Secondary Care Facilities Research Articles

English

Children are more vulnerable to adverse events related to use of drugs. It is therefore important to study drug use in children in order to optimize pharmacotherapy. The aim of this study was to compare drug utilization in paediatric outpatient departments of primary and secondary health care facilities. The patient and drug information of 600 patients was analyzed for World Health Organization (WHO) recommended prescribing indicators. The average number of drugs per prescription was significantly (p < 0.0005) lower in secondary (2.97) compared to primary (3.62) facilities, while average consultation time was shorter (p < 0.0005) in primary than secondary facilities. Percentages of drugs prescribed from Nigerian Essential Drug List (EDL, primary {89.78%}; secondary {91.79%}) and by generic name (primary {55.04%}; secondary {57.88%}) were insignificantly different between the facilities. The use of injectables was low (8.32% in primary versus 3.74% in secondary facilities) while antibiotic use was high (54.14% in primary to 60.28% in secondary facilities). Analysis of the dispensing indicators showed that the secondary facilities were significantly (p < 0.05) better than the primary facilities, even though not a single drug was adequately labeled in both the primary and secondary facilities. Prescription from EDL was found to be fair in the study area while use of injections was low. There is a need for improvement in case of medicines prescribed by generic name.

Glycemic Control and Co morbidities of Patients with Type 1 and Type 2 Diabetes Referred to the National Diabetes and Endocrine Centre in Muscat, Oman

Aims: To assess the clinical profile, glycemic control associated risk factors, co morbidities and complications of patients with diabetes who were referred from primary health care facilities. Methods: A highly specialized National Diabetes and Endocrine center (NDEC) has been established in Muscat, Oman in 2013. Clinical details, glycemic control and co morbidities of all referred patients between February 2013 to January 2014 were recorded from their medical records. A total of 611 patients with type 1 and type 2 diabetes of any age and either sex were included in this study. The center receives cases requiring a better care for complicated patients with diabetes from primary, secondary and tertiary care facilities on referral base. Results: A total of 611 patients were registered and among them 476 were with type 2 and 135 with type 1 diabetes. The mean age was 45.3 years. Nearly, 31% and 50% were overweight and obese among type 2 patients. The study highlights that above 40% patients had an HbA1c of >10% (85.8 mmol/mol) at baseline. A greater reduction in HbA1c (1.4%) was observed in type 2 patients whereas it was 0.5 % in type 1. Majority of type 2 had dyslipidaemia (84%) and hypertension (62.8%). Nephropathy was found in 40.1 and 24.4% with type 2 and type 1 diabetes whereas retinopathy was reported in 14.3 and 8.9% respectively. Female gender and longer duration of diabetes emerged as significant risk factors associated with poor glycemic control. Conclusions: Patients with diabetes referred to a tertiary care setup in Oman had high percentage of overweight and obesity. Majority of them had poor glycemic control with associated presence of co-morbidities. Effective strategies, including education of staff and patients, are highly recommended to improve the current setup at primary care level to facilitate early detection of complications.

The knowledge, perception, and attitude of patients living with glaucoma and attending the eye clinic of a secondary health care facility in South-East, Nigeria

Background: In the developing countries, most patients present with advanced disease or glaucoma blindness. This has been attributed to lack of awareness and poor knowledge as major contributing factors. The outcome of glaucoma management, however, depends largely on the understanding and perception of the illness by the patients. Objectives: This study aims to determine the knowledge, perception, and attitude of patients living with glaucoma and attending the Eye Clinic of the Imo State Specialist Hospital Owerri Imo State, Nigeria. The information obtained can be utilized by the health authorities in planning eye health education programs. Subjects and Methods: This was a cross-sectional study involving all previously diagnosed glaucoma patients attending the eye clinic of the hospital during the study period. Data were collected on knowledge, perception, and social disclosure attitude of the subjects using a structured questionnaire. Results: Twenty-nine males and 25 females participated in this study. The majority (42.6%) had only primary school education with petty trading accounting for 38.9% of the different occupations. The mean age at presentation was 60.9 years. The majority (88.8%) identified their eye problem as glaucoma, 46.3% knew it caused a progressive, irreversible loss of vision, and most (68.5%) did not know glaucoma to be familial. Approximately 67% of the subjects rated their management as satisfactory, 37% considered the drugs expensive, 70% and 13%, respectively had no, and negative perception of glaucoma surgery while 87.0% had a poor disclosure attitude. Conclusion: The subjects had a good knowledge of their diagnosis but a poor knowledge of the disease process. There was also an appreciable poor disclosure attitude and a negative perception of glaucoma surgery. Education and interaction with eye care personnel and other glaucoma patients using focal groups may bring about the desired change.

