Secondary Health Care Systems Research Articles

Integration of palliative rehabilitation in cancer care: a multinational mixed method study

Abstract Background Incurable cancer is a major contributor to societal suffering and disability, and palliative rehabilitation is recommended to be integrated within and between cancer services at all healthcare levels. However, little knowledge exists on how integration of palliative rehabilitation in cancer is understood and achieved in clinical practice. INSPIRE (Integrated short-term palliative rehabilitation to improve quality of life and equitable care access in incurable cancer) is a large European-funded project that aims to promote quality of life through a novel rehabilitation model for people disabled by advanced cancer. Aim To compare the existing integration of palliative rehabilitation in cancer within official documents and in clinical practice across five European countries including United Kingdom, France, Denmark, Norway, and Italy. Methods Mixed methods study with a concurrent research design, comprising a document analysis (N = 23), stakeholder interviews (N = 22), and an online survey (N = 225). Data from each sub-study were analysed separately before results were merged. Results There was limited integration of palliative rehabilitation in cancer in official documents and in clinical practice, though some indicators of integration, including participation in multidisciplinary teams and adherence to standardised pathways, were identified in the survey. Notably, integration of palliative rehabilitation in cancer in clinical practice was observed within limited organisations in secondary healthcare systems, without widespread adoption. Although palliative rehabilitation in cancer as a concept was sparingly used by stakeholders, they recognised the need for a comprehensive approach including multidisciplinary teams that aligns with the individual patient’s needs and goals. Moreover, the ambiguous distinction between the terms ‘palliative rehabilitation’ and ‘palliative care’, insufficient funding, lack of well-defined care pathways and competence gaps among healthcare professionals represented barriers to integration of palliative rehabilitation in cancer into clinical practice. Conclusion Integration of palliative rehabilitation in cancer was limited in the five EU partnership countries investigated. Clarifying the concept of palliative rehabilitation, including adoption of the concept into official documents and delineating it from palliative care, is essential for more successful integration. This can possibly be achieved by addressing the barriers identified and fostering close collaboration across disciplines.

The interplay between patients and healthcare professionals in a cross-sectoral setting in connection with the treatment and care of patients with diabetic foot ulcers: a realistic evaluation

BackgroundDiabetes-related lower extremity complications such as diabetic foot ulcer (DFU) are a global disability burden. Treatment and care for patients with DFU call for a multisectoral approach that incorporates interdisciplinary care pathways. We aimed to explore the interplay between patients with DFU and healthcare professionals in cross-sectoral settings that address treatment and care and to determine “what works, for whom, and under what circumstances”.MethodThe study was designed as a realistic evaluation. The data were generated from September 2022 to March 2023 and drew upon approximately 60 h of participant observation of 14 patients during the treatment and care of DFUs in their homes (primary care) and/or at outpatient clinics (wound specialist clinics in a hospital setting) in a Danish cross-sectoral setting. The Standards for Reporting Qualitative Research (SRQR) were applied in this study.ResultsWe identified three illuminating themes that described the interplay between patients with DFU and related healthcare professionals representing both primary and secondary health care systems: (1) humour is a relationship-enhancing element between nurses and patients; (2) support from patients’ coping strategies promotes patient-centeredness and collaboration; and (3) patients and professionals occupy unnegotiated identity roles.ConclusionOur study led to a refined programme theory developed through the realistic evaluation process that allows us to propose an answer to the problem of “what works, for whom, and under what circumstances”. The interplay between patients with DFU and healthcare professionals in a cross-sectoral setting for treatment and care is characterised by the use of humour as a relation-enhancing element and by improving support for patient coping strategies, which encourages healthcare professionals to promote health literacy. Future research should examine strategies for negotiating identity roles between patients with DFU and healthcare professionals to enhance collaboration, patient health literacy, and health promotion in cross-sectoral healthcare settings.

