Inter-organisational communication networks in healthcare: centralised versus decentralised approaches

Background: To afford efficient and high quality care, healthcare providers increasingly need to exchange patient data. The existence of a communication network amongst care providers will help them to exchange patient data more efficiently. Information and communication technology (ICT) has much potential to facilitate the development of such a communication network. Moreover, in order to offer integrated care interoperability of healthcare organizations based upon the exchanged data is of crucial importance. However, complications around such a development are beyond technical impediments. Objectives: To determine the challenges and complexities involved in building an Inter-organisational Communication network (IOCN) in healthcare and the appropriations in the strategies. Case study: Interviews, literature review, and document analysis were conducted to analyse the developments that have taken place toward building a countrywide electronic patient record and its challenges in The Netherlands. Due to the interrelated nature of technical and non-technical problems, a socio-technical approach was used to analyse the data and define the challenges. Results: Organisational and cultural changes are necessary before technical solutions can be applied. There are organisational, financial, political, and ethicolegal challenges that have to be addressed appropriately. Two different approaches, one ‘‘centralised’’ and the other ‘‘decentralised’’ have been used by Dutch healthcare providers to adopt the necessary changes and cope with these challenges. Conclusion: The best solutions in building an IOCN have to be drawn from both the centralised and the decentralised approaches. Local communication initiatives have to be supervised and supported centrally and incentives at the organisations’ interest level have to be created to encourage the stakeholder organisations to adopt the necessary changes

Linkage to treatment following RR-TB diagnosis in the Western Cape

Includes bibliographical referencesPatients diagnosed with rifampicin resistant (RR) tuberculosis (TB) in South Africa frequently fail to link to appropriate drug resistant (DR) TB treatment. The aim of this study was to explore barriers and enablers to expedited linkage to treatment following RR-TB diagnosis in the Western Cape Province, within the context of ongoing decentralisation of DRTB services and the scale-up of Xpert MTB/RIF diagnostics. Methods: An embedded case study approach, using qualitative research methods, was employed to explore barriers and enablers to expedited treatment linkage following RR-TB diagnosis. The case of investigation in this study was 'treatment linkage following RR-TB diagnosis in the Western Cape Province during the ongoing decentralisation of DR-TB services and scale-up of Xpert diagnostics'. DR-TB is used in this study as an encompassing term to refer to RR, multidrug resistant and extensively drug resistant TB. The embedded units of analysis in this study were patients' linkage outputs, defined as: (1) expedited treatment initiation, (2) delayed treatment initiation and (3) non-initiation of treatment following sputum collection on which RR-TB was diagnosed. Seventeen patient, 8 family member, 49 healthcare worker and 4 key informant open-ended, in-depth interviews were conducted and 59 patient folders were reviewed. Additionally, an extensive literature review was conducted. The tools used for data collection in this study were developed from the literature review and Coker et al.'s (201) conceptual framework for evaluation of a communicable disease intervention. A framework approach using Coker et al.'s conceptual framework was applied for analysis. Results: This study identified multiple factors that enabled and constrained expedited treatment linkage following RR-TB diagnosis. Enabling factors included: 1) the availability of clinic level DR-TB counsellors and tracers; 2) living in walking distance of decentralised services and 3) having a strong social support network. Constraining factors included: 1) low usage of Xpert diagnostics, 2) delays in acting on results and missed (or unseen) results, 3) rotation of nurses or the lack of dedicated TB nurses in clinics, 4) limited clinic-level administrative support, 5) information systems challenges and 6) waiting lists for beds and limited access to transport services in rural areas . In linking to treatment, patients commonly face challenges due to competing subsistence needs and household or employment responsibilities. Additionally, substance addiction, having a history of treatment interruption, hopelessness regarding treatment, as well as not having a stable place to stay or social support may increase patients' risks of linkage failure. Conclusion: Within the Western Cape Province, there is significant opportunity to improve linkage to treatment through strengthening the health systems mechanisms to link patients to treatment following RR-TB diagnosis. Expanding access to psychosocial services (substance abuse rehabilitation and psychosocial evaluations) following RR-TB diagnosis may assist in linking high-risk patients to treatment. Additionally, the provision of food support (in addition to social grants) should be evaluated as a tactic to improve treatment linkage and adherence