Role of oral physician in Indian public health system

The Indian public health scenario is gradually receiving the due attention it deserved at least in the academic front. Oral medicine and radiology in itself is a very vast branch concerned with the diagnosis and non-surgical management of diseases of oral and paraoral structures. The specialty of oral medicine and radiology being in this crucial position as a link between medicine and dentistry can contribute much more to strengthen public health eff orts than it is currently contributing. This branch covers diseases not only related to the teeth, surrounding jaws, joints, and salivary glands but also systemic diseases, their inter-relation to oral health and their manifestations in the oral cavity. This vast bank of knowledge can be exploited with integrated oral and general health programs. With the growing burden of non-communicable diseases globally as well as nationally a greater role for the oral physician needs to be carved out. In a threetier health care delivery system the oral physicians could be taken up into the secondary care facilities to diagnose oral cancer, precancers, indications of systemic diseases and management of their oral manifestations, counsel on tobacco cessation, etc. Academics, health care delivery and research are viewed as distinct fragmented structures. Breaking these silos to achieve integrated people-centered care should be our long-term vision. This article delves into each of the silos to examine the gaps and propose some solutions to delineate the optimal role of an oral physician in the complex health care landscape of India.

Frequency, types and factors associated with potentially harmful drug interactions in ambulatory elderly patients in Nigeria.

To determine the frequency, types and factors associated with potentially harmful drug interactions among ambulatory elderly (≥65 years) patients in Ibadan, Nigeria. A 4-week cross-sectional study was conducted among 229 elderly patients who consented and were prescribed two or more medicines within a 4-week study period at a major 256-bed secondary care facility in Ibadan, Nigeria. Chi-square and risk ratio were used to identify the factors associated with the potentially harmful drug-drug interactions. Potentially harmful drug-drug interactions were identified in about two-thirds (65%, 149/229) of the patients. The risk of occurrence drug interactions was significantly higher among patients who had at least six prescribed medicines (relative risk: 7.8 (95% confidence interval, 6.9 to 9.5) (P < 0.001)), and a significant majority were also females (73.8%) (110) (P < 0.001). The most frequent interacting drug combination was angiotensin-converting enzyme inhibitors and amiloride + hydrochlorothiazide (34.7%). Potentially harmful drug interactions that are significantly associated with high multiple prescribing are considerable among elderly patients in Nigeria.

The value of signs, symptoms and plasma heart-type fatty acid-binding protein (H-FABP) in evaluating patients presenting with symptoms possibly matching acute coronary syndrome: background and methods of a diagnostic study in primary care.

BackgroundChest complaints presented to a general practitioner (GP) are frequently caused by diseases which have advantageous outcomes. However, in some cases, acute coronary syndrome (ACS) is present (1.5-22% of cases). The patient’s signs, symptoms and electrocardiography results are insufficient diagnostic tools to distinguish mild disease from ACS. Therefore, most patients presenting chest complaints are referred to secondary care facilities where ACS is then ruled out in a majority of patients (78%). Recently, a point of care test for heart-type fatty acid-binding protein (H-FABP) using a low cut-off value between positive and negative of 4 ng/ml has become available. We aim to study the role of this point of care device in triage of patients presenting chest complaints possibly due to ACS, in primary care. Our research protocol is presented in this article. Results are expected in 2015.Methods/DesignParticipating GPs will register signs and symptoms in all patients presenting chest complaints possibly due to ACS. Point of care H-FABP testing will also be performed. Our study will be a derivation study to identify signs and symptoms that, combined with point of care H-FABP testing, can be part of an algorithm to either confirm or rule out ACS. The diagnostic value for ACS of this algorithm in general practice will be determined.DiscussionA safe diagnostic elimination of ACS by application of the algorithm can be of significant clinical relevance. Improved triage and thus reduction of the number of patients with chest complaints without underlying ACS, that are referred to secondary care facilities, could lead to a substantial cost reduction.Trial registrationClinicalTrials.gov, NCT01826994, accepted April 8th 2013.

Increasing retention in care of HIV-positive women in PMTCT services through continuous quality improvement-breakthrough (CQI-BTS) series in primary and secondary health care facilities in Nigeria: a cluster randomized controlled trial. The Lafiyan Jikin Mata Study.

