Clinical and Financial Implications of Medicine Consumption Patterns at a Leading Referral Hospital in Kenya to Guide Future Planning of Care

Background: Medicines can constitute up to 70% of total health care budgets in developing countries as well as considerable expenditure in hospitals. Inventory management techniques can assist with managing resources efficiently. In Kenyatta National Hospital (KNH), a leading hospital in Kenya, over 30% of medical expenses are currently allocated to medicines, and this needs to be optimally managed. Objective: To investigate drug consumption patterns, their costs and morbidity patterns at KNH in recent year. Methodology: Cross-sectional retrospective record review. Inventory control techniques, ABC (Always, Better, Control), VEN (Vital, Essential and Non-essential) and ABC-VEN matrix analysis used to study drug expenditure patterns. Morbidity data extracted from the Medical Records. Results: Out of an average of 811 medicine types procured annually (ATC 5), 80% were formulary drugs and 20% were non-formulary. Class A medicines constituted 13.2% to 14.2% of different medicines procured each year but accounted for an average of 80% of total annual drug expenditure. Class B medicines constituted 15.9%-17% of all the drugs procured yearly but accounted for 15% of the annual expenditure, whilst Class C medicines constituted 70% of total medicines procured but only 5% of the total expenditure. Vital and Essential medicines consumed the highest percentage of drug expenditure. ABC-VEN categorization showed that an average of 31% medicine types consumed an average of 85% of total drug expenditure. Therapeutic category and Morbidity patterns analysis showed a mismatch between drug expenditure and morbidity patterns in over 85% of the categories. Conclusion: Class A medicines are few but consume the largest proportion of hospital drug expenditure. Vital and essential items consume the highest drug expenditure, and need to be carefully managed. ABC-VEN categorization identified medicines were major savings could potentially be made helped by Therapeutic category and Morbidity pattern analysis. There was a high percentage of non-formulary items, which needs to be addressed. Inventory control techniques should be applied routinely to optimize medicine use within available budgets especially in low and middle income countries. This is now being implemented

Pre-treatment loss to follow-up in adults with pulmonary TB in Kenya

County referral hospital in western Kenya. To ascertain the proportion of pre-treatment loss to follow-up (PTLFU) and associated patient factors in adults with pulmonary TB (PTB) in western Kenya. A retrospective data review of laboratory and treatment registers for adults with bacteriologically confirmed PTB between January 2018 to December 2021. We defined PTLFU as failure to initiate treatment within 14 days of diagnosis. We used multivariable logistic regression modelling to identify patient factors associated with PTLFU. Of 476 patients with PTB, 67.2% were male; the mean age was 36.1 years; 37.0% were HIV-positive; 5.7% had a history of anti-TB treatment; 40.6% were not traceable in the treatment register; 202 (42.4%, 95% CI 38.1–46.9) experienced PTLFU. Age ≥55 years (aOR 2.6, 95% CI 1.0–6.7) and providing only an address (aOR 34.2, 95% CI 18.7–62.5) or only a telephone contact number (aOR 22.3, 95% CI 3.5–141.1) were associated with PTLFU. Sex, HIV status, history of anti-TB treatment and place of residence were not associated with PTLFU. PTLFU contributes markedly to TB patient losses in western Kenya. Strengthening systems for documenting patient information and actively monitoring PTLFU are crucial for attrition reduction

Quality of comprehensive emergency obstetric care through the lens of clinical documentation on admission to labour ward

Background: Clinical documentation gives a chronological order of procedures and activities that a patient is given during their management.Objective: To determine the level of quality of comprehensive emergency obstetric care, through the lens of clinical documentation of process indicators of selected emergency obstetric conditions that mostly cause maternal mortality on admission to labour wardDesign: Multi-site cross sectional survey.Setting: Twenty two Government Hospitals in Kenya with capacity to offer comprehensive emergency obstetric care.Subjects: Process variables were abstracted from patient’ case records with a diagnosis of normal vaginal delivery, obstetric haemorrhage, severe pre eclampsia/eclampsia and emergency cesarean section.Results: Availability of structure indicators were graded excellent and good except for long gloves, misoprostol, ergometrin and parenteral cefuroxime that were graded low. A total of 1,216 records were abstracted for process analysis. The median (IQR) for the: six variables of obstetric history was five (4-5); five variables of antenatal profile was four (1-5); five variables of vital signs documentation was three (2-4); five variables for obstetric exam was four (4-5); seven variables of vaginal examination one (0-2); ten variables for partograph was seven (2-9); five variables for obstetric hemorrhage was three (2-4) and eleven variables for severe pre-eclampsia/eclampsia was five (3-6). The median (IQR) from decision-to-operate to caesarean section was three (2-4) hours.Conclusion: Quality of emergency obstetric care based on documentation depicts inadequacy. There is an urgent need to objectively address the need for proper clinical documentation as an indicator of quality performance

