefs. Despite the widespread practice of female genital mutilation...

Primary eye care in India - The vision center model.

The World Health Organization (WHO) Global Action Plan (GAP) 2014-19 emphasize providing Comprehensive Eye Care (CEC) using the health system approach to achieve Universal Eye Health Coverage (UEHC). An important aspect of CEC is Primary Eye Care (PEC). The scope of PEC varies significantly with primary health workers providing PEC in most parts of the developing world, whereas in developed nations PEC is provided by specialized personnel such as optometrists. This article focuses on delivery of PEC models in India, specifically through the vision center (VC) approach. VCs are part of a larger eye care network and provide PEC in remote rural areas of the country. The authors describe the how PEC is delivered in more than 300 VCs operated by six mentor hospitals in India under the Global Sight Initiative (GSI). Key factors compared include: The role of leadership; human resource planning, including recruitment and retention; service delivery; leveraging technology for planning and reaching key populations; financial sustainability; supply chain management; and quality and monitoring. It also discusses issues to be considered to strengthen VCs as we move ahead towards our collective goal of achieving UEHC and eliminating avoidable blindness.

The approach to gender violence from the perspective of communities in northern Córdoba Province, Argentina

Gender violence is a human rights violation and a serious public health problem that should be addressed with an inter-sector and interdisciplinary focus. Collaboration and coordination between sectors, including the health sector, is essential for guaranteeing such approach. The study aimed to learn which actors address gender violence in the communities and to study the communities' opinions concerning the public health system's role in (and approach to) this problem. A qualitative action-research project was conducted with local community self-diagnosis workshops, using various qualitative techniques and thematic analysis. The results pointed to various local actors that address the problem and showed that primary healthcare plays a relevant role, due mainly to its proximity to the population and interdisciplinary approach. The obstacles identified by the communities for the health system approach mainly involved the biomedical model of care, decentralization, and lack of resources, training, and integrated policies. In conclusion, the workshops facilitated the development of collective knowledge on the local reality, underlining the role of primary healthcare and the need to link action and approaches between sectors and communities.

Phytomedicinal and Nutraceutical Benefits of the GC-FID Quantified Phytocomponents of the Aqueous Extract of Azadirachta indica leaves

Background: The continued human disruptive exploitation of the ecosystem has given room to sustained health hazard due to saturated environmental free radicals culminating in the emergence of disease states borne out of low immune systems and damaged body cells orchestrated by environmental free radicals causing the diminished quality of life and life-span. Health system approach to therapy exploiting and utilizing the rich antioxidants and other useful phytocontituents of plant origin as free radical scavengers will go a long way to boost the quality of life and immune system as well as lessen morbidity and mortality rates.

Understanding mistreatment during institutional delivery in Northeast Nigeria: a mixed-method study

BackgroundImproving quality of care including the clinical aspects and the experience of care has been advocated for improved coverage and better childbirth outcomes.ObjectiveThis study aimed to explore the quality of care relating to the prevalence and manifestations of mistreatment during institutional birth in Gombe State, northeast Nigeria, an area of low institutional delivery coverage.MethodsThe frequency of dimensions of mistreatment experienced by women delivering in 10 health facilities of Gombe State were quantitatively captured during exit interviews with 342 women in July–August 2017. Manifestations of mistreatment were qualitatively explored through in-depth interviews and focus groups with 63 women living in communities with high and low coverage of institutional deliveries.ResultsThe quantitative data showed that at least one dimension of mistreatment was reported by 66% (95% confidence interval (CI) 45–82%) of women exiting a health facility after delivery. Mistreatment related to health system conditions and constraints were reported in 50% (95% CI 31–70%) of deliveries. In the qualitative data women expressed frustration at being urged to deliver at the health facility only to be physically or verbally mistreated, blamed for poor birth outcomes, discriminated against because of their background, left to deliver without assistance or with inadequate support, travelling long distances to the facility only to find staff unavailable, or being charged unjustified amount of money for delivery.ConclusionsMistreatment during institutional delivery in Gombe State is highly prevalent and predominantly relates to mistreatment arising from both health system constraints as well as health worker behaviours, limiting efforts to increase coverage of institutional delivery. To address mistreatment during institutional births, strategies that emphasise a broader health systems approach, tackle multiple causes, integrate a detailed understanding of the local context and have buy-in from grassroots-level stakeholders are recommended.

