An evaluation of the role of an Intermediate Care facility in the continuum of care in Western Cape, South Africa

BACKGROUND: A comprehensive Primary Health Care approach includes clear referral and continuity of care pathways. South Africa lacks data that describe Intermediate Care (IC) services and its role in the health system. This study aimed to describe the model of service provision at an IC facility and the role it plays in the continuity of care in Cape Town. METHODS: Sixty-eight patients (65% Response Rate) were recruited in a prospective cohort design over a one-month period in mid-2011. Patient data were collected from a clinical record review and an interviewer-administered questionnaire, administered at a median interval between admission and interview of 11 days to assess primary and second ary diagnosis, knowledge of and previous use of Home Based Care (HBC) services, reason for admission, demographics and information on referring institution. A telephonic interviewer-administered questionnaire to patients or their family members post-discharge recorded their vital status, use of HBC post-discharge and their level of satisfaction with care received at the IC facility. A Cox regression model was run to identify predictors of survival and the effect of a Care-plan on survival. Seventy staff members (82%) were recruited in a cross-sectional study using a self-administered questionnaire to describe demographics, level of education and skills in relation to what they did for patients and what they thought patients needed. RESULTS: Of the 68 participants, 38 % and 24% were referred from a secondary and tertiary hospital, respectively, and 78% were resident of a higher income community. Stroke (35%) was the most common single reason for admission at acute hospital. The three most common reasons reported by patients why care was better at the IC facility than the referring institution was the caring and friendly staff, the presence of physiotherapy and the wound care. Even though a large proportion of the IC inpatients had been admitted in a health facility on the year preceding the study, only 13 patients (21%) had used a Community Health Worker (CHW) ever before and only 25% (n=15) of the discharged patients had a confirmed CHW visit post-discharge. The presence of a Care-plan was significantly associated with a 62% lower risk of death (Hazard Ratio: 0.380; CI 0.149-0.972). Notably, 46% of staff members reported performing roles that were outside their scope of practice and there was a mismatch between what staff reported doing and their actual tasks. In addition, of the 57 patients that could be traced on follow-up 21(37%) had died. CONCLUSION: Patients and family understood this service as a caring environment that is primarily responsible for rehabilitation services. Furthermore, a Care-plan which extends beyond admission could have a significant impact on reducing mortality. IC services should therefore be recognised as an integral part of the health system and it should be accessed by all who need it

An evaluation of the role of an Intermediate Care facility in the continuum of care in Western Cape, South Africa

BACKGROUND: A comprehensive Primary Health Care approach includes clear referral and continuity of care pathways. South Africa lacks data that describe Intermediate Care (IC) services and its role in the health system. This study aimed to describe the model of service provision at an IC facility and the role it plays in the continuity of care in Cape Town. METHODS: Sixty-eight patients (65% Response Rate) were recruited in a prospective cohort design over a one-month period in mid-2011. Patient data were collected from a clinical record review and an interviewer-administered questionnaire, administered at a median interval between admission and interview of 11 days to assess primary and second ary diagnosis, knowledge of and previous use of Home Based Care (HBC) services, reason for admission, demographics and information on referring institution. A telephonic interviewer-administered questionnaire to patients or their family members post-discharge recorded their vital status, use of HBC post-discharge and their level of satisfaction with care received at the IC facility. A Cox regression model was run to identify predictors of survival and the effect of a Care-plan on survival. Seventy staff members (82%) were recruited in a cross-sectional study using a self-administered questionnaire to describe demographics, level of education and skills in relation to what they did for patients and what they thought patients needed. RESULTS: Of the 68 participants, 38 % and 24% were referred from a secondary and tertiary hospital, respectively, and 78% were resident of a higher income community. Stroke (35%) was the most common single reason for admission at acute hospital. The three most common reasons reported by patients why care was better at the IC facility than the referring institution was the caring and friendly staff, the presence of physiotherapy and the wound care. Even though a large proportion of the IC inpatients had been admitted in a health facility on the year preceding the study, only 13 patients (21%) had used a Community Health Worker (CHW) ever before and only 25% (n=15) of the discharged patients had a confirmed CHW visit post-discharge. The presence of a Care-plan was significantly associated with a 62% lower risk of death (Hazard Ratio: 0.380; CI 0.149-0.972). Notably, 46% of staff members reported performing roles that were outside their scope of practice and there was a mismatch between what staff reported doing and their actual tasks. In addition, of the 57 patients that could be traced on follow-up 21(37%) had died. CONCLUSION: Patients and family understood this service as a caring environment that is primarily responsible for rehabilitation services. Furthermore, a Care-plan which extends beyond admission could have a significant impact on reducing mortality. IC services should therefore be recognised as an integral part of the health system and it should be accessed by all who need it

