Suboptimal Services Research Articles

Availability of drugs and medical supplies for emergency obstetric care: experience of health facility managers in a rural District of Tanzania

BackgroundProvision of quality emergency obstetric care relies upon the presence of skilled health attendants working in an environment where drugs and medical supplies are available when needed and in adequate quantity and of assured quality. This study aimed to describe the experience of rural health facility managers in ensuring the timely availability of drugs and medical supplies for emergency obstetric care (EmOC).MethodsIn-depth interviews were conducted with a total of 17 health facility managers: 14 from dispensaries and three from health centers. Two members of the Council Health Management Team and one member of the Council Health Service Board were also interviewed. A survey of health facilities was conducted to supplement the data. All the materials were analysed using a qualitative thematic analysis approach.ResultsParticipants reported on the unreliability of obtaining drugs and medical supplies for EmOC; this was supported by the absence of essential items observed during the facility survey. The unreliability of obtaining drugs and medical supplies was reported to result in the provision of untimely and suboptimal EmOC services. An insufficient budget for drugs from central government, lack of accountability within the supply system and a bureaucratic process of accessing the locally mobilized drug fund were reported to contribute to the current situation.ConclusionThe unreliability of obtaining drugs and medical supplies compromises the timely provision of quality EmOC. Multiple approaches should be used to address challenges within the health system that prevent access to essential drugs and supplies for maternal health. There should be a special focus on improving the governance of the drug delivery system so that it promotes the accountability of key players, transparency in the handling of information and drug funds, and the participation of key stakeholders in decision making over the allocation of locally collected drug funds.

Referral source, symptoms, and severity at diagnosis of ocular hypertension or open-angle glaucoma in various practices

ObjectiveTo evaluate the severity of glaucoma at presentation and the relationship to referral source and presenting symptoms. DesignProspective, multicentre, cross-sectional, study. ParticipantsPatients newly diagnosed with ocular hypertension (OH) or open-angle glaucoma (OAG). MethodsEligible subjects underwent comprehensive ocular examinations, including medical histories and presenting symptoms. The referral source was also documented. Patients were classified as OH or mild, moderate, or advanced OAG. The proportion of subjects in each disease category was determined and compared for differences in demographics, ocular findings, referral sources, and presenting symptoms. ResultsWe enrolled 404 subjects; 113 (28%) were diagnosed as having OH and 291 (72%) as having OAG. In the OAG group 151 (52%) had mild, 79 (27%) moderate, and 61 (21%) advanced disease at initial diagnosis. The majority of the referrals were from optometrists (82%), followed by family physicians (7%) and ophthalmologists (7%). Referral patterns and presenting symptoms were significantly different for advanced disease as compared to the other severity levels (p = 0.03 and p 0 .003, respectively). In more than half of the patients, the referral was made because of an abnormality noted by the referring source in an asymptomatic subject. Visual symptoms noted by the subject were more common in advanced OAG (23%) as compared to OH (9%), mild (4%), and moderate (9%) OAG. ConclusionsNearly half of the patients with OAG had moderate or advanced disease at the time of initial diagnosis. Although optometrists were responsible for the majority of the referrals, the proportion was significantly less for advanced disease. These results raise the possibility of suboptimal detection services for glaucoma.

Middle East Experience in Palliative Care

Palliative Care (PC) is still a relatively new concept in the Middle East (ME). It was first introduced in Saudi Arabia in 1992 and only recently in countries such as Qatar, Bahrain, and the UAE. Although the majority of Middle-Eastern countries, including Palestine, Iraq, Oman and Lebanon are in the capacity building phase, others such as Saudi and Jordan already have localized provision. In the absence of any of the ME countries approaching integration with the mainstream service providers, Saudi Arabia and Jordan are currently setting examples of achievement in the field. There are still countries with little or no known Palliative Care activity (Yemen and Syria). Political issues, scarcity of resources, and lack of education and awareness seem to be the common factors restricting the progress of this field in most countries. In order to improve the suboptimal PC services in the ME, emphasis should be directed toward providing formal education to professionals and raising awareness of the public. It is also necessary to put all differences aside and develop cross-border collaborations, whether through third party organizations such as the Middle East Cancer Consortium (MECC) or otherwise. This review compiles the available literature on the history and progress of the field of PC in most ME countries, while pointing out the major obstacles encountered by the active parties of each country.

Social Costs of Bank Capital Requirements in the Presence of a Deposit Insurance Subsidy

Bank capital requirements would entail large social costs if they made resource allocation suboptimal and banking services costly by unduly limiting the banks’ ability to lend. This paper considers three main factors that may make capital requirements relevant, namely, deposit insurance subsidies, stock valuation errors, and tax shields derived from debt financing. The theoretical model analyzes the combined effects of the three factors on the banks’ incentives to make fairly priced loans, which should also be socially optimal loans. A key finding is that the long-term cost of capital requirements is likely to be very small when deposit insurance is underpriced. Short-term adjustment costs can still be large, but it should be relatively easy to mitigate the short-term effects.

