Antiretroviral therapy dose adjustments based on calculated creatinine clearance

Background: Whereas therapy for HIV is dependent on level of creatinine clearance, most laboratories locally only report an absolute creatinine value. There is likelihood that the patients already on antiretroviral therapy (ART) may have required dosage adjustment at the time of initiation of therapy or sometime during ongoing therapy. This paper explores a group of patients who are already on ART to determine their creatinine clearance and assess the need for ART dose adjustment. Objective: To determine the proportion of stable HIV outpatients who have a documented creatinine clearance (CrCI) and the proportion requiring antiretroviral drug dose adjustments depending on their creatinine clearance. Design: Retrospective observational study. Setting: One stop HIV medical clinic, Aga Khan University Hospital, Nairobi between January and February 2007. Subjects: Ninety three patients seen. Results: None of the study subjects had a calculated creatinine clearance in their medical records. Fifteen of the 93 patients (16.1%) had no serum creatinine performed in the twelve months preceding the last clinic visit. Nine of the remaining 78 patients (11.5%) had evidence of renal insufficiency (CrCI \u3c60mls/min) as estimated by the Cockroft Gault method, with six patients (7.7%) requiring dose adjustments to the one or more drugs in their antiretroviral therapy (ART) regime (CrCI \u3c50mls/min). Conclusion: It is imperative to have a CrCI prior to and during follow up of patients with HIV disease on ART to reduce potential drug toxicities and interactions, especially with the increased utilisation of newer and potentially more nephrotoxic antiretrovirals

Utility of liver biopsy in HIV-infected patients presenting with febrile illnesses and inconclusive evaluation

Objectives: To determine the utility of liver biopsy in providing a diagnosis in HIVinfected patients presenting with febrile illnesses and inconclusive initial investigative work up. Design: A retrospective descriptive study. Setting: The Aga Khan University Hospital, Nairobi. Subjects: Twelve in-patients with HIV disease who underwent liver biopsy following inconclusive initial investigative work up for febrile illnesses between January and December 2007. Results: Seven out of 12 patients had granulomatous hepatitis reported on histology with characteristic tuberculous epitheloid granulomas all having stainable acid-alcohol fast bacilli on Ziehl-Nielsen (ZN) stain. The mean alkaline phosphatase (ALP) and gamma glutamyl transpeptidase (GGT) levels in these seven patients were 260U/L and 304U/L respectively, while the mean aspartate aminotransferase (SGOT) and alanine aminotransferase (SGPT) were 106U/L and 72U/L respectively. Conclusion: Disseminated tuberculosis is still among the most common causes of unexplained pyrexia in our HIV- infected cohort and a liver biopsy, performed earlier in the investigative work up of unexplained fever in the HIV-infected patient, would be a useful adjunct in providing a diagnosis

Acase of a private university teaching hospital

Dissertation submitted in partial fulfillment of the degree of Master of Business AdministrationHospitals increase their revenues usually by increasing bed and other service charges with the assurance that health services are price inelastic. They increase charges across the entire hospital. Hospital price increase is usually pegged to inflationary pressure and what other competing hospitals are doing. There is therefore a tendency to wait and see what the competitors are doing. This wait and see approach implies that the overall tendency is not to increase prices as there is a fear that increase in prices without competitors doing likewise will lead to migration of patients (a dominant price reducing strategy), that is, if the hospitals do not price their services correctly, they lose market share. A high price will cause patients to move to competitor, too Iowa price will cause financial and developmental targets to go unmet. Therefore, the hospital must be able to price appropriately. This dissertation looks at one private hospital that is also a teaching hospital. The policy in this hospital is to increase price once a year across the entire hospital. This study shows that this strategy is flawed. The study identified relationship of different departments' bed occupancy and number of patients admitted with the overall income of the hospital. In effect, the dissertation determines the price elasticity of the hospital in general, and each department specifically. In doing so, the study has shown that hospital services are not homogenous. Different department have different price elasticity and therefore one pricing strategy across the hospital is inappropriate. Each department's services should be priced independently

Determinants of Patients’ Choice of Healthcare Facilities in the Private Sector in Kenya: Optimizing Hospital Strategic Positioning

