Mortality In South Africa Research Articles

Levels and Trends of Under-Five Mortality in South Africa from 1998 to 2012

Levels and Trends of Under-Five Mortality in South Africa from 1998 to 2012

Evaluating the time interval from diagnosis to fibrinolysis at centres in the drainage area of Tygerberg Hospital, Cape Town, South Africa

ST-segment elevation myocardial infarction (STEMI) is one of the main contributors to morbidity and mortality in South Africa (SA). Timeous intervention by means of percutaneous coronary intervention (PCI) or fibrinolysis can significantly improve the outcome of STEMI. To determine the median time interval between diagnosis and fibrinolysis in patients presenting to centres within the drainage area of Tygerberg Hospital, Cape Town, SA, and compare it with the European Society of Cardiology (ESC) recommendation of 10 minutes. A retrospective medical record review of patients presenting to the abovementioned centres between 1 March 2017 and 28 February 2018 was performed. The primary presenting centre, time between diagnosis and fibrinolysis and discharge medication were recorded, in addition to other relevant demographic information. A total of 492 patients were identified, of whom 447 were included in the study. Three hundred and eighteen patients received fibrinolysis, of whom 18 (5.7%) were treated within 10 minutes of diagnosis. The median time interval between diagnosis and fibrinolysis was 67 (interquartile range (IQR) 32.5 -122.5) minutes. Most patients received fibrinolysis >10 minutes after diagnosis, which indicates suboptimal therapy when compared with the ESC guidelines. Future studies should investigate the factors prolonging this therapeutic delay.

Trends in Suicide Mortality in South Africa, 1997 to 2016.

Suicide rates worldwide are declining; however, less is known about the patterns and trends in mortality from suicide in sub-Saharan Africa. This study evaluates trends in suicide rates and years of potential life lost from death registration data in South Africa from 1997 to 2016. Suicide (X60–X84 and Y87) was coded using the 10th Revision of the International Classification of Diseases (ICD-10). Changes in mortality rate trends were analysed using joinpoint regression analysis. The 20-year study examines 8573 suicides in South Africa, comprising 0.1% of all deaths involving persons 15 years and older. Rates of suicide per 100,000 population were 2.07 in men and 0.49 in women. Joinpoint regression analyses showed that, while the overall mortality rate for male suicides remained stable, mortality rates due to hanging and poisoning increased by 3.9% and 3.5% per year, respectively. Female suicide mortality rates increased by 12.6% from 1997 to 2004 before stabilising; while rates due to hanging increased by 3.0% per year. The average annual YPLL due to suicide was 9559 in men and 2612 in women. The results show that suicide contributes substantially to premature death and demonstrates the need for targeted interventions, especially among young men in South Africa.

The search for a simple injury score to reliably discriminate the risk of in-hospital mortality in South Africa

BackgroundThe Injury Severity Score and Trauma and Injury Severity Score are used commonly to quantify the severity of injury, but they require comprehensive data collection that is impractical in many low- and middle-income countries . We sought to develop an injury score that is more feasible to implement in low- and middle-income countries with discrimination similar to the Injury Severity Score and the Trauma and Injury Severity Score. MethodsClinical data from KwaZulu-Natal, South Africa were used to compare the discrimination of the Injury Severity Score and the Trauma and Injury Severity Score with that of the 5, simple injury scores that rely primarily on physiologic data: Revised Trauma Score for Triage, “Mechanism, Glasgow Coma Scale, Age, Pressure” Score, Kampala Trauma Score, modified Kampala Trauma Score, and “Reversed Shock Index Multiplied by Glasgow Coma Scale” Score. ResultsData for 3,991 patients were analyzed. The Trauma and Injury Severity Score, the Injury Severity Score, and Kampala Trauma Score had similar discrimination (area under the receiver operating curve 0.85, 0.84, and 0.84, respectively). The simple injury scores demonstrated worse discrimination among patients presenting more than 6 hours postinjury, although Kampala Trauma Score maintained the best discrimination of the simple injury scores. ConclusionIn this patient population, Kampala Trauma Score demonstrated discrimination similar to the Injury Severity Score and the Trauma and Injury Severity Score and may be useful to quantify the severity of injury when calculation of the Injury Severity Score or the Trauma and Injury Severity Score is not feasible. Delay in presentation can degrade the discrimination of simple injury scores that rely primarily on physiologic data.