NATIONAL HEALTH INSURANCE POLICY AND PROGRAMME AND ACCESS TO HEALTH CARE SERVICE AMONG FEDERAL GOVERNMENT WORKERS IN NIGERIA

The study examined the effect of National Health Insurance on health care service delivery Among Federal Workers in Nigeria. This mixed research design study investigates the relationships between primary and secondary health care service providers and the provision of essential healthcare services to enrollees in Nigeria. The population of the study encompasses federal governamnt workers with primary and secondary health care facilities across various regions in Nigeria. A sample size of 400 enrollees and 50 health care providers was selected using stratified random sampling techniques. Data were collected through structured interviews and surveys, focusing on the perceptions and experiences of both health care providers and enrollees regarding the provision of affordable health care, testing and diagnostic services, and referral services. The collected data were analyzed usingboth qualitative and quantitative methods, including thematic analysis and correlation analysis. The findings reveal significant relationships between primary health care service providers and the provision of affordable health care and testing and diagnostic services to enrollees in Nigeria. Moreover, the study identifies a significant relationship between secondary health care service providers and the provision of referral services to enrollees, highlighting the importance of collaboration between primary and secondary healthcare sectors to ensure comprehensive healthcare delivery in Nigeria. These results underscore the need for policy interventions and resource allocation strategies aimed at strengthening primary and secondary healthcare systems to improve access to essential healthcare services for all enrollees in Nigeria. The study recommends that Federal Government through the NHIA shouldimplement policies that aim to increase the affordability of healthcare services for all citizens, especially those in lower socioeconomic strata. This may involve subsidizing healthcare costs, expanding insurance coverage, or introducing targeted assistance programs for vulnerable populations. Additionally, encourage healthcare providers to offer transparent pricing structures and explore innovative payment models, such as sliding-scale fees or income-based discounts, to improve access for individuals with varying financial capacities.

Associations between care home residents’ characteristics and acute hospital admissions – a retrospective, register-based cross-sectional study

BackgroundCare home residents are frail, multi-morbid, and have an increased risk of experiencing acute hospitalisations and adverse events. This study contributes to the discussion on preventing acute admissions from care homes. We aim to describe the residents’ health characteristics, survival after care home admission, contacts with the secondary health care system, patterns of admissions, and factors associated with acute hospital admissions.MethodData on all care home residents aged 65 + years living in Southern Jutland in 2018–2019 (n = 2601) was enriched with data from highly valid Danish national health registries to obtain information on characteristics and hospitalisations. Characteristics of care home residents were assessed by sex and age group. Factors associated with acute admissions were analysed using Cox Regression.ResultsMost care home residents were women (65.6%). Male residents were younger at the time of care home admission (mean 80.6 vs. 83.7 years), had a higher prevalence of morbidities, and shorter survival after care home admission. The 1-year survival was 60.8% and 72.3% for males and females, respectively. Median survival was 17.9 months and 25.9 months for males and females, respectively. The mean rate of acute hospitalisations was 0.56 per resident-year. One in four (24.4%) care home residents were discharged from the hospital within 24 h. The same proportion was readmitted within 30 days of discharge (24.6%). Admission-related mortality was 10.9% in-hospital and 13.0% 30 days post-discharge. Male sex was associated with acute hospital admissions, as was a medical history of various cardiovascular diseases, cancer, chronic obstructive pulmonary disease, and osteoporosis. In contrast, a medical history of dementia was associated with fewer acute admissions.ConclusionThis study highlights some of the major characteristics of care home residents and their acute hospitalisations and contributes to the ongoing discussion on improving or preventing acute admissions from care homes.Trial registrationNot relevant.

Burden of Obstetrics and Gynaecological Referrals to Tertiary Health Care System

OBJECTIVES This study aimed to assess the burden of obstetrics and gynaecological cases, causes and pattern of referral to tertiary care hospital. METHODOLOGY This descriptive cross-sectional study was carried out from May 2022-July 2022 using the data of patients who were referred to the Department of Obstetrics and Gynecology Unit 2 at Isra University Hospital from various primary, secondary, tertiary, and private hospitals for any obstetric or gynaecological emergency were the primary source of data. The confidentiality of each patient was carefully respected. This study evaluated the prevalence, reasons and pattern of referral of various obstetric and gynaecological conditions for which patients were referred to Isra University Hospital within the study duration and the management options provided to these patients. RESULTS The gynaecological cases accounted for the majority (71%) of referrals. Patients between 21-30 yrs of age comprised 51% of the total. Most patients (20%) were multipara in their third trimester (18%). High-risk patients (60%) were this study’s most common reason for referral, whereas financial restrictions (4%) were the least common. Only 5% of patients were referred from other tertiary care facilities, whereas 49% of patients came from the primary sector (49%), secondary (33%), and private (13%). CONCLUSION There is an imperative need to upgrade health system infrastructure, mainly primary and secondary health care systems and especially in the field of maternal and childcare, to enable prompt and appropriate diagnosis and management of various conditions in all nearby hospitals.

