Distribution and determinants of pneumonia diagnosis using Integrated Management of Childhood Illness guidelines: a nationally representative study in Malawi

Background: Pneumonia remains the leading cause of child mortality in sub-Saharan Africa. The Integrated Management of Childhood Illness (IMCI) strategy was developed to standardise care in low-income and middle-income countries for major childhood illnesses and can effectively improve healthcare worker performance. Suboptimal clinical evaluation can result in missed diagnoses and excess morbidity and mortality. We estimate the sensitivity of pneumonia diagnosis and investigate its determinants among children in Malawi. Methods: Data were obtained from the 2013–2014 Service Provision Assessment survey, a census of health facilities in Malawi that included direct observation of care and re-examination of children by trained observers. We calculated sensitivity of pneumonia diagnosis and used multilevel log-binomial regression to assess factors associated with diagnostic sensitivity. Results: 3136 clinical visits for children 2–59 months old were observed at 742 health facilities. Healthcare workers completed an average of 30% (SD 13%) of IMCI guidelines in each encounter. 573 children met the IMCI criteria for pneumonia; 118 (21%) were correctly diagnosed. Advanced practice clinicians were more likely than other providers to diagnose pneumonia correctly (adjusted relative risk 2.00, 95% CI 1.21 to 3.29). Clinical quality was strongly associated with correct diagnosis: sensitivity was 23% in providers at the 75th percentile for guideline adherence compared with 14% for those at the 25th percentile. Contextual factors, facility structural readiness, and training or supervision were not associated with sensitivity. Conclusions: Care quality for Malawian children is poor, with low guideline adherence and missed diagnosis for four of five children with pneumonia. Better sensitivity is associated with provider type and higher adherence to IMCI. Existing interventions such as training and supportive supervision are associated with higher guideline adherence, but are insufficient to meaningfully improve sensitivity. Innovative and scalable quality improvement interventions are needed to strengthen health systems and reduce avoidable child mortality

A new route to sol-gel crystalline wollastonite bioceramic

Artificial bone graft materials formed from wollastonite have been extensively used in bone repair because of their high degree of bioactivity and biocompatibility, thereby justifying the development of a protocol for large-scale production. This work reports a novel route for preparing wollastonite via the sol-gel process using bentonite clay as a cheap silica source. The obtained wollastonite was characterized for morphology, elemental composition, phase composition and bioactivity using scanning electron microscopy, energy dispersive X-ray analysis, X-ray diffraction and Fourier transform infrared spectroscopy. Results obtained revealed that wollastonite phase was successfully formed in the material and it showed ability to induce formation of apatite within 0.5 day in biological fluid, an indicator for bone-bonding capability. Overall, the wollastonite prepared from the bentonite clay exhibited properties comparable to that synthesized from commercially obtained sodium metasilicate. Hence, our synthetic route may be useful for commercial-scale preparation of wollastonite

Differential associations of homelessness with emergency department visits and hospitalizations by race, ethnicity, and gender

ObjectiveTo investigate the differential associations of homelessness with emergency department (ED) visits and hospitalizations by race, ethnicity, and gender.Data sourcesCalifornia Medicaid enrollment and claims.Study designWe identified beneficiaries experiencing homelessness (BEH) and those who did not (NBEH) using diagnosis and place of service codes and residential addresses. Outcomes include four ED visit measures and four hospitalization measures. We compared the use of these services by BEH to NBEH overall and by race, ethnicity, and gender groups in regression models controlling for covariates.Data collectionWe used a sample of Medicaid beneficiaries who met eligibility criteria for a California Medicaid demonstration program in 2017 and 2018 but were not enrolled in the program. We identified 473,069 BEH, and the rest (1,948,422) were considered NBEH. We used the 2018 data for utilization analyses and most covariates. We constructed lagged measures of health conditions using 2017 data.Principal findingsWe found that homelessness was significantly associated with 0.34 more ED visits (p < 0.01) and a higher likelihood of frequent ED visits (2.77 percentage points [pp], p < 0.01), any ED visits due to mental health conditions (0.79 pp, p < 0.01), and any ED visits due to substance use disorders (1.47 pp, p < 0.01). Experiencing homelessness was also significantly associated with 0.03 more hospitalizations (p < 0.01), a higher likelihood of frequent hospitalizations (0.68 pp, p < 0.01) and high frequent hospitalizations (0.28 pp, p < 0.01), and a longer length of stay (0.53 days, p < 0.01). We found a larger association for American Indian and Alaska Native, Black, Native Hawaii or Pacific Islander, and White populations than that for Asian and Hispanic populations. The associations are larger for males than females.ConclusionsOur findings identified distinct utilization patterns by race, ethnicity, and gender. They indicated the need for developing race, ethnicity, and gender-specific strategies to reduce ED visits and hospitalizations of BEH

Differential associations of homelessness with emergencydepartment visits and hospitalizations by race, ethnicity, andgender

Objective To investigate the differential associations of homelessness with emergency department (ED) visits and hospitalizations by race, ethnicity, and gender. Data Sources California Medicaid enrollment and claims. Study Design We identified beneficiaries experiencing homelessness (BEH) and those who did not (NBEH) using diagnosis and place of service codes and residential addresses. Outcomes include four ED visit measures and four hospitalization measures. We compared the use of these services by BEH to NBEH overall and by race, ethnicity, and gender groups in regression models controlling for covariates. Data Collection We used a sample of Medicaid beneficiaries who met eligibility criteria for a California Medicaid demonstration program in 2017 and 2018 but were not enrolled in the program. We identified 473,069 BEH, and the rest (1,948,422) were considered NBEH. We used the 2018 data for utilization analyses and most covariates. We constructed lagged measures of health conditions using 2017 data. Principal Findings We found that homelessness was significantly associated with 0.34 more ED visits (p < 0.01) and a higher likelihood of frequent ED visits (2.77 percentage points [pp], p < 0.01), any ED visits due to mental health conditions (0.79 pp, p < 0.01), and any ED visits due to substance use disorders (1.47 pp, p < 0.01). Experiencing homelessness was also significantly associated with 0.03 more hospitalizations (p < 0.01), a higher likelihood of frequent hospitalizations (0.68 pp, p < 0.01) and high frequent hospitalizations (0.28 pp, p < 0.01), and a longer length of stay (0.53 days, p < 0.01). We found a larger association for American Indian and Alaska Native, Black, Native Hawaii or Pacific Islander, and White populations than that for Asian and Hispanic populations. The associations are larger for males than females. Conclusions Our findings identified distinct utilization patterns by race, ethnicity, and gender. They indicated the need for developing race, ethnicity, and gender-specific strategies to reduce ED visits and hospitalizations of BEH.https://doi.org/10.1111/1475-6773.1400