Assessing joint spatial autocorrelations between mortality rates due to cardiovascular conditions in South Africa.

South Africa is experiencing an increasing burden of noncommunicable diseases (NCDs). There is evidence of co-morbidity of several NCDs at small geographical areas in the country. However, the extent to which this applies to joint spatial autocorrections of NCDs is not known. The objective of this study was to derive and quantify multivariate spatial autocorrections for NCDrelated mortality in South Africa. The study used mortality attributable to cerebrovascular, ischaemic heart failure and hypertension captured by the country's Department of Home Affairs for the years 2001, 2007 and 2011. Both univariate and pairwise spatial clustering measures were derived using observed, empirical Bayes smoothed and age-adjusted standardised mortality rates. Cerebrovascular and ischaemic heart co-clustering was significant for the years 2001 and 2011. Cerebrovascular and hypertension co-clustering was significant for the years 2007 and 2011, while hypertension and ischaemic heart co-clustering was significant for the year 2011. Co-clusters of cerebrovascular-ischaemic heart disease are the most profound and located in the south-western part of the country. It was successfully demonstrated that bivariate spatial autocorrelations can be derived for spatially dependent mortality rates as exemplified by mortality rates attributed to three cardiovascular conditions. The identified co-clusters of spatially dependent health outcomes may be targeted for an integrated intervention and monitoring programme.

Venous thromboembolism in pregnancy

Pregnancy-related venous thromboembolic events are important preventable causes of morbidity and mortality in South Africa. All pregnant patients should be evaluated for thrombotic risk at different stages of their pregnancy and appropriate preventive steps taken. Maternal and fetal wellbeing must be kept in mind, as well as physiological changes leading to altered drug pharmacokinetics. Managing the patient with thrombotic risk in pregnancy, diagnosing venous thromboembolism (VTE) during pregnancy and treatment of venous thromboembolic events should be managed by a team. Excellent recent reviews on this subject are available, including risk factor stratification in anticoagulant therapy; managing the patient at time of labour; diagnosing VTE; and managing neuraxial anaesthesia in the pregnant patient on anticoagulant therapy.

Figures of the dead: A decade of tuberculosis mortality registrations in South Africa.

South Africa (SA) is committed to reducing tuberculosis (TB) mortality rates in line with the World Health Organization's End TB Strategy and the Sustainable Development Goal (SDG) targets. From mortality reports released by Statistics South Africa, this study analysed reported TB mortality in SA from 2006 to 2016 to inform our understanding of TB mortality and the development of strategies needed to attain the SDG targets. TB mortality includes all deaths reported to the Department of Home Affairs with TB reported as the underlying cause of death based on the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) definition. Although TB remains the leading cause of death, TB mortality rates in SA have fallen substantially in the past decade. From 2006 to 2016, the number of deaths due to TB plummeted from 76 881 to 29 399 and the proportion of all-cause mortality due to TB more than halved from 13% to <6%. Furthermore, the profile of people dying from TB has changed, with a decrease in the proportion of children aged <15 years, adults of reproductive age (15 - 49) and women, and an increase in the proportion aged ≥50. This change has largely mirrored the overall pattern of deaths in SA, with large decreases in deaths in adults aged 15 - 49, especially women, thought to be because of the scale-up of the antiretroviral treatment programme for HIV. The End TB Strategy target of a 95% reduction in TB mortality by 2035 is achievable in SA. However, sustained effort in high-risk groups together with improved vital registration data are needed to ensure attainment of the target.

An analysis of the direct cost of renal dialysis provided through a public-private partnership at a tertiary hospital in Limpopo Province, South Africa.