The use of state sponsored educational initiatives for Sustainable Health Workforce Solutions: Alignment of Policies and Practices in Selected Southern African Countries

Introduction Return-of-service (RoS) initiatives are government-funded strategies used to educate health professionals by contracting beneficiaries to undertake government work following their qualifications. It is envisaged that once they have served their contracts, they will be attracted to serve in the same area or government institution beyond the duration of their obligatory period. Little is known about the processes that have led to the development and implementation of RoS policies. This research aimed to evaluate RoS initiatives, explore their effectiveness and sustainability across four Southern African countries to determine their value as a sustainable solution and propose areas for improvement. Methods and Analysis This study was conducted in South Africa, Eswatini, Lesotho and Botswana in a phased approach through a multi-methods approach of policy reviews, literature reviews, and quantitative and qualitative research. Data were sourced from multiple provincial or national information systems and/or databases. The fourth and final phase included data analyses and triangulation of the findings, enabling recommendations on restructuring and enhancing, maintaining or even eliminating RoS schemes as a viable mechanism for expanding healthcare coverage. Findings The precise origins of South African RoS schemes could not be established. The origins of RoS schemes in Botswana, Eswatini and Lesotho could be established. RoS schemes aim to address critical skills shortages, contribute to citizens’ education, comply with legislation and boost the economy. The schemes are poorly planned, poorly implemented and poorly monitored, and they have not been evaluated. This study also revealed that the schemes lack effectiveness, incur significant costs, experience high defaulter rates and suffer from inadequate information management. Conclusion RoS schemes do not currently offer sustainable health workforce solutions in the four countries studied and will not unless governance, planning and implementation (including coordination and monitoring) are improved. Better monitoring and placement of beneficiaries in suitable health facilities could lead to quick improvements. Over the longer term, improved identification of the service need and appropriate incentivisation of needed skills could lead to a worthwhile investment through improved beneficiary retention

Rapid testing for respiratory syncytial virus in a resource-limited paediatric intensive care setting

Newman H, Tshabalala D, Mabunda S, et al. Rapid testing for respiratory syncytial virus in a resource-limited paediatric intensive care setting. Afr J Lab Med. 2020;9(1)We analysed the performance characteristics of the respiratory syncytial virus lateral flow rapid antigen assay in use when compared to a multiplex polymerase chain reaction for detection of respiratory viruses. The study was conducted at a tertiary paediatric hospital in Port Elizabeth, South Africa, from 01 January 2017 to 31 December 2018. We found the clinical sensitivity (36.8%) of the rapid test to be too low for routine diagnostic use. Knowledge of assay performance characteristics of rapid tests are important for appropriate interpretation of rapid test results

An Evaluation of the Role of an Intermediate Care Facility in the Continuum of Care in Western Cape, South Africa

Abstract Background: A comprehensive primary healthcare (PHC) approach requires clear referral and continuity of care pathways. South Africa is a lower-middle income country (LMIC) that lacks data on the role of intermediate care (IC) services in the health system. This study described the model of service provision at one facility in Cape Town, including reason for admission, the mix of services and skills provided and needed, patient satisfaction, patient outcome and articulation with other services across the spectrum of care. Methods: A multi-method design was used. Sixty-eight patients were recruited over one month in mid-2011 in a prospective cohort. Patient data were collected from clinical record review and an interviewer-administered questionnaire, administered shortly after admission to assess primary and secondary diagnosis, referring institution, knowledge of and previous use of home based care (HBC) services, reason for admission and demographics. A telephonic questionnaire at 9-weeks post-discharge recorded their vital status, use of HBC post-discharge and their satisfaction with care received. Staff members completed a self-administered questionnaire to describe demographics and skills. Cox regression was used to identify predictors of survival. Results: Of the 68 participants, 38% and 24% were referred from a secondary and tertiary hospital, respectively. Stroke (35%) was the most common single reason for admission. The three most common reasons reported why care was better at the IC facility were staff attitude, the presence of physiotherapy and the wound care. Even though most patients reported admission to another health facility in the preceding year, only 13 patients (21%) had ever accessed HBC and only 25% (n=15) of discharged patients used HBC post-discharge. Of the 57 patients traced on follow-up, 21(37%) had died. The presence of a Care-plan was significantly associated with a 62% lower risk of death (hazard ratio: 0.38; CI 0.15–0.97). Notably, 46% of staff members reported performing roles that were outside their scope of practice and there was a mismatch between what staff reported doing and their actual tasks. Conclusion: Clients understood this service as a caring environment primarily responsible for rehabilitation services. A Care-plan beyond admission could significantly reduce mortality. There was poor referral to and poor articulation with HBC services. IC services should be recognised as an integral part of the health system and should be accessible

Prevalence of obesity and associated risk factors among children and adolescents in the Eastern Cape Province