Researching the health workforce: a framework for action

Abstract Background The importance of a sustainable health workforce is increasingly recognised. However, the building of a future health workforce that is responsive to diverse population needs and demographic and economic change remains challenging. There is a need to improve research and education to address these questions effectively and build capacity for public health approaches in health workforce policy. This paper introduces an agenda for health workforce research. Methods The research agenda has been developed through bringing together expertise and knowledge from a wide range of authors and leading organisations involved in health workforce research and policy. It takes a health system approach and focuses on Europe. Results Six major objectives for health workforce policy were identified: (1) to develop frameworks that align health systems/governance and health workforce policy/planning, (2) to explore the effects of changing skill mixes and competencies across sectors and occupational groups, (3) to map how education and health workforce governance can be better integrated, (4) to analyse the impact of health workforce mobility on health systems, (5) to optimise the use of international/EU, national and regional health workforce data and monitoring and (6) to build capacity for policy implementation. The research highlights critical knowledge gaps that currently hamper the opportunities of effectively responding to these challenges and advising policymakers in different health systems. Closing these knowledge gaps is therefore an important step towards future health workforce governance and policy implementation. Conclusions There is an urgent need for building health workforce research as an independent, interdisciplinary and multi-professional field. Action has to be taken to establish new training courses and Master programmes to create competences for leadership in health workforce research.

2059. Antimicrobial Stewardship of Community Parenteral Antimicrobial Therapy: A Health System Approach

BackgroundCommunity parenteral antimicrobial therapy (CoPAT) allows patients to receive intravenous (IV) antimicrobials outside the hospital; however, inappropriate use occurs and can lead to adverse outcomes. In addition, these patients are at high risk of readmission. Our objective was to assess the quality of CoPAT in a large healthcare system in order to guide implementation of an intervention requiring mandatory review by antimicrobial stewardship.MethodsWe identified patients with orders for IV antimicrobials at discharge between January 1 and December 10, 2018. Patients were excluded if transferred to an acute care facility, left against medical advice, or died. 250 patients were selected using a random number generator and reviewed consecutively until 100 confirmed CoPAT encounters were identified. Each encounter was evaluated for evidence of ID consultation, opportunities for stewardship interventions in seven categories (See Table 1), and adverse events such as emergency room (ER) visits and readmissions.ResultsThe query identified 4,642 potential CoPAT discharges from 22 hospitals (see Table 2). 117 encounters were reviewed to reach 100 true CoPAT discharges (85% query accuracy). Of these, 55 (55%) received a formal ID consult, 6 (6%) had an ID pharmacist or ID physician curbside, and 5 (5%) had an ID clinic follow-up appointment scheduled without formal ID consult. Opportunity for stewardship intervention was found in 50 (50%) patients (see Table 1). There were 31 (31%) patients who were seen in the ER (n = 21) and/or re-admitted (n = 19) to the hospital during or shortly after completion of CoPAT, of which 25 (81%) were potentially related to CoPAT, including abnormal laboratory findings, PICC-line complications, and signs or symptoms of infection.ConclusionCoPAT patients are complex with high healthcare utilization. Mandatory ID review of patients receiving CoPAT has the potential to impact 2,000 lives annually in a large health system. Disclosures All authors: No reported disclosures.

Artificial intelligence in clinical imaging: a health system approach

The development and application of artificial intelligence (AI) to radiology requires an approach that encompasses a health system. The UK government and National Health Service (NHS) are creating an ecosystem to facilitate academic/industrial partnerships aimed at accelerating the creation of relevant and robust AI tools, which will improve the development and delivery of healthcare imaging. A series of recent initiatives are described, which will drive the development and adoption of AI in clinical imaging.

Aetiology of invasive bacterial infection and antimicrobial resistance in neonates in sub-Saharan Africa: a systematic review and meta-analysis in line with the STROBE-NI reporting guidelines

Aetiological data for neonatal infections are essential to inform policies and programme strategies, but such data are scarce from sub-Saharan Africa. We therefore completed a systematic review and meta-analysis of available data from the African continent since 1980, with a focus on regional differences in aetiology and antimicrobial resistance (AMR) in the past decade (2008-18). We included data for microbiologically confirmed invasive bacterial infection including meningitis and AMR among neonates in sub-Saharan Africa and assessed the quality of scientific reporting according to Strengthening the Reporting of Observational Studies in Epidemiology for Newborn Infection (STROBE-NI) checklist. We calculated pooled proportions for reported bacterial isolates and AMR. We included 151 studies comprising data from 84 534 neonates from 26 countries, almost all of which were hospital-based. Of the 82 studies published between 2008 and 2018, insufficient details were reported regarding most STROBE-NI items. Regarding culture positive bacteraemia or sepsis, Staphylococcus aureus, Klebsiella spp, and Escherichia coli accounted for 25% (95% CI 21-29), 21% (16-27), and 10% (8-10) respectively. For meningitis, the predominant identified causes were group B streptococcus 25% (16-33), Streptococcus pneumoniae 17% (9-6), and S aureus 12% (3-25). Resistance to WHO recommended β-lactams was reported in 614 (68%) of 904 cases and resistance to aminoglycosides in 317 (27%) of 1176 cases. Hospital-acquired neonatal infections and AMR are a major burden in Africa. More population-based neonatal infection studies and improved routine surveillance are needed to improve clinical care, plan health systems approaches, and address AMR. Future studies should be reported according to standardised reporting guidelines, such as STROBE-NI, to aid comparability and reduce research waste. Uduak Okomo was supported by a Medical Research Council PhD Studentship.