Management of Type 2 Diabetes at Vihiga County referral hospital, Kenya: compliance with guidelines and prevalence of complications

Background: In 2013, 382 million people suffered from diabetes globally, with 19.8 million in Africa and a Kenyan prevalence of 4.2%. Poor diabetic related outcomes such as complications, high blood sugar levels have resulted due to inadequate management of the condition. To ensure effective diagnosis, management and monitoring of Type 2 diabetic patients, the healthcare team should adopt and adhere to standard treatment guidelines that are valid and up-to date Objective: To assess the management, monitoring and complications of Type 2 diabetes among adult outpatients at Vihiga County Referral Hospital, Kenya. Methodology: A retrospective cross sectional study design was used to obtain data from 212 patient files selected through a systematic random sampling. Using a pre-designed data collection form, data on patient demographics, blood pressure, blood sugar, weight and complications was collected. Descriptive statistics were used to summarize findings to determine the proportion of adult Type 2 diabetic cases diagnosed, managed and monitored as per the Institute of Clinical Systems Improvement (ICSI) guidelines. Inferential analysis using t-test and chi square test were also carried out to ascertain extent of adherence to the guidelines. Results: Majority of the participants (31.1%) were aged 50 – 59 years (31.1%), and most were female (70.3%). Most, 39.6% had had diabetes for 1 to 5 years. Random blood sugar test was the most used method of diagnosis (58.5%) whilst fasting blood glucose test was performed in 34%. A compliance rate of 72.2% was reported in ensuring metformin was part of first line therapy as recommended. The recommended blood pressure, weight and cholesterol monitoring at initiation of treatment was observed in 96.7, 1.4 and 6.1% of the patients, respectively. Of the 141 patients monitored using fasting blood sugar, 113 (80.1%) had uncontrolled blood sugar levels (median blood sugar = 8.9(IQR.7.4, 12.75) mmol/L; P=0.741). The prevalence of reported neuropathy, retinopathy and nephropathy were 41, 33 and 0.9% respectively. Discussion: The diagnosis, management and monitoring of most patients fell short of the ICSI treatment guideline recommendations especially to monitoring of blood sugar, lipid levels and weight. The presence of anomalies calls for sensitization of healthcare workers on the importance of adoption and adherence to evidence based, up to date treatment guidelines and optimize patient health outcomes. Key words: Type 2 diabetes, treatment guidelines, healthcare provider

Health worker views on pre-treatment loss to follow-up in adults with pulmonary TB in Western Kenya

SETTING: County referral hospital in Western Kenya. OBJECTIVES: To explore factors contributing to pre-treatment loss to follow-up (PTLFU) in adults with pulmonary TB and propose solutions to address PTLFU from healthcare worker (HCW) perspectives. DESIGN: This was an exploratory qualitative study using thematic analysis. RESULTS: We conducted 19 key informant interviews with HCWs representing laboratory, clinical care, management and the community. Participant age ranged from 26 to 62 years; 14 (74%) were females; and most (74%) had worked in TB care for 5 years. They reported that patients experienced stigma and had misconceptions about TB that contributed to PTLFU. HCWs were hesitant to work in the TB clinic, which contributed to suboptimal patient care, leading to PTLFU. Unclear linkage between laboratory and clinician, and limited financial resources to track patients were among the healthcare system factors that led to PTLFU. HCWs suggested having proper patient preparation, assigning resources to track patients and holding regular interdisciplinary meetings as practical solutions to address PTLFU. CONCLUSION: HCWs reported multiple factors that may influence PTLFU and recommended various solutions to address these. Knowledge of TB management, patient preparation, resources to track patients and multidisciplinary meetings will be central to addressing PTLFU

Clinical and financial implications of medicine consumption patterns in Kenya

Introduction: Medicines can constitute up to 70% of total health care budgets in developing countries and considerable expenditure in hospitals. Inventory management techniques can assist with managing resources efficiently. In Kenyatta National Hospital (KNH) over 30% of expenditures are for medicines and this needs optimal management. Consequently, we investigated drug consumption patterns, their costs and morbidity patterns at KNH. Methodology: Cross-sectional retrospective record review. Inventory control techniques, ABC (Always, Better, Control), VEN (Vital, Essential and Non-essential) and ABC-VEN matrix analyses were used to study drug expenditure patterns. Morbidity data extracted from Medical Records. Results: An average of 811 medicine types are procured annually (ATC 5), 80% were formulary drugs and 20% were non-formulary. Class A medicines constituted 13.2% to 14.2% of different medicines procured each year but accounted for an average of 80% of total annual drug expenditure. Class B medicines constituted 15.9%-17% of all medicines procured but accounted for 15% of annual expenditure, whilst Class C medicines constituted 70% of total medicines procured but only 5% of total expenditure. Vital and Essential medicines consumed the highest proportion of drug expenditure. ABC-VEN categorization showed 31% medicine types consumed an average of 85% of total expenditure. Therapeutic category and morbidity patterns analysis showed a mismatch between expenditure and morbidity which needs investigation. Conclusion: Class A medicines are few but consume the largest proportion of hospital drug expenditure. Vital and essential items account for the highest drug expenditure, and also need to be carefully managed. ABC-VEN categorization identified medicines were major savings could potentially be made helped by Therapeutic category and Morbidity pattern analysis. There was a high percentage of non-formulary items, which needs to be addressed. Inventory control techniques should be applied routinely to optimize medicine use within hospitals within available budgets especially in low and middle income countries. This is now being implemented

