Patient-focused quality improvement in primary health care: Opportunities with the patient evaluation scale

Background: Patient evaluation of primary health care (PHC) is an evidenced-based approach to quality assessment but its use in Nigeria is still minimal.Objective: This article explored approaches for using the patient evaluation scale (PES) for PHC performance measurement, ranking, comparing sub-national PHC systems and undertaking patient-focused quality improvement of PHC in Nigeria.Method: Secondary analyses of data obtained from a cross-sectional national representative exit survey of patients’ experiences of PHC which was conducted with the PES. The PES QUALISTAT is an array of analytic procedures and approaches for presenting data on PHC performance. Colour coding of performance (red colour = severe underperformance requiring urgent action, yellow = suboptimal performance requiring action and green = optimal performance) in relation to thresholds of a standard performance scale were illustrated. The implications of this for practice and policy which shows the opportunities for patient-focused quality improvement using the PES were discussed.Results: Raw analysis shows red colours in 0-38%, 4-29% and 0-16% of attributes across the various health centres, Local Governments Areas and States, respectively. The most frequently rated attribute as being satisfactory was neatness reported in 20.8% of health centres. A preponderance of health centres had deficiencies in relation to availability of electricity (58.3%) and water supply (58.3%).Conclusion: This study demonstrates the opportunities in patient-based review using the PES for the development of PHC in Nigeria. The use of simple, clear and actionable presentation of finding may make it suitable and attractive for use by researchers, practitioners and policy makers. Implications are the imperatives for administrative and policy support needed to institutionalised periodic nationwide patient surveys, benchmarking, performance ranking of PHC facilities and trend analysis to enhance timely identification and remediation of problems in Nigeria’s PHC system.Keyword: Primary health care, Patient evaluation, Performance, Patient Evaluation Scale, Nigeria

Questionnaires for Patient Evaluation of Primary Health Care: A Systematic Review and Implications for the Nigerian Practice Setting

Background: An increasing number of questionnaires have been developed for patient evaluation of primary health care (PHC) but these are mostly designed for developed countries' settings.Aim: To review the development, contents, measurement properties of published questionnaires for patient evaluation of PHC and draw implications for the Nigerian practice setting.Design: A systematic reviewData Sources: Systematic search for worldwide published literature from Medline (1950 to 2014), CINAHL Plus, EMBASE, and PsycINFO databases were concluded on the 30th of April 2014.Study eligibility criteria: Studies included in this review reported the development and/or validation of a questionnaire for patients' evaluation of primary (health) care.Data extraction: Data was extracted with a template prepared in accordance with the review objectives. Template had article identifier, setting, context, developmental processes, contents (domains, items, and scales), potential utility and measurement properties (reliability, validity, and acceptability) were extracted and narrative reports were presented.Findings: Twenty-three studies met all the eligibility criteria for inclusion. The majority were published after 2000 (83%), developed in Europe (61%), and mostly in the United Kingdom (48%). Only 2 (9%) of these questionnaires were developed in countries in Africa. Majority (65%) of these questionnaires were developed through the cycle, contained between 20 – 40 core items (44%) and had bipolar response scale (52%) The most commonly reported measurement index was the Cronbach's alpha (74%) and contents of 58% of questionnaires had scope for potential evaluation of the continuum of structure, process and outcome dimensions of quality. There was no published report on the development or validation of any of these questionnaires for the Nigerian practice setting.Conclusion: Most questionnaires were developed to suit specific context and practice setting. The wholesome transfer of such questionnaire across cultural and practice setting remains a difficult issue. The limited application of existing questionnaires in the Nigerian PHC setting could be a justification for the development of a contextually sound and conceptually relevant measure for local use

Out-of-Pocket Payment for Healthcare and Implications for Households: Situational Analysis in Yenagoa, Bayelsa State