Deriving literature-based benchmarks for pediatric appendectomy and cholecystectomy complications from national databases in high-income countries: A systematic review and meta-analysis

BackgroundHealth systems must identify preventable adverse outcomes to improve surgical safety. We conducted a systematic review to determine national rates of postoperative complications associated with two common pediatric surgery operations in High-Income Countries (HICs). MethodsNational database studies of complication rates associated with pediatric appendectomies and cholecystectomies (2000–2016) in Canada, the US, and the UK were included. Outcomes included mortality, length of hospital stay (LOS), and other surgical complications. Outcome data were extracted and comparisons made between countries and databases. ResultsThirty-three papers met inclusion criteria (1 Canadian, 1 UK, and 4 US Databases). Mean LOS was 3.00 (±1.42) days and 3.44 (±1.55) days for appendectomy and cholecystectomy, respectively. Mortality was 0.06% after appendectomy and 0.24% after cholecystectomy. Readmission and reoperation rates were 6.79% and 0.32% for appendectomy, and 1.37% and 0.71% for cholecystectomy. For appendectomies, LOS was shorter in Canadian and UK studies compared to US studies, and mortality and readmission rates were lower (OR 0.46 95%CI 0.23 to 0.93, OR 3.63 to 3.77 95%CI) in UK studies compared to US studies. ConclusionsOutcomes after pediatric appendectomy and cholecystectomy are good but vary between HICs. Understanding national outcomes and intercountry differences is essential in developing health system approaches to pediatric surgical safety. Level of evidenceII

Cooling The Hot Spots Where Child Hospitalization Rates Are High: A Neighborhood Approach To Population Health.

Improving population health requires a focus on neighborhoods with high rates of illness. We aimed to reduce hospital days for children from two high-morbidity, high-poverty neighborhoods in Cincinnati, Ohio, to narrow the gap between their neighborhoods and healthier ones. We also sought to use this population health improvement initiative to develop and refine a theory for how to narrow equity gaps across broader geographic areas. We relied upon quality improvement methods and a learning health system approach. Interventions included the optimization of chronic disease management; transitions in care; mitigation of social risk; and use of actionable, real-time data. The inpatient bed-day rate for the two target neighborhoods decreased by 18percent from baseline (July 2012-June 2015) to the improvement phase (July 2015-June 2018). Hospitalizations decreased by 20percent. There was no similar decrease in demographically comparable neighborhoods. We see the neighborhood as a relevant frame for achieving equity and building a multisector culture of health.

Collaborative design of a decision aid for stroke survivors with multimorbidity: a qualitative study in the UK engaging key stakeholders

ObjectivesEffective secondary stroke prevention strategies are suboptimally used. Novel development of interventions to enable healthcare professionals and stroke survivors to manage risk factors for stroke recurrence are required. We sought...

The right to health as the basis for universal health coverage: A cross-national analysis of national medicines policies of 71 countries.

Persistent barriers to universal access to medicines are limited social protection in the event of illness, inadequate financing for essential medicines, frequent stock-outs in the public sector, and high prices in the private sector. We argue that greater coherence between human rights law, national medicines policies, and universal health coverage schemes can address these barriers. We present a cross-national content analysis of national medicines policies from 71 countries published between 1990–2016. The World Health Organization’s (WHO) 2001 guidelines for developing and implementing a national medicines policy and all 71 national medicines policies were assessed on 12 principles, linking a health systems approach to essential medicines with international human rights law for medicines affordability and financing for vulnerable groups. National medicines policies most frequently contain measures for medicines selection and efficient spending/cost-effectiveness. Four principles (legal right to health; government financing; efficient spending; and financial protection of vulnerable populations) are significantly stronger in national medicines policies published after 2004 than before. Six principles have remained weak or absent: pooling user contributions, international cooperation, and four principles for good governance. Overall, South Africa (1996), Indonesia and South Sudan (2006), Philippines (2011–2016), Malaysia (2012), Somalia (2013), Afghanistan (2014), and Uganda (2015) include the most relevant texts and can be used as models for other settings. We conclude that WHO’s 2001 guidelines have guided the content and language of many subsequent national medicines policies. WHO and national policy makers can use these principles and the practical examples identified in our study to further align national medicines policies with human rights law and with Target 3.8 for universal access to essential medicines in the Sustainable Development Goals.