Clinical and Financial Implications of Medicine Consumption Patterns at a Leading Referral Hospital in Kenya to Guide Future Planning of Care

Background: Medicines can constitute up to 70% of total health care budgets in developing countries as well as considerable expenditure in hospitals. Inventory management techniques can assist with managing resources efficiently. In Kenyatta National Hospital (KNH), a leading hospital in Kenya, over 30% of expenditure is currently allocated to medicines, and this needs to be optimally managed.Objective: To investigate drug consumption patterns, their costs and morbidity patterns at KNH in recent years.Methodology: Cross-sectional retrospective record review. Inventory control techniques, ABC (Always, Better, and Control), VEN (Vital, Essential, and Non-essential) and ABC-VEN matrix analyses were used to study drug expenditure patterns. Morbidity data was extracted from the Medical Records.Results: Out of an average of 811 medicine types procured annually (ATC 5), 80% were formulary drugs and 20% were non-formulary. Class A medicines constituted 13.2–14.2% of different medicines procured each year but accounted for an average of 80% of total annual drug expenditure. Class B medicines constituted 15.9–17% of all the drugs procured yearly but accounted for 15% of the annual expenditure, whilst Class C medicines constituted 70% of total medicines procured but only 5% of the total expenditure. Vital and Essential medicines consumed the highest percentage of drug expenditure. ABC-VEN categorization showed that an average of 31% of medicine types consumed an average of 85% of total drug expenditure. Therapeutic category and Morbidity patterns analysis showed a mismatch between drug expenditure and morbidity patterns in over 85% of the categories.Conclusion: Class A medicines are few but consume the largest proportion of hospital drug expenditure. Vital and essential items account for the highest drug expenditure, and need to be carefully managed. ABC-VEN categorization identified medicines where major savings could potentially be made helped by Therapeutic category and Morbidity pattern analysis. There was a high percentage of non-formulary items, which needs to be addressed. Inventory control techniques should be applied routinely to optimize medicine use within available budgets especially in low and middle income countries

Topical umbilical cord care for prevention of infection and neonatal mortality.

Umbilical cord care varies often reflecting community or health-worker beliefs. We undertook a review of current evidence on topical umbilical cord care. Study quality was assessed using the Grading of Recommendations, Assessment, Development and Evaluation system, and a meta-analysis was conducted for comparable trials. Available moderate-quality to high-quality evidence indicate that cord cleansing with 4% chlorhexidine may reduce the risk of neonatal mortality and sepsis (omphalitis) in low-resource settings

Evidence review of hydroxyurea for the prevention of sickle cell complications in low-income countries.

Hydroxyurea is widely used in high-income countries for the management of sickle cell disease (SCD) in children. In Kenyan clinical guidelines, hydroxyurea is only recommended for adults with SCD. Yet many deaths from SCD occur in early childhood, deaths that might be prevented by an effective, disease modifying intervention. The aim of this review was to summarise the available evidence on the efficacy, effectiveness and safety of hydroxyurea in the management of SCD in children below 5 years of age to support guideline development in Kenya. We undertook a systematic review and used the Grading of Recommendations Assessment, Development and Evaluation system to appraise the quality of identified evidence. Overall, available evidence from 1 systematic review (n=26 studies), 2 randomised controlled trials (n=354 children), 14 observational studies and 2 National Institute of Health reports suggest that hydroxyurea may be associated with improved fetal haemoglobin levels, reduced rates of hospitalisation, reduced episodes of acute chest syndrome and decreased frequency of pain events in children with SCD. However, it is associated with adverse events (eg, neutropenia) when high to maximum tolerated doses are used. Evidence is lacking on whether hydroxyurea improves survival if given to young children. Majority of the included studies were of low quality and mainly from high-income countries. Overall, available limited evidence suggests that hydroxyurea may improve morbidity and haematological outcomes in SCD in children aged below 5 years and appears safe in settings able to provide consistent haematological monitoring