Study of the clinical aspect of diabetic foot ulcers and its surgical management

Objective: Diabetes is a global epidemic and a leading cause of death by disease. It is the common underlying cause of foot ulcers, infection, and ischemia, which are among the most serious complications of diabetes. This work aimed to study the clinical profile, surgical management, and outcome of patients with diabetic foot infections. Methods: Prospective study recruiting patients >18 years of age with diabetic foot infections. All patients underwent a detailed history and clinical examination, being distributed as per their different sociodemographic, clinical, and foot ulcer site characteristics, with further management and evaluation. Results: One hundred patients were recruited, with a mean age of 51.32±11.45 years. Majority of patients (73%) had a lower socioeconomic status. All patients had type 2 diabetes, with male predominance (78%). Mean diabetes mellitus duration was 9.68±5.03 years. Ulcer (92.31%) and discharge (72.31%) were the commonest complaints. During correlation analysis, a strong statistically significant (p<0.001) correlation was observed between amputation and HBA1c level (0.747) and SINBAD score (0.871), while correlation with RBS level was weak (0.532). Commonest presenting site was forefoot, followed by hindfoot. Conclusion: The SINBAD score is simple to use in daily practice, being more effective in describing diabetic foot. Primary and secondary healthcare systems in developing countries have limited resources, using different approaches to manage diabetic foot care. The SINBAD system can be used as a primary screening tool. Provision of correct and convenient footwear and efficient treatment of minor injuries are recommended to downturn ulcer occurrence. Level of Evidence II; Prospective Study; Lesser Quality (eg, patients enrolled at different points in their disease or <80% follow-up).

CHALLENGES FACED BY DENTISTS WORKING IN RURAL HEALTH CENTERS IN PUNJAB: COVID-19 PERSPECTIVE

This study aimed to explore the challenges faced by dentists working in rural health centers in Punjab, Pakistan. Data from 90 general dentists was collected from 45 RHCs in Punjab using cluster sampling. The data was collected via telephonic communication by extracting contact numbers from the official website of primary and secondary health care system. The results revealed that 64.6% of general dentists working in RHCs in Punjab are performing dental emergencies while knowing therisk of being Corona positive which was contrary for performing elective dental procedures. The majority of dentists reported unnecessary emphases from the patient’s side (72.2%) for executing dental emergencies which was contrary in performing elective dental procedures. Patients’ rigid behavior was also reported by 88% of the dentists on treatment refusal due to covid-19 contagion while 12% of patients believed that covid-19 does not exist while considering it a political propaganda for funding from WHO.

Prevalence of survey-based criteria for fibromyalgia and impact on hospital burden: a 7 year follow-up study from an outpatient clinic

Objectives To evaluate the prevalence of survey-based criteria for fibromyalgia (FM) among newly referred patients in a rheumatic outpatient clinic, and to compare the use of secondary healthcare services between survey-based FM and non-FM cases. Method Newly referred patients to an outpatient clinic were screened for the fulfilment of the 2011 FM survey criteria during a 6 month period in 2013 in this observational cohort study. Demographic data were obtained at baseline. Patients’ medical files were evaluated and comparisons between groups were made regarding the use of hospital healthcare facilities during the 7 year observation period. Results Out of 300 invited patients, 248 (83%) completed the questionnaire; 90 patients (36%) fulfilled survey-based criteria for FM at enrolment. FM cases were primarily women (80% vs 54% of non-FM cases), and received more medications (median 4 vs 3 drugs) and public economic support (62% vs 20%). At the 7 year follow-up, crude analyses showed that FM cases had a higher number of hospital courses (median 10 vs 8) and had undergone more invasive procedures (78% vs 60%). Neurologists (42% vs 28%), gastroenterologists (30% vs 13%), endocrinologists (40% vs 21%), pain specialists (13% vs 3%), psychiatrists (20% vs 7%), and abdominal surgeons (43% vs 30%) were consulted more often by FM than by non-FM cases. Conclusion Fulfilment of FM survey criteria among newly referred patients to a rheumatic outpatient clinic is frequent. Our study findings show that FM continues to present a challenge for healthcare professionals as well as for patients. RESEARCH HIGHLIGHTS ● Fulfilment of FM survey criteria among newly referred patients to a rheumatic outpatient clinic is frequent. ● The burden on the secondary healthcare system for these patients is significant. ● This study suggests the need for increased awareness about the diagnosis of FM among certain medical and surgical specialties.