Obesity is a global public health concern that begins in childhood and is on the rise among people aged 18 and up, with substantial health consequences that offer socioeconomic challenges at all levels, from households to governments. Obesity and associated risk factors were investigated in children and adolescents in the Eastern Cape Province of South Africa. A cross-sectional study was conducted at Mt Frere among 209 conveniently selected participants using anthropometric measurements and a structured questionnaire. Chi-squared statistics or Fisher’s exact test were used to evaluate the risk factors predicting different outcomes such as hypertension or diabetes mellitus

Doctors’ practice and attitudes towards red blood cell transfusion at Mthatha Regional Hospital, Eastern Cape, South Africa: A mixed methods study

Background: Unnecessary blood transfusion exposes recipients to potential harms. Aim: The aim of this study was to describe blood transfusion practice and explore doctors’ attitudes towards transfusion. Setting: A hospital providing level 1 and 2 services. Methods: A mixed-methods study design was used. In the cross-sectional descriptive component, a sample was taken from patients transfused over a 2-month period. Blood use was categorised as for medical anaemia or haemorrhage, and appropriate or not. The qualitative component comprised a purposeful sample for focus group and individual semistructured interviews. Results: Of 239 patients sampled, 62% were transfused for medical anaemia and 38% for haemorrhage. In the medical anaemia group, compliance with age-appropriate transfusion thresholds was 69%. In medical anaemia and haemorrhage, 114 (77%) and 85 (93.4%) of recipients had orders for ≥ 2 red blood cell (RBC) units, respectively. In adults ≥ 18 years old with medical anaemia, 47.1% of orders would have resulted in a haemoglobin (Hb) > 8 g/dL. Six doctors participated in focus group and eleven in individual interviews. There was a lack of awareness of institutional transfusion guidelines, disagreement on appropriate RBC transfusion thresholds and comments that more than one RBC unit should always be transfused. Factors informing decisions to transfuse included advice from senior colleagues, relieving symptoms of anaemia and high product costs. Conclusion: Most orders were for two or more units. In medical anaemia, doctors’ compliance with RBC transfusion thresholds was reasonable; however, almost half of the orders would have resulted in overtransfusion. The attitudes of doctors sampled suggest that their transfusion practice is influenced more by institutional values than formal guidelines. Keywords: red blood cell transfusion; doctors’ attitudes; doctors’ practice; transfusion thresholds; overtransfusion; descriptive study; qualitative study

The effect of the Xpert MTB/RIF test on the time to MDR-TB treatment initiation in a rural setting: a cohort study in South Africa’s Eastern Cape Province

Background: There are significant delays in initiation of multidrug-resistant tuberculosis (MDR –TB) treatment. The Xpert MTB/RIF test has been shown to reduce the time to diagnosis and treatment of MDR-TB predominantly in urban centres. This study describes the time to treatment of MDR-TB and the effect of Xpert MTB/RIF on time to treatment in a deprived rural area in South Africa. Methods: This was a retrospective cohort study analysing the medical records of patients diagnosed with MDR-TB in King Sabata Dalindyebo Sub-District between 2009 and 2014. Numerical data were reported using the Kruskal-Wallis and Wilcoxon sum rank tests and categorical data compared using the two-sample test of proportions. Results: Of the 342 patients with MDR-TB identified, 285 were eligible for analysis, of whom 145 (61.4%) were HIV positive. The median time from sputum collection to MDR-TB diagnosis was 27 days (IQR: 2–45) and differed significantly between diagnostic modalities: Xpert MTB/RIF, 1 day (IQR: 1–4; n = 114: p less 0.0001); Line Probe Assay 12 days (IQR: 8–21; n = 28; p less 0.0001); and culture/phenotypic drug sensitivity testing 45 days (IQR: 39–59; n = 143: p less 0.0001). The time from diagnosis to treatment initiation was 14 days (IQR: 8–27) and did not differ significantly between diagnostic modality. The median time from sputum collection to treatment initiation was 49 days (IQR: 20–69) but differed significantly between diagnostic modalities: Xpert MTB/RIF, 18 days (IQR: 11–27; n = 114; p less 0.0001); Line Probe Assay 29 days (IQR: 14.5–53; n = 28; p les 0.0001); and culture/phenotypic drug sensitivity, 64 days (IQR: 50–103; n = 143: P less 0.0001). Age, sex and HIV status did not influence the time intervals. Conclusions: Xpert MTB/RIF significantly reduced the time to MDR-TB treatment in a deprived rural setting as a result of a reduced time to diagnosis. However, the national target of five days was not achieved. Further research is needed to explore and address programmatic and patient-related challenges contributing to delayed treatment initiation. Keywords: Xpert MTB/RIF, MDR-TB, Rural, Time-to-treatment, Cohort stud