Rates of retention in care of HIV-positive pregnant women in care programs in Nigeria remain generally poor with rates around 40% reported for specific programs. Poor quality of services in health facilities and long waiting times are among the critical factors militating against retention of these women in care. The aim of the interventions in this study is to assess whether a continuous quality improvement intervention using a Breakthrough Series approach in local district hospitals and primary health care clinics will lead to improved retention of HIV-positive women and mothers. A cluster randomized controlled trial with 32 health facilities randomized to receive a continuous quality improvement/Breakthrough Series intervention or not. The care protocol for HIV-infected pregnant women and mothers is the same in all sites. The quality improvement intervention started 4 months before enrollment of individual HIV-infected pregnant women and initially focused on reducing waiting times for women and also ensuring that antiretroviral drugs are dispensed on the same day as clinic attendance. The primary outcome measure is retention of HIV-positive mothers in care at 6 months postpartum. Results of this trial will inform whether quality improvement interventions are an effective means of improving retention in prevention of mother-to-child transmission of HIV programs and will also guide where health system interventions should focus to improve the quality of care for HIV-positive women. This will benefit policymakers and program managers as they seek to improve retention rates in HIV care programs.

Non-physician communities in Japan: are they still disadvantaged?

Non-physician community' (NPC) is a policy term that indicates a medically underserved area in Japan. Designated NPCs are politically targeted as the foci of medical resource allocation. NPC is defined as a specified district where 50 or more persons dwell within a geographic diameter of 4 km and medical care is not easily accessible. The definition of NPC was first introduced in 1960 and has been unchanged for more than half a century despite radical social changes in rural Japan. This study examines whether designated NPCs are still more disadvantaged in terms of geographical access to healthcare in comparison to other communities. Hiroshima prefecture, which has the largest number of NPCs in terms of tertiary healthcare areas of Japan, was used as the study area. Targeted communities were all the NPCs in the prefecture, and, as controls, two community groups were selected: non-NPC adjacent to NPC, and municipal center. We measured driving time from NPCs and control communities to the nearest healthcare facilities, which were classified into the following two types: primary or secondary care facilities (n=2636) and tertiary care facilities (equal to tertiary emergency care centers; n=6). We further calculated the driving time to the nearest facilities for secondary emergency care (n=246) extracted from the 2636 primary or secondary care facilities. The median driving times to the nearest primary or secondary healthcare facility for NPC, non-NPC, and municipal center were 11 minutes, 11 minutes, and 1 minute, respectively; the times to a tertiary healthcare facility (equal to an accident and emergency care center) were 80 minutes, 84 minutes, and 68 minutes, respectively; and the times to a secondary emergency care facility were 24 minutes, 18 minutes, and 15 minutes, respectively. Although a municipal center was significantly more advantageous in driving time compared to a primary or secondary care facility, the disadvantage of a NPC in access was no more obvious than an adjacent non-NPC for any type of healthcare facility. NPCs had a disadvantage in access time to primary, secondary and tertiary medical care compared with a municipal center. NPCs, however, did not have a greater access disadvantage in comparison to adjacent rural communities for any type of medical facility. As such, future resource allocation policies in Japan need to redefine medically underserved communities.

Research round-up

Research round-up

Death Due to Munchausen Syndrome: A Case of Idiopathic Recurrent Right Ventricular Failure and a Review of the Literature

Factitious disorders are rare, identified in less than 1% of patients evaluated by the consultation-liaison psychiatry service in tertiary care centers. These disorders involve falsification of psychologic or physical signs or symptoms; induction of injury or disease associatedwith identified deception; and presentations of oneself as ill, injured, or impaired. Unlike with malingering, there is no obvious external reward. Despite recent attempts at improved classification, factitious disorders continue to be underrecognized and underdiagnosed in general medical patients. Munchausen syndrome accounts for approximately 10% of all factitious illnesses in hospital settings and represents its most persistent and extreme form. This disorder can be associated with high morbidity and medical expenditures but it rarely results in a patient's death. We describe the case of a young woman with Munchausen syndrome who presented to multiple secondary and tertiary care facilities with recurrent right ventricular failure, ascribed to air emboli, who died of her self-injurious behavior. We also review the literature on fatalities associated with factitious illness. 2014. From Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA. Send correspondence and reprint requests toMuthiahVaduganathan,M.D., M.P.H., Department ofMedicine,MassachusettsGeneralHospital, Harvard Medical School, 55 Fruit St, GRB 740, Boston, MA 02114; e-mail: muthu@md.northwestern.edu & 2014 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved. Case Report

Validation of the Greek translation of the Nursing Dimensions Inventory questionnaire (NDI-35).