"Not otherwise specified headache" in emergency department: an analysis of 149,603 visits to nine Upa's 24h in Fortaleza

Introduction
 Headache is one of the most common neurological symptoms and is almost a universal experience that requires medical attention on many occasions. Patients often seek medical advice for headaches in primary or secondary health care systems. In these scenarios, establishing the correct diagnosis of headache and referring further treatment to a specialist is essential. Hundreds of low-complexity Emergency Care Units (called UPAs 24h) were opened throughout the country in the last decade. Working 24/7, many UPA 24 h are one of the preferred places by patients to treat acute headaches.
 Objectives
 This study aims to evaluate the frequency of the "Not otherwise specified headache diagnoses" in patients who seek UPA's 24-h for headache.
 Methods
 We evaluated the ED charts of 149,603 visits motivated by headache to nine UPAs 24h in Fortaleza, Ceará, from January 2017 to April 2022. In addition to the demographic data, the care flow chart, the MTS classification, the times of each step of care (from risk classification to discharge or death), and the final diagnosis coded by the attendant physician using the International Classification of Diseases (ICD-10). Data were analyzed using statistical software, and a p <0.05 was considered for significance.
 Results
 The 149,603 consultations, which represented 3,5% of the total, were made by men and women (72 and 28% respectively) with 38.2 (± 14.6) years of age, on average. Regarding the diagnosis, only 25,121 (16.8%) patients received the diagnosis of migraine, and 4,671 (3.1%) were diagnosed with “other cephalic algic syndromes”. The remaining 119,811 (80.1%) had the not otherwise specified headache discharge diagnosis in their charts.
 (To see the complet abstract, please, check out the PDF.)

IS DIABETES IN FEMALES A RISK FACTOR FOR THE DEVELOPMENT OF TB

TYPE: Late Breaking Abstract TOPIC: Chest Infections PURPOSE: The availability of TRUENAT in secondary health care systems during Covid pandemics made us make early diagnosis tuberculosis also. The high sensitivity of TRUENAT helped to detect paucibacillary tuberculosis cases in patients with comorbid conditions. Here we are trying to evaluate TB incidents in such comorbid conditions and their relationship with gender. Aim: To assess any difference in TB incidence among comorbid and its differential pattern on a gender basis. METHODS: All the TB cases diagnosed at General Hospital Alappuzha were included in the study. Data are collected by the officer responsible for sputum TRUENAT testing. The study was conducted between 01.03.2021 and 31.08.2021. RESULTS: Of the total 70 cases detected, 55 were male and 15 were female in a ratio of 4.6: 1, comparable to gender-based incidents of TB. Among the 55 males, 10(18.1%) had diabetes and 5 have COPD (3 with COPD alone). Among 15 females, 6(40%) had diabetes, and 2 with COPD. Even though 18(25%) have smoking habits and 20(28%) are alcoholic among males. So even with additional risk for TB among males, TB is relatively lower in them compared to females. CONCLUSIONS: Female diabetes may probably be more prone to active tuberculosis disease. CLINICAL IMPLICATIONS: Conclusion and clinical implications Diabetic females should be screened with the molecular method of diagnosis for detecting tuberculosis. DISCLOSURE: Nothing to declare. KEYWORD: TRUENAT

Continuous Positive Airway Pressure (CPAP)-Can this be a boon to tide over ICU crisis in pandemic? A case series.

Coronavirus Disease 19 (COVID-19) disease has caused unusual overload of health care systems all over the world. We describe four severe COVID cases managed by non-intensivist. We had four unvaccinated cases with acute onset influenza like illness with signs of respiratory failure. Apart from general and COVID-specific measures, we started Continuous Positive Airway Pressure (CPAP) trial for these patients. All these patients were weaned off CPAP and were discharged once they recovered. Limitation of bed numbers in ICU has caused unforeseen stress upon the system to manage sudden increase of severe acute respiratory distress syndrome during COVID pandemics. Studies have shown non-invasive ventilation (NIV) and high frequency nasal cannula (HFNC) have improved patient outcomes. But managing NIV and HFNC is resource intensive in terms of manpower and equipment. We have found that patients with severe COVID disease can be managed safely using CPAP in secondary care with minimal training of non-intensivist healthcare workers in a cost-effective and efficient way of treating severe COVID who are unlikely to worsen. With the imminent third COVID wave looming, it is high time to strengthen our existing primary and secondary health care system by these novel methods to reduce the burden of our tertiary care.