Dynamic trust negotiation for decentralised e-health collaborations

In the Internet-age, the geographical boundaries that have previously impinged upon inter-organisational collaborations have become decreasingly important. Of more importance for such collaborations is the notion and subsequent nature of security and trust - this is especially so in open collaborative environments like the Grid where resources can be both made available, subsequently accessed and used by remote users from a multitude of institutions with a variety of different privileges spanning across the collaboration. In this context, the ability to dynamically negotiate and subsequently enforce security policies driven by various levels of inter-organisational trust is essential. Numerous access control solutions exist today to address aspects of inter-organisational security. These include the use of centralised access control lists where all collaborating partners negotiate and agree on privileges required to access shared resources. Other solutions involve delegating aspects of access right management to trusted remote individuals in assigning privileges to their (remote) users. These solutions typically entail negotiations and delegations which are constrained by organisations, people and the static rules they impose. Such constraints often result in a lack of flexibility in what has been agreed; difficulties in reaching agreement, or once established, in subsequently maintaining these agreements. Furthermore, these solutions often reduce the autonomous capacity of collaborating organisations because of the need to satisfy collaborating partners demands. This can result in increased security risks or reducing the granularity of security policies. Underpinning this is the issue of trust. Specifically trust realisation between organisations, between individuals, and/or between entities or systems that are present in multi-domain authorities. Trust negotiation is one approach that allows and supports trust realisation. The thesis introduces a novel model called dynamic trust negotiation (DTN) that supports n-tier negotiation hops for trust realisation in multi-domain collaborative environments with specific focus on e-Health environments. DTN describes how trust pathways can be discovered and subsequently how remote security credentials can be mapped to local security credentials through trust contracts, thereby bridging the gap that makes decentralised security policies difficult to define and enforce. Furthermore, DTN shows how n-tier negotiation hops can limit the disclosure of access control policies and how semantic issues that exist with security attributes in decentralised environments can be reduced. The thesis presents the results from the application of DTN to various clinical trials and the implementation of DTN to Virtual Organisation for Trials of Epidemiological Studies (VOTES). The thesis concludes that DTN can address the issue of realising and establishing trust between systems or agents within the e-Health domain, such as the clinical trials domain

Delays and loss to follow-up before treatment of drug-resistant tuberculosis following implementation of Xpert MTB/RIF in South Africa: A retrospective cohort study.

BACKGROUND: South Africa has a large burden of rifampicin-resistant tuberculosis (RR-TB), with 18,734 patients diagnosed in 2014. The number of diagnosed patients has increased substantially with the introduction of the Xpert MTB/RIF test, used for tuberculosis (TB) diagnosis for all patients with presumptive TB. Routine aggregate data suggest a large treatment gap (pre-treatment loss to follow-up) between the numbers of patients with laboratory-confirmed RR-TB and those reported to have started second-line treatment. We aimed to assess the impact of Xpert MTB/RIF implementation on the delay to treatment initiation and loss to follow-up before second-line treatment for RR-TB across South Africa. METHODS AND FINDINGS: A nationwide retrospective cohort study was conducted to assess second-line treatment initiation and treatment delay among laboratory-diagnosed RR-TB patients. Cohorts, including approximately 300 sequentially diagnosed RR-TB patients per South African province, were drawn from the years 2011 and 2013, i.e., before and after Xpert implementation. Patients with prior laboratory RR-TB diagnoses within 6 mo and currently treated patients were excluded. Treatment initiation was determined through data linkage with national and local treatment registers, medical record review, interviews with health care staff, and direct contact with patients or household members. Additional laboratory data were used to track cases. National estimates of the percentage of patients who initiated treatment and time to treatment were weighted to account for the sampling design. There were 2,508 and 2,528 eligible patients in the 2011 and 2013 cohorts, respectively; 92% were newly diagnosed with RR-TB (no prior RR-TB diagnoses). Nationally, among the 2,340 and 2,311 new RR-TB patients in the 2011 and 2013 cohorts, 55% (95% CI 53%-57%) and 63% (95% CI 61%-65%), respectively, started treatment within 6 mo of laboratory receipt of their diagnostic specimen (p < 0.001). However, in 2013, there was no difference in the percentage of patients who initiated treatment at 6 mo between the 1,368 new RR-TB patients diagnosed by Xpert (62%, 95% CI 59%-65%) and the 943 diagnosed by other methods (64%, 95% CI 61%-67%) (p = 0.39). The median time to treatment decreased from 44 d (interquartile range [IQR] 20-69) in 2011 to 22 d (IQR 2-43) in 2013 (p < 0.001). In 2013, across the nine provinces, there were substantial variations in both treatment initiation (range 51%-73% by 6 mo) and median time to treatment (range 15-36 d, n = 1,450), and only 53% of the 1,448 new RR-TB patients who received treatment were recorded in the national RR-TB register. This retrospective study is limited by the lack of information to assess reasons for non-initiation of treatment, particularly pre-treatment mortality data. Other limitations include the use of names and dates of birth to locate patient-level data, potentially resulting in missed treatment initiation among some patients. CONCLUSIONS: In 2013, there was a large treatment gap for RR-TB in South Africa that varied significantly across provinces. Xpert implementation, while reducing treatment delay, had not contributed substantially to reducing the treatment gap in 2013. However, given improved case detection with Xpert, a larger proportion of RR-TB patients overall have received treatment, with reduced delays. Nonetheless, strategies to further improve linkage to treatment for all diagnosed RR-TB patients are urgently required