Context:The concept of care is a fundamental issue in nursing science. Therefore the development and the use of tools for assessing care is an imperative for the nursing profession. The NDI-35 questionnaire is one such tool for assessing the nursing care.Objectives:The purpose of this paper is to adapt and use the NDI-35 questionnaire in Greek nursing practice. A translation and validation of NDI-35 questionnaire is performed.Methods:Exploratory factor analyses, as well as internal consistency and test–retest analyses, were conducted.Forward translations from English were produced by three independent Greek translators and then back translations by five independent bilingual translators. The Greek NDI-35 questionnaire that was produced was administered to 200 nurses (144 women and 56 men) from tertiary and secondary health care facilities. Data were analyzed using principal component analysis and Cronbach’s alpha.Results:One hundred and eighty four nurses that answered the NDI-35 questionnaire were graduates from the Technological Educational Institute (T.E.I.) and 64% of the respondents had more than 15 years of professional experience. Two subscales arbitrarily called “clinical work” and “patient needs” emerged, with the mean “clinical work” subscale score being at 70.16 ±12.90 (a maximum of 85) and mean “patient needs” subscale at 21.49± 6.16. Considerable differences in scoring among different items were observed when the NDI-35 answers were compared to their Greek counterparts’. Results confirmed that: (a) the translated versions are an accurate translation of the original, (b) factor analyses established similar factor solutions as that of the English versions, (c) reliability coefficients are satisfactory (i.e., Cronbach’s α coefficients and test–retests), and (d) construct validity revealed similarities between English and Greek versions, replications consistent with past research, as well as differences explained through theoretical frameworks. Therefore, both scales were accepted as valid and reliable measures in Greek-speaking populations.Conclusion:Alphas and test-retest correlation suggest the Greek translated and validated NDI-35 questionnaire is a reliable tool for assessing nursing care. Factor analysis and focus group input suggest it is a valid tool. Nurses in different settings may perceive nursing care differently. The findings of the current paper are discussed in the context of nurse education and assessment of care.

Promoting self-management and adherence with strength and balance training for older people with long-term conditions: a mixed-methods study.

In the context of an ageing population, increasing numbers of older people with long-term conditions are presenting to secondary health care facilities in the United Kingdom having experienced a fall or fall-related injury. Despite such observations, falls and long-term conditions have traditionally been regarded as entirely separate entities. The purpose of this study was to explore the process of behaviour change in a small sample of older people with the fall-associated chronic liver disease primary biliary cirrhosis (PBC) receiving either a standard or an enhanced programme of strength and balance training (SBT). A qualitatively driven mixed-methods approach was employed that juxtaposed semi-structured interviews with graphical representations of patient-reported outcome measures collected during the course of an experimental case series in nine older people with the fall-associated chronic liver disease PBC. Participants receiving both the standard and enhanced intervention completed the programme of SBT as instructed throughout the course of the case series. However, only the enhanced intervention, which focused on self-determination and self-management support, was associated with continued active participation on completion of the programme. Longer, but not necessarily more intensive, periods of clinical intervention are necessary to support individuals at risk of falling to move through the incremental stages of behaviour change. Effective self-management support should focus on the development of a wide range of strategies and behaviours to empower older people with long-term conditions develop an ongoing active commitment to SBT.