Between the criminal justice and healthcare sectors: responsibilities in securing healthcare needs for people with intellectual disabilities after an investigative interview

ABSTRACT People with intellectual and developmental disabilities (PWIDD) who are victims of physical or sexual abuse are interviewed at Barnahus as part of a police investigation in Norway. Barnahus is responsible for ensuring victims receive the help they need to cope with such experiences. There is, however, limited knowledge of how the justice and healthcare sectors collaborate in cases of this kind. This study aims to describe the collaboration between the justice and healthcare sectors in healthcare needs after an investigative interview. A document study was conducted that included 10 real-life cases investigated by the Norwegian police. Five structured interviews with healthcare professionals were also conducted. The analysis shows that informal collaboration between the justice and healthcare sectors depends on specific persons in the organizations. Treatment or healthcare service is offered either by the Barnahus consultant or the primary or secondary healthcare system. There are no formal guidelines and procedures in this collaboration. The Barnahus’ responsibility for ensuring PWIDD receive the help they require to cope with abusive experiences depends on the services involved before the incident. Such disparities in services offered require further study. This can enable us to provide the highest attainable healthcare services to PWIDD after an abusive experience.

Quantifying the direct secondary health care cost of seasonal influenza in England

BackgroundThe winter pressure often experienced by NHS hospitals in England is considerably contributed to by severe cases of seasonal influenza resulting in hospitalisation. The prevention planning and commissioning of the influenza vaccination programme in the UK does not always involve those who control the hospital budget. The objective of this study was to describe the direct medical costs of secondary care influenza-related hospital admissions across different age groups in England during two consecutive influenza seasons.MethodsThe number of hospital admissions, length of stay, and associated costs were quantified as well as determining the primary costs of influenza-related hospitalisations. Data were extracted from the Hospital Episode Statistics (HES) database between September 2017 to March 2018 and September 2018 to March 2019 in order to incorporate the annual influenza seasons. The use of international classification of disease (ICD)-10 codes were used to identify relevant influenza hospitalisations. Healthcare Resource Group (HRG) codes were used to determine the costs of influenza-related hospitalisations.ResultsDuring the 2017/18 and 2018/19 seasons there were 46,215 and 39,670 influenza-related hospital admissions respectively. This resulted in a hospital cost of £128,153,810 and £99,565,310 across both seasons. Results showed that those in the 65+ year group were associated with the highest hospitalisation costs and proportion of in-hospital deaths. In both influenza seasons, the HRG code WJ06 (Sepsis without Interventions) was found to be associated with the longest average length of stay and cost per admission, whereas PD14 (Paediatric Lower Respiratory Tract Disorders without Acute Bronchiolitis) had the shortest length of stay.ConclusionThis study has shown that influenza-related hospital admissions had a considerable impact on the secondary healthcare system during the 2017/18 and 2018/19 influenza seasons, before taking into account its impact on primary health care.

Brazilian Primary and Secondary Public Oral Health Attention: Are Dentists Ready to Face the COVID-19 Pandemic?

To investigate knowledge and practice of Brazilian public primary and secondary health care dentists during the coronavirus disease (COVID-19) pandemic. An online questionnaire with sociodemographic and COVID-19 knowledge questions was used. A total of 4048 dentists working in the Brazilian public primary and secondary health care system were investigated; 4024 (99.41%) believe that COVID-19 can be transmitted through dental procedures. A fair level of COVID-19 symptoms knowledge by these dentists was observed (3.76±1.27 of 6.00), as well as the skepticism in personal protective equipment (3382; 83.55%) and biosafety procedures (3278; 80.98%) used as an efficient form of COVID-19 transmission prevention. Country region, performance of social distancing, dental specialty, the use of personal protective equipment, and biosafety preventive measures influenced the likelihood of dentists to perform dental treatment, either elective or urgent, during the COVID-19 pandemic. The need of extra preventive barriers for dental treatment may bring an extra financial stress in the Brazilian public primary and secondary health care system, as well as in the patient-dentist relationship, which may have to be reframed. Internationally accepted public guideline policies regarding dental treatment safety, as well as the technological development of preventive tools, are needed to deal with the challenges brought by COVID-19.