Background: Healthcare financing remains a critical issue in the on-going discourse on universal health coverage (UHC). This community-based study sought to examine the payment for healthcare and its relationship to indicators of catastrophic health expenditure (CHE) among households (HH) in Yenagoa.Methods: Data was obtained from a cross-sectional survey of  households in two randomly selected communities in Yenagoa. A  pretested, structured, interviewer-administered questionnaire was used to obtain information on HH income, general expenditures and financing for healthcare. HH spending more than 10% total income and 40% non-food expenditure were deemed to have suffered CHE and both CHE thresholds were calculated for the sampled population and compared between payment modes.Results: Responses were received from 525 HHs with median HH monthly income, total and healthcare expenditures of ₦115,000,  ₦112,170 and ₦9,250, respectively. Out-of-pocket (OOP) was the most prevalent (95.6%) mode of payment for healthcare. The incidence of CHE was 32.8% with reference to total income and 12.8% using non-food expenditure threshold. The Catastrophic Overshoots were 7% and -19.9% while Mean Positive Overshoots were 21% and 12% with respect to both thresholds for the entire study population. The  incidence of CHE was significantly higher in HHs with OOP than  insured HHs.Conclusion: OOP was the main payment option for healthcare and exposes significantly higher proportion of HHs to CHE. Findings  support the need to expand the coverage of the social insurance scheme to reduce exposure to financial risks by HHs and achieve UHC in Yenagoa. Keywords: Out-of-pocket; Healthcare financing; Catastrophic Health Expenditure; Households; Yenagoa; Nigeria

Investigating outcomes in the management of hypertension by specialists in a University Hospital

Background: Hypertension is an acknowledged risk factor for other cardiovascular diseases and this risk is heightened with the co-existence of other risk factors and long-term co-morbidities. This study reviewed clinical outcomes in the management of hypertension at the medical outpatient clinic of the University of Port Harcourt Teaching Hospital, Nigeria.Method: Cross-sectional survey and review of records of 182 randomly selected regular patients at the medical out-patients’ clinic. Outcomes measured were patients’ adherence to treatment, persisting risk factors, co-morbidities, trend in patients’ blood pressure over last three consecutive visits. Descriptive and analytic statistics were conducted using (SPSS) version 20.0.Results: A majority of the patients were females (62.6%) and about half (45.0%) reported adherence to the treatment protocol. Common persisting risk factors were overweight (73.1%) and high low density lipoprotein cholesterol (81.0%) while co-morbidity was diabetes (26.9%). Proportion of clients with uncontrolled BP progressively declined over the last 3 consecutive visits (63.7 → 60.4 → 54.4%). The progressive declines were statistically significant with p-value of 0.039 and 0.001 respectively. Poor adherence (p = 0.01), older ages (p = 0.047), and shorter duration of illness (p = 0.023) were significantly associated with uncontrolled hypertension.Conclusion: Adherence to treatment protocol and regular follow-up of hypertensive patients were modifiable predictors of adequate BP control. Most of the persisting risk factors are related to behavioural and dietary practices among hypertensive subjects. Findings have implications for periodic clinical audit as a strategy for clinical governance and quality improvement.Keywords: clinical audit, outcome, hypertension management, specialist clinic, UPTH, Nigeri

Variations in health-related quality of life of patients with long-term medical conditions in Nigeria: Implications for an all-inclusive system support