The use of knowledge translation and legal proceedings to support evidence-based drug policy in Canada: opportunities and ongoing challenges.

There is growing recognition, particularly in the areas of illicit drug policy and HIV prevention, that policy-makers are in many instances implementing suboptimal programs and services because they are not basing their decisions on the best available scientific evidence. One notable example where a policy-making body has failed to use scientific evidence to inform policy is the Canadian federal government's opposition to Vancouver's supervised injection facility despite a large body of scientific evidence indicating that the program is associated with a range of health and social benefits. Two of the key strategies that have been used to try to shift drug policy toward an evidence-based approach and maintain the operation of this evidence-based health facility are knowledge translation and legal actions. We provide an overview of these two strategies and hope it will offer lessons for the implementation of evidence-based approaches in other controversial areas of public policy.

Impact of delay in asthma diagnosis on health care service use

Delays in diagnosing asthma in children are common and are known to delay asthma-specific treatment. Few studies have investigated whether a delay in asthma diagnosis impacts the use of health care services. This study was designed to assess whether a delay in diagnosis of asthma influences the use of health care services. This was a retrospective cohort study with subjects elicited from a convenience sample of 839 healthy children. The criteria for asthma was met in 276 (33%) subjects; of these subjects 179 (65%) had a delay in the diagnosis of asthma and 97 (35%) had a timely diagnosis. Data on health care services (e.g., flu shot, availability of a peak flow meter, hospitalizations, and urgent care or emergency department visits) and the frequency of systemic steroid treatments were collected from medical records during the first 18 years of life. The frequencies of health service and use of systemic steroids were compared using Poisson and logistic regression models in asthmatic children with and without a delay in asthma diagnosis. Children with a delay in asthma diagnosis were more likely to visit urgent care centers at least once (40.8% versus 21.6%; p < 0.001), compared with those with a timely diagnosis. There were no significant differences in other health care service or systemic steroid use. A delay in the diagnosis of asthma was associated with an increase in urgent care visits suggesting suboptimal care. Clinicians should be aware that a delay in the diagnosis of asthma in children may result in the use of suboptimal health care services.

Religion and HIV/AIDS stigma: Implications for health professionals in Puerto Rico

HIV/AIDS stigma continues to be a barrier for prevention efforts. Its detrimental effects have been documented among people living with HIV/AIDS and encompass loss of social support and depression. When it is manifested by health professionals, it can lead to sub-optimal services. Although strides have been made to document the effects of HIV/AIDS stigma, much needs to be done in order to understand the structural factors that can foster it. Such is the case of religion's role on HIV/AIDS stigma in Puerto Rico. The Caribbean Island has a Judeo-Christian-based culture due to years of Spanish colonisation. This religious influence continued under Protestantism as part of the Island's integration as a non-incorporated territory of the USA. The main objective of this study was to explore the role of religion in HIV/AIDS stigma manifested by Puerto Rican health professionals in practice and in training. Through a mixed-method approach, 501 health professionals completed qualitative interviews (n=80) and self-administered questionnaires (n=421). Results show that religion plays some role in conceptualisations of health and illness among participants in the study. Furthermore, the importance placed on religion and participation in such activities was related to higher levels of HIV/AIDS stigma.

Health Services–Seeking Behaviors of People Traveling From Developed Areas—A Case of Hong Kong Residents Visiting Mainland China

The study investigated risk perceptions and inclination to defer seeking of medical services among Hong Kong residents if they become sick in mainland China, and prevalence and factors associated with purchase of travel medical insurance. A random, population-based telephone survey was conducted on 406 Hong Kong Chinese aged 18 to 60. Of all respondents, 70.9, 62.9, and 57.2%, respectively, would defer seeking medical consultation until back to Hong Kong for mild conditions of influenza, injury, and acute disease; 55.6, 36.7, and 37.3%, respectively, would do so even for the three severe medical conditions. Concern for inferior medical standards in mainland China is the main reason for inclination to defer seeking medical services when traveling in mainland China. Multivariately, fear for nosocomial infection, lack of family/social support, and lack of knowledge about medical services in mainland China were significant factors associated with the inclination. Travel medical insurance was purchased by 20.0% of the respondents. Other difficulties for using medical services in mainland China and demands for relevant services were reported. A dilemma exists between deferring seeking medical services and exposure to risk due to suboptimal medical services when people are traveling from developed areas to developing areas.

Are some perinatal deaths in immigrant groups linked to suboptimal perinatal care services?