Community-based homecare nursing in Denmark: exploring factors related to substitution of nurses by ancillary health professionals.

Demographic changes and shorter hospital stays have made community-based homecare nursing an increasingly important part of the healthcare organisation. This development may also impact the secondary healthcare system. Optimal use of resources is key to meeting the future challenges. Nevertheless, the research-based knowledge on homecare nursing is scarce. The aim of this study was to examine factors related to homecare nursing tasks that could have been performed by ancillary health professionals. A population-based survey involving all homecare nurses in the homecare services in one municipality in Denmark was performed. The nurses registered all contacts during daytime for one week using a registration form with a series of items to identify factors related to possible substitution of nurse-performed tasks. Statistical analyses were used to identify associations between specific factors and potential substitution of the performing type of healthcare professional. The study was approved by and is registered at VIA University College in accordance with the General Data Protection Regulation of the EU. Homecare nurses registered 941 representative visits in the municipality. Substitution by ancillary health professionals was considered a possibility by the nurses in 28.3% of the cases. When adjusting for age, gender, type of visit, need for extra healthcare services and vulnerability, we established that the nurses more often found that ancillary health professionals could have provided the care in unplanned visits and in visits to patients above 90years of age. The results indicate potential for optimising the available nursing resources as substitution by ancillary health professionals was considered possible in numerous visits. In view of the increasing demands for community-based homecare nursing, it is important to make the most of the available resources in the future. Substitution of nurses for some tasks could be a feasible solution.

PRO28 LIFETIME HOSPITAL COSTS OF DANISH PATIENTS SUFFERING FROM LEU111MET TRANSTHYRETIN AMYLOID CARDIOMYOPATHY

A unique Danish mutation, Leu111Met (methionine-for-leucine substitution at amino acid number 111), of cardiac phenotype causing transthyretin (TTR) amyloid cardiomyopathy (ATTR-CM) has been identified to at least three unrelated Danish families with almost 100% penetration. Healthy carriers convert to patients after a median of 10 years at a median age of 47.5 years. If left untreated patients die from cardiac failure. No specific medical treatment exists. At first evidence of ATTRm patients are offered a liver transplant and 33.3% further a heart transplant (Statistics Denmark 2019). The objective of this study was to estimate the Danish lifetime hospital costs associated with treatment of ATTRm, before and after carriers convert to patients, respectively. We developed a model for Danish lifetime hospital costs associated with ATTRm including cost of monitoring and diagnosis carriers, transplants, post-transplant treatment and hospital admissions post-diagnosis (inpatient, outpatient and ambulatory). Since there are no published Danish healthcare data on hospital admissions for the specific Danish Leu111Met population, we rely on conservative estimates of frequencies from clinical experts. Carriers are followed closely 10 years prior to diagnosis and have an average life-expectancy of 18.5 years from diagnosis. Estimates of the cost of diagnosis, transplantations and hospitalizations were based on relevant publicly available Danish reference costs (DRG rates). The average cost of monitoring and diagnosing a carrier was US$ 24,304. Heart(33.3%) and liver transplant(100%) were the single largest cost drivers and amounts to an average of US$ 270,664 per patient. The total hospital costs after a carrier convert to patient is US$ 103,294 per patient. The total cumulative lifetime (28.5 years) hospital cost associated with ATTRm was US$ 398,262. Caring for ATTRm patients incurs a significant economic burden to the secondary health care system. This analysis is conservative and limited by excluding primary care sector costs (medication) and productivity loss.