A dissertation submitted to Chandaria School of Business in partial fulfillment for the degree of the Doctor of Business Administration (DBA)Strategic positioning is about how a company positions itself to create value different from that of competition. Therefore, strategic positioning is defined as a firm’s relative position in the industry. It must lead to one of two outcomes – lower cost or higher premium. Higher premium can be charged when there is unique focus on either a product/ service or the unique needs of a few exclusive customers (niche market). Lower cost on the other hand implies a high production efficiency. One may then choose to either retain the benefits or pass them on to the customers (price competitiveness). The lower cost model is associated with mass marketing. Accordingly, Michael Porter defined strategic positioning as delivering value through cost leadership, differentiation and focus. The core value is what then the customer consumes. In the health industry, it is healthcare. This healthcare can be measured and identified customer needs can be met or exceeded. This presupposes that customers’ needs are known. There must be a process of identifying and evaluating the customers’ needs – their expectations and their experiences. This expectation-experience gap is the basis of customer perception of quality. Hospital quality comprises both technical as well as functional components. Technical quality is about the value that is delivered to the patients (the “what”) whereas functional quality is the process of delivering that value (the “how”). What is in the purview of the patient is the functional quality. The patient makes a choice of hospital depending on this functional quality. On the other hand, hospitals leadership and doctors have access to data on technical (clinical) outcomes. The hospital leadership’s basis of competition tends to be technical quality. This may cause a misalignment between patients’ expectations and the basis of competition. Further, patients are influenced by doctors and Medical Insurance Providers. Medical Insurance Providers are the primary payers in the private health sector. Patients’ perception of quality was evaluated using a modified version of the SERVQUAL tool that is based on the identification of the expectation-experience gap. This study then looked at the doctor and the Medical Insurance Provider perception of quality and their influence on the patient. In factoring in all the three key players, that is, the patients, doctors and Medical Insurance Providers, the study defined an optimal strategic position. The study used a post-positivism approach, collecting data using a questionnaire requiring participants to answer paired questions of their expectation and their experience using a five point Likert scale. After pilot testing and validating the data collection tool, data was collected from patients in the 12 out of the 14 (86% response rate) eligible level five and six private hospitals across Kenya. Thereafter data was also collected from the doctors who treated the recruited patients, the Medical Insurance Providers (for those that were insured) and from the hospitals’ leadership. Tests for reliability and validity were initially carried out. Factors analyses were done to extract, aggregate and reduce the relevant factors. The original six factors – Interpersonal, Environment of Care, Administrative, Access, Clinical Outcomes and Medical Equipment – were reduced to four where clinical outcomes collapsed into interpersonal dimension and medical equipment was dropped altogether. These factors were regressed against future behavioral intention (intention to return should the need arise and intention to refer others to the institution). The influence of the Doctor and Medical Insurance Provider were then discerned. Regional variation as well as the alignment of the administrator to the customers’ needs was ascertained. Results showed a clear hierarchical quality dimension determinants in the following diminishing order of influencing patients’ future behavioral intentions - Interpersonal, Environment of Care, Administrative and Access. This study showed that doctors and Medical Insurance Providers significantly influence patients’ perception of quality. Whereas the hospitals’ leadership appear well aligned to the customers’ perception of quality, there is incongruity between Doctors and Medical Insurance Providers understanding of patients’ expectation and experience from actual patients’ expectation and experience. There is a statistically significant regional variation of patients’ perception of quality. Even then, in each region, the perception of quality dimensions still significantly affected patients’ future behavioral intention. In conclusion, currently many of the hospitals are perceived to be strategically positioned based on product leadership. It is recommended to either maintain the product leadership or change to cost leadership and transferring the benefit back to the patients (price leadership) are the most sustainable strategic positioning. In understanding that the patients’ perception of quality is affected in a hierarchical manner by the dimensions of quality, it is recommended that regional factors such as market structure and competition, affordability by the population and within-country cultural variances should be taken into consideration. This study is delimited by the fact that it was a perception study. There was no in-depth attempt made to explain the perceptions of the various customers. This is left as an opportunity for further study by others

Real-world challenges for patients with breast cancer in sub-Saharan Africa: a retrospective observational study of access to care in Ghana, Kenya and Nigeria

Objective: To evaluate medical resource utilisation and timeliness of access to specific aspects of a standard care pathway for breast cancer at tertiary centres in sub-Saharan Africa. Design: Data were retrospectively abstracted from records of patients with breast cancer treated within a prespecified 2-year period between 2014 and 2017. The study protocol was approved by local institutional review boards. Setting: Six tertiary care institutions in Ghana, Kenya and Nigeria were included. Participants: Health records of 862 patients with breast cancer were analysed: 299 in Ghana; 314 in Kenya; and 249 in Nigeria. Interventions: As directed by the treating physician. Outcome measures: Parameters selected for evaluation included healthcare resource and use, medical procedure turnaround times and out-of-pocket (OOP) payment patterns. Results: Use of mammography or breast ultrasonography was \u3c45% in all three countries. Across the three countries, 78%-88% of patients completed tests for hormone receptors and human epidermal growth factor receptor 2 (HER2). Most patients underwent mastectomy (64%-67%) or breast-conserving surgery (15%-26%). Turnaround times for key procedures, such as pathology, surgery and systemic therapy, ranged from 1 to 5 months. In Ghana and Nigeria, most patients (87%-93%) paid for diagnostic tests entirely OOP versus 30%-32% in Kenya. Similarly, proportions of patients paying OOP only for treatments were high: 45%-79% in Ghana, 8%-20% in Kenya and 72%-89% in Nigeria. Among patients receiving HER2-targeted therapy, the average number of cycles was five for those paying OOP only versus 14 for those with some insurance coverage. Conclusions: Patients with breast cancer treated in tertiary facilities in sub-Saharan Africa lack access to timely diagnosis and modern systemic therapies. Most patients in Ghana and Nigeria bore the full cost of their healthcare and were more likely to be employed and have secondary or postsecondary education. Access to screening/diagnosis and appropriate care is likely to be substantively lower for the general population