Elimination of hepatitis C: positioning document of the Spanish Association for the Study of the Liver (AEEH)

Hepatitis C; Diagnóstico descentralizado; Tratamiento antiviral; Población vulnerableHepatitis C; Decentralised diagnosis; Antiviral treatment; Vulnerable populationHepatitis C; Diagnòstic descentralitzat; Tractament antiviral; Població vulnerableLa Asociación Española para el Estudio del Hígado (AEEH) está convencida de que la eliminación de la hepatitis C en España es posible siempre y cuando seamos capaces de emplear los recursos y las herramientas necesarias para la misma. Este documento refleja la posición de la AEEH respecto a la eliminación del virus de la hepatitis C (VHC), estableciendo una amplia serie de recomendaciones que se pueden agrupar en cinco categorías: 1) cribado del VHC en función de la edad, de la existencia de factores de riesgo clásicos de adquisición de la infección, búsqueda activa de pacientes diagnosticados con anterioridad y desarrollo de estrategias de microeliminación en poblaciones vulnerables; 2) simplificación del diagnóstico del VHC (diagnóstico en un solo paso y diagnóstico en el punto de atención del paciente); 3) simplificación del tratamiento de los pacientes y mejora de los circuitos asistenciales; 4) medidas de política sanitaria, y, finalmente, 5) establecimiento de indicadores de eliminación del VHC.The Spanish Association for the Study of the Liver (AEEH) is convinced that the elimination of hepatitis C virus (HCV) in Spain is possible as long as we are able to use the resources and tools necessary for it. This document reflects the position of the AEEH regarding the elimination of HCV, establishing a wide range of recommendations that can be grouped into five categories: 1) Screening of HCV according to age, of the existence of classic acquisition risk factors of infection, active search of previously diagnosed patients and development of microelimination strategies in vulnerable populations; 2) Simplification of HCV diagnosis (onestep diagnosis and diagnosis at the point of patient care); 3) Simplification of patient treatment and improvement of care circuits; 4) Health policy measures, and, finally, 5) Establishment of HCV elimination indicators

A simulation model for evaluating national patient record networks in South Africa.

Includes abstract.Includes bibliographical references.This study has shown that modelling and simulation is a feasible approach for evaluating NPR solutions in the developing context. The model can represent different network models, patient types and performance metrics to aid in the evaluation of NPR solutions. Using the current model, more case studies can be investigated for various public health issues - such as the impact of disease or regional services planning

Drug resistant tuberculosis treatment outcomes at an urban ambulatory TB Unit in the City of Johannesburg