Post - effects of obstetric fistula in Uganda; a case study of fistula survivors in KITOVU mission hospital (MASAKA), Uganda

BackgroundObstetrical fistula (OF) is a public health challenge that is among the previously neglected components of maternal health in the developing world. The condition, which in the recent past has increasingly drawn more attention from the public, has a devastating impact on the health and wellbeing of both women and girls worldwide. The most common cause of obstetric fistula in developing countries is prolonged obstructed labor affecting approximately 2 million women and girls across Africa and Asia.The objective of this study was to examine the post-effects of fistula and reintegration strategies of fistula survivors in Uganda.MethodsA descriptive case study design was used to collect data from women aged 15–49 years who had experienced OF and been successfully treated/repaired. Data collection was aided by in-depth interview guides designed for collecting qualitative data which was analyzed using thematic and content analysis.ResultsThe study results showed that 45.6% were aged 18–24 years, 43% had only primary level education and 55.7% of the women were married. Fistula survivors continue to suffer from shame, rejection, isolation and stigma, trauma and disgrace among other effects even after successful repair/surgery. Some of the reintegration strategies for fistula survivors include; seeking for successful repair, remarriage and relocation from their parent communities to new environments.ConclusionIn addition to capacity building, changing attitudes and strengthening the health system, a comprehensive and holistic fistula care approach is required to facilitate the reintegration process and restoration of women dignity.

Do Quality Improvement Initiatives Improve Outcomes for Patients in Antiretroviral Programs in Low- and Middle-Income Countries? A Systematic Review.

There have been a range of quality improvement (QI) and quality assurance initiatives in low- and middle-income countries to improve antiretroviral therapy (ART) treatment outcomes for people living with HIV. To date, these initiatives have not been systematically assessed and little is known about how effective, cost-effective, or sustainable these strategies are in improving clinical outcomes. We conducted a systematic review adhering to PRISMA guidelines (PROSPERO ID: CRD42017071848), searching PubMed, MEDLINE, Embase, Web of Science, and the Cochrane database of controlled trials for articles reporting on the effectiveness of QI and quality assurance initiatives in HIV programs in low- and middle-income countries in relation to ART uptake, retention in care, adherence, viral load suppression, mortality, and other outcomes including cost-effectiveness and long-term sustainability. One thousand eight hundred sixty articles were found, of which 29 were included. QI approaches were categorized as follows: (1) health system approaches using QI methods; (2) QI learning networks including collaboratives; (3) standard-based methods that use QI tools to improve performance gaps; and (4) campaigns using QI methods. The greatest improvements were seen in ART uptake [median increase of 14.0%; interquartile range (IQR) -9.0 to 29.3], adherence [median increase of 22.0% (IQR -7.0 to 25.0)], and viral load suppression [median increase 26.0% (IQR -8.0 to 26.0)]. QI interventions can be effective in improving clinical outcomes; however, there was significant variability, making it challenging to identify which aspects of interventions lead to clinical improvements. Standardizing reporting and assessment of QI initiatives is needed, supported by national quality policies and directorates, and robust research.

Creating online personal medical accounts: Recent experience in two developed countries

BackgroundOnline personal medical accounts are increasingly viewed as a useful mechanism to both inform and educate patients and citizens about their individual health condition. A number of countries have announced major national projects to put this type of information system in place. MethodsThis article adopts a comparative health systems approach to examine the experience of two smaller developed countries – Taiwan and Estonia – that now have universal national medical account systems in current service. The comparison focuses on the structural similarities and differences of both core characteristics of these two health systems and of their specific personal medical account arrangements. ResultsWhile Taiwan has multiple separated systems with voluntary options for patients, Estonia has a single integrated one which is mandatory for all citizens. Further, the Estonian system is more advanced in providing the ability to book or cancel medical appointments. Both systems directly control patients for system management purposes, allow patients access to prior medical records, and reorient the focus of health management from curative toward preventive care. A centralized and technically competent government agency and the political willingness of citizens to grant information-gathering powers to it appear to be essential elements in the successful implementation of these systems. Concerns about individual privacy protection and citizens' ability to decide whether to participate are also discussed. ConclusionA number of core issues regarding the technical introduction and political acceptability of personal medical accounts remain unresolved and will require considerable attention in the future.