Quality of anticoagulation with warfarin in rural Chhattisgarh, India

Background & objectives:In most of rural India, warfarin is the only oral anticoagulant available. Among patients taking warfarin, there is a strong association between poor control of the international normalized ratio (INR) and adverse events. This study was aimed to quantify INR control in a secondary healthcare system in rural Chhattisgarh, India.Methods:The INR data were retrospectively obtained from all patients taking warfarin during 2014-2016 at a secondary healthcare system in rural Chhattisgarh, India. Patients attending the clinic had their INR checked at the hospital laboratory and their warfarin dose adjusted by a physician on the same day. The time in therapeutic range (TTR) was calculated for patients who had at least two INR visits.Results:The 249 patients had 2839 INR visits. Their median age was 46 yr, and the median body mass index was 17.7 kg/m2. They lived a median distance of 78 km (2-3 h of travel) from the hospital. The median INR was 1.7 for a target INR of 2.0-3.0 (n=221) and 2.1 for a target of 2.5-3.5 (n=28). The median TTR was 13.0 per cent, and INR was subtherapeutic 66.0 per cent of the time. Distance from the hospital was not correlated with TTR.Interpretation & conclusions:INR values were subtherapeutic two-thirds of the time, and TTR values were poor regardless of distance from the health centre. Future studies should be done to identify interventions to improve INR control.

Assessment of Quality of Healthcare in Secondary Health Care Systems Doiwala, District of Dehradun

Introduction: In an era of increasing accountability throughout our society, it is not surprising that questions about the efficacy and efficiency of our health care system are also being raised. Both functional and technical qualities have to be monitored and managed effectively.
 Objectives: To enhance service effectiveness CHC/PHC health delivery systems. To evaluate the quality of care rendered by CHC, PHCs, Sub centres, AWCs by IPHS guidelines, Likert’s scale and WHO Assessment tool. To assess the health workforce in their capabilities. Patient satisfaction in the quality of care.
 Methodology: Out of the thirteen districts of Uttarakhand, the district of Dehradun has six blocks of which Doiwala is the largest block. A qualitative study design: One Community Health Centre namely CHC Doiwala, which has five Primary Health centres were studied using three different tools. (i) IPHS standards (ii) SARA (WHO) (iii) Likerts scale for patient satisfaction. However, in the COVID scenario some limitations have been considered in the study.
 Results: The quality of health care in the healthcare delivery system has been assessed as per scale and has been found that factors of patient satisfaction, infrastructure and outcomes for assessment of quality are strong contending variables.
 Conclusion: The PPP model has upgraded the healthcare system with substantial contribution from the private sector.

Awareness, knowledge and attitude toward secondary health care system: survey of physicians in Kosovo

Objective: To assess knowledge, awareness and attitude among hospital physicians from Kosovo toward current situation of Health Care System (HCS) especially Secondary Health Care (SHC) in Kosovo.
 Methods: In this cross-sectional study, anonymous questionnaire were delivered to three regional hospitals in Kosovo. The main outcome measures were physician’s awareness of the management of secondary health care institutions, awareness and use of new technology for improving health care in second level and their suggestions for further improvement.
 Results: Results are divided into three main categories: I. Relevant information on the knowledge of the health care system, were respondents had valuable information and insight; II. Relevant information on suggested improvements, in which respondents gave their proposals regarding workplace and inter managerial relations and III. Relevant information on continues education possibilities for medical staff.
 Conclusions: In conclusion there is a need to prioritize proper cooperation between primary, secondary, and third level of health institutions, in terms of entire health management in order to increase the quality of health services delivery, in line with western standards.
 Bangladesh Journal of Medical Science Vol.18(2) 2019 p.288-293

Flexible intramedullary nailing in pediatric femoral fractures, short term results at a secondary healthcare system

Background: Femoral fractures in children are among the most common fractures of long bones. The definitive treatment modalitiy remains controversial. Flexible intramedullary nailing has emerged as an accepted procedure for femoral fractures in school going children. We thus undertook a prospective study of paediatric femoral fractures treated with flexible titanium nailing at our centre which is a secondary health care. Material and Methods: Our study included 18 patients having femoral fractures treated with retrograde flexible intramedullary nailing. In our study we had males and females with right side and on left side. Patients were followed up for a mean period of 10 months. Results: Patients were followed up till their fractures healed or until the last followup visit. The mean length of follow-up was 10 months. All patients united uneventfully. Radiological union was evident in a mean time of 8.44 weeks ranging from 6 to 12 weeks. Three patients got limb lengthening of 1 – 1.5cm. Two patients got a varus angulation of less than 10o. There was no case of entry site irritation or any nerve palsy. One patient got a peculiar entry site medial localized cortical longitudinal fracture. There were 12 excellent and 6 satisfactory results using outcome criteria of Flynn et al for titanium elastic nail. Conclusion: Flexible nailing in pediatric femoral fractures yields excellent and satisfactory outcome with a relatively free from major complications.