Chronic kidney disease (CKD) is increasingly recognised as an important cause of morbidity and mortality in South Africa (SA). Although the cost of dialysis is well documented in developed countries, little is known about this cost in sub-Saharan Africa. To review the costs of providing peritoneal dialysis (PD) and haemodialysis (HD) at the Pietersburg renal dialysis public-private partnership (PPP) unit in Limpopo Province, SA. A retrospective review of the cost of inputs required for HD and PD was conducted from a provider's perspective, covering the period 2007 - 2012. A top-down approach was used to estimate the average annual cost per patient on HD and PD. During the 6-year period under review, the number of patients on dialysis increased from 77 in 2007 to 182 in 2012. More than 60% of the patients were on HD. The average annual cost per patient was estimated to be ZAR212 286 (USD25 888) and ZAR255 076 (USD31106) for HD and PD, respectively, in 2012. Personnel cost, PD supplies, HD supplies, the outsourcing fee and pharmaceutical supplies were the main cost drivers. PD proved to be more expensive than HD, despite the use of locally manufactured fluids. The study highlights the exceptionally high cost of dialysis treatment. Dialysis should be made more accessible by implementing measures to address the main cost drivers. Moreover, a comprehensive approach that includes prevention of CKD at primary healthcare level, an organ donation programme and an effective kidney transplant programme is urgently required in Limpopo. Further research is required to evaluate the cost-effectiveness of the PPP approach.

Trends and inequities in amenable mortality between 1997 and 2012 in South Africa.

Amenable mortality comprises causes of death that should not occur with timely and effective healthcare. It is commonly used to assess healthcare performance. It could also be used to assess the effectiveness of the pending National Health Insurance (NHI) in South Africa (SA), but to do this, the level and distribution of amenable mortality are required using a local list of amenable causes. To establish an amenable cause-of-death list appropriate for SA and to determine the levels, trends, geographical distribution, population group differences and international comparisons of mortality amenable to healthcare. A local list of amenable causes of death was developed with input from public health and disease-specific medical experts. The Second SA National Burden of Disease estimates were reclassified into amenable mortality. Analyses of age-standardised death rates (ASDRs) and amenable mortality proportions were conducted by province and population group between 1997 and 2012. Excess mortality in relation to the best- performing province and population group was also analysed. ASDRs for SA were compared with those of European Union (EU) and Organisation for Economic Co-operation and Development (OECD) countries. The local list of amenable conditions contained 45 causes of death. There were large disparities in amenable mortality between provinces and population groups, which did not attenuate over time. There was an average annual percentage increase in amenable ASDRs, but when HIV/AIDS was excluded from the analysis there was an average annual decrease of 1.12%. In the post-peak HIV/AIDS period between 2008 and 2012, an annual average of 207 810 amenable deaths could have been saved if all provinces had the same ASDR as the Western Cape. SA's ASDR was 2.6 and 2.2 times higher than that of the worst-performing EU and OECD country, respectively. This is the first study known to the authors that has established a local amenable mortality list and described the epidemiology of amenable mortality in SA. Amenable mortality could be used as an indicator of the performance of the pending NHI over time and, in combination with other indicators, could identify areas of the health system that require improvement. Benchmarking could also quantify gaps in health system performance between geographical regions and indicate whether these are reduced with time.

Inflammatory biomarkers prior to antiretroviral therapy as prognostic markers of 12-month mortality in South Africa and Uganda.