A dissertation submitted in partial fulfillment of Master of Science in the field of Infectious Disease Epidemiology. June 2018.Background: Treatment of Drug Resistant Tuberculosis has historically been centralised and this model of care has posed challenges in management of such patients. Prolonged time to treatment and potential risk for continued community and nosocomial transmissions, capacity at these sites and availability of human resources to treat the increasing numbers of DRTB patients has been among those challenges. WHO set out to improve all DRTB outcomes especially in countries where the burden is high. Decentralisation of DRTB care has shown to improve these outcomes in many settings. Objectives: The main aim of the study was to describe any Rifampicin-resistant TB treatment outcomes in an ambulatory care model and to assess predictors of unsuccessful outcomes. Survival times for unsuccessful treatment outcomes were also determined. A comparison of the treatment outcomes by HIV status was also assessed. Methods: A retrospective cohort review of 335 patients with any Rifampicin-resistant TB diagnosis between January 2010 and January 2014, at Charlotte Maxeke Johannesburg Academic hospital DR-TB focal point was conducted. Survival analysis was done for unsuccessful outcomes. Multivariable Cox regression models were used to determine predictors of mortality, default and overall unsuccessful outcomes. Differences in outcomes by HIV status were compared using Pearson’s chi-square Results: Of the 335 patients analysed, 14 (4.2%) patients were still on treatment, 64 (19.1%) were successfully treated [with 17 (5.1%) cured and 47 (14%) completed treatment]. Unsuccessful outcomes were seen in 122 (36.4%) of the patients [with 30 (9%) died and 92 (27.5%) defaulted]. The remaining 135 (40.3%) patients were transferred out. There were no treatment failures in this cohort. Median survival time for unsuccessful outcomes was 3.2 months (IQR:1.4 to 9.2). Median time to death and default were 4.6 months (IQR:0.9 to13.8) and 3 months (IQR:1.4 to 8.5) respectively. There was no statistical difference found in proportions of successful and unsuccessful outcomes between HIV co-infected and HIV negative patients. Overall predictors of unsuccessful outcomes were: confirmed RMR-TB (HR=8.5; 95% CI: 2.0-35.2; p=0.003) and unconfirmed Rifampicin-resistance diagnosed on GXP alone (HR=10.9; 95% CI: 2.6-44.8; p=0.001). There were no statistically significant predictors of mortality found in this study. Predictors of default were: confirmed RMR-TB (HR=15.9; 95% CI: 2.1-116.5; p=0.006) and unconfirmed Rifampicin-resistance diagnosed on GXP alone (HR=17.2; 95% CI: 2.4-125.3; p=0.01). For a subgroup of HIV co-infected patients, being initiated on ART had 90% less hazards of defaulting (HR=0.1; 95% CI: 0.05-0.2; p=0.000). Age category >40 years also had 60% less hazards of defaulting in the HIV co-infected patients. Patients co-infected with HIV had higher hazards of default if they were diagnosed as confirmed RMR-TB (HR=10.8; 95% CI: 1.4-84.1; p=0.023) and unconfirmed Rifampicin-resistance diagnosed on GXP alone (HR=10.6; 95% CI: 1.4-80.2; p=0.022). Not initiated on ART was a predictor of unsuccessful outcome among HIV co-infected patients (HR=7.6; 95% CI: 4.1-14.1; p=0.000). Conclusion: Overall treatment outcomes were poor, with a low success rate (19.1%) and a high defaulter rate (27.5%). Mortality was comparable with other studies. Predictors of unsuccessful outcomes were confirmed RMR-TB and Rifampicin-resistance diagnosis on GXP only. Being initiated on ART and age >40 years reduced odds of defaulting by 90% and 60% respectively among HIV co-infected patients. Key recommendations: The high defaulter rate within the first few months of treatment impacts negatively on the control of DRTB, hence efforts to improve this are needed. Addressing factors associated with defaulting is crucial in DRTB clinics to curb transmission of DRTB in the community. All patients diagnosed with a GXP need immediate confirmation by LPA and culture/DST. Key words: Rifampicin resistant TB, Drug Resistant TB Treatment outcomes, Ambulatory DRTB care, DRTB/HIV co-infectionLG201

Solid and liquid modernity: A comparison of the social geography of places to die in the UK and Australia.

Preferred place of care and death is a widely used quality measure for palliative and end of life care services. In this article we explore the use of Zygmunt Bauman's ideas on solid and liquid modernity to understand the complexity of the social geographical contexts of delivering and receiving care. Although solid ways of dying offer certainty and standardized care, more liquid ways allow for individualized care connected to family and communities. Understanding the complex tensions between solid and liquid aspects of palliative care may allow practitioners to help dying people to die in the ways and places they prefer