Objective: To measured and compared health-related quality of life (HRQOL) among hypertensive (HYP) and human immunodeficiency virus (HIV) patients at tertiary health facilityDesign: Comparative cross-sectional study.Setting: The medical outpatient clinic of the University of Port Harcourt Teaching Hospital in Nigeria.Subject: Systematic recruitment of 300 HYP and HIV patients; self-reported assessment of the HRQOL using the WHOQOL-BREF questionnaireMain outcome measures: HROQL along domains of the WHOQOL-BREF questionnaire – general, physical health, psychological health, social and environmental health.Data analysis: Exploratory and confirmatory data analyses were conducted using Statistical Package for Social Science version 23 and p-value ≤ 0.05 were considered significant.Result: Response rate was 98% and Cronbach’s alpha was 0.882. About 29.3% and 24.7% reported poor HRQOL for HYP and HIV patients respectively. The mean differences in the HRQOL between HYP and HIV patients along physical, psychological, social, environmental domains and overall HRQOL were physical -15.3(95%CI: -17.2, -13.4, p<0.0001); psychological -17.0(95%CI: -18.9, -15.1, p<0.0001); social 4.2(95%CI: -1.0, 7.4, p = 0.01); environmental -12.6(95%CI: -15.1, -10.1, p<0.001) and overall HRQOL -10.0(95%CI: -11.9, -8.1, p<0.001) respectively. Except for the general health and social domains, HIV patients reported significantly better HRQOL than patients with hypertension.Conclusion: The HRQOL of hypertensives was poorer than HIV patients in most domains of the WHOQOL-BREF instrument. Findings call for more clinical, social and environmental support for all patients with LTMCs especially those with non-communicable diseases like hypertension who currently enjoy no subsidy. Key words: Health-Related Quality of Life, HRQOL, WHOQOL-BREF, hypertension, human immunodeficiency virus patients, HIV, tertiary hospital, UPTH

Weibull Distributions Applied to Cost and Risk Analysis for Aero Engines

This paper presents the use of Weibull formulation to the life analysis of different parts of the engine in order to estimate the cost of maintenance, the direct operating costs (DOC) and net present cost (NPC) of future type turbofan engines. The Weibull distribution is often used in the field of life data analysis due to its flexibility—it can mimic the behavior of other statistical distributions such as the normal and the exponential. The developed economic model is composed of three modules: a lifing module, an economic module and a risk module. The lifing module estimates the life of the high pressure turbine blades through the analysis of creep and fatigue over a full working cycle of the engine. The value of life calculated by the lifing is then taken as the baseline distribution to calculate the life of other important modules of the engine using the Weibull approach. Then the lower of the values of life of all the distributions is taken as time between overhaul (TBO), and used into the economic module calculations. The economic module uses the TBO together with the cost of labour and the cost of the engine (needed to determine the cost of spare parts) to estimate the cost of maintenance and DOC of the engine. In the present work five Weibull distributions are used for five important sources of interruption of the working life of the engine: Combustor, Life Limited Parts (LLP), High Pressure Compressor (HPC), General breakdowns and High Pressure Turbine (HPT). The risk analysis done in this work shows the impact of the breakdown of different parts of the engine on the NPC and DOC, the importance that each module of the engine has in its life, and how the application of the Weibull theory can help us in the risk assessment of future aero engines. A detailed explanation of the economic model is done in two other works (Pascovici et. al. [6] and Pascovici et. al. [7]), so in this paper only a general overview is done

Weibull Distributions Applied to Cost and Risk Analysis for Aero Engines

This paper presents the use of Weibull formulation to the life analysis of different parts of the engine in order to estimate the cost of maintenance, the direct operating costs (DOC) and net present cost (NPC) of future type turbofan engines. The Weibull distribution is often used in the field of life data analysis due to its flexibility—it can mimic the behavior of other statistical distributions such as the normal and the exponential. The developed economic model is composed of three modules: a lifing module, an economic module and a risk module. The lifing module estimates the life of the high pressure turbine blades through the analysis of creep and fatigue over a full working cycle of the engine. The value of life calculated by the lifing is then taken as the baseline distribution to calculate the life of other important modules of the engine using the Weibull approach. Then the lower of the values of life of all the distributions is taken as time between overhaul (TBO), and used into the economic module calculations. The economic module uses the TBO together with the cost of labour and the cost of the engine (needed to determine the cost of spare parts) to estimate the cost of maintenance and DOC of the engine. In the present work five Weibull distributions are used for five important sources of interruption of the working life of the engine: Combustor, Life Limited Parts (LLP), High Pressure Compressor (HPC), General breakdowns and High Pressure Turbine (HPT). The risk analysis done in this work shows the impact of the breakdown of different parts of the engine on the NPC and DOC, the importance that each module of the engine has in its life, and how the application of the Weibull theory can help us in the risk assessment of future aero engines. A detailed explanation of the economic model is done in two other works (Pascovici et. al. [6] and Pascovici et. al. [7]), so in this paper only a general overview is done