The aim of this study was to determine the utility of biomarkers of immune activation, systemic inflammation and coagulopathy prior to antiretroviral therapy to predict mortality during the first year of antiretroviral therapy (ART) in sub-Saharan Africa. A prospective, observational cohort. We measured soluble CD14, interleukin-6 and D-dimer in nonpregnant individuals initiating ART in South Africa and Uganda in the Measuring Early Treatment Adherence (META) Study. We used survival analysis methods to estimate their association with 12-month mortality, and fit receiver operator curves (ROC) to assess the prognostic value of each biomarker. Six-hundred and sixty individuals were enrolled and had pretreatment biomarkers measured. Approximately 60% were women, with a median CD4 cell count of 187 cells/μl [interquartile range (IQR) 111-425] and approximately half were enrolled each from South Africa and Uganda. We observed 34 deaths for a crude mortality of 5.3 deaths/100 person-years (py) (95% confidence interval 3.8-7.4), which ranged from 0/100 py to 13.7/100 py in the lowest and highest tertile of pretreatment sCD14, respectively. In Cox models, all three biomarkers were strongly predictive of the hazard of death (adjusted hazard ratio 3-6, all P < 0.01). In multivariable models including biomarkers, both pretreatment CD4 cell count and pretreatment viral load became borderline or nonsignificantly associated with mortality. The c-statistic for area under ROC was higher for all three biomarkers than for CD4 cell count (P < 0.01). Biomarkers of immune activation, systemic inflammation and coagulopathy prior to ART initiation are strongly predictive of early death on treatment after adjustment for CD4 cell count. Such biomarkers might serve as important prognostic indicators for patient triage in this population.

Trends in maternal and neonatal mortality in South Africa: a systematic review.

BackgroundMeasuring and monitoring progress towards Millennium Development Goals (MDG) 4 and 5 required valid and reliable estimates of maternal and child mortality. In South Africa, there are conflicting reports on the estimates of maternal and neonatal mortality, derived from both direct and indirect estimation techniques. This study aimed to systematically review the estimates made of maternal and neonatal mortality in the period from 1990 to 2015 in South Africa and determine trends over this period.MethodsNationally-representative studies reporting on maternal and neonatal mortality in South Africa were included for synthesis. Literature search for eligible studies was conducted in five electronic databases: Medline, Africa-Wide Information, Scopus, Web of Science and CINAHL. Searches were restricted to articles written in English and presenting data covering the period between 1990 and 2015. Reference lists of retrieved articles were screened for additional publications, and grey literature was searched for relevant documents for the review. Three independent reviewers were involved in study selection, data extractions and achieving consensus.ResultsIn total, 969 studies were retrieved and 670 screened for eligibility yielding 25 studies reporting data on maternal mortality and 14 studies on neonatal mortality. Most of the studies had a low risk of bias. Estimates from the institutional reporting differed from the international metrics with wide uncertainty/confidence intervals. Moreover, modelled estimates were widely divergent from estimates obtained through empirical methods. In the last two decades, both maternal and neonatal mortality appear to have increased up to 2009, followed by a decrease, more pronounced in the care of maternal mortality.ConclusionEstimates from both global metrics and institutional reporting, although widely divergent, indicate South Africa has not achieved MDG 4a and 5a goals but made a significant progress in reducing maternal and neonatal mortality. To obtain more accurate estimates, there is a need for applying additional estimation techniques which utilise available multiple data sources to correct for underreporting of these outcomes, perhaps the capture-recapture method.Systematic review registrationPROSPERO CRD42016042769

South African guidelines for receptor radioligand therapy (RLT) with Lu-177-PSMA in prostate cancer

Prostate cancer is an important cause of morbidity and mortality in South Africa, as it is in the rest of the world. In African men, however, prostate cancer tends to follow a more aggressive course when compared to their European counterparts. This is attributed to a plethora of diverse factors of which an underlying genetic component has been shown to be an important aspect. Such differences highlight the need for individualised therapy and for local guidelines. The aim of this guideline is to aid nuclear physicians and other clinicians who manage patients with prostate cancer in the correct identification and treatment of patients who are likely to benefit from receptor radioligand therapy. There are a multitude of treatment modalities available for the treatment of prostate cancer and these therapies may be required at various time points during the course of the disease in any individual patient. A multidisciplinary approach is crucial in deciding which therapy, or combination of therapies, would be most advantageous at particular time points. The multidisciplinary team should include a urologist, oncologist and nuclear medicine physician as a minimum, and should ideally also involve a palliative/pain specialist, a dietician and a psychologist. Treatment with 177Lu-PSMA has emerged as a promising systemic modality, which involves the delivery of targeted radiation therapy in the form of β-particles to sites of tumour tissue. Therapy is provided on an outpatient basis, is well tolerated with relatively few side effects and has a positive effect on overall survival and quality of life. At present, it is used mostly in the setting of advanced, castrate-resistant cancer. Patients are selected (amongst other criteria) based on the prior PSMA-based SPECT/PET/CT imaging (99mTc-,68Ga- or 18F-PSMA), which should demonstrate sufficient receptor expression in order to consider PSMA-based targeted radionuclide therapy. Such imaging of an intended target prior to its therapeutic targeting is known as a theranostic approach.

Irrigation dams, water and infant mortality: Evidence from South Africa

Irrigation dams enable farmers to harness substantial water resources. However, their use consumes finite water supplies and recycles agricultural water pollutants back into river systems. This paper examines the net effect of irrigation dams on infant mortality in South Africa. It relies on both fixed effects and instrumental variables approaches to counteract potential bias associated with non-random dam placement, with the latter approach predicting dam placement based on geographic features and policy changes. The analysis reveals that additional irrigation dams within South Africa's former homeland districts after Apartheid increased infant mortality by 10–20 percent. I then discuss and evaluate possible channels. Dam-induced increases in agricultural activity could increase water pollution and reduce water availability, and I provide supporting evidence that both channels may contribute. These results suggest a potential trade-off between the health costs of agricultural water use and the economic benefits of increased agricultural production.

Can routine inpatient mortality data improve HIV mortality estimates? Inpatient mortality at an urban hospital in South Africa.

South Africa (SA) has one of the world's largest HIV treatment programmes, to which a dramatic increase in life expectancy has been attributed. However, there continue to be concerns regarding the reporting of HIV-related mortality in SA, which varies by source. As accurate HIV mortality estimates are key to measuring the success of the national programme as well as identifying areas for improvement, we propose a complementary approach to monitoring changes in HIV-related mortality using routine inpatient records to examine trends in causes of death and HIV status over time. To investigate the feasibility of this approach by calculating mortality due to natural causes in the medical ward of a hospital during 2010 by HIV status. We conducted a cross-sectional study of inpatient mortality at a regional hospital in Johannesburg, SA, analysing all deaths due to natural causes among adult medical ward inpatients. Cause of death was recorded from the mortuary register. HIV status was ascertained directly from the mortuary register or from laboratory tests specific for HIV diagnosis or monitoring. Of 1 167 inpatients who died, the majority were HIV-positive (58%). HIV positivity among males (55%) was slightly lower than that among females (61%), and HIV-positive patients were younger (median 40 years) than those who were HIV-negative (56 years) and of unknown HIV status (68 years). 'Infections and parasites' was the most common cause of natural death (29%). On average, HIV-positive patients were admitted for slightly longer (mean 10.5 days) than HIV-negative patients (9.6 days) and those of unknown HIV status (8.9days), yet HIV-positive inpatient deaths accounted for the majority (62%) of the total bed days. Even with widespread access to antiretroviral therapy, the majority of inpatient natural deaths at a large public sector hospital in 2010 were of HIV-positive patients and were probably related to HIV. In view of the importance of accurate data on causes of death, both for the HIV programme and to track other diseases, large-scale expansion of this approach over a longer period should be considered.

Lipid profiles of patients presenting with acute myocardial infarction in a South African regional hospital

Background: Cardiovascular disease is an important cause of morbidity and mortality in South Africa and hyperlipidaemia is a major contributing modifiable risk factor. Objectives: To describe the lipid profiles of patients with acute myocardial infarction and to compare values with recommended target levels outlined in the South African Dyslipidaemia Guideline Consensus Statement. Methods: We performed a retrospective chart review of patients admitted with a diagnosis of acute myocardial infarction to a regional hospital in Durban, South Africa, between 1 January and 31 December 2016. Patients had a non-fasting lipogram taken within the first 24 hours of admission. Results: We enrolled 126 subjects. The mean age was 57.6 (SD ± 9.4) years. One hundred and ten subjects (87.3%) met criteria for hyperlipidaemia. Previous statin therapy was associated with lower LDL-cholesterol values (3.43mmol/L vs. 4.03mmol/L, p=0.02), but only 9 (11.2%) of the 80 subjects on therapy (88.8%) fell below the levels recommended for their risk category by the South African Dyslipidaemia Guideline Consensus Statement. Overall, 23 subjects (18.3% of the entire study group) demonstrated LDL-C values at presentation that were below the recommended values. Conclusions: A high proportion of subjects presenting with acute myocardial infarction show evidence of suboptimal control of pre-existing hyperlipidaemia.

Liver cancer mortality trends in South Africa: 1999\u20132015

BackgroundIn South Africa (SA), liver cancer (LC) is a public health problem and information is limited.MethodsJoinpoint regression analysis was computed for the most recent LC mortality data from Statistics South Africa (StatsSA), by age group, sex and population group. The mortality-to-incidence ratios (MIRs) were calculated as the age-adjusted mortality rate divided by the age-adjusted incidence rate.ResultsFrom 1999 to 2015, the overall LC mortality significantly decreased in men (− 4.9%) and women (− 2.7%). Overall a significant decrease was noted in black African men aged 20–29 and 40–49 years, and white women older than 60 years but mortality rates increased among 50–59 and 60–69 year old black African men (from 2010/2009–2015) and women (from 2004/2009–2015). The mortality rates increased with age, and were higher among blacks Africans compared to whites in all age groups - with a peak black African-to-white mortality rate ratio of six in men and three in women at ages 30–39 years. The average MIR for black African men and women was 4 and 3.3 respectively, and 2.2 and 1.8 in their white counterparts. Moreover, decreasing LC mortality rates among younger and the increase in rates in older black Africans suggest that the nadir of the disease may be near or may have passed.ConclusionsFindings of population-age subgroup variations in LC mortality and the number of underdiagnosed cases can inform surveillance efforts, while more extensive investigations of the aetiological risk factors are needed. Impact: There was a large race, sex and age differences in trends of LC mortality in SA. These findings should inform more extensive evaluation of the aetiology and risk factors of LC in the country in order to guide control efforts.

The prevalence of type 2 diabetes in South Africa: a systematic review protocol

IntroductionType 2 diabetes mellitus is a major source of morbidity and mortality in South Africa, spurred by increased urbanisation and unhealthy lifestyle factors. Local epidemiological data are required to inform...

The socioeconomic profile of alcohol-attributable mortality in South Africa: a modelling study

BackgroundGlobally, illness and life expectancy follow a social gradient that puts people of lower socioeconomic status (SES) at higher risk of dying prematurely. Alcohol consumption has been shown to be a factor contributing to socioeconomic differences in mortality. However, little evidence is available from low- and middle-income countries. The objective of this study was to quantify mortality attributable to alcohol consumption in the adult (15+ years) general population of South Africa in 2015 by SES, age, and sex.MethodsA comparative risk assessment was performed using individual and aggregate data from South Africa and risk relations reported in the literature. Alcohol-attributable fractions (AAFs) and alcohol-attributable mortality rates were estimated for cause-specific mortality by SES, sex, and age. Monte Carlo simulation techniques were used to calculate 95% uncertainty intervals (UI).ResultsOverall, approximately 62,300 (95% UI 27,000–103,000) adults died from alcohol-attributable causes in South Africa in 2015, with 60% of deaths occurring in people in the low and 15% in the high SES groups. Age-standardized, alcohol-attributable mortality rates per 100,000 adults were highest for the low SES group (727 deaths, 95% UI 354–1208 deaths) followed by the middle (377 deaths, 95% UI 165–687 deaths) and high SES groups (163 deaths, 95% UI 71–289 deaths). The socioeconomic differences were highest for mortality from infectious diseases.People of low SES had a lower prevalence of current alcohol use but heavier drinking patterns among current drinkers. Among men, AAFs were elevated at low and middle SES, particularly for the middle and higher age groups (35+). Among women, AAFs differed less across SES groups and, in the youngest age group (15–34), women of high SES had elevated AAFs.ConclusionsAlcohol use contributed to vast socioeconomic differences in mortality. Where observed, elevated AAFs for people of low and middle SES arose from higher levels of consumption among current drinkers and not from the prevalence of current alcohol use per se. The findings can direct preventive measures and interventions on those at highest risk. Future research is needed to investigate socioeconomic differences in the risk functions relating alcohol use to cause-specific mortality.

A retrospective analysis of time delays in patients presenting with stroke to an academic emergency department.

BackgroundStroke presents commonly to the emergency department (ED), and is a common cause of morbidity and mortality in South Africa. Early ED presentation and early neuroimaging are required in order for thrombolysis to be a potential therapeutic modality.ObjectivesTo determine the time to ED presentation, time to computed tomography (CT) scan and the potential influencing factors for patients with stroke.MethodsA retrospective record review of all patients who presented with clinical features of stroke to a tertiary academic ED in Johannesburg, South Africa, from 01 January to 31 December 2014.ResultsData from 232 eligible stroke patients were analysed. The median time to presentation to the ED was 33 h with the majority of patients (81.3%) presenting after the 4.5 h window for thrombolysis. The median time to CT was 8 h. Only 3.9% of patients had a CT scan within one hour of arrival. Patients with loss of consciousness were associated with earlier hospital presentation (p = 0.001). None of the patients were thrombolysed.ConclusionPatients with stroke commonly present late to hospital. If we are to make a difference in this group of vulnerable patients, further education and training needs to be emphasised regarding ‘time is brain’. Communication and commitment is also required by the emergency medical services, ED and radiology staff in order to prioritise stroke patients and to reduce delays.

A Teledermatology Scale-Up Framework and Roadmap for Sustainable Scaling: Evidence-Based Development.

BackgroundThe objectives of South Africa’s electronic health (eHealth) strategy recognize the value proposition that telemedicine practices hold for rural and urban referrals, but a lack of accepted and formalized scale-up has impeded realization of benefits. While both synchronous and asynchronous teledermatology exist, these remain localized and not scaled-up. Skin pathology is often the first sign of an HIV/AIDS infection, which remains a major cause of morbidity and mortality in South Africa. It is essential to replace the current inefficient dermatology referral process with a swift, organized, and efficacious one.ObjectiveThe objective of this study is to present an evidenced-based teledermatology scale-up framework (TDSF) and implementation roadmap (TDSF-IR).MethodsA qualitative method with a design science research process model was used which consisted of 5 phases: (1) Awareness, which confirmed the need for an evidence-based TDSF and supporting TDSF-IR; (2) Suggestion, where a proposal was delivered on how to develop a TDSF and TDSF-IR; (3) Development, where we identified recommended design requirements and used these to identify and critique existing teledermatology or related scale-up frameworks; (4) Evaluation and validation, where we assessed outputs of the development phase against the design requirements and validated by confirming the veracity of the TDSF and TDSF-IR (validation involved 4 key senior teledermatology stakeholders using a questionnaire with a 5-point Likert scale); and (5) Conclusion, where validation results were used to finalize and communicate the TDSF and TDSF-IR to users.ResultsThe study identified 5 TDSF components: eHealth building blocks, eHealth strategic objectives and budget, scale-up continuum periods, scale-up drivers, and scale-up phases. In addition, 36 subcomponents were identified. Each was further characterized and described to enable design of the final evidence-based TDSF. An implementation roadmap (TDSF-IR) was also prepared as a guide for an implementer with step-by-step instructions for application of the TDSF. For the validation study of the TDSF and supporting TDSF-IR, 4 purposively selected key senior teledermatology management stakeholders were asked if they found it useful as a guide to assist the South African public health system with teledermatology scale-up. The mean (SD) of Likert-scale rating was 4.0 (0.53) where 4=Agree and 33 of 36 responses were either agree or strongly agree.ConclusionsThis study developed a TDSF and supporting roadmap (TDSF-IR) that are evidence-based. The proposed approach and described tools could be adapted to assist with ensuring scale-up and sustainability for other eHealth practices in other locations.