Real-world challenges for patients with breast cancer in sub-Saharan Africa: a retrospective observational study of access to care in Ghana, Kenya and Nigeria

Objective To evaluate medical resource utilisation and timeliness of access to specific aspects of a standard care pathway for breast cancer at tertiary centres in sub-Saharan Africa.Design Data were retrospectively abstracted from records of patients with breast cancer treated within a prespecified 2-year period between 2014 and 2017. The study protocol was approved by local institutional review boards.Setting Six tertiary care institutions in Ghana, Kenya and Nigeria were included.Participants Health records of 862 patients with breast cancer were analysed: 299 in Ghana; 314 in Kenya; and 249 in Nigeria.Interventions As directed by the treating physician.Outcome measures Parameters selected for evaluation included healthcare resource and use, medical procedure turnaround times and out-of-pocket (OOP) payment patterns.Results Use of mammography or breast ultrasonography was <45% in all three countries. Across the three countries, 78%–88% of patients completed tests for hormone receptors and human epidermal growth factor receptor 2 (HER2). Most patients underwent mastectomy (64%–67%) or breast-conserving surgery (15%–26%). Turnaround times for key procedures, such as pathology, surgery and systemic therapy, ranged from 1 to 5 months. In Ghana and Nigeria, most patients (87%–93%) paid for diagnostic tests entirely OOP versus 30%–32% in Kenya. Similarly, proportions of patients paying OOP only for treatments were high: 45%–79% in Ghana, 8%–20% in Kenya and 72%–89% in Nigeria. Among patients receiving HER2-targeted therapy, the average number of cycles was five for those paying OOP only versus 14 for those with some insurance coverage.Conclusions Patients with breast cancer treated in tertiary facilities in sub-Saharan Africa lack access to timely diagnosis and modern systemic therapies. Most patients in Ghana and Nigeria bore the full cost of their healthcare and were more likely to be employed and have secondary or postsecondary education. Access to screening/diagnosis and appropriate care is likely to be substantively lower for the general population

Access to care and financial burden for patients with breast cancer in Ghana, Kenya, and Nigeria

Background: Breast cancer is the most frequently diagnosed malignancy and the most common cause of cancer-related death in women in Ghana, Kenya, and Nigeria. We evaluated healthcare resource use and financial burden for patients treated at tertiary cancer centers in these countries. Methods: Records of breast cancer patients treated at the following government/private tertiary centers were included – Ghana: Korle-Bu Teaching Hospital and Sweden Ghana Medical Centre; Kenya: Kenyatta National Hospital and Aga Khan University Hospital; Nigeria: National Hospital Abuja and Lakeshore Cancer Center. Patients presenting within a prespecified 2-year period were followed until death or loss to follow-up. Results: The study included 299 patient records from Ghana, 314 from Kenya, and 249 from Nigeria. The use of common screening modalities (eg, mammogram, breast ultrasound) was \u3c 45% in all 3 countries. Use of core needle biopsy was 76% in Kenya and Nigeria, but only 50% in Ghana. Across the 3 countries, 91-98% of patients completed blood count/chemistry, whereas only 78-88% completed tests for hormone receptor and human epidermal growth factor receptor 2 (HER2). Most patients underwent surgery: mastectomy (64-67%) or breast-conserving Most patients in Ghana and Nigeria (87-93%) paid for their diagnostic tests entirely out of pocket (OOP) compared with 30-32% in Kenya. Similar to diagnostic testing, the proportion of patients paying OOP only for treatments was high: 72-89% in Nigeria, 45-79% in Ghana, and 8-20% in Kenya. Among those receiving HER2-targeted therapy, average number of cycles was 5 for patients paying OOP only vs 14 for patients with some level of insurance coverage. Conclusions: Patients treated in tertiary facilities in sub-Saharan African countries lack access to common imaging modalities and systemic therapies. Most patients in Ghana and Nigeria bore the full cost of their breast cancer care, suggestive of privileged financial status. Access to screening/diagnosis and appropriate care is likely to be substantively lower for the general population