EVA - A Tool for EnVironmental Assessment of Novel Propulsion Cycles

This paper presents the development of a tool for EnVironmental Assessment (EVA) of novel propulsion cycles implementing the Technoeconomical Environmental and Risk Analysis (TERA) approach. For nearly 3 decades emissions certification and legislation has been mainly focused on the landing and take-off cycle. Exhaust emissions measurements of NOx, CO and unburned hydrocarbons are taken at Sea Level Static (SLS) conditions for 4 different power settings (idle, descent, approach and take-off) and are consecutively used for calculating the total emissions during the ICAO landing and take-off cycle. With the global warming issue becoming ever more important, stringent emissions legislation is soon to follow, focusing on all flight phases of an aircraft. Unfortunately, emissions measurements at altitude are either extremely expensive, as in the case of altitude test facility measurements, or unrealistic, as in the case of direct in flight measurements. Compensating for these difficulties, various existing methods can be used to estimate emissions at altitude from ground measurements. Such methods, however, are of limited help when it comes to assessing novel propulsion cycles or existing engine configurations with no SLS measurements available. The authors are proposing a simple and fast method for the calculation of SLS emissions, mainly implementing ICAO exhaust emissions data, corrections for combustor inlet conditions and technology factors. With the SLS emissions estimated, existing methods may be implemented to calculate emissions at altitude. The tool developed couples emissions predictions and environmental models together with engine and aircraft performance models in order to estimate the total emissions and Global Warming Potential of novel engine designs during all flight phases (i.e. the whole flight cycle). The engine performance module stands in the center of all information exchange. In this study, EVA and the described emissions prediction methodology have been used for the preliminary design analysis of three spool high bypass ratio turbofan engines. The capability of EVA to radically explore the design space available in novel engine configurations, while accounting for fuel burn and global warming potential during the whole flight cycle of an aircraft, is illustrated

EVA - A Tool for EnVironmental Assessment of Novel Propulsion Cycles

This paper presents the development of a tool for EnVironmental Assessment (EVA) of novel propulsion cycles implementing the Technoeconomical Environmental and Risk Analysis (TERA) approach. For nearly 3 decades emissions certification and legislation has been mainly focused on the landing and take-off cycle. Exhaust emissions measurements of NOx, CO and unburned hydrocarbons are taken at Sea Level Static (SLS) conditions for 4 different power settings (idle, descent, approach and take-off) and are consecutively used for calculating the total emissions during the ICAO landing and take-off cycle. With the global warming issue becoming ever more important, stringent emissions legislation is soon to follow, focusing on all flight phases of an aircraft. Unfortunately, emissions measurements at altitude are either extremely expensive, as in the case of altitude test facility measurements, or unrealistic, as in the case of direct in flight measurements. Compensating for these difficulties, various existing methods can be used to estimate emissions at altitude from ground measurements. Such methods, however, are of limited help when it comes to assessing novel propulsion cycles or existing engine configurations with no SLS measurements available. The authors are proposing a simple and fast method for the calculation of SLS emissions, mainly implementing ICAO exhaust emissions data, corrections for combustor inlet conditions and technology factors. With the SLS emissions estimated, existing methods may be implemented to calculate emissions at altitude. The tool developed couples emissions predictions and environmental models together with engine and aircraft performance models in order to estimate the total emissions and Global Warming Potential of novel engine designs during all flight phases (i.e. the whole flight cycle). The engine performance module stands in the center of all information exchange. In this study, EVA and the described emissions prediction methodology have been used for the preliminary design analysis of three spool high bypass ratio turbofan engines. The capability of EVA to radically explore the design space available in novel engine configurations, while accounting for fuel burn and global warming potential during the whole flight cycle of an aircraft, is illustrated