To test the hypothesis that suboptimal factors in perinatal care services resulting in perinatal deaths were more common among immigrant mothers from the Horn of Africa, when compared with Swedish mothers. A perinatal audit, comparing cases of perinatal deaths among children of African immigrants residing in Sweden, with a stratified sample of cases among native Swedish women. Sixty-three cases of perinatal deaths among immigrant east African women delivered in Swedish hospitals in 1990-1996, and 126 cases of perinatal deaths among native Swedish women. Time of death and type of hospital were stratified. Suboptimal factors in perinatal care services, categorised as maternal, medical care and communication. The rate of suboptimal factors likely to result in potentially avoidable perinatal death was significantly higher among African immigrants. In the group of antenatal deaths, the odds ratio (OR) was 6.2 (95% CI 1.9-20); the OR for intrapartal deaths was 13 (95% CI 1.1-166); and the OR for neonatal deaths was 18 (95% CI 3.3-100), when compared with Swedish mothers. The most common factors were delay in seeking health care, mothers refusing caesarean sections, insufficient surveillance of intrauterine growth restriction (IUGR), inadequate medication, misinterpretation of cardiotocography (CTG) and interpersonal miscommunication. Suboptimal factors in perinatal care likely to result in perinatal death were significantly more common among east African than native Swedish mothers, affording insight into socio-cultural differences in pregnancy strategies, but also the suboptimal performance of certain health care routines in the Swedish perinatal care system.

Are some perinatal deaths in immigrant groups linked to suboptimal perinatal care services?

Objective To test the hypothesis that suboptimal factors in perinatal care services resulting in perinatal deaths were more common among immigrant mothers from the Horn of Africa, when compared with Swedish mothers. Design A perinatal audit, comparing cases of perinatal deaths among children of African immigrants residing in Sweden, with a stratified sample of cases among native Swedish women. Population and setting Sixty-three cases of perinatal deaths among immigrant east African women delivered in Swedish hospitals in 1990–1996, and 126 cases of perinatal deaths among native Swedish women. Time of death and type of hospital were stratified. Main outcome measures Suboptimal factors in perinatal care services, categorised as maternal, medical care and communication. Results The rate of suboptimal factors likely to result in potentially avoidable perinatal death was significantly higher among African immigrants. In the group of antenatal deaths, the odds ratio (OR) was 6.2 (95% CI 1.9–20); the OR for intrapartal deaths was 13 (95% CI 1.1–166); and the OR for neonatal deaths was 18 (95% CI 3.3–100), when compared with Swedish mothers. The most common factors were delay in seeking health care, mothers refusing caesarean sections, insufficient surveillance of intrauterine growth restriction (IUGR), inadequate medication, misinterpretation of cardiotocography (CTG) and interpersonal miscommunication. Conclusions Suboptimal factors in perinatal care likely to result in perinatal death were significantly more common among east African than native Swedish mothers, affording insight into socio-cultural differences in pregnancy strategies, but also the suboptimal performance of certain health care routines in the Swedish perinatal care system.

The urban and rural divide for women giving birth in NSW, 1990-1997

To examine trends in the pregnancy profile and outcomes of urban and rural women. Data were obtained from the NSW Midwives Data Collection on births in NSW, 1990-1997. Associations between place of residence (urban/rural) and maternal factors and pregnancy outcomes were examined, including changes over time. From 1990 to 1997 there were 685,631 confinements in NSW and these mothers resided as follows: 76% metropolitan, 5% large rural centres, 8% small rural centres, 11% other rural areas and 1% remote areas. Rural mothers were more likely to be teenagers, multiparous, without a married or de facto partner, public patients and smokers. Births in rural areas declined, particularly among women aged 20-34 years. Infants born to mothers in remote communities were at increased odds of stillbirth and low Apgar scores (all women) and small-for-gestational- age (SGA) (Indigenous women only). The profile of pregnant women in rural NSW is different from their urban counterparts and is consistent with relative socioeconomic disadvantage and possibly suboptimal maternity services in some areas. While increased risk of SGA is associated with environmental factors such as smoking and nutrition, the reasons the increased risk of stillbirth are unclear. Although there does not appear to be an increase d risk of preterm birth for rural women this may be masked by transfer of high risk pregnancies interstate. Maternity services need to be available and accessible to all rural women with targeting of interventions known to reduce low birthweight and perinatal death.

Implementation and financial analysis of an operating room satellite pharmacy

The rationale and implementation of an operating room (OR) pharmacy satellite is described, and the first-year savings are evaluated. The OR in an 874-bed university teaching hospital, consisting of 17 rooms for inpatients, 6 rooms for ambulatory patients, and a postanesthesia care unit, lacked comprehensive pharmacy services; this resulted in poor drug-use control and accountability, varied controlled-substance audit trails, and suboptimal patient services. A task force examined other institutions' OR pharmacy satellites and chose to implement a satellite that provides all pharmaceuticals and i.v. admixtures by using case trays for each surgical patient. One year after implementation of the satellite, inventory in the operating-room areas was reduced by 56.5%, annual pharmaceutical costs by 2.6% (adjusted for inflation), and average cost per patient by 8.0% (adjusted for inflation). First-year cost reductions and revenue identification exceeded operating costs for materials, supplies, and labor by $271,755. Implementation of an OR pharmacy satellite reduced the net cost of providing pharmaceutical services to the OR.