Rehabilitation after lumbar disc surgery

Several rehabilitation programmes are available for individuals after lumbar disc surgery. To determine whether active rehabilitation after lumbar disc surgery is more effective than no treatment, and to describe which type of active rehabilitation is most effective. This is the second update of a Cochrane Review first published in 2002.First, we clustered treatments according to the start of treatment.1. Active rehabilitation that starts immediately postsurgery.2. Active rehabilitation that starts four to six weeks postsurgery.3. Active rehabilitation that starts longer than 12 months postsurgery.For every cluster, the following comparisons were investigated.A. Active rehabilitation versus no treatment, placebo or waiting list control.B. Active rehabilitation versus other kinds of active rehabilitation.C. Specific intervention in addition to active rehabilitation versus active rehabilitation alone. We searched CENTRAL (2013, Issue 4) and MEDLINE, EMBASE, CINAHL, PEDro and PsycINFO to May 2013. We included only randomised controlled trials (RCTs). Pairs of review authors independently assessed studies for eligibility and risk of bias. Meta-analyses were performed if studies were clinically homogeneous. The GRADE approach was used to determine the overall quality of evidence. In this update, we identified eight new studies, thereby including a total of 22 trials (2503 participants), 10 of which had a low risk of bias. Most rehabilitation programmes were assessed in only one study. Both men and women were included, and overall mean age was 41.4 years. All participants had received standard discectomy, microdiscectomy and in one study standard laminectomy and (micro)discectomy. Mean duration of the rehabilitation intervention was 12 weeks; eight studies assessed six to eight-week exercise programmes, and eight studies assessed 12 to 13-week exercise programmes. Programmes were provided in primary and secondary care facilities and were started immediately after surgery (n = 4) or four to six weeks (n = 16) or one year after surgery (n = 2). In general, the overall quality of the evidence is low to very low. Rehabilitation programmes that started immediately after surgery were not more effective than their control interventions, which included exercise. Low- to very low-quality evidence suggests that there were no differences between specific rehabilitation programmes (multidisciplinary care, behavioural graded activity, strength and stretching) that started four to six weeks postsurgery and their comparators, which included some form of exercise. Low-quality evidence shows that physiotherapy from four to six weeks postsurgery onward led to better function than no treatment or education only, and that multidisciplinary rehabilitation co-ordinated by medical advisors led to faster return to work than usual care. Statistical pooling was performed only for three comparisons in which the rehabilitation programmes started four to six weeks postsurgery: exercise programmes versus no treatment, high- versus low-intensity exercise programmes and supervised versus home exercise programmes. Very low-quality evidence (five RCTs, N = 272) shows that exercises are more effective than no treatment for pain at short-term follow-up (standard mean difference (SMD) -0.90; 95% confidence interval (CI) -1.55 to -0.24), and low-quality evidence (four RCTs, N = 252) suggests that exercises are more effective for functional status on short-term follow-up (SMD -0.67; 95% CI -1.22 to -0.12) and that no difference in functional status was noted on long-term follow-up (three RCTs, N = 226; SMD -0.22; 95% CI -0.49 to 0.04). None of these studies reported that exercise increased the reoperation rate. Very low-quality evidence (two RCTs, N = 103) shows that high-intensity exercise programmes are more effective than low-intensity exercise programmes for pain in the short term (weighted mean difference (WMD) -10.67; 95% CI -17.04 to -4.30), and low-quality evidence (two RCTs, N = 103) shows that they are more effective for functional status in the short term (SMD -0.77; 95% CI -1.17 to -0.36). Very low-quality evidence (four RCTs, N = 154) suggests no significant differences between supervised and home exercise programmes for short-term pain relief (SMD -0.76; 95% CI -2.04 to 0.53) or functional status (four RCTs, N = 154; SMD -0.36; 95% CI -0.88 to 0.15). Considerable variation was noted in the content, duration and intensity of the rehabilitation programmes included in this review, and for none of them was high- or moderate-quality evidence identified. Exercise programmes starting four to six weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment, with small to medium effect sizes, and high-intensity exercise programmes seem to lead to a slightly faster decrease in pain and disability than is seen with low-intensity programmes, but the overall quality of the evidence is only low to very low. No significant differences were noted between supervised and home exercise programmes for pain relief, disability or global perceived effect. None of the trials reported an increase in reoperation rate after first-time lumbar surgery. High-quality randomised controlled trials are strongly needed.

Reaching out to the forgotten: providing access to medical care for the homeless in Italy

BackgroundA program for outpatient and intermediate inpatient care for the homeless was pioneered by the humanitarian organization Médecins Sans Frontières (MSF) in Milan, Italy, during the winter of 2012-2013. We aimed to document the characteristics and clinical management of inpatients and outpatients seen during this program.MethodsA clinic providing outpatient and intermediate inpatient care (24 bed capacity) was set up in an existing homeless hostel. Patients were admitted for post-hospitalization intermediate care or for illnesses not requiring secondary care. This study was a retrospective audit of the routine program data.ResultsFour hundred and fifty four individuals presented for outpatient care and 123 patients were admitted to inpatient intermediary care. On average one outpatient consultation was conducted per patient per month, most for acute respiratory tract infections (39.8%; 522/1311). Eleven percent of all outpatients suffered from an underlying chronic condition and 2.98% (38/1311) needed referral to emergency services or secondary care facilities. Most inpatients were ill patients referred through public reception centers (72.3%; 89/123), while 27.6% (34/123) were post-hospitalization patients requiring intermediate care. Out of all inpatients, 41.4% (51/123) required more than 1 week of care and 6.5% (8/123) needed counter-referral to secondary care.ConclusionsThe observed service usage, morbidity patterns, relatively long lengths of stay, high referral completion and need for counter-referrals, all reflect the important gap-filling role played by an intermediate care facility for this vulnerable population. We recommend that in similar contexts, medical non-governmental organizations (NGOs) focus on the setup of inpatient intermediary care services; while outpatient services are covered by the public health system.

Assessment of quality of prescribing in patients of hypertension at primary and secondary health care facilities using the Prescription Quality Index (PQI) tool.

Objective:To determine the quality of prescribing in hypertension in primary and secondary health care settings using the Prescription Quality Index (PQI) tool and to assess the reliability of this tool.Materials and Methods:An observational cross-sectional study was carried out for 6 months in order to assess quality of prescribing of antihypertensive drugs using Prescription Quality Index (PQI) at four primary (PHC) and two secondary (SHC) health care facilities. Patients attending these facilities for at least 3 months were included. Complete medical history and prescriptions received were noted. Total and criteria wise PQI scores were derived for each prescription. Prescriptions were categorized as poor (score of ≤31), medium (score 32-33) and high quality (score 34-43) based on PQI total score. Psychometric analysis using factor analysis was carried out to assess reliability and validity.Results:Total 73 hypertensive patients were included. Mean age was 61.2 ± 11 years with 35 (48%) patients above 65 years of age. Total PQI score was 26 ± 11. There was a significant difference in PQI score between PHC and SHC (P < 0.05) Out of 73 prescriptions, 43 (59%) were of poor quality with PQI score <31. The value of Cronbach's α for the entire 22 criteria of PQI was 0.71 suggesting good reliability of PQI tool in our setting.Conclusions:Based on PQI scores, quality of prescribing in hypertensive patients was poor, somewhat better in primary as compared to secondary health care facility. PQI is reliable for measuring prescribing quality in hypertension in Indian set up.

Midwifery and Midwives Service Scheme: A Panacea for Improvement of Some Maternal and Neonatal Indices in Nigeria—A Brief Review

Introduction: Midwifery is the art of caring for women during childbearing. It is practiced throughout the world according to the norms, traditions and cultural practices found in each country. Maternal mortality in Nigeria is high but there are wide variations between the geopolitical zones of the country. Government has established the midwives service scheme (MSS) as part of efforts towards reversing the country’s unacceptably high maternal mortality trends. To improve these indices, the MSS in Nigeria engaged newly graduated unemployed and retired midwives to work temporarily in rural areas. The midwives are posted for twelve months to selected primary care facilities linked through a cluster model in which four such facilities with the capacity to provide basic essential obstetric care are clustered around a secondary care facility with the capacity to provide comprehensive emergency obstetric care. This brief review is an attempt at exploring the impact of the midwives service scheme on maternal and neonatal indices in Nigeria. Main content: The outcome of the MSS four years has been an improvement though unevenly and marginally, in these indices in the various geopolitical zones of Nigeria. Improvements have been noticed in maternal indices such as antenatal care attendance, women receiving two doses of tetanus toxoid and number of deliveries by skilled personnel. Also reduction in maternal and neonatal mortality has been observed over the years following introduction of the scheme. Major challenges however, include lack of essential drugs, poor accommodation facilities for MSS staff, irregular payment of their remuneration and lack of water/power supply to some designated facilities for the scheme. Recommendations and conclusions: It is therefore recommended that 24 hours availability of essential drugs at primary healthcare centers be maintained. This should happen in conjunction with regular payment of full entitlements and benefits and provision of secured, habitable and good accommodation for MSS staff. Finally, aggressive community mobilization should continue in order to engender community involvement and participation for sustainable program development.

Prescribing quality in patients with chronic diseases at primary and secondary health care facilities using prescription quality index tool

Background: Prescribing quality is a matter of major concern worldwide. This study was carried out to determine the quality of prescribing in chronic diseases at primary health care (PHC) and secondary health care (SHC) settings using the new prescription quality index (PQI) tool. Methods: A cross-sectional observational study was carried out at four PHC and two SHC facilities in Anand district of India. Patients attending these facilities for at least 3 months were included. Complete medical history and prescriptions received were noted. Total and criteria wise PQI scores were derived for each prescription. Prescriptions were categorized as poor (score of ≤31), medium (score 32-33), and high quality (score 34-43) based on PQI total score. The internal consistency of PQI was measured using item total correlation and Cronbach’s α so as to validate it in our settings. Data were analyzed using Statistical Package for Social Science 20. Results: A total of 134 prescriptions were collected and evaluated for quality of prescribing. Mean age of patients was 60.6 ± 13.5 years. Mean PQI score was 23.60 ± 9.3 with 71.6% prescriptions being of poor quality. Quality of prescribing did not differ at PHC and SHC ( P &gt;0.05). Of 22 criteria, PQI score was strongly correlated with drug indication, drug effectiveness, evidence-based prescribing, unnecessary duplication, duration of therapy, and cost ( P &lt;0.01). PQI total score was negatively correlated to the number of drugs per prescription. Cronbach’s α for the entire 22 criteria were 0.90. Conclusion: PQI was found to be a reliable tool for assessment of prescribing quality in chronic diseases.

Outcomes of a joint replacement surgical home model clinical pathway.

Optimizing perioperative care to provide maximum benefit at minimum cost may be best achieved using a perioperative clinical pathway (PCP). Using our joint replacement surgical home (JSH) model PCP, we examined length of stay (LOS) following total joint arthroplasty (TJA) to evaluate patient care optimization. We reviewed a spectrum of clinical measurements in 190 consecutive patients who underwent TJA. Patients who had surgery earlier in the week and who were earlier cases of the day had a significantly lower LOS than patients whose cases started both later in the week and later in the day. Patients discharged home had significantly lower LOS than those discharged to a secondary care facility. Patients who received regional versus general anesthesia had a significantly lower LOS. Scheduling patients discharged to home and who will likely receive regional anesthesia for the earliest morning slot and earlier in the week may help decrease overall LOS.

Pain Medicine in Crisis—A Possible Model toward a Solution: Empowering Community Medicine to Treat Chronic Pain

Pain medicine in Israel and in the world has reached a crisis. The lack of available pain medicine services is resulting in the unsatisfactory treatment for chronic pain sufferers. The main causes of this crisis are: 1) the high prevalence of chronic pain, reaching levels of 17% in the adult population;2) the lack of appropriate training of primary care physicians in the field of chronic pain management; and 3) the paucity of consultation services in the field of chronic pain. In this journal article, we propose a possible model for the solution of the problem, based upon levels of treatment according to the severity of the disease and upon training of primary and secondary care physicians in the treatment of pain. According to the model, the vast majority of treatment and management will take place in the community after appropriate training of primary care physicians. More complex cases will be referred to secondary care community-based pain clinics manned by physicians with further in-depth training. Only the most complex of patients, or those needing specialized treatment such as invasive analgesic therapy, will be referred to tertiary pain centers manned by specialists in pain medicine. Implementation of this model will necessitate training of primary care physicians and the establishment of secondary care facilities and can, in our opinion, pose a pragmatic solution for the hundreds of thousands of patients suffering from chronic pain.

Pain Medicine in Crisis—A Possible Model toward a Solution: Empowering Community Medicine to Treat Chronic Pain

Pain medicine in Israel and in the world has reached a crisis. The lack of available pain medicine services is resulting in the unsatisfactory treatment for chronic pain sufferers. The main causes of this crisis are: 1) the high prevalence of chronic pain, reaching levels of 17% in the adult population;2) the lack of appropriate training of primary care physicians in the field of chronic pain management; and 3) the paucity of consultation services in the field of chronic pain. In this journal article, we propose a possible model for the solution of the problem, based upon levels of treatment according to the severity of the disease and upon training of primary and secondary care physicians in the treatment of pain. According to the model, the vast majority of treatment and management will take place in the community after appropriate training of primary care physicians. More complex cases will be referred to secondary care community-based pain clinics manned by physicians with further in-depth training. Only the most complex of patients, or those needing specialized treatment such as invasive analgesic therapy, will be referred to tertiary pain centers manned by specialists in pain medicine. Implementation of this model will necessitate training of primary care physicians and the establishment of secondary care facilities and can, in our opinion, pose a pragmatic solution for the hundreds of thousands of patients